1. KHANI.M,MD MEDICAL ONCOLOGIST&HEMATOLOGIST ISFAHAN BLOOD&CANCER INSTITUE WWW.IBCI.IR

2. First step?

3. CASE NO :1 55 Y old previously obese man Progressive dysphagia & chest pain & weight loss since 3 month ago Past history of GERD for 5 years+smoking 20p/y PHE:cachexia,temporal muscle wasting,no lap LAB:hb=10,plt=180,000,serum alb=2.5

4. Endoscopy result A polypoid 3*3 cm mass lesion in distal esophageus near z line,multiple biopsy taken the scope don’t pass the lesion so evaluaion of stomach wasn’t possible

5. Second step?

6. EUS wasn’t available Thoracic ct scan:mass like lesion in distal esohagus highly suggest GE junction tumor, regional(diaphragmatic&pericardial) lap present Echo=EF 65%.mild pericardial effusion

7. Third step?

8. Abdominoplvic ct scan: no lymphadenopathy, no metastatic lesion

9. Laparascopy? PET PET/CT Pelvic &cervical ct?

10. Pathology report Poorly differentiated adenocarcinoma Tumor invades muscularis propria

11. Clinical staging T2,N1,M0 Stage IIb

12. Next step? Surgery Radiation Chemoradiation then surgery Definitive chemoradiation Chemo then chemorad then surgery +- chemo

13. This patient recived 2course ECF then chemoradiation then surgery

14. SURGERY TRANSHIATAL

15. Post surgery pathology report Poorly differentiated adenocarcinoma All margin free Tumor invades adventitia 4 out of 4 lymph node free of tumor T3N0/1M0 at least IIA

16. NEXT? 2 more ECF Follow up

17. Thank You

18. CASE NO:2 A 60 y/o male PMH:CLL BINET B (chlorambucil+pred),SCC of face skin (surgery+radiation+flap),DM(insulin) Heavy smoker, Progressive dysphagia&weight loss since 3 mo ago+intractable vomiting PHE:several deformity of face due to flap with dirty wound,cervical lap 2*3 cm,hoarsness

19. ENDOSCOPY RESULT A MASS LESION LOCATED IN 25 CM OF INCISURA TEETH CAUSE NEAR COMPLETE OBSTRUCTION OF LUMEN,MULTIPLE BIOPSY WAS TAKEN

20. PATHOLOGY REPORT SQUAMOUS CELL CARCINOMA

21. NEXT STEP? CERVICAL,THORACIC CT SCAN ABDOMINOPELVIC CT? BRONCHOSCOPY LAPAROSCOPY? PET OR PET/CT? EUS

22. RESULTS MASS LESION IN THORACIC ESOPHAGUS,DIMINISH FAT STRIP BETWEEN TRACHEA&ESOPHAGUS WITH MULTIPLE MEDIASTINAL LAP NORMAL ABDOMINOPELVIC CT BRONCHOSCOPY:NORMAL,NEGATIVE BIOPSY OF SUSPICIOUS AREA

23. T3/T4,N1,M0 STAGE III

24. NEXT STEP? SURGERY DEFINITIVE CRT CX -> CRT-> CX ->+-SURGERY CX-> CRT > SURGERY

25. CRT (50GY+CIS+FU) FOR 5 WEEK

26. AFTER 5 WEEK CONTINUE DYSPHAGIA ENDOSCOPY:DECREASED STENOSIS BUT PERSISTANT MASS THORACIC CT:NO OBVIOUS CHANGES COMPARE TO PREVIOUS CT,NO OBVIOUS OTHER ORGAN ADHESION

27. PET BIOPSY

28. RADIATION SURGERY CX