Background

2009 衛生署生命統計報告惡性腫瘤 : 97 年十大主要癌症順位與死亡人數占率• (1) 肺癌 20.0%• (2) 肝癌 19.7%• (3) 結腸直腸癌 11.0%• (4) 女性乳癌 4.0%• (5) 胃癌 5.9%• (6) 口腔癌 5.7%• (7) 攝護腺癌 2.3%• (8) 子宮頸癌 1.8%• (9) 食道癌 3.7%• (10) 胰臟癌 3.5%

97 年前十大主要癌症順位與去年相同

圖 20. 97年主要癌症死亡率

33.8 33.3

18.5

13.5

10.0 9.6

7.76.2 6.2 5.9

7.6 7.8

5.74.7 5.0 4.7

14.4

10.7

26.826.3

0.00

4.00

8.00

12.00

16.00

20.00

24.00

28.00

32.00

36.00

粗死亡率標準化死亡率

附 註：標準化死亡率係以W.H.O.2000年世界標準人口數為基準。

每十萬人口死亡率

2009 衛生署統計室

我國癌症趨勢十大癌症年增率比較 ( 標準化死亡率 )

• 除子宮頸癌、胃癌、肺癌下降外，餘均上升

• 食道癌、胰臟癌標準化死亡率年增率均在 2至 4

％間，增幅較為明顯

• 肝癌、結腸直腸癌、女性乳癌、與攝護腺癌標準化死亡率年增率均在 2 ％以下。

我國癌症趨勢癌症死亡年齡中位數後延• 10年來除食道癌外，癌症死亡年齡中位數有後延趨勢

• 97 年國人癌症死亡者平均年齡為 66.7 歲，較 87 年增加 2.4 歲

• 死亡年齡中位數為 69.0 歲，較 87 年增 2 歲，其中男性增 2 歲；女性增 3 歲。

單位：歲

全體 男 女 全體 男 女 全體 男 女

所有癌症死亡原因 69 69 69 67 67 66 2 2 3

肺癌 73 73 71 70 70 69 3 3 2

肝癌 68 65 72 64 62 68 4 3 4

結腸直腸癌 73 73 73 70 70 69 3 3 4

女性乳癌 56 … 56 54 … 54 2 … 2

胃癌 74 75 72 71 71 70 3 4 2

口腔癌 55 54 63 54 53 67 1 1 -4

攝護腺癌 80 80 … 76 76 … 4 4 …

子宮頸癌 65 … 65 63 … 63 2 … 2

食道癌 58 58 72 66 65 75 -8 -7 -3

胰臟癌 71 70 72 69 69 69 2 1 3

表2. 癌症死亡年齡中位數比較

97 (A)年 87 (B)年 增減歲數 (A-B)

2009 衛生署統計室

我國癌症趨勢癌症死因死亡年齡• 十大主要癌症死因中肝癌、女性乳癌、口

腔癌、子宮頸癌、食道癌等 5 類癌症死因死亡年齡中位數低於所有癌症死亡年齡中位數 69 歲，而女性乳癌、口腔癌與食道癌死亡年齡中位數更低於 60 歲。

• 近 10 年來，各主要癌症死因中死亡年齡中位數除食道癌下降 8歲外，其餘各主要癌症死因之死亡年齡均有增長趨勢。

2003年全國男性與 25-44歲男性癌症發生率之比較

順位全國男性 25-44歲男性

原發部位 個案數 粗發生率 原發部位 個案數 粗發生率

1 肝及肝內膽管 6,753 58.64 口腔、口咽及下咽 1,050 27.48

2 肺、支氣管及氣管 5,025 43.64 肝及肝內膽管 841 22.01

3 結腸及直腸 4,677 40.62 鼻咽 406 10.63

4 口腔、口咽及下咽 4,040 35.08 結腸及直腸 350 9.16

5 胃 2,308 20.04肺、支氣管及氣管 175 4.58

6 攝護腺 2,237 19.43 食道 166 4.34

7 膀胱 1,318 11.45 胃 141 3.69

8 食道 1,258 10.92 白血病 126 3.3

9 鼻咽 1,157 10.05 皮膚 108 2.83

10 皮膚 960 8.34 甲狀腺 97 2.54

單位：0/0000、%

全體 男 女 全體 男 女 全體 男 女

所有癌症死亡原因 133.7 174.4 94.4 140.5 174.5 104.3 -4.8 0.0 -9.5

肺癌 26.3 36.5 16.5 27.6 37.2 17.2 -4.7 -2.0 -4.0

肝癌 26.8 39.3 14.7 28.1 41.8 13.8 -4.8 -6.1 6.8

結腸直腸癌 14.4 17.1 11.8 14.5 16.5 12.4 -0.8 3.3 -4.8

女性乳癌 10.7 … 10.7 9.5 … 9.5 12.5 … 12.5

胃癌 7.6 10.2 5.1 11.8 15.3 8.1 -35.3 -33.2 -36.8

口腔癌 7.8 14.8 0.9 5.5 9.9 0.9 41.2 49.1 5.0

攝護腺癌 5.7 5.7 … 5.5 5.3 … 4.4 8.3 …

子宮頸癌 4.7 … 4.7 10.0 … 10.0 -52.7 … -52.7

食道癌 5.0 9.3 0.7 4.1 7.1 1.0 21.3 31.2 -25.3

胰臟癌 4.7 5.6 3.8 4.3 4.9 3.6 8.9 13.8 5.9

表3. 癌症標準化死亡率比較

97 (A)年 87 (B)年 增減百分比

2009 衛生署統計室

我國癌症趨勢主要癌症標準化死亡率的變動• 10 年來主要癌症的標準化死亡率變動，以子宮頸

癌與胃癌分別減少 52.7%與 35.3% 最為顯著• 肺癌與肝癌雖列居癌症死因順位的前 2 名，但 10

年來肺癌與肝癌標準化死亡率分別減少 4.7%與4.8%

• 此 4 主要癌症標準化死亡率的減少，是國人整體癌症標準化死亡率降低的主因

• 另外， 10 年來口腔癌、食道癌與女性乳癌之標準化死亡率都是兩位數字的成長，尤其男性口腔癌成長 49.1% ；女性則以乳癌、肝癌分別成長12.5%與 6.8% 較為顯著

Esophageal Cancer

Incidence Taiwan male: 7 /100,000 female: 0.6/100,000

CGMH 60 cases annually in Keelung CGMH (include 20 that outside of Keelung)

Staging Workup

TNM Staging System for Esophageal Neoplasms

Primary tumor (T)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor invades lamina propria or submucosa

T2 Tumor invades muscularis propria

T3 Tumor invades adventitia

T4 Tumor invades adjacent structures

Regional lymph nodes (N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastases

N1 Regional lymph node metastasis

Distant metastasis (M)

• Distant Metastasis (M) • MX Distant metastasis cannot be assessed • M0 No distant metastasis • M1 Distant metastasis

• L/3, Tumors of the lower thoracic esophagus: • M1a Metastasis in celiac lymph nodes • M1b Other distant metastasis

• M/3, Tumors of the mid thoracic esophagus: • M1a Not applicable • M1b Nonregional lymph nodes and/or other distant metastasis

• U/3, Tumors of the upper thoracic esophagus: • M1a Metastasis in cervical nodes • M1b Other distant metastasis

Stage Grouping

Stage 0 Stage I Stage IIA Stage IIB Stage III Stage IV Stage IVA Stage IVB

M0 M0 M0 M0 M0 M0 M0 M0 M1 M1a M1b

Tis T1 T2 T3 T1 T2 T3 T4 Any T Any T Any T

N0 N0 N0 N0 N1 N1 N1 Any N Any N Any N Any N

Histologic Grade (G)

• GX Grade cannot be assessed • G1 Well differentiated • G2 Moderately differentiated • G3 Poorly differentiated • G4 Undifferentiated

Histology: other than grade

• predicting LN mets in early esophageal ca

1. depth of tumor invasion2. Microscopic vascular

invasion3. Microscopic lymphatic

invasion4. Neural invasion

Aug 2008 Ann Surg Oncol

About lymph node status: N

Mid third (M/3) Lower third (L/3)

About lymph node status: N • Involvement of more-distant lymph nodes is currently considered distant

metastasis (M1a). (e.g. cervical or celiac nodes for intrathoracic tumors)

• Recent studies suggest: distant LN mets (M1) had a better overall survival than visceral mets (M1) , and 10% chance of cure at 5 years after surgical resection.

• Ever suggested: distant LN mets be classified as N2 rather than M1a • but such a change in classification requires further study.

Waiting a new staging systemlung cancer as the example

History & PE

PESEsophagography * （ optional）EUS (endoscopic ultrasound)Bronchoscopy * （ tumor above carina）SMA-12、 CBC/DC

CRPHBsAg、 AntiHCV

Ac SugarCT scan * （ H&N、 Chest、 Abdomen）Bone scanPET If no visceral M1bLiver echo * （ if liver disease suspected）Biopsy * （ proof for suspected metastatic sites if

possible）Pulmonary function testEKGNutritional counseling

ESOPHAGEAL CANCER 2009 KEELUNG CGMH Guideline Workup

0424 0806

0424 0806

Treatment

• Local ablation therapy• Surgical resection• Concurrent chemoradiotherapy (CCRT)

ESOPHAGEAL CANCER 2009 KEELUNG CGMH Guideline Treatment in non-M1b disease• Surgery： 1、 non-cervical T1 No & T2 No 2、 could be offered for localized resectable disease 3、 C/3 (cervical esophageal cancer) is preferred for CCRT 4、 higher U/3 will put to esophagus panel discussion• Endoscopic mucosal resection (EMR) could be offered for stage I limited in mucosa layer

• induction CCRT followed by surgery1、 P.S.＜ 22、 adequate PFT 3、 liver cirrhosis Child’s classification B or C will be excluded 4、 T1-4, N0-1, M0-1a5、M1b with possible curetive resection and good performance status will put to panel discussion6、 RT 4500-5040 cGy7、 chemotherapy： cisplatin/5FU based regimens or clinical trials 8、 before surgery, repeat（ i） CT scan（ ii） PET recommended（ iii） PES optional• primary CCRT: only after panel discussion• postop CCRT: given only if no induction CCRT

ESOPHAGEAL CANCER 2009 KEELUNG CGMH Guideline

Supportive treatment in M1b disease with visceral metastasis

• chemotherapy or best supportive care• palliative RT• stent• esophagus dilatation • NG, Percutaneous gastrostomy (PEG) or feeding jejunostomy

18

24

32

4040

40

Endoscopic Mucosal Resection (EMR) in Tis & T1a• 132 (74%) were in the endoscopic endoscopic (ENDO*) group

and 46 (26%) were in the surgical (SURG) group.• Treatment modality was not a significant predictor of survival

on multivariable analysis. • Recurrence in 12% of patients in the ENDO group, all

successfully re-treated endoscopically without impact on overall survival.

• Overall survival in mucosal (T1a) EAC in ENDO: comparable with SURG group

ENDO*: EMR or EMR + PhotoDynamic Tx

Endoscopic and Surgical Treatment of Mucosal (T1a) Esophageal Adenocarcinoma in Barrett's Esophagus. Prasad et al. Gastroenterology 2009;137:815-823.

For most patients who have locally advanced esophageal cancer

• Primary CCRT• CCRT followed by surgery

Treatment Timetable

wk 1 2 3 4 5 6 7 8 9 10

11

chemo C C C

RT RT

RT

RT

RT

RT

RT

OP Op

← ←

CT, EUS CT

PET PET

• Radiotherapy

• Surgery

Role of CT Scan• CT is inaccurate in determining T stage, • because it cannot define individual layers of the esophageal wall and will miss small T1 and T2 tumors.

• CT assessment of LNs (regional or distant) is limited by relatively low sensitivity (50% to 70%) due

to its reliance on size criteria (larger than 1 cm) alone.

• accuracy in determining lymph node involvement is limited (approximately 60%).

• Because lymph node involvement is frequently seen in small or normal-size lymph nodes, the false-negative rate is high, and despite a reasonable specificity of 85%,

Role of PET• The accuracy of FDG-PET in assessing regional lymph nodes :

between the low and high accuracy of CT and EUS, respectively

• FDG-PET is superior to CT, with a sensitivity, specificity,

and accuracy all in the range of 80% to 90%, in detection of distant metastases, as numerous studies confirm

• This translates into the detection of unsuspected metastatic disease

• up-staging in 15% of patients and; down-staging in 10%, which leads to alteration of the intended treatment plan in at least 20% of patients.

• FDG-PET appears to have some value in evaluating response to chemotherapy and radiotherapy

An analysis of multiple staging management strategies for carcinoma of the esophagus: computed tomography, endoscopic ultrasound, positron

emission tomography, and thoracoscopy/laparoscopy

• comparing the health care costs and efficacy of staging procedures including CT scan, EUS FNA, PET, and thoracoscopy-laparoscopy reported :

• CT plus EUS FNA was the least expensive and offered the most quality-adjusted life-years on average than all the other strategies.

• PET plus EUS FNA was somewhat more effective but also more expensive

• Wallace MB, Nietert PJ, Earle C, et al.. Ann Thorac Surg 2002;74:1026.