Spring 2010 Northeast Florida Medicine Journal by Hartley Press

We never forget they’re your patients. Connect instantly to patient updates through Mayo Clinic’s Online Services for Referring Physicians Esophageal Diseases For specialized care related to benign and malignant diseases of the esophagus, look to Mayo Clinic in Florida — an internationally recognized leader in the diagnosis and treatment of gastrointestinal disorders. Comprehensive services include: s Medical and surgical treatment of all diseases of the esophagus including Barrett’s esophagus, carcinoma, gastroesophageal reﬂux, dysphagia, non-cardiac chest pain and others. s

Use of state-of-the art imaging techniques, including high resolution endoscopy with narrow band imaging, confocal laser endomicroscopy and other advanced systems.

A comprehensive Barrett’s program providing all FDA-approved treatments — photodynamic therapy, endoscopic resection, radiofrequency ablation, cryotherapy and surgical resection.

Esophagectomy using conventional and laparoscopic minimally invasive techniques.

NCI-designated comprehensive cancer center with numerous clinical trials evaluating novel tests and treatments for esophageal cancer and other gastrointestinal malignancies.

Refer to Mayo Clinic through Online Services for Referring Physicians and you’ll have the same access to lab results, radiology reports, summary letters, hospital discharges and other patient records that we do. Our secure, HIPAA-compliant, 24/7 Online Services for Referring Physicians is just one of the ways we partner with you for superior patient care. To learn more, call (904) 953-2517 or visit us online at www.mayoclinic.org/medicalprofs.

REFERRING PHYSICIAN OFFICE 4500 San Pablo Road, Jacksonville, FL 32224 904.953.2583 | MCJRPO@mayo.edu

From the Editor’s Desk

Volunteerism: Not a Day at the Beach, But Rewarding Since January, the media has kept us informed of the crisis in Haiti, and while the Haitians have immense medical and social needs, it is a stark reminder of all the underserved populations here and abroad. As physicians we have much to offer, not only with our financial support, but more importantly, with our medical skills. There are multitudes of international, national and local opportunities, emergent and non-emergent, prospects to share the human touch and show compassion on those whose needs are so much greater than our own. Locally, the Sulzbacher Clinic, (www.sulzbacher.org), serves homeless patients downtown Jacksonville and at Jacksonville Beach. Dr Mary Robinson would welcome surgical practitioners to volunteer a few hours a month in a surgical clinic to address wounds and other minor surgical issues. A full list of Primary Care Clinics that serve the underserved is in the DCMS Membership Directory, p.49. Volunteers in Medicine - Jacksonville, (www.vim-jax.org) and We Care Jacksonville, Inc. (www. wecarejacksonville.org) provide free healthcare for the medically underserved and working uninsured. They encourage physician service commitment. (see DCMS Membership Directory, p.48 for complete details) Because Floridians live under the annual threat of hurricanes, we can assist in our own communities and throughout the state. On a state level, one can register to become a Medical Reserve Corps member through www.Servfl.com, the State of Florida’s online system for managing public health and medical disaster responders or call the County Health Department at 904-253-1795. The website provides valuable information for the volunteer to review ahead of time including considering deployment, personal equipment, pre-deployment assessment, and how to take care of yourself while deployed. Due to the austere environment in disaster situations, prior preparation is essential for individual safety. Nationally, we have experienced the horror of 9/11 and Hurricane Katrina. Future terrorist events

Joan L. Huﬀman, MD, FACS and major disasters will challenge us in the years to come, and while all disasters are local, there are Editor-in-Chief times when national response is required to support rescue and recovery eﬀorts. National medical Northeast Florida Medicine and Federal organizations maintain lists of medical volunteers to call upon in time of need. Contact

your own medical specialty society for occasions that can utilize your personal expertise. The following examples address surgical, critical care, medical and pediatric needs: 1. American College of Surgeons, Operation Giving Back http://www.operationgivingback.facs.org/ 2. Society of Critical Care Medicine http://www.sccm.org/Public_Health_and_Policy/Disaster_Resources/ 3. National Disaster Medical System http://www.hhs.gov/aspr/opeo/ndms/join/index.html Overseas, tsunamis and earthquakes, peoples displaced by war, and epidemics cry out for medical response. Non-governmental organizations (NGOs) abound, in the public and private sector. Your church affiliation may provide opportunity, i.e. the Catholic Relief Services, http://www.crs.org/. Look at a broad clearinghouse of international relief agencies at http://www. disastercenter.com/agency.htm. Two excellent resources are Project Hope, www.projecthope.org, and Project Cure, www.projectcure.org. A third group, Partners in Health, www.pih.org, provides healthcare for the poor in 8 countries and the USA. In addition, there is Doctors Without Borders/Medecins Sans Frontieres, http://doctorswithoutborders.org/, which provides worldwide medical response. A Google search of medical relief agencies will reveal many more worthwhile organizations. Of course, it is always wise to try and check the “track record” of these groups with someone who has served with them. I had the life-altering experience of serving in Haiti the second week after “The Event”. (see “Blessures”, p.10 of insert) I hope that you, too, will review your abilities, and see where you can reach out and touch a soul in need, either at home or in another country. Share a day a month with a local clinic to help the homeless, unemployed or uninsured in Jacksonville. Alternatively, kick it up a notch and consider donating a week of your vacation to volunteer. While it will not be a week at the beach and will be physically and emotionally demanding, the rewards will far outweigh the financial and personal efforts you contribute.

“...see where you can reach out and touch a soul in need, either at home or in another country.”

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From the President’s Desk

A Signiﬁcant Year Ahead for Practices and Patients “The health of the people is really the foundation upon which all their happiness and all their powers as a state depend.” Benjamin Disraeli

It is not difficult for you or me to see the significance of the year ahead, for our practices, for organized medicine and most importantly of all, for our patients. Publicly displaying any concern for ourselves (and our practices) is anathema for most physicians because we have had one overriding principle inculcated into our collective psyches from the first day of medical school: the welfare of our patient is always paramount. This credo has guided us through years of delayed gratification and many sleepless nights. But maintaining the best quality of care for our patients and the economic viability of our practices can preclude our ability to commit time and energy to organized medicine. Yet if we don’t protect our practices from inappropriate regulation, how can we expect to have a viable practice in which to care for our patients? In the name of improving the quality of patient care, our federal government is in the throes of ‘reforming’ your practice of medicine to a greater degree than you could have ever imagined, and physicians as a whole have shown varying degrees of interest. We who have studied this evolving process and have seriously considered the drastic changes that it could have on medicine as we know it, are quite interested. But we each know many dozens of colleagues who are ‘too busy’ to get involved except to hear the occasional factoid presented by variously stilted news outlets and then complain bitterly about how organized medicine has let them down.

John W. Kilkenny III, MD 2010 DCMS President

What is ‘organized medicine’? It has a bad connotation for some because they’ve not liked the results that it has been able to achieve or more importantly not achieve in their behalf. How often we have heard our colleagues (and occasionally ourselves) complain about ‘what the DCMS is doing’ on any number of topics that may not mesh with their or our own personal beliefs. This is not unique from that of any other organization and its members; it’s just more pronounced the larger the group and the greater the distance that the members feel from their leadership. Issues are complex, individual preferences are varied and strongly held.

The practice of medicine will never again be ‘the way it was’, but instead of regretting that things are not as they used to be, we need to prevent them from becoming worse. Surely, any group cannot be ‘everything for everyone’ as the old adage goes. But consider the years of divisiveness, lassitude, disinterest and all of the other forces that have separated and divided this great body of individuals known as the American Physician. Yes we have costs for medical care escalating at a precipitous rate, but are we physicians charging our patients more for their care? Not hardly, when we are one of the only professions in the land working under price controls that are ultimately set by the federal government with Medicare reimbursement. Most of us are working harder and longer for decreasing reimbursement. We are described by pundits far and wide as driving up the cost of medical care by ordering all these extra tests to save ourselves from the trial lawyers. But have we seen any evidence of tort reform in the grand package of health care reform that is being foisted upon us? Make no mistake; without opposition, the heady power of political brokering will always trump what we are responsible for, the simple goal of quality patient care. In this historic time of negotiating some sort of health care reform, the power-wielding ‘players at the table’ are those with the largest stacks of bargaining chips: the medical device industry, Big Pharma, the hospital associations and the health insurance industry. Does it not strike you as odd that the actual purveyors of health care, we physicians who use the medical devices, who prescribe the drugs, and who admit the patients to the hospitals, are essentially not being included in the negotiations? Now is not the time for physicians to be passive, peripheral observers of this process. No one else knows the intricacies of what we, our patients and our community need and should have when it comes to the provision of health care. With committed participation, groups can truly be greater than the proverbial sum of their parts. To encourage the support of organized medicine by your peers demonstrates individual leadership. One-on-one discussions with your partners, group discussions at the hospital and specialty society levels; these are the underpinnings of a vibrant organization that will grow and achieve success. I wholeheartedly endorse and will work to further our collaborations with the Northeast Florida Area Medical Association, the Indo-Asian Medical Society, the Philippine Medical Society, private physician groups and those at the Naval Hospital, the University of Florida and the Mayo Clinic and our fellow county and state medical societies in order to foster membership participation and engagement in this multitude of challenges that we face. Let us not forget the critical opportunity that exists with mentoring and advising our younger members, to include the residents in training. Their added years of input and involvement will be invaluable, and they look to you, the experienced members of our professional societies for your wise counsel. Without your individual commitments, membership solicitation can be little more than an extraneous letter or email. The times are so uncertain, and the course required so unchartered, that it will take the collective expertise of all of us to successfully move our profession into the future. (see complete Inaugural Speech at www.dcmsonline.org) www . DCMS online . org

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Did You Know... March is Brain Injury Awareness Month. Each year, 1.4 million people sustain a traumatic brain injury (TBI) in the United States. In Jacksonville, approximately 6,350 people sustain a TBI each year.

With more than 35 years of expertise in treating brain injuries, Brooks offers patients a comprehensive approach for brain injury rehabilitation. •Brooks Rehabilitation Hospital provides a full range of therapies and a highly trained staff, which includes board-certified neuropsychologists. •Brooks offers intensive Day Treatment to ease the transition from acute care to home. •Brooks Outpatient Therapy helps patients continue the progress they’ve made. • The Brooks Center for Rehabilitation Studies conducts clinical research trials on TBI to determine best practices in treatment. • The Brooks Clubhouse helps individuals regain social, physical, cognitive and vocational abilities.

brookshealth.org Rehabilitation Hospital • Home Health Care • Outpatient Therapy • Sub-Acute Care Rehabilitation Research • Community Health Programs

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www.dannagracey.com www . DCMS online . org

Northeast Florida Medicine Vol. 61, No. 1 2010 5

Guest Editorial: Leadership Award Recipient

Lead by Example J. Bracken Burns, DO 2009 Philip H. Gilbert Young Physician Leadership Award Recipient I am honored and humbled at being the 2009 recipient of the Philip H. Gilbert Young Physician Leadership Award. I never had the opportunity to meet Mr. Gilbert, but I hope he would agree that I was worthy of this award that bears his name. Receiving this honor made me look within myself to answer, “What do I know about leadership?” I reflected on some of the physician leaders who have influenced my career since I became a physician, including Dr. Richard Bracken, Dr. Jay Johannigman, Dr. Andrew Kerwin, and Dr. Michael Nussbaum. None of these individuals ever sat me down and said, “This is how you become a leader.” However, all of these physician mentors have taught me about leadership. They all had different styles of leadership and they all showed me in their own way. They did it by their actions and lead by example. Thinking about this further, I realized the primary person who taught me about leadership was my father, J. Bracken Burns Sr. He is a strong man, dedicated to his work and his principles; he is a true leader. Yes, my father is the primary person who taught me about leadership, and he did it all by example. As I was growing up I got to see my father’s leadership in action as Director of Emergency Services for Washington County, Pennsylvania. He loves to teach and got me involved at an early age. In fact for “show and tell” in first grade I taught CPR to my classmates on a stuffed animal. Since he became a County Commissioner he has continued to demonstrate leadership by going beyond the “call of duty” and always looking out for those less fortunate. I remember one time when a concerned citizen called about a missing person who was mentally challenged, my father after notifying the proper authorities, said “let’s go” and we drove around for hours looking until we found this individual. He is my model for leadership and my hero. There are many other ways to learn about leadership. A person interested in leadership can attend lectures, take classes, or read books like Leadership Secrets of Attila the Hun by Wess Roberts. I recently completed a three-part workshop sponsored by the Eastern Association for the Surgery of Trauma (EAST) on leadership development. During this workshop, there were lectures and advice from leaders in the field of Trauma Surgery. This was a very valuable experience, and it supplemented what I already had come to know. As physicians we have an obligation to society to be leaders in health care. We are, and must remain, the leaders in patient care. We must strive to lead by example and teach the next generation of physicians about the honor of our profession. I am thankful that organizations like the Duval County Medical Society provide me a way to be involved in helping the medical profession survive and improve. I hope I am a leader to those around me, and I want to strive to be like my father and mentors; those who lead by example.

J. Bracken Burns, DO, received the 2009 Philip H. Gilbert Young Physician Leadership Award. (see p. 2, insert) This award, created to honor the memory and service of Philip H. Gilbert who served as Executive Vice President of the DCMS from 1984 until his death in 2004, recognizes Young Physicians with leadership traits that Mr. Gilbert would have admired. Candidates must meet the following eligibility criteria: A “Young Physician” from Northeast Florida, under 40 years of age or within the first eight years of professional practice after residency and fellowship training, as defined by the AMA; active in the DCMS or other organized medicine service; active in civic service; medical staff (or similar) leadership experience; and be a strong advocate for medicine.

Pencil sketch by Alexander Braddock

(Left) Dr. Burns with Dr. John Kilkenny III, newly inaugurated DCMS President. (Center) A special pencil sketch of Philip Gilbert. (Right) Dr. Burns receiving his award from Dr. R. Stephen Lucie, now DCMS Immediate-Past President.

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2010 DCMS Annual Meeting Photo Highlights

(L to R) Dr. John Kilkenny III presents the Past President’s plaque to Dr. R. Stephen Lucie; Dr. Kilkenny with Northeast Florida Medicine Guest Editors Dr. Jeﬀ Johns and Dr. Dat Pham; Dr. & Mrs. John W. Kilkenny III; Dr. & Mrs. Malcolm Foster - Dr. Foster is DCMS President-Elect.

(L to R) Mrs. Kilkenny (Elaine) accepts gifts from Mrs. Joan Harmon with the DCMS Alliance; Dr. Stephen Clark with Dr. Kilkenny and Dr. & Mrs. Eli Lerner; FMA President Dr. James B. Dolan, Dr. Kilkenny, Dr. Lucie and Dr. Miguel Machado.

(L to R) Dr. Mary Robinson receives a DCMS Community Service Award from Dr. Lucie; DCMS Life Members Dr. Robert O. Pohl and Dr. Ross T. Krueger with Dr. Lucie; Dr. & Mrs. James Dolan; Dr. John Mazur receives the Clyde M. Collins, MD, Humanitarian Award from Dr. Lucie; Dr. George Trotter giving the traditional “Roll Call”.

(L to R) Dr. Kilkenny, Editor-in-Chief of Northeast Florida Medicine for three years receives a plaque honoring his editorship tenure from Dr. Lucie; Dr. Machado, his daughter, DCMS EVP Jay Millson, and Dr. Ashley Booth Norse; Dr. & Mrs. Kilkenny and guests at their table listen to Dr. Lucie’s opening remarks; Dr. Kilkenny at the podium delivering his inaugural address. (See insert pages 2 and 3 for an article about all the Annual Meeting activities and a list of vendors in the Exhibit Hall)

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This 7th Annual Symposium will again be held at the Marriott Sawgrass Hotel, Ponte Vedra Beach, Florida

PLEASE REGISTER EARLY! Saturday, May 1, 2010 All Sessions Will Be Conducted in The Masters Ballroom Registration and Breakfast Welcome

7:00 AM – 8:15 AM 8:15 AM – 8:30 AM

LIPIDS/PREVENTIVE CARDIOLOGY Introduction of Speakers and Case Presentation Henry Ginsberg, MD Does Treating Diabetic Dyslipidemia Lower Cardiac Risk? Roger Blumenthal, MD, FACC Primary & Secondary Prevention of CVD: ABC Simple as 1, 2, 3 Panel Discussion BREAK

8:30 AM – 8:40 AM 8:40 AM – 9:10 AM 9:10 AM – 9:40 AM 9:40 AM – 10:00 AM 10:00 AM – 10:30 AM

PULMONARY HYPERTENSION/SLEEP APNEA Introduction of Speakers and Case Presentation Barry Rayburn, MD, FACC Pulmonary Hypertension – the Other Hypertension Virend Somers, MD, PhD Cardiovascular Disease and Sleep Apnea – Evidence, Mechanisms and Clinical Implications Panel Discussion LUNCH Chris Granger, MD, FACC STEMI Network DIASTOLIC DYSFUNCTION Introduction of Speakers and Case Presentation William Zoghbi, MD, FACC Diastolic Dysfunction – Central Role of Echocardiography Peter Carson, MD, FACC Heart Failure with Preserved Ejection Fraction: Myth, Controversies, and Fact Panel Discussion BREAK

10:30 AM – 10:40 AM 10:40 AM – 11:10 AM 11:10 AM – 11:40 AM 11:40 AM – 12:00 PM 12:15 PM

1:30 PM – 1:40 PM 1:40 PM – 2:10 PM 2:10 PM – 2:40 PM 2:40 PM – 3:00 PM 3:00 PM – 3:30 PM

VALVULAR DISEASE Blasé Carabello, MD, FAC Hartzell Schaff, MD, FACC

Reception and Dinner Fred Bove, MD, PhD, FACC

Introduction of Speakers and Case Presentation Two Sides of Severe Aortic Stenosis: The Asymptomatic Patient and the Patient with Severe LV Dysfunction The Surgical Challenges of Managing Valve Disease in Patients with Left Ventricular Dysfunction Panel Discussion

3:30 PM – 3:40 PM 3:40 PM – 4:10 PM 4:10 PM – 4:40 PM 4:40 PM – 5:00 PM 5:00 PM – 7:30 PM

Health Care Reform – Impact on Cardiology

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Featuring Clinical Controversies and Case Discussions and also including discussions on: s Cardiovascular Disease Prevention s Pulmonary Hypertension/ Sleep Apnea s Diagnostic Dysfunction s Valvular Disease and Special Dinner Presentation on HealthCare Reform and Its Impact on Cardiology

For more information and to register visit our web site at www.pvcardiacsymposium.com or call 727-512-9864

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This Issue’s Focus: Esophageal Cancer

Esophageal Cancer Treatment Needs Multidisciplinary Approach Esophageal cancer has one of the highest mortality rates among patients with gastrointestinal cancers. Five-year survival is less than 20%, although patients with relatively early, localized disease may be cured. It is estimated that only 30% to 40% of patients initially present with resectable disease, and 3-year survival has ranged between 6% and 37% with surgical therapy alone. Five-year survival has improved from approximately 5% in the 1970s to 15% to 20% at present, which likely indicates improvement in staging, surgical techniques, and postoperative support.1 However, even with a complete R0 resection, locoregional recurrences and metastatic spread are common, indicating a need for better local and systemic control of the malignancy. Once a rare tumor, adenocarcinoma of the esophagus is currently the cancer with the fastest increasing incidence in America, and recent reports indicate that in the United States since 1975, the rate of increase of adenocarcinoma of the esophagus has outpaced the next closest cancer, melanoma, by nearly three times. Gastroesophageal reflux disease (GERD) predisposes to Barrett’s esophagus, a metaplastic change of esophageal epithelium that is a precursor to adenocarcinoma. At this time, early detection (while the tumor is still intramucosal) and complete surgical resection are the beast ways to cure esophageal cancer. Endoscopic surveillance for patients with Barrett’s esophagus and perhaps endoscopic or micro-camera screening of patients with reflux symptoms may be the most useful current strategies. The risks of esophagectomy can be significantly reduced by a variety of factors, which include a large volume hospital, a high-volume surgeon, a surgeon with specialty training, and the daily involvement of critical care specialists. In this journal issue, esophageal cancer is discussed in “Esophageal Carcinoma: Epidemiology and Pathogenesis” by Robert Zaiden, MD; “Esophageal Stenting in Patients with Advanced Esophageal Cancer” by Silvio W. de Melo, Jr., MD and Michael B.Wallace, MD, MPH; “Esophageal Cancer: Neoadjuvant and Adjuvant Therapies by Bradford S. Hoppe, MD and R. Charles Nichols, MD; “The Surgical Management of Esophageal Cancer” by Ziad T. Awad, MD, FACS; “Esophageal Stenting in Patients with Advanced Esophageal Cancer,” by Juan C. Munoz, MD; and “Advanced Imaging and Ablation for the Endoscopic Detection and Treatment of Barrett’s Disease” by Abraham M. Panossian, MD, Lois L. Hemminger, NP-C and Herbert C. Wolfsen, MD. Ziad T. Awad, MD, FRCSI, FACS Assistant Professor of Surgery, University of Florida College of Medicine Jacksonville

The articles show an excellent collaboration from two local academic centers: The University of Florida College of Medicine Jacksonville and Mayo Clinic Jacksonville and cover important aspects in the management of this complex problem while emphasizing the need for a multidisciplinary team approach to achieve optimal results. Reference: Schneider BJ, Urba SG. Preoperative chemoradiation for the treatment of locoregional esophageal cancer: the standard of care? Semin Radiat Oncol. 2007 Jan;17(1):45-52.

Tubular Plant More Aesthetic Than Esophagus The “Golden Shrimp Plant” (aka “Lollipop Plant”) is tubular in shape and could remind one of the esophagus; that muscular tube through which food passes from the pharynx to the stomach. Such a medical analogy was probably not on the mind of photographer Lee-Margaret Borland when she spotted this lovely plant in Balboa Park Gardens in San Diego in 2002. She was intrigued and compelled to take the photograph because “most of the blooms I have seen in Jacksonville are salmon colored and not nearly as compact and tall. This plant is bright yellow and has overall symmetry, shape, height and compactness of the bloom. Note the white ‘shrimp’ on the very top of the bloom.” To view more of Mrs. Borland’s photography, visit www.throughthelensoﬂee-margaret.com.

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Esophageal Carcinoma: Epidemiology and Pathogenesis Robert Zaiden, MD Abstract: Esophageal cancer is a signiﬁcant cause of cancer morbidity and mortality worldwide, with dramatic geographical variation in incidence. In the US there has been a dramatic shift in histology within the past decades, with adenocarcinoma now being more prevalent than squamous histologies. The reasons for this are not clearly understood at this time. Squamous cell carcinoma is still more prevalent worldwide, and typically seen in the upper 2/3 of the esophagus. It is associated with repeated mucosal insults, including tobacco. Adenocarcinoma is more common in the distal esophagus, and more closely associated with obesity and GERD. Current research is looking into tumor suppressor genes and molecular pathways to further elucidate the pathogenesis of this disease.

Background Esophageal cancer (EC) is the 4th most common GI malignancy and 8th most common cancer worldwide, but only about 1% of all cancers and 6% of GI tumors in the U.S. It is the 7th most common cause of cancer-related death in the U.S. (6th worldwide), with males affected 3 times more than females. 1,9,15 There is remarkable geographic and ethnic variability in its incidence with the highest frequency seen in northern China (Hunan Province), Iran, central Asia, Afghanistan, Mongolia and Siberia. The incidence in some of these areas may be 20-30 times higher than the U.S. There is up to a 60-fold difference between low and high prevalence geographic areas such as the ‘Asian belt’. Notably, even within high prevalence areas of the ‘Asian belt’, the incidence of EC appears to be higher in Turkish and/or Mongol ethnicities compared to their counterparts.2 In the U.S., median age at diagnosis is 67, with blacks and males affected more than whites and females. Dysphagia is consistently the most common symptom on presentation. Since >60% of the lumen must be involved by the time there is frank dysphagia, the disease is usually advanced and incurable at presentation. There is significant morbidity due both to its direct effects on quality of life (QOL) and as a result of therapeutic interventions. Overall, when accounting for the rate of death-to-diagnosis, EC mirrors lung cancer at less than 10% overall cure rate. This compares to approximately 80% for breast, prostate and rectal carcinomas.3

AD, especially of the GE junction, where the clinical course mirrors gastric cancer. Recently, the incidence has been rising even in non-whites and women, but there is still a 6:1 ratio compared to non-whites.3 In Hispanics, the prevalence of AD falls in between that of Caucasians and AA. The incidence of SC is higher in African American and lower socio-economic groups, with a 4:1 ratio compared to Caucasians, but this has declined by over 60% since the late 1970s, from 21/100,000 to 7.6/100,000 in 2002. Hispanics have a 48% higher incidence than Caucasians, but AA have a 70% higher incidence than Hispanics.4 Survival rates have also increased, likely reflecting improved diagnosis and treatment modalities. Analysis of SEER data by Brown and Devesa in 2002 showed a 5 year relative survival of 4.6% (SC) and 5.3% (AD) in 1974-1979, compared to 12% (SC) and 13.7% (AD) in 1992-1997. Worldwide, SC continues to predominate, likely reflecting the different causative etiologies.4

Pathogenesis SC and AD are the two most common histologies in the U.S., although other subtypes such as mucoepidermoid, adenosquamous, adenoid cystic, undiﬀerentiated, malignant melanoma, and small cell are also seen with much less frequency. SC is more prevalent in the upper 2/3 thoracic esophagus, and is associated with chronic mucosal injury. AD is usually conﬁned to the lower esophagus, including the GE junction. Repeated irritation or trauma causes damage at the cellular level, promoting a release of cytokines which stimulate cell migration to the site of injury. Pathologic survival advantage may be conferred to one cell clone, either by mutation or growth factors present on healing epithelium resulting in AD.5

In the U.S., there has been a dramatic shift in histology and incidence over the past 50 years. In the 1960s, 90% of EC was Squamous cell (SC); over the past 30 yrs, however, there has been a 350 % increase in adenocarcinoma (AD), and it now represents over 60% of new EC diagnosis. The reason for this shift and increase in incidence is not clearly understood. Caucasian males are the most likely to have

Moderate alcohol consumption has been associated with EC, with hard liquor and whiskey more closely linked than beer and wine. Duration of exposure and to a lesser degree, amount, seems to play a more defined carcinogenic role, with a 10 fold higher incidence of SC compared to minimal or negligible effect for AD. Direct toxic irritation to the epithelium, as well as resultant dietary deficiencies have been suggested, since multiple studies have shown a positive dose-response relationship with alcohol use, and the decline of SC EC has paralleled the reduced consumption of alcohol seen in the early 1980s. A study by Yang et al suggested the carcinogenic effects of acetaldehyde, a main metabolite of alcohol, as the causative factor.6

Address Correspondence to: Robert Zaiden, MD, Division of Hermatology/Oncology, University of Florida - Shands, Jacksonville, 655 W. 8th Street, Pav. 4N, Jacksonville, FL 32209. Phone: (904) 244-1690. Email: Robert.zaiden@jax.uﬂ.edu.

Mutations in aldehyde dehydrogenase and alcohol dehydrogenase are prevalent in eastern Asian populations but are rare in the western hemisphere, correlating with the statistically higher risk seen in multiple studies. The quantity of alcohol consumption confers higher risk than the duration of use.

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Tobacco use is also linked to EC. The NIH-AARP study by Freedman et al showed that current and former smokers accounted for 77% of SC and 58% of AD, compared to those who never smoked.7 The risk for SC declines after 10 years of smoking cessation, whereas this has been estimated at 30 years for AD.8 Smoking and alcohol use are synergistic in their carcinogenic effects, and the duration, more than the quantity contributes to carcinogenesis. Obesity is also associated with EC. BMI levels correlate directly with a higher incidence of AD but inversely with SC. The higher likelihood of Barrett’s esophagus (BE) in overweight patients is thought to contribute to this effect, since other than gastroesophageal reflux disease (GERD), this is the main risk factor in AD. The most common risk factor for BE is the adenomatous metaplasia of normal epithelial lining to a columnar or glandular histology, as seen in chronic GERD. Whereas functional abnormalities in tumor suppressor genes p53 and p16, and loss of heterozygosity at 17p contribute to early tumorigenesis, loss of cell cycle checkpoints are implicated in late transformations.9 Prospective studies estimate that 20-25% of BE eventually becomes adenocarcinoma, and medical therapy of reflux does not significantly alter this transformation.10-12 It is unclear if the higher incidence of GERD in the preceding decades has led to the drastic increase in AD, since an estimated 40% of AD patients do not have recurrent reflux. Interestingly, Edelstein et al showed that central adiposity, more than just BMI correlated with likelihood of BE.13 Visceral fat is more metabolically active than subcutaneous fat, producing more pro-inflammatory cytokines, and this is felt to be another mechanism contributing to increased AD. Why obesity decreases the risk of SC is not completely understood, but micronutrient deficiency is suspect. Additionally, tobacco and alcohol abusers typically have lower BMIs than their counterparts. Fresh fruit and raw vegetable intake correlates with lower incidence of AD and SC subtypes of EC, whereas consumption of pickled, processed or salted foods increase risk of SC, and low fiber, high fat diets probably increase AC. Repeated thermal injury from hot liquids (tea, coffee, soup) is thought to be an etiology of SC, either by direct damage, or facilitation of carcinogen absorption. The data on AC is controversial and multiple large studies in the US, Uruguay, and China have shown conflicting results. A compelling body of evidence has recently suggested that reduced gastric acid production due to Helicobacter pylori colonization lowers the risk of AD, and that the declining incidence of this infection in the recent decade has contributed to the rise of this cancer. Ye et al demonstrated a reduced risk of AD with H pylori infection and suggested that nitrosamine production by this organism also significantly contributed to SC, accounting for the shifting trends in EC.14 Jansson et al measured seropositivity and compared it to rates of SC and AD, finding no change in risk when adjusted for H pylori status.15 Currently, www . DCMS online . org

there is no consensus on this hypothesis and more studies are needed. Other common causes of AD are caustic exposure to lye, esophageal webs (Plummer-Vinson syndrome), congenital hyperkeratosis (Tylosis), chronic achalasia, and radiation exposure.16 While lye-induced caustic damage can increase the risk of SC 1,000X, the prognosis is usually better because of earlier presentation due to already narrowed esophagus, and surrounding cicatrization which limits early metastasis.17 Betel nut (Areca catechu) chewing for stimulant eﬀect, common in Asian and Indian populations has also been linked to SC, as well as to oral and hepatocellular cancers. Arecoline and arecaidine alkaloids in the nut, and safrole in the leaves are thought to promote formation of N-nitroso compounds, and cause poly-ADP-ribosylation of chromosomal proteins, thus altering their structure and function. The carcinogenic eﬀect is especially pronounced when the nut is fermented or combined with chewing tobacco.18,19

Summary While much progress has been made in elucidating the pathogenesis of EC, it is still not completely understood. The shift in histology and incidence seen in the US has not been seen in other countries, reinforcing the eﬀect of social and environmental factors. EC remains a disease with high mortality and no generally acceptable screening or preventative modality exists. As our understanding of molecular pathways improve and data from other studies accumulate, perhaps novel strategies for detection, prevention and treatment will decrease the impact of this disease.

References 1.

Devesa S et al. Changing patterns in incidence of esophageal and gastric carcinoma in the United States. Cancer. 1998;83(10):2049-2053.

Lambert R, et al. Esophageal cancer: causes and causes (part 1). Endoscopy 2007;39:550-555.

Holmes RS, et al. Epidemiology and pathogenesis of esophageal cancer. Semin Radiat Oncol 2007;17:2-9.

Wu X, et al. Incidence of esophageal and gastric cancers among Hispanics, non-Hispanic whites, and non-hispanic blacks in the United States: subsite and histology diﬀerences. Cancer Causes Control. 2007;18:595-593.

Yang SJ, et al. Genetic polymorphisms of ADH2 and ALDH2 association with esophageal cancer risk in southwest China. World J Gastroenterol. 2007;13:5760-5764.

Freedman ND, et al. A prospective study of tobacco, alcohol and the risk of esophageal and gastric cancer subtypes. Am J Epidemiol. 2007;165:1434-1433.

Gammon MD, et al. Tobacco, alcohol and socioeconomic status, and adenocarcinoma of the esophagus and gastric cardia. J Natl Cancer Inst. 1997;89:1277-1284.

Jankowski JA, Wright NA, Meltzer SJ, et al. Molecular evolution of the metaplasia-dysplasia-adenocarcinoma sequence in the esophagus. Am J athol. Apr 1999;154(4):965-73.

Kantarjian HM, Robert A, et al. Carcinoma of the esophagus and gastric carcinoma. In: The MD Anderson Manual of Medical Oncology. Columbus, Ohio, McGraw-Hill; 2006:14:315-348. Northeast Florida Medicine Vol. 61, No. 1 2010 11

10.

Lagergren J, Bergstrom R, Lindgren A, et al. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med. Mar 18 1999;340(11):825-31.

11. Layke JC, Lopez PP. Esophageal cancer: a review and update. American Family Physician 2006; 73 (12): 2187–94. 12. Rastogli A, et al. Incidence of adenocarcinoma in patients with Barrett’s esophagus and high grade dysplasia: a meta-analysis. Gastrointest Endosc. 2008;67:394-398. 13. Ye W, et al. Helicobacter pylori infection and gastric atrophy: risk of adenocarcinoma and squamous cell carcinoma of the esophagus and adenocarcinoma of the gastric cardia. J Natl Cancer Inst. 2004;96:388-396. 14. Jansson C, et al. Socioeconomic factors and risk of esophageal carcinoma: A nationwide Swedish case-control study. Cancer Epidemiol Biomarkers Prev 2005;14:1754-1761. 15.

Blot WJ, McLaughlin JK. The changing epidemiology of esophageal cancer. Semin Oncol. Oct 1999;26(5 Suppl 15):2-8.

16. Cancers of the Gastrointestinal Tract. In: DeVita VT, Hellman S, Rosenberg SA, eds. Cancer:Principles and Practice of Oncology. 8th ed. Philadelphia, PA, Lippincott Williams & Wilkins; 2008:33:1037-42. 17. Kochhar R et al. (2006) Corrosive induced carcinoma of esophagus: report of three patients and review of literature. J Gastroenterol Hepatol 21: 777–780. 18. Peters CJ and Fitzgerald RC (2007) Systematic review:the application of molecular pathogenesis to preventionand treatment of oesophageal adenocarcinoma. Aliment Pharmacol Ther 25: 1253–1269. 19. Nair, J, Nair, UJ, Oshima, H, Bhide, SV & Bartsh, H (1987). Endogenous nitrosation in the oral cavity of chewers while chewing betel quid with or without tobacco, IARC Scientiﬁc Publications 84, 465–469.

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Esophageal Cancer Staging: A Review of Diagnostic Modalities Silvio W. de Melo, Jr., MD and Michael B. Wallace, MD, MPH Editor’s Note: Due to production constraints, Figures 1-7 are not printed in the journal. They are available online at www.dcmsonline.org as web illustrations. Abstract: Esophageal cancer, specifically adenocarcinoma of the esophagus, is increasing in incidence over the past two decades. Several diagnostic modalities are used for its diagnosis and staging. Esophagogastroduodenoscopy (EGD) is the most common method to diagnose esophageal cancer and to obtain tissue confirmation. Endoscopic ultrasound (EUS) has the highest sensitivity for locoregional staging as well as the ability to perform fine-needle aspiration for confirmation of malignant lymph node (LN) involvement. Computed tomography (CT) of the chest and abdomen, and, more specifically, CT with positron emission tomography (PET) has high sensitivity and specificity for distant metastasis and LN involvement. There is no single study that can give the clinician all the staging information, thus, PET-CT of the thorax and abdomen with EUS-FNA should be considered to accurately stage patients with esophageal carcinoma.

Introduction Esophageal cancer is a broad term used for the two most common histological types of esophageal malignancies: squamous cell carcinoma (SCC) and adenocarcinoma (ACE). Squamous cell carcinoma of the esophagus is associated with tobacco and alcohol consumption; whereas adenocarcinoma is associated with chronic gastroesophageal reflux disease, Barrett’s esophagus, and increasing body mass index. It is estimated that in 2009 there will have been approximately 16,470 new cases of esophageal cancer with 14,530 patients losing their lives. Between 1973 and 2002, there has been a 30% decrease in the incidence of SCC of the esophagus, but ACE increased four fold over the same period of time.1 Esophageal cancer remains a highly lethal disease with particularly high prevalence among white males.2 The standard of care for treatment of early invasive cancer is an esophagectomy, often combined with radiochemotherapy for locoregional disease: a procedure with relatively high morbidity and mortality rates. If diagnosed in its very early stages, the patient may benefit from less invasive therapeutic modalities such as radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR), thus accurate staging is critical to treatment planning. The purpose of this article is to discuss the different methods available to stage a patient with esophageal cancer.

Staging Esophageal cancer staging is based on the American Joint Committee for Cancer’s (AJCC) Tumor Lymph Node and Metastasis (TNM) classiﬁcation as shown in Table 1.3 (p. 14) The current staging system for esophageal cancer is largely based on a retrospective series from Japan where most patients had SCC of the upper third and middle third of the Address Correspondence to: Michael B. Wallace, MD, MPH, Director of Endoscopic Research, Mayo Clinic, Jacksonville, 4500 San Pablo Rd., Jacksonville, FL 32224. Email: Wallace. Michael@ mayo.edu. www . DCMS online . org

esophagus.4 The staging system has been widely criticized for calling abdominal LN as M1 disease because patients with the most common cancer in the U.S., adenocarcinoma, do not seem to have such a grave prognosis with abdominal LN as they do with distant organ metastasis.5 Patients with regional and/or celiac axis lymphadenopathy should not necessarily be considered to have unresectable disease caused by metastases, and these lymph nodes are designated M1a to indicate a better prognosis. Complete resection of the primary tumor and appropriate lymphadenectomy should be attempted when possible.2

Early Diagnosis The most important component of treatment and good outcomes in esophageal carcinoma is early diagnosis. Studies are focusing on using different mucosal imaging modalities to detect early changes. Newer generation endoscopes have a much improved image quality and it is called high definition endoscopy (HDE). These instruments also have the ability to apply a filter in the image to enhance the mucosal vascular pattern, called narrow band imaging (NBI) by Olympus, Fuji intelligent chromo endoscopy (FICE) by Fujinon, and iScan by Pentax. Another technique used is called autofluorescence imaging (AFI) which can potentially differentiate tissue types based on their difference in fluorescence emissions. The main problem with AFI is its high false positive rates. A multicenter study combined HDE, NBI, and AFI to investigate the ability to detect early cancer in Barrett’s esophagus.6 AFI increased the sensitivity of HDE from 45% to 90% but had a false positive rate of 81%, which was decreased to 26% with NBI. The combination of HDE, AFI and NBI shows promising results in the ability to detect early esophageal cancer but further studies are necessary before it can be widely available. Endoscopic mucosal resection (EMR) is an endoscopic resection technique where a 1-2cm wide circumference of tissue can be removed down to the deep submucosa. It can be suited for both staging as well as treatment in early esophageal cancer limited to the mucosa.7-9 EMR allows for determination of lymphovascular invasion, a poor prognostic finding.10

Endoscopic Ultrasound

Since its development, endoscopic ultrasound (EUS) has become an important tool in staging of gastrointestinal malignancies.11,12 EUS produces ﬁve echo layers which have important anatomical correlation with the esophageal wall. From the lumen towards the adventitia, there is: a hyperechoic layer (mucosa), hypoechoic layer (muscularis mucosae), hyperechoic layer (submucosa), hypoechoic layer (muscularis propria) and another hyperechoic layer (adventitia in the esophagus and serosa in the remainder of the gastrointestinal tract).11,12 These echo layers with their respective correlation can then be used for the tumor (T) staging in the TNM classiﬁcation. Lymph nodes (LN) metastasis can also be evaluated by EUS. Several echo characteristics have been associated with

Northeast Florida Medicine Vol. 61, No. 1 2010 13

Table 1 TNM Classiﬁcation and Staging for Esophageal Cancer

Tumor (T)

Lymph Node (N)

Metastasis (M)

TX: Primary tumor cannot be assessed

NX: Regional lymph nodes cannot be assessed

MX: Distant metastasis cannot be assessed

T0: No evidence of primary tumor

N0: No regional lymph node metastasis

M0: No distant metastasis

Tis: Carcinoma in situ

N1: Regional lymph node metastasis

M1: Distant metastasis

T1: Tumor invades lamina propria or submucosa

Tumors of the lower thoracic esophagus:

T2: Tumor invades muscularis propria

M1a: Metastasis in celiac lymph nodes

T3: Tumor invades adventitia

M1b: Other distant metastasis

T4: Tumor invades adjacent structures

Tumors of the midthoracic esophagus: M1a: Not applicable M1b: Nonregional lymph nodes and/or other distant metastasis Tumors of the upper thoracic esophagus: M1a: Metastasis in cervical nodes M1b: Other distant metastasis AJCC Stage Groupings

Stage 0 Stage I Stage IIA Stage IIB Stage III

Tis, N0, M0 T1, N0, M0 T2, N0, M0; T3, N0, M0 T1, N1, M0; T2, N1, M0 T3, N1, M0; T4, any N, M0

Stage IV

Any T, any N, M1

Stage IVA Stage IVB

Any T, any N, M1a Any T, any N, M1b

malignant involvement: size greater than 0.5-1 cm, round shape, hypoechogenicity, and sharp borders.13 All four features have a sensitivity of 89% and speciﬁcity of 92% for LN metastasis. The addition of Fine Needle Aspiration (FNA) further increases the sensitivity, speciﬁcity and accuracy for LN metastasis (Figure 1, www.dcmsonline.org).14,15 For staging of esophageal cancer, the radial array echoendoscope (which gives cross-sectional images at 270-360º) and the curvilinear array echoendoscopes, also known as linear echoendoscopes, have similar diagnostic accuracy for T staging 14 Vol. 61, No. 1 2010 Northeast Florida Medicine

and Nodes/Metastic staging, but the linear echoendoscopes have the ability to perform fine-needle aspiration (EUS-FNA) (Figure 2,www.dcmsonline.org).16 Multiple studies showed that EUS remains an important diagnostic tool for locoregional staging of esophageal carcinoma.16-27 A recent meta-analysis reported that the sensitivity and specificity of EUS to diagnose T1 was 81.6% (95% CI: 77.8-84.9) and 99.4% (95% CI: 99.0-99.7), respectively. In T4, EUS had a pooled sensitivity of 92.4% (95% CI: 89.2-95.0) and specificity of 97.4% (95% CI: 96.6-98.0). www . DCMS online . org

With Fine Needle Aspiration (FNA), sensitivity of EUS to diagnose N stage improved from 84.7% (95% CI: 82.9-86.4) to 96.7% (95% CI: 92.4-98.9).28 The use of mini-probe endosonography which has higher frequencies (20-30 MHz) than a standard echoendoscope (5-12 MHz) and can be passed through the working channel of the endoscope, has been evaluated to investigate the ability to differentiate mucosal (stage Tis) versus submucosal infiltration (stage T1). Mini-probe had an accuracy, sensitivity, and specificity to differentiate T1is from T1 tumors of 73.5 %, 62 %, and 76.5 %, respectively. No statistically significant difference was seen between SCC and ACE.7,24 EMR has allowed much more accurate staging of very early cancer and thus is replacing EUS for T-staging in this setting.

Computed Tomography and EUS Because of its ease of access and wide availability, computed tomography (CT) of the chest and abdomen is usually the initial test of choice for staging esophageal carcinoma. It can determine the presence of liver metastasis (Figure 3, www. dcmsonline.org) and, sometimes, identify the presence of esophageal mass/thickening (Figure 4, www.dcmsonline.org) but it is a poor test to interrogate for celiac axis lymphadenopathy.29 EUS is also better than CT for determination of the degree of tumor invasion into the esophageal wall and adjacent structures, i.e. to determine the T staging, and to determine presence of periesophageal lymphadenopathy: the N staging.29-31 EUS is considered the most accurate study for locoregional staging, thus, in hospitals where EUS is easily accessible and of good quality, performing EUS first is considered a cost-effective strategy as it can image the esophagus, liver and celiac axis as well as obtain tissue for pathologic confirmation.32 In recent years, the use of MULTIdetector computed tomography (MDCT) and CT esophagography has been evaluated as one staging study for both distant and locoregional disease. Unfortunately, the accuracy for T and N staging was 43-92% and 86-83%, respectively.33,34 This technique shows promise, but its overall accuracy is still inferior to EUS, and it is not able to perform FNA.

Positron Emission Tomography Positron emission tomography (PET) is a study which measures the amount of update of the radionuclide 18-Ffluoro-deoxy-D-glucose (FDG-PET) into tissues, with specific update into neoplastic and inflammatory areas. After standard CT of the chest and abdomen and EUS, PET can provide additional information about unsuspected advanced disease in about 20-41% (Figure 5 and Figure 6, www.dcmsonline. org).35-38 On the other hand, a prospective cohort study from the Netherlands reported new advanced disease in 15% of patients but, of those, 7.5% were false positives. The investigators raised concern about widespread use of FDG-PET in all patients with esophageal cancer.39 Recently, the PET-CT has been investigated in esophageal cancer staging. This technique combines CT imaging with anatomical localization with metabolic information obtained from the PET (Figure 7,www,dcmsonline.org). PET-CT for regional LN disease has a sensitivity of 46-60%, specificity of 83-99%, accuracy of 71-95%, positive predictive value of 87-94%, negative predictive value of 94-96%.40-44 In addition, www . DCMS online . org

PET-CT is also important to assess recurrence of disease as well as response to chemotherapeutic agents.45-48

New Techniques A study was performed investigating the role of bone scintigraphy in patients with T3N1 ACE and SCC. It showed histologically confirmed metastatic disease in approximately 10%.49 But the use of bone scintigraphy to investigate for bone metastasis in esophageal cancer still is not widely used. Several different MRI techniques have also been investigated to determine T staging and N staging. Two pilot studies showed good correlation with T staging (92%).50,51 Magnetic resonance imagine (MRI) with ferumoxtran-10 was used to differentiate benign from malignant periesophageal lymphadenopathy with sensitivity of 100%, specificity of 95%, and accuracy of 96%.52 But further studies are necessary before we can recommend the use of MRI for T and N staging in esophageal cancer.

Holy Grail: Multimodality Approach Currently, for the accurate staging of esophageal carcinoma there is no single study that can provide both locoregional and distant metastatic information. Therefore, the clinician has to use a combination of tests that are complementary in order to answer this important question. The options are: CT, PET, PET-CT, EUS-FNA, thoracoscopy/laparoscopy.53-56 The choice of which tests to use depends on local expertise and availability of those services. Based on decision model analysis investigating CT, EUS-FNA, PET, thoracoscopy/laparoscopy, and a combination of these, the most cost-eﬀective combination of tests is: PET-CT and EUS-FNA. In places where there is no PET availability or its costs are prohibitive, CT and EUS-FNA should be the next choice.57

Restaging After Chemotherapy and Radiation It had been shown that in a patient with locally advanced disease (T3N1M0), response to treatment as measured by downstaging in T and N status is associated with increased survival.58 Attempting to confidently identify those patients who experience this downstaging, and, therefore, would benefit from surgery, remains a challenge. EUS has been investigated in this setting after chemotherapy and radiation and has an overall accuracy of 60% in terms of T staging. Its principal role is to confirm the presence of N1 disease through FNA. On the other hand, a 50% decrease in tumor thickness is associated with increase survival.59 PET-CT is emerging as a tool in the setting of restaging. It can measure response to therapy by both measuring a decrease in the uptake of the radiotracer, but, more importantly, a decrease in tumor length is associated in increased survival.46,60 In addition, PET-CT can identify suspicious lymph nodes which can be targeted by EUS-FNA. In summary, in the setting of restaging, here also the combination of PET-CT and EUS-FNA is the recommended standard.

Conclusion The incidence of adenocarcinoma in the United States is rising. Early diagnosis, and thus screening of patients at risk, is key. No single study is able to provide all the necessary information to adequately stage the patient. A combination of studies is recommended. The use of PET-CT plus EUSFNA has the highest accuracy to stage the patient aﬀected Northeast Florida Medicine Vol. 61, No. 1 2010 15

with adenocarcinoma or squamous cell carcinoma of the esophagus. The same combination of studies can be used to restage after chemoradiation therapy.

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22. Kutup A, Link BC, Schurr PG, et al. Quality control of endoscopic ultrasound in preoperative staging of esophageal cancer. Endoscopy. 2007;39:715-719. 23. McGrath K, Brody D, Luketich J, Khalid A. Detection of unsuspected left hepatic lobe metastases during EUS staging of cancer of the esophagus and cardia. American Journal of Gastroenterology. 2006;101:1742-1746. 24. Rampado S, Bocus P, Battaglia G, Ruol A, Portale G, Ancona E. Endoscopic ultrasound: accuracy in staging superficial carcinomas of the esophagus. Annals of Thoracic Surgery. 2008;85:251-256. 25. Shimpi RA, George J, Jowell P, Gress FG. Staging of esophageal cancer by EUS: staging accuracy revisited.[see comment]. Gastrointest Endosc. 2007;66:475-482. 26. Sultan J, Robinson S, Hayes N, Griffin SM, Richardson DL, Preston SR. Endoscopic ultrasonography-detected low-volume ascites as a predictor of inoperability for oesophagogastric cancer. British Journal of Surgery. 2008;95:1127-1130. 27. Vazquez-Sequeiros E, Levy MJ, Clain JE, et al. Routine vs. selective EUS-guided FNA approach for preoperative nodal staging of esophageal carcinoma.[see comment]. Gastrointest Endosc. 2006;63:204-211. 28. Puli S-R, Reddy J-B, Bechtold M-L, Antillon D, Ibdah JA, Antillon M-R. Staging accuracy of esophageal cancer by endoscopic ultrasound: a meta-analysis and systematic review. World Journal of Gastroenterology. 2008;14:1479-1490. 29. Romagnuolo J, Scott J, Hawes RH, et al. Helical CT versus EUS with fine needle aspiration for celiac nodal assessment in patients with esophageal cancer. Gastrointest Endosc. 2002;55:648-654. 30. Pech O, May A, Gunter E, Gossner L, Ell C. The impact of endoscopic ultrasound and computed tomography on the TNM staging of early cancer in Barrett’s esophagus. American Journal of Gastroenterology. 2006;101:2223-2229. 31. Blackshaw G, Lewis WG, Hopper AN, et al. Prospective comparison of endosonography, computed tomography, and histopathological stage of junctional oesophagogastric cancer. Clinical Radiology. 2008;63:1092-1098. www . DCMS online . org

32. Hadzijahic N, Wallace MB, Hawes RH, et al. CT or EUS for the initial staging of esophageal cancer? A cost minimization analysis. Gastrointest Endosc. 2000;52:715-720. 33.

Kim SH, Lee JM, Han JK, et al. Three-dimensional MDCT imaging and CT esophagography for evaluation of esophageal tumors: preliminary study. European Radiology. 2006;16:2418-2426.

34. Onbas O, Eroglu A, Kantarci M, et al. Preoperative staging of esophageal carcinoma with multidetector CT and virtual endoscopy. European Journal of Radiology. 2006;57:90-95. 35. Blackstock AW, Farmer MR, Lovato J, et al. A prospective evaluation of the impact of 18-F-ﬂuoro-deoxy-D-glucose positron emission tomography staging on survival for patients with locally advanced esophageal cancer. International Journal of Radiation Oncology, Biology, Physics. 2006;64:455-460. 36. Chatterton BE, Ho Shon I, Baldey A, et al. Positron emission tomography changes management and prognostic stratiﬁcation in patients with oesophageal cancer: results of a multicentre prospective study. European Journal of Nuclear Medicine & Molecular Imaging. 2009;36:354-361. 37. Gananadha S, Hazebroek EJ, Leibman S, et al. The utility of FDG-PET in the preoperative staging of esophageal cancer. Diseases of the Esophagus. 2008;21:389-394. 38. Salahudeen HM, Balan A, Naik K, Mirsadraee S, Scarsbrook AF. Impact of the introduction of integrated PET-CT into the preoperative staging pathway of patients with potentially operable oesophageal carcinoma. Clinical Radiology. 2008; 63:765-773. 39. van Westreenen HL, Westerterp M, Sloof GW, et al. Limited additional value of positron emission tomography in staging oesophageal cancer. British Journal of Surgery. 2007;94:15151520.

47. Rizk N, Downey RJ, Akhurst T, et al. Preoperative 18[F]-ﬂuorodeoxyglucose positron emission tomography standardized uptake values predict survival after esophageal adenocarcinoma resection.[see comment]. Annals of Thoracic Surgery. 2006;81:1076-1081. 48. Roedl JB, Sahani DV, Colen RR, Fischman AJ, Mueller PR, Blake MA. Tumour length measured on PET-CT predicts the most appropriate stage-dependent therapeutic approach in oesophageal cancer. European Radiology. 2008;18:2833-2840. 49. Jennings NA, Griﬃn SM, Lamb PJ, et al. Prospective study of bone scintigraphy as a staging investigation for oesophageal carcinoma. British Journal of Surgery. 2008;95:840-844. 50. Riddell AM, Hillier J, Brown G, et al. Potential of surface-coil MRI for staging of esophageal cancer. AJR. 2006;American Journal of Roentgenology. 187:1280-1287. 51. Yamada I, Izumi Y, Kawano T, et al. Esophageal carcinoma: evaluation with high-resolution three-dimensional constructive interference in steady state MR imaging in vitro. Journal of Magnetic Resonance Imaging. 2006;24:1326-1332. 52. Nishimura H, Tanigawa N, Hiramatsu M, Tatsumi Y, Matsuki M, Narabayashi I. Preoperative esophageal cancer staging: magnetic resonance imaging of lymph node with ferumoxtran10, an ultrasmall superparamagnetic iron oxide. Journal of the American College of Surgeons. 2006;202:604-611. 53. Berrisford RG, Wong W-L, Day D, et al. The decision to operate: role of integrated computed tomography positron emission tomography in staging oesophageal and oesophagogastric junction cancer by the multidisciplinary team. European Journal of Cardio-Thoracic Surgery. 2008;33:1112-1116.

40. Hsu W-H, Hsu P-K, Wang S-J, et al. Positron emission tomography-computed tomography in predicting locoregional invasion in esophageal squamous cell carcinoma. Annals of Thoracic Surgery. 2009;87:1564-1568.

54. Davies AR, Deans DAC, Penman I, et al. The multidisciplinary team meeting improves staging accuracy and treatment selection for gastro-esophageal cancer.[see comment]. Diseases of the Esophagus. 2006;19:496-503.

41. Kato H, Kimura H, Nakajima M, et al. The additional value of integrated PET/CT over PET in initial lymph node staging of esophageal cancer. Oncology Reports. 2008;20:857-862.

55. de Graaf GW, Ayantunde AA, Parsons SL, Duﬀy JP, Welch NT. The role of staging laparoscopy in oesophagogastric cancers. European Journal of Surgical Oncology. 2007;33:988-992.

42. Okada M, Murakami T, Kumano S, et al. Integrated FDGPET/CT compared with intravenous contrast-enhanced CT for evaluation of metastatic regional lymph nodes in patients with resectable early stage esophageal cancer. Annals of Nuclear Medicine. 2009;23:73-80.

56. Pfau PR, Perlman SB, Stanko P, et al. The role and clinical value of EUS in a multimodality esophageal carcinoma staging program with CT and positron emission tomography. Gastrointest Endosc. 2007;65:377-384.

43. Sandha GS, Severin D, Postema E, McEwan A, Stewart K. Is positron emission tomography useful in locoregional staging of esophageal cancer? Results of a multidisciplinary initiative comparing CT, positron emission tomography, and EUS. Gastrointest Endosc. 2008;67:402-409. 44. Schreurs LM, Pultrum BB, Koopmans KP, et al. Better assessment of nodal metastases by PET/CT fusion compared to side-by-side PET/CT in oesophageal cancer. Anticancer Research. 2008;28:1867-1873. 45. Omloo JMT, Sloof GW, Boellaard R, et al. Importance of fluorodeoxyglucose-positron emission tomography (FDG-PET) and endoscopic ultrasonography parameters in predicting survival following surgery for esophageal cancer. Endoscopy. 2008;40:464-471. 46. Port JL, Lee PC, Korst RJ, et al. Positron emission tomographic scanning predicts survival after induction chemotherapy for esophageal carcinoma. Annals of Thoracic Surgery. 2007;84:393-400; discussion 400.

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57. Wallace MB, Nietert PJ, Earle C, et al. An analysis of multiple staging management strategies for carcinoma of the esophagus: computed tomography, endoscopic ultrasound, positron emission tomography, and thoracoscopy/laparoscopy. Ann Thorac Surg. 2002;74:1026-1032. 58. Korst RJ, Kansler AL, Port JL, Lee PC, Kerem Y, Altorki NK. Downstaging of T or N predicts long-term survival after preoperative chemotherapy and radical resection for esophageal carcinoma. Annals of Thoracic Surgery. 2006;82:480-484; discussion 484-485. 59. Ribeiro A, Franceschi D, Parra J, et al. Endoscopic ultrasound restaging after neoadjuvant chemotherapy in esophageal cancer.[see comment]. American Journal of Gastroenterology. 2006;101:1216-1221. 60. Roedl JB, Harisinghani MG, Colen RR, et al. Assessment of treatment response and recurrence in esophageal carcinoma based on tumor length and standardized uptake value on positron emission tomography-computed tomography.[see comment]. Annals of Thoracic Surgery. 2008;86:1131-1138. Northeast Florida Medicine Vol. 61, No. 1 2010 17

Esophageal Cancer: Neoadjuvant and Adjuvant Therapies Bradford S. Hoppe, MD and R. Charles Nichols, MD Editor’s Note: Due to production constraints, Figure 1 is not printed in the journal. It is available online at www. dcmsonline.org as a web illustration.

Neoadjuvant/Preoperative Radiation Therapy

Abstract: Esophageal cancer is a lethal disease with poor survival rates. Definitive surgery was traditionally the treatment of choice, with definitive radiation being reserved for patients with medically inoperable or metastatic disease. Unfortunately, high rates of local-regional and distant relapses after either surgery alone or radiation alone required advancements in treating this malignancy. Over the last 25 years, studies have shown that radiation and chemotherapy can improve the control rates and, subsequently, survival rates of patients with resectable esophageal cancer. In patients with medically inoperable esophageal cancer, adding chemotherapy to radiotherapy appears to further improve outcomes. Although the magnitude of the clinical benefit is currently small, novel chemotherapy regimens and more sophisticated radiotherapy equipment, such as proton therapy, should improve the therapeutic ratio and survival outcomes. This article reviews the progress made with neoadjuvant and adjuvant therapy in esophageal cancer.

The earliest form of adjuvant therapy in esophageal cancer was radiation therapy. In the 1970s and 1980s, several randomized studies explored its use in the preoperative setting by comparing preoperative radiotherapy with surgery alone.13-16 For the most part, these studies did not show a significant survival advantage to preoperative radiation therapy. Overall, these studies suffered by delivering lackluster radiation doses (20-40 Gy) and using poor radiation techniques, but they did show a pathologic complete response in 8% to 28% of the patients. Additionally, a recent meta-analysis comparing surgery alone to preoperative radiotherapy recognized a modest improvement with an absolute survival benefit of 3% at 2 years and 4% at 5 years with preoperative radiotherapy (p=0.062).17 Preoperative radiotherapy alone is no longer used, but combined with chemotherapy it has been found to be a potent tool and will be discussed later in this review.

Introduction

Adjuvant/Postoperative Radiation Therapy

Esophageal cancer is a lethal diagnosis with 5-year survival rates for localized, regional, and distant disease of 30%, 15%, and <5%, respectively.1 In patients with non-metastatic disease who are medically fit, surgery has played the predominant role in managing both squamous cell carcinoma and adenocarcinoma. In patients who are older and/or medically unfit, definitive treatment was traditionally radiotherapy. Due to the poor survival rates and the pattern of failure in patients treated with either surgery alone or radiotherapy alone, an opportunity exists to improve disease-control rates and thus improve overall-survival rates through the use of additional neoadjuvant and/or adjuvant therapy.

Postoperative radiotherapy has typically been reserved for patients with gross residual disease or microscopic residual disease following esophagectomy. However, a few randomized studies have investigated the role of postoperative radiotherapy in more detail.18-20 Teniere et al. randomized 221 patients with esophageal cancer to either no further treatment or to 45-55 Gy of postoperative radiotherapy.19 Although the study showed improvements in local-regional recurrences (85% vs 70%, with an insigniﬁcant p value), adding postoperative radiotherapy did not improve overall survival. A study by Fok et al. from Hong Kong evaluated 130 patients, including 60 patients who had undergone a curative resection and 70 patients who had undergone a palliative resection. Patients were randomized to 2 groups: no further treatment or postoperative radiotherapy (49-52.5 Gy).18 Although there were fewer intrathoracic recurrences in the postradiotherapy group, the likelihood of a local recurrence improved with radiotherapy only in those patients who had undergone a palliative operation. Considering these ﬁndings in addition to the 5 treatment-related deaths observed in the postoperative radiotherapy arm that resulted from gastric ulceration and bleeding, the study concluded a limited role for postoperative radiotherapy, restricting it to patients with residual tumor.

Resectable Disease Esophagectomy has conventionally been the treatment of choice for patients with non-metastatic esophageal cancer who are medically fit. Esophagectomy alone is sufficient for Stage I disease; however, with more advanced stages, it has been associated with survival rates between 5% and 35%.2-10 These poor survival rates with esophageal cancer can be attributed, in part, to the high perioperative morbidity of an esophagectomy, but mostly results from the high rates of local-regional relapses (40-60%) and/or distant relapses (50-70%).4,7,9,11,12 Due to this pattern of failure in surgical patients, a role exists for neoadjuvant and adjuvant therapies, such as radiotherapy and chemotherapy, to improve outcomes. Some clinicians are concerned, however, that these neoadjuvant therapies could be toxic and compromise the delivery of the definitive part of the treatment, namely surgery, and possibly further increase the risk of perioperative death. Address Correspondence to: Bradford S. Hoppe, MD, 2015 N. Jefferson Street, Jacksonville, FL 32206. Phone: (904) 588-1800. Email: bhoppe@floridaproton.org.

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The third study by Xiao et al. randomized 549 patients to either surgery alone or surgery followed by radiotherapy and found improvements in intrathoracic recurrences in all patients as well as an overall survival beneﬁt in those patients with lymph-node involvement at the time of surgery.20 Although some of these studies suggest a role for adjuvant radiotherapy, the increased toxicities of delivering radiotherapy postoperatively have lead to an interest in delivering the radiotherapy before surgery (preferably combined with chemotherapy).

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Neoadjuvant Chemotherapy Studies Early phase II studies have shown promising outcomes using preoperative radiotherapy or chemotherapy. These studies inspired a randomized comparison of chemotherapy versus preoperative radiotherapy in esophageal cancer at Memorial Sloan Kettering Cancer Center.21 Kelsen et al. included 96 patients who received either 2 cycles of cisplatin, vindesine, and bleomycin or 55 Gy of radiation therapy before undergoing a resection. They showed similar objective response rates (radiotherapy, 64% vs chemotherapy, 75%) at the time of surgery. Since operability rates, resection rates, and operative mortality were similar between the 2 groups, they concluded that chemotherapy was the preferred preoperative treatment approach. Chemotherapy was as effective in controlling local disease and had the theoretical advantage of impacting systemic recurrences. As a result of the earlier study, Intergroup 0113 set out to directly compare preoperative chemotherapy to surgery alone.7 In this study, 440 patients were randomized to either 3 cycles of cisplatin and fluorouracil followed by surgery and then followed by 2 additional cycles of chemotherapy, or to surgery alone. The outcomes of the study showed no benefit to preoperative chemotherapy with median survival rates of 14.9 months in the chemotherapy arm and 16.1 months in the surgery-alone arm. This was in contrast to the Medical Research Council Oesophageal Cancer Working Group’s finding of a median survival benefit of 3.5 months with this same drug regimen.22 Following the Intergroup study, many institutions abandoned preoperative chemotherapy alone for esophageal cancer. A recent report of the UK MAGIC (Medical Research Council Adjuvant Gastric Infusional Chemotherapy) trial, however, has re-sparked interest in this approach at some institutions.6 The MAGIC trial was limited to adenocarcinomas, but included stomach, esophagogastric junction, and lower esophagus tumors. The study randomized 503 patients to either 3 cycles of ECF epirubicin, cisplatin, and fluorouracil (ECF) followed by surgery and then followed by 3 more cycles of ECF, or to surgery alone. The 5-year survival rates were significantly better with ECF (36% vs 23%) as were progression-free survival rates. Additionally, no difference was seen regarding postoperative complications or acute surgical deaths within 30 days. The results of this study have lead to preoperative and adjuvant chemotherapy as the standard of care at many institutions.

Neoadjuvant Chemoradiation Following the poor outcomes observed with preoperative chemotherapy in the Intergroup 0113 trial, subsequent studies took another approach and explored the role of preoperative chemotherapy combined with radiotherapy before resection. Several phase III studies and 2 meta-analyses have explored preoperative chemoradiation compared with surgery alone to evaluate the possible increase in perioperative mortality as well as long-term disease control and overall survival.

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Walsh et al10 randomized 113 patients to either 2 cycles of fluorouracil and cisplatin with concurrent radiotherapy (40 Gy in 15 fractions) followed by surgery or to surgery alone. Median survival for the preoperative chemoradiation groups was 16 months (p=0.01) compared with 11 months for the surgery-alone group. Additionally, 25% of the patients who received chemoradiation had a pathologic complete response (CR) at the time of surgery. Unfortunately, this study had an extremely low 3-year survival rate in the surgery-alone arm (6%), which has been criticized as the reason why the preoperative chemoradiation arm was significantly better. Another study, performed at the University of Michigan, randomized 100 patients to either surgery alone or preoperative chemotherapy using cisplatin, fluorouracil, and vinblastine in combination with radiation therapy (45 Gy delivered at 1.5 Gy twice daily over 21 days).9 The study’s main end point was overall survival, and although preoperative chemoradiation was associated with a better 3-year survival (30% vs 16%) this was not significant (p=0.15) due to an inadequate sample size. In this study, patients who received neoadjuvant therapy had a 28% pathologic CR rate, which was also associated with improvements in 3-year survival (64% vs 19%). Additionally, the site of first failure was more likely to be local-regional if the patient did not receive neoadjuvant therapy (p=0.02). A larger study from Australia randomized 356 patients to surgery alone or to chemotherapy (cisplatin and fluorouracil) with concurrent radiotherapy (35 Gy in 15 fractions).3 The study’s primary end point was progression-free survival, which was improved by adding preoperative therapy (16 months vs 12 months), although this was not statistically significant. Overall survival was also improved in the preoperative chemoradiation groups (median overall survival, 22.2 months vs 19.3 months), which was also not statistically significant. Subgroup analysis looking at patients with only squamous cell carcinoma showed a small, significant benefit to neoadjuvant therapy. Pathologic CR was recorded in 16 patients (16%) and was more common with squamous cell histologies (10/37) than with adenocarcinoma (6/66). Those patients with a pathologic CR had a median progression-free survival of 26.2 months and 3-year survival rates of 49%. This study has been criticized for its negative results, due to an inadequate sample size as well as inadequate radiation doses, which may have contributed to the lower pathologic CR compared to other studies. Most recently, results were reported from the CALGB 9781 study, which randomized patients to either esophagectomy alone or to neoadjuvant cisplatin and fluorouracil with concurrent radiation (50.4 Gy in 1.8 Gy per fraction) followed by surgery.12 Although, the study failed to meet its targeted accrual of 475 patients by enrolling only 56 patients, it did show an improvement in median survival of 4.5 years for preoperative chemoradiation compared with 1.8 years for surgery alone (p=0.002), and an improvement in progressionfree survival (3.5 years compared with 1 year for surgery alone). Five-year survival and progression-free survival rates were 39% and 28% compared with 16% and 15%, respectively.

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Also, pathologic CR was seen in 40% (10/25) of the patients getting neoadjuvant therapy. Since the randomized studies evaluating preoperative neoadjuvant chemoradiation compared with surgery alone did not show clear-cut benefits supporting neoadjuvant therapies, 2 meta-analyses have been performed to strengthen the argument.23,24 Urschel et al24 evaluated 9 randomized control studies that, in total, included over 1,000 patients and showed improvements in 3-year overall survival with an odds ratio (OR) of 0.66 (range, 0.47-0.92; p=0.016), local-regional recurrence with an OR of 0.38 (range, 0.23-0.63; p=0.0002), and distant recurrence with an OR of 0.88 (range, 0.55-1.41; p=0.6) as well as a pathological CR of 21%. This study revealed higher rates of operative morality, 1.72 (range, 0.96-3.07; p=0.07), associated with neoadjuvant chemoradiation, but this was not statistically significant. The second, more recent, meta-analysis by Gebski et al23 looked at both neoadjuvant chemoradiation as well as neoadjuvant chemotherapy compared with surgery alone. This study showed that, compared with surgery alone, which corresponded to a 13% absolute difference in survival at 2 years, there was an improvement in all-cause mortality with neoadjuvant chemoradiation with a hazard ratio of 0.81 (range, 0.7-0.93; p=0.002). This data was similar for both squamous cell carcinoma and adenocarcinoma. In those studies, a survival benefit was observed when analyzing patients treated with only neoadjuvant chemotherapy; however, the benefit was less noteworthy than that found with neoadjuvant chemoradiation. The 2-year absolute survival benefit was only 7% with neoadjuvant chemotherapy; it was not significant for squamous cell carcinoma, but was significant for adenocarcinoma. These studies support the role of neoadjuvant therapy, specifically a combined approach with concurrent chemotherapy and radiation therapy for both overall and progression-free survival benefits. As radiation therapy techniques improve and more potent chemotherapy regimens are recognized, survival rates should increase due to better disease control and less morbidity from the treatment. Specifically, using more advanced radiation techniques, such as 3-dimensional (3-D) conformal radiation therapy, intensity-modulated radiation (IMRT), and proton therapy, we are better able to localize the radiation dose within the tumor and better spare the heart and lung.25-27 Studies have shown that the amount of normal lung that is irradiated to 5-15 Gy can significantly increase the risk of radiation pneumonitis.28,29 However, proton therapy (Figure 1, www. dcmsonline.org), when compared to either 3-D conformal radiotherapy or IMRT, has been shown to reduce the amount of lung exposed to doses between 5 and 20 Gy, thereby decreasing the risk of radiation pneumonitis.27 In fact, the University of Florida Proton Therapy Institutes in Jacksonville, is one of the few proton therapy facilities in the country for the treatment of cancer that is currently investigating the use of proton therapy for esophageal cancer.

Adjuvant Chemoradiation Adjuvant chemoradiation has not been evaluated in great depth; however, Intergroup 0116 did evaluate postoperative 20 Vol. 61, No. 1 2010 Northeast Florida Medicine

chemoradiation for gastric cancer, which included approximately 20% of patients with GE junction tumors.30 This study randomized 556 patients to either definitive surgery or surgery followed by 1 cycle of fluorouracil with leucovorin followed by concurrent radiation therapy (45 Gy in 1.8 Gy fractions) and reduced-dose flourouracil and leucovorin. In this study, those patients who received adjuvant chemoradiation had significantly better local control and overall survival, supporting the role of adjuvant therapy in gastric cancer and GE junction tumors.

Conclusions in Surgically Resectable Patients Stage I patients have good survival and local control rates with modern surgical procedures and, therefore, as per the National Cancer Center Network (NCCN) guidelines, do not require adjuvant therapy.31 Unfortunately, the majority of patients are diagnosed with more advanced disease, Stage II-IVa, and beneﬁt from neoadjuvant chemotherapy and neoadjuvant chemoradiation with improvements in overall survival and local control compared with surgery alone. Due to the ﬁndings of the randomized trials discussed earlier, the NCCN guidelines recommend using either neoadjuvant chemotherapy or chemoradiation prior to surgery in operable patients with Stage II-IVa esophageal cancer.

Unresectable Esophageal Cancer Many patients diagnosed with esophageal cancer are unable to undergo an esophagectomy because of comorbid medical conditions (such as chronic obstructive pulmonary disease, heart failure, etc), age, or advanced disease that cannot be completely excised safely. In these patients, radiation therapy has tradiationally played the role of definitive therapy; however, outcomes have generally been poor with 5-year overall survival rates between 0% and 10%.32,33 Due to these poor survival rates and because of the high incidence of local and distant failures, adjuvant therapies have been explored in this setting too. Chemotherapy has been integrated into this regimen to act as a radiosensitizer and improve the curability of this often fatal cancer. One of the most important studies evaluating definitive therapy with concurrent chemoradiation is the Radiation Therapy Oncology Group (RTOG) 8501 trial, which randomized 123 patients to either radiation alone (64 Gy in 2 Gy per fraction) or concurrent chemoradiation (50 Gy in 2 Gy per fraction) with cisplatin and fluorouracil.32,33 Long-term results from this study revealed improvements in overall survival of 26% in the concurrent chemoradiation arm compared with 0% in the radiation-alone arm. An additional 50 patients were not randomized and allocated to the chemoradiation arm, but their 5-year overall survival was 14%. No difference was observed in outcomes between squamous cell carcinoma and adenocarcinoma. The conclusions from this study were that chemoradiation was the new standard of care in medically inoperable or unresectable esophageal cancer. Researchers have attempted to improve the treatment regimen outlined in RTOG 8501. A follow-up study was performed by Intergroup 0123, which looked at radiation-dose escalation www . DCMS online . org

with concurrent chemotherapy.34 In this study, patients were randomized between cisplatin and ﬂuorouracil with either 50.4 Gy of radiation or 64.8 Gy of radiation. Unfortunately, this study was closed early because of excessive toxicity and treatment-related deaths found in the high-dose radiation arm. On closer inspection, each excess death occurred during the patient’s radiation treatment, usually at dose levels below 50.4 Gy. Therefore, the question regarding the appropriate radiation dose in these patients is still unsettled. Due to similar outcomes between the chemoradiation studies and the surgical literature, some have suggested that surgery could be unnecessary even in the surgical candidates. Two studies have recently explored this question, randomizing patients to either chemoradiation followed by surgery or followed by further chemoradiation.35,36 These studies have not found a diﬀerence in survival rates between the 2 randomized groups, but have shown improvements in local control and progression-free survival when these patients undergo surgery instead of additional chemoradiation. Furthermore, those who received surgery also appeared to have fewer esophageal strictures and thus fewer esophageal dilatation procedures.

Conclusions in Unresectable Patients Researchers have found that patients with unresectable esophageal cancers, either because of extensive disease components or because of comorbid medical conditions, beneﬁt dramatically from the addition of chemotherapy to radiation. This approach is supported by the NCCN guidelines for patients with unresectable esophageal cancer, whether it is squamous cell carcinoma or adenocarcinoma.

Summary Although patients with esophageal cancer have typically had a poor prognosis, adjuvant therapies appear to improve outcomes. In surgically resectable patients, neoadjuvant chemotherapy and radiotherapy have been shown to improve progression-free survival and overall survival rates compared to surgery alone. In medically inoperable patients, concurrent chemotherapy with radiotherapy improves overall survival compared with radiotherapy alone. New therapies, including novel chemotherapy agents and regimens and modern radiotherapy techniques, such as 3D conformal, intensity modulated radiotherapy, and proton therapy, hold promise and are currently under investigation.

References 1.

Jemal A, Siegel R, Ward E et al. Cancer statistics, 2009. CA Cancer J Clin. 2009;59:225-249.

Altorki N, Kent M, Ferrara C et al. Three-ﬁeld lymph node dissection for squamous cell and adenocarcinoma of the esophagus. Ann Surg. 2002;236:177-183.

Bosset JF, Gignoux M, Triboulet JP et al. Chemoradiotherapy followed by surgery compared with surgery alone in squamous cell cancer of the esophagus. N Engl J Med. 1997;337:161-167.

Burmeister BH, Smithers BM, Gebski V et al. Surgery alone versus chemoradiotherapy followed by surgery for resectable cancer of the oesophagus: a randomised controlled phase III trial. Lancet Oncol. 2005;6:659-668.

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Chang AC, Ji H, Birkmeyer NJ et al. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg. 2008;85:424-429.

Cunningham D, Allum WH, Stenning SP et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355:11-20.

Kelsen DP, Ginsberg R, Pajak T et al. Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. N Engl J Med. 1998;339:1979-1984.

Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy: clinical experience and reﬁnements. Ann Surg. 1999;230:392-400.

Urba SG, Orringer MB, Turrisi A et al. Randomized trial of preoperative chemoradiation versus surgery alone in patients with locoregional esophageal carcinoma. J Clin Oncol. 2001;19:305-313.

10. Walsh TN, Noonan N, Hollywood D et al. A comparison of multimodal therapy and surgery for esophageal adenocarcinoma. N Engl J Med. 1996;335:509-510. 11. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma: I. A critical review of surgery. Br J Surg. 1980;67:381-390. 12. Tepper J, Krasna MJ, Niedzwiecki D et al. Phase III trial of trimodality therapy with cisplatin, ﬂuorouracil, radiotherapy, and surgery compared with surgery alone for esophageal cancer: CALGB 9781. J Clin Oncol. 2008;26:1086-1092. 13. Arnott SJ, Duncan W, Kerr GR et al. Low dose preoperative radiotherapy for carcinoma of the oesophagus: Results of a randomized clinical trial. Radiother Oncol. 1992;24:108-113. 14. Gignoux M, Roussel A, Paillot B et al. The value of preoperative radiotherapy in esophageal cancer: Results of a study by the EORTC. Recent Results Cancer Res. 1988;110:1-13. 15. Launois B, Delarue D, Campion JP et al. Preoperative radiotherapy for carcinoma of the esophagus. Surg Gynecol Obstet. 1981;153:690-692. 16. Wang M, Gu XZ, Yin WB et al. Randomized clinical trial on the combination of preoperative irradiation and surgery in the treatment of esophageal carcinoma: Report on 206 patients. Int J Radiat Oncol Biol Phys. 1989;16:325-327. 17. Arnott SJ, Duncan W, Gignoux M et al. Preoperative radiotherapy for esophageal carcinoma. Cochrane Database Syst Rev 2005;CD001799. 18. Fok M, Sham JS, Choy D et al. Postoperative radiotherapy for carcinoma of the esophagus: a prospective, randomized controlled study. Surgery. 1993;113:138-147. 19. Teniere P, Hay JM, Fingerhut A et al. Postoperative radiation therapy does not increase survival after curative resection for squamous cell carcinoma of the middle and lower esophagus as shown by a multicenter controlled trial. French University Association for Surgical Research. Surg Gynecol Obstet. 1991;173:123-130. 20. Xiao ZF, Yang ZY, Miao YJ et al. Inﬂuence of number of metastatic lymph nodes on survival of curative resected thoracic esophageal cancer patients and value of radiotherapy: report of 549 cases. Int J Radiat Oncol Biol Phys. 2005;62:82-90. 21. Kelsen DP, Minsky B, Smith M et al. Preoperative therapy for esophageal cancer: a randomized comparison of chemotherapy versus radiation therapy. J Clin Oncol. 1990;8:1352-1361.

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The Surgical Management of Esophageal Cancer Ziad T. Awad, MD, FRCSI, FACS Abstract: Surgical resection remains the main treatment modality in eradicating cancer of the esophagus. Unfortunately, patient morbidity is high because of the extensive nature of the surgery, which traditionally involves opening the chest and abdomen. To decrease the perioperative morbidity associated with esophagectomy, minimally invasive esophagectomy (MIE) is used in select groups of patients. In MIE, body cavities are accessed using a camera and ﬁne, narrow instruments inserted through small incisions. Experience with abdominal surgery over the past decade suggests that a number of operative variables are improved using minimally invasive procedures, such as blood loss, rate of perioperative complications, and length of hospital stay. Data also suggests that the minimally invasive approach is comparable to or more advantageous than open procedures, in terms of both short and long term outcomes. Similarly, based on the limited data available today, short term outcomes after MIE are at least comparable with outcomes associated with open procedures. Minimally invasive resection of the esophagus for the management of esophageal cancer is feasible and safe. Whether MIE is better than traditional open techniques remains to be determined.

Introduction In the United States, esophageal cancer comprises 5% of gastrointestinal cancers; adenocarcinoma is the most common histological subtype. The prognosis remains unsatisfactory despite signiﬁcant advances in surgical techniques and perioperative management, with a 5-year survival rate of 14%.1,2 Surgical resection is the primary curative therapy for patients with resectable esophageal cancer. There are, however, several controversies in the optimal management of esophageal cancer, including the surgical approach, extent of resection, and the role of multimodality treatment.3 Optimal surgical treatment strategies include appropriate patient selection, accurate staging, risk assessment, selection of an appropriate surgical approach and the use of multimodality treatment in the management of these patients. The objective of this article is to discuss the various surgical approaches available for esophagectomy.

Risk Assessment The patient’s physiologic status should be thoroughly evaluated to make an assessment of the risks of esophagectomy. This evaluation should include an assessment of the patient’s performance status, cardiovascular function, pulmonary function, and nutritional status. Pulmonary complications, particularly pneumonia, are an important determinant of early postoperative outcome (4). In a study of preoperative risk assessment by Ferguson and colleagues (5), pulmonary complications were associated with more than a fourfold increase in mortality. Multivariate analysis showed that age Address Correspondence to: Ziad T. Awad, MD, FRCSI,FACS, Assistant Professor of Surgery, Director of Minimally Invasive Surgery, University of Florida College of Medicine Jacksonville, 638 W. 8th Street, 3rd FL Faculty Clinic, Jacksonville, FL 32209. Phone: (904) 244-3971. Fax: (904) 244-3870. Email: ziad.awad@jax.uﬂ.edu.

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and decreased forced expiratory volume in 1 second (FEV1) were predictive of pulmonary complications. These authors developed a scoring system based on this retrospective analysis, incorporating age, spirometry, and performance status to predict the likelihood of cardiovascular and pulmonary complications (5). Nutritional management of esophageal cancer patients is uniquely challenging. Patients with esophageal cancer are faced with the double threat of a catabolic state induced by the malignancy and the potential for dysphagia caused by an obstructing tumor. Evidence clearly indicates that malnourished patients that undergo major operations are predisposed to infectious complications and poor outcomes (6,7). Supplementation via the enteral route is preferred to the parenteral route but requires tube feeding placement. Endoscopically placed silicone stents have also shown promise as a mean of to alleviate malnutrition and avoid invasive feeding tubes. The risk assessment should be individualized, taking into consideration a complete assessment of the patient’s physiologic status by the surgeon, and treatment should be individualized according to the risks.

Anesthetic Management Continuous intra-arterial blood pressure monitoring is performed because cardiac displacement during the mediastinal dissection may cause hypotension.Two large-bore intravenous catheters should be placed in case rapid volume replacement is needed. An epidural catheter is routinely placed and improves postoperative pain control, leading to improvements in pulmonary function.8 A standard endotracheal tube is used and can be advanced into the distal trachea or left bronchus if a tear occurs in the membranous trachea. In cases in which the patient has a history of prior esophageal surgery, upper or middle-third tumors, or if thoracotomy is planned, a double-lumen endotracheal tube is required. During the mediastinal dissection, close cooperation and communication between the surgeon and anesthesiologist are required to minimize hypotension.

Surgical Approaches The three most common techniques for esophagectomy are the transhiatal approach, the Ivor Lewis esophagectomy or transthoracic esophagectomy (right thoracotomy and laparotomy), and the McKeown technique (right thoracotomy followed by laparotomy and neck incision with cervical anastomosis).9 Transhiatal esophagectomy (THE) was popularized by Orringer at the University of Michigan. This approach avoids thoracotomy and involves a cervical esophagogastric anastomosis with the purported advantage of pain reduction, subsequently minimizing respiratory complications.10 Intraoperative complications associated with THE include pneumothorax, hemorrhage, and tracheal tear. Early Northeast Florida Medicine Vol. 61, No. 1 2010 23

complications that occur within 10 days include hoarseness or difficulty swallowing due to recurrent laryngeal nerve injury, disruption of the anastomosis, gastric tip necrosis, arrhythmias, chylothorax, and sympathetic pleural effusion. An inadequate gastric drainage procedure, narrowing of the hiatus, or tumor recurrence can also lead to delayed gastric emptying. Late complications are relatively uncommon and include diaphragmatic hernia and cervical anastomotic stricture. In some series, the cervical anastomosis has decreased morbidity and mortality if anastomotic leak occurs.11 Recently, authors have questioned the belief that anastomotic leak in the chest has a higher mortality if adequate drainage is achieved.12 The Ivor-Lewis approach allows esophageal mobilization and lymphadenectomy under direct vision with an intrathoracic anastomosis. Disadvantages include increased incisional pain with potentially greater respiratory complications and greater potential morbidity from an intrathoracic anastomotic leak.13 There have been several small, underpowered randomized trials comparing transhiatal esophagectomy with standard transthoracic esophagectomy, but none have shown important differences between the two approaches.13,14 In a meta-analysis by Hulscher et al., the 5-year survival was approximately 20% after both transthoracic and transhiatal resection, though transthoracic resection was associated with significantly higher early morbidity and mortality.15 In contrast, Hagen et al. demonstrated significantly better survival (41 vs. 14%; p < 0.001) in 30 patients who underwent en bloc esophagectomy compared with 39 patients who underwent transhiatal esophagectomy.16 They claimed the superiority of extended en bloc esophagectomy over transhiatal resection for carcinoma of the lower esophagus and cardia. There have been three randomized clinical trials comparing transthoracic with transhiatal esophagectomy.17-19 All of these randomized clinical trials failed to detect any significant differences in patient survival between the two procedures. The randomized study by Hulscher et al. compared 106 patients who underwent transhiatal esophagectomy and 114 who underwent transthoracic esophagectomy for adenocarcinoma of the esophagus and cardia.19 Transhiatal esophagectomy was associated with lower morbidity than transthoracic esophagectomy with extended en bloc lymphadenectomy. Although median overall, disease-free, and quality-adjusted survival did not differ statistically between the groups, there was a trend toward improved long-term survival at 5 years with the extended transthoracic approach. Using the Surveillance, Epidemiology, and End Results–Medicare linked database (1992 to 2002), Change et al. identified 868 patients (225 underwent transhiatal and 643 received transthoracic esophagectomy).20 Lower operative mortality rate was observed after a transhiatal than transthoracic approach (6.7% versus 13.1%, p = 0.009). Observed 5-year survival was higher for patients undergoing transhiatal rather than transthoracic esophagectomy (30.5% versus 22.7%, p = 0.02). After adjusting for differences in tumor 24 Vol. 61, No. 1 2010 Northeast Florida Medicine

stage, patient, and provider factors, this survival advantage was no longer statistically significant (adjusted hazard ratio for mortality, 0.95, 95% confidence interval: 0.75 to 1.20). Patients undergoing transhiatal esophagectomy were more likely to require endoscopic dilatation within 6 months of surgery (43.1% versus 34.5% for transthoracic operations, p = 0.02). Other controversies include the extent of lymph node dissection. Proponents of extended three-field lymph node dissection point out the low recurrence rates and the benefits of accurate staging. Nishihara et al conducted a randomized trial of 62 patients comparing two-field lymphadenectomy (thoracic and abdominal) with three fields, including cervical and superior mediastinal lymphadenectomy.21 Complications were significantly increased in the extended lymphadenectomy group, including a 53% tracheostomy rate and 13% incidence of phrenic nerve palsy, although a trend towards better survival was noted on long-term follow-up. Three field lymph node dissection is primarily practiced in Japan and in very few selected centers in the West.22,23

Minimally Invasive Esophagectomy Although laparoscopic surgery for benign esophageal disease has met with widespread acceptance, this has not been the case for esophageal cancer. However, minimally invasive esophagectomy (MIE) surgery offers several potential benefits for these patients. Open esophagectomy is associated with a significant morbidity and mortality, even in experienced centers.24 Two of the more frequent complications following esophagectomy are pneumonia and pulmonary failure. These complications are associated with significant mortality. Indeed patients who develop pneumonia following esophagectomy face up to a 20% risk of death.25 The avoidance of laparotomy and thoracotomy incisions may very well impact on the incidence of these complications. Techniques have now been developed for both a complete transhiatal laparoscopic and a combined thoracoscopic/laparoscopic esophagectomy. The former approach simplifies patient positioning and does not require single-lung ventilation. It is associated with significant disadvantages; mainly, the working space through the hiatus allows only limited access to the middle and upper third of the esophagus, the inherent dangers of dissection near the pulmonary vessels high in the mediastinum, and the inability to perform thoracic lymphadenectomy with this approach. This author has applied minimally invasive techniques in a selective way based on pathology and patient anatomy. Thoracoscopic mobilization of the thoracic esophagus, laparoscopic gastric mobilization and conduit construction, and cervical esophagogastrostomy is the author’s preferred approach. Alternatively, if the anastomosis is planned in the thoracic cavity, laparoscopic portion is completed first, followed by intrathoracic anastomosis. Although early in our experience, MIE was only offered to patients with Barrett’s disease and early-stage tumors, it is now offered to patients www . DCMS online . org

Dr. Kilkenny Inaugurated 123rd DCMS President and Awards Presented During 2010 Annual Meeting John W. Kilkenny III, MD, was inaugurated as the 123rd president of the Duval County Medical Society (DCMS) at its 157th Annual Meeting, Thursday, January 21, 2010 at the Jacksonville Municipal Stadium Touchdown Club West. His wife, Elaine, administered the Oath of Office. (see below) Dr. Kilkenny is an Attending Surgeon in General Surgery for the University of Florida (UF) & Shands in Jacksonville, FL. He is an Associate Professor in the Department of Surgery at UF College of Medicine and a General Surgeon at UF & Shands. From 2007-2009 Dr. Kilkenny served as Editor-inChief of Northeast Florida Medicine. Dr. Kilkenny was inaugurated before 150+ DCMS members and guests attending the Annual Meeting. During his inaugural remarks, Dr. Kilkenny emphasized there is a significant year ahead for practices and patients. (see p.3, “From the President’s Desk”) A tribute was given to members deceased during 2009, DCMS and FMA Past Presidents were recognized, and annual elections took place during the meeting. Malcolm T. Foster, Jr., MD, is the DCMS president-elect. Other 2010 officers are: Ashley Booth Norse, MD, vice president; Neel G. Karnani, MD, vice president; Anne H. Waldron, MD, vice president; Jeffrey H. Wachholz, MD, secretary; Eli N. Lerner, MD, treasurer; and R. Stephen Lucie, MD, immediate past president. The entire 2009 DCMS Board of Directors was recognized. Dr. Lucie expressed appreciation to his family, colleagues and the DCMS staff for their support during his year as president. He commented “Health Care reform didn’t happen on my watch,” yet he emphasized representation and input from DCMS, FMA and AMA will be needed in the future to impact this major issue and others. He thanked the Platinum Sponsor of the Annual Meeting – First Professionals Insurance Company (FPIC) and he expressed appreciation for Gold Sponsors – Associated Medical Office Experts, Baptist Health, Blue Cross Blue Shield of Florida, Signet Diagnostic Imaging Services, SunTrust Bank, and the University of Florida College of Medicine, Jacksonville, as well as all Silver and Exhibitor Sponsors. James B. Dolan, MD, Florida Medical Association president, gave an “FMA Report”, emphasizing ongoing developments in national health care reform, a “landmark year” for FMA in the Florida Legislature, the need for Haiti relief donations and volunteer service and announcing 20,268 FMA membership. Benjamin Moore, MD, DCMS Foundation president, also addressed the group and gave an update on the Foundation’s project to encourage middle and high school students in Duval County to choose careers in medicine. Joan Harmon, DCMS 2 Vol. 61, No. 1 2010

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Alliance Treasurer made remarks about 2010 Alliance projects and presented Mrs. Elaine Kilkenny with a gift. DCMS Annual Awards were given and special recognitions were also made. (see p. 7 for “Annual Meeting Photo Highlights”) J. Bracken Burns, DO, received the 2009 Philip H. Gilbert Young Physician Leadership Award created to honor the memory and service of Philip H. Gilbert, Executive Vice President of the DCMS from 1984 until his death in 2004. (see p. 6 for Dr. Burns’ Guest Editorial) John Mazur, MD, received the 2009 Clyde M. Collins Humanitarian Award for annually leading a team of physicians and residents to deliver free orthopedic care in Haiti. Dr. Mazur took a moment to report that after the Haiti earthquake, the three hospitals he has volunteered at are still standing. He is putting together teams to go and help the injured. This award was created in 1997 in memory of Dr. Clyde Collins to recognize volunteer efforts by physicians. Stanton Longenecker, MD, and Mary Robinson, MD, received the 2009 DCMS Community Service Award. Dr. Longenecker has volunteered his service for We Care Jacksonville and been on its Board for 10 years. Dr. Robinson serves as the Medical Director for the I.M. Sulzbacher’s Health Centers (see p.27 for her CME article on health care access for the homeless). This award was established by the Duval County Medical Society in 1998 to recognize outstanding volunteer efforts of DCMS Physicians performed in the community. DCMS Life Members (those who have been members 35 years) recognized were William W. Buckingham, Jr., MD; William L. Carriere, MD; Earl H. Eye, Jr., MD; R. Donald Garrison, MD; David P. Johnston, Jr., MD; Stephen G. Lazoff, MD; Frank G. Long, MD; George L. Mayer, MD; Alan B. Miller, MD; Robert O. Pohl, MD; and C. Davis Whelchel, III, MD. Guest Editors for 2009 issues of Northeast Florida Medicine were presented with commemorative plaques by Editor-inChief Dr. John Kilkenny, III. The editors were Dr. Dat Pham, Dr. Connie Haan, Dr. Jeff Johns and Dr. Michael Sands. In addition, Dr. Kilkenny was presented with a plaque honoring his three years as Editor-inChief of Northeast Florida Medicine. (see photo to right) George Trotter, MD, gave the traditional Roll Call for the Business Session of the meeting. Dressed in 1880s attire, he called the name of “Francis P. Wellford, MD” as a way to honor this important DCMS Past President who died in 1887 after treating those afflicted with Yellow Fever. There was a full Exhibit Hall area featuring vendors displaying their products and services and seventeen Poster Presentations were made by DCMS members and resident physicians. Insert

2010 DCMS Annual Meeting Exhibit Hall a Success At the 2010 DCMS Annual Meeting, January 21, 2010, there was a full Exhibit Hall area featuring vendors displaying their products and services. (see exhibitor list, below) In addition, there were 17 Poster Presentations. Below are some photos from the Exhibit Hall.

Platinum Sponsor

Exhibitor Sponsors

FPIC

Akerman Senterﬁtt Baptist Home Health Care/Baptist Infusion Therapy Everest University Florida Doctor Magazine Heartland Rehabilitation Svcs. Heritage Publishing, Inc. Jacksonville Jaguars Jacksonville Mobile Imaging Svc. Jacksonville Sports Medicine Program Judi Garwood, LUTCH/Maureen Kirschhofer, CLU, ChFC JW Custom Homes, Inc. Memorial Family Practice Assoc. LLC dba Memorial Family Medicine New York Life Northeast Florida Medicine Journal Nova SE University PA Program-JAX Prudential Financial Svcs. Ray Howard & Associates Reynolds, Smith & Hills, Inc. The Bittinger Law Firm U.S. Army Healthcare We Care Jacksonville, Inc. Wekiva Springs Center

Gold Sponsors Associated Medical Oﬃce Experts, LLC Baptist Health Blue Cross Blue Shield of Florida Signet Diagnostic Imaging Services SunTrust Bank Unviersity of Florida College of Medicine/Jacksonville

Silver Sponsors Brooks Rehabilitation Clinet Corporation Community Hospice of NE Florida Haven Hospice MetLife mPay Gateway OptaComp Pﬁzer, Inc. Professional Medical Insurance Svcs. SeaCrest Healthcare Management SunCrest Home Health Warner Chilcott Pharmaceuticals

(L to R, above) General Exhibit Hall, Group representing Signet Diagnostic Imaging Services, General Exhibit Hall. (L to R, below) Poster presentation prepared by Navy physicians, poster presentation prepared by Shands, Registration area.

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Special Section - Haiti Relief Efforts Editor’s Note: After the devastating 7.0 earthquake hit Haiti on January 12, 2010, DCMS physicians were quick to respond to the medical needs of the Haitian people. Some went to the crippled island nation to bring healing and others remained in the U.S. to gather needed supplies and financial assistance for the relief effort. Along with a responsive nation, DCMS members showed compassion for a hurting people and a desire to give of Ameria’s bounty to an impoverished third world country. The relief efforts detailed in these pages are only a few of the many that DCMS members and the entire First Coast medical community have been participating in since the first rumble of that deadly quake. Dr. John Mazur organized medical teams through the CRUDEM Foundation. Jacksonville Orthopedic Institute, Raven Transport, Baptist Health and Solantic, as well as Florida Orthopaedic Society and DCMS, coordinated the contribution of used orthopedic equipment as a part of “Operation Walk Haiti”. St. Vincent’s Healthcare formed relief medical teams. Some early responders were Dr. John F. Lovejoy, Jr., MD, a DCMS Past President, and the medical group he assembled, as well as Dr. Joan Huffman, the journal’s Editor-in-Chief and a team she went with to Haiti. Their experiences and some photos are featured in the following pages. The journal welcomes information about other teams who have gone to Haiti and additional collections that have benefited the Haitian people. Send details to Leora Legacy, managing editor at llegacy@dcmsonline.org.

“The clinic had been turned into a triage area and all three ORs were running” Haiti Response Journal John F. Lovejoy, Jr., MD/DCMS Past President TEAM: John F Lovejoy, Jr., MD, ORS Team Leader Jacksonville; John F Lovejoy, III, MD, ORS Children’s Medical Center, Washington DC; Edward Fink, MD ORS Children’s Medical Center, Washington DC; Pat Balanky, RN, OR Nurse Jacksonville Florida; Kim O’Brien, PA, Children’s Medical Center, Washington DC; and Stephanie Gano, RN, Children’s Medical Center, Washington, DC.

Tuesday, January 12, 2010 Haiti suffers a 7.0 Richter earthquake. The center is near the capital of Port-au-Prince (PAP) and all the major structures are damaged; the Presidential Palace, the docks, the cathedral and most of the homes. Literally thousands of people are buried under the debris. We called Crudem Foundation and the Hospital Sacred Heart in Milot, Haiti. It received a 4.9 quake and only sustained minor damage and no loss of life. We put out the word that our hospital is functioning and could handle some of the trauma patients. It is a 73-bed hospital with two operating rooms and has its own power and water supply and is now run by Haitians. It has the best lab in the country and is supplied by multiple visiting subspecialty teams who come on a regular basis. To respond to this emergency, the staff cleared the soccer field for helicopters to land on, opened an annex in the school across the street, set up a dorm for visiting medical teams and turned their infant feeding station into a cafeteria. Since most of the hospitals in PAP were destroyed, the word got out and they started air evacuating the patients to the hospital.

Wed.-Sat., January 13-16, 2010 Meanwhile, at home, we were struggling with forming a response team. Pat and I volunteered and my son, John III called and said he, another orthopedic surgeon, a PA and a nurse – all from the Children’s National Hospital in Washington, DC were volunteering. Now we had to find a flight. The government told us no NCO were being transported by the military and the airlines were either booked or not flying. Carol Fipp (daughter of Dr. George Fipp) finally found Insert

transportation. We then began assembling the team. The group from DC arrived Saturday night. Suppies were needed and St. Vincent’s, Memorial, and Baptist got us the essentials in half a day and Jacksonville Emergency rescue provided backpacks and fanny packs full of equipment. The team rallied at my house. A ﬁlm crew came to record our trip for a documentary and Channel 12 did a story. We ate, packed, and lightened our load. We were allowed 1000 lbs and had 960 in body weight. Needless to say, we were down to our bare essentials; toiletry and underwear! We ﬁnally hit the sack about 11 p.m. It was a restless night trying to think of things we might need that we had forgotten.

Sunday, January 17, 2010 We left Jacksonville at 4:15 a.m. to drive to Orlando and waited to board the plane; a Pilatus PC12, made in Switzerland and donated by Andy Laskmann from Jackson Hole, Wy., who is also the pilot. We took off at 8 a.m. and flew to Ft Lauderdale to fuel and head south. We would be some of the “first responders” going down to help. We arrived on a sunny day in Haiti and were met by a missionary coordinator who helped expedite our clearance and transportation to the Hospital Sacred Heart in Milot. About the time we were arriving, a helicopter flew over and we raced to the soccer field to meet it. Several severely injured patients were transferred to the hospital. We went to the residency, got scrubs and went to work. The clinic had been turned into a triage area and the ORs were all three running. Our orthopedic equipment was scattered in the depot at the hospital and residency. We started pulling trays and organizing them. Went to the depot and found several containers of equipment from the last trip and searched until I found my fluro machine. By the end of the day we had found most of our gear. Some of the crew had difficulty with the level of care we could perform with the equipment we had on hand, but we worked through it. By dinner time we had done two cases and were partly organized. After dinner we met and assigned the cases and went back to pull the instruments for the cases today. By 9 p.m. we were all exhausted after being up about 19 hours. Northeast Florida Medicine

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“We became a Mash Unit today.” Monday, January 18, 2010

Thursday, January 21, 2010

Someone set their alarm to 5:30 a.m., so all of us woke up and heard the roosters crowing. Breakfast was a little bleak with grapefruit and toast. We then went to surgery and started our cases. We did 16 cases and ﬁnished at 11:30 pm, very exhausted but expecting a full day tomorrow.

I was up early and tried to get organized. We had a meeting and discussed patients that we will be treating. It is now eight days out and almost all the wounds are infected. There is little chance of limb salvage, so we need to go ahead with deﬁnitive treatment unless there is a good chance of salvage. We also discussed the transition from team to team. The new orthopedists, David Vittetie and Mathew Dewall are great. They came in and pulled their own instruments and did the cases with little need of assistance. Pat has worked her heart out and is physically exhausted but continues to keep us all with equipment to do the cases. Imagine having just one sterilizer, a prep room the size of a bathroom, equipment loose in a storage closet, reusing wraps, looking for equipment but still able to run four rooms and keep seven orthopedists and as many general surgeons happy---what a woman!

Tuesday, January 19, 2010 Up at 7 a.m. to shower and have breakfast – then off to surgery. There was some confusion in the OR, but we managed to get started. We had sent a desperate message to our U.S. contacts to get equipment. It arrived this afternoon. We received 25 patients by noon and did a dozen cases. I got everyone off to lunch and then a helicopter brought in a load of kids that were badly injured. (One of our team said, “We became a Mash Unit today”). I could not contain myself and just cried. I set up a triage at the school and our gear arrived. Thank God! Stephanie met the helicopter and appealed to the pilot for equipment and gave him a list. The next load they brought much needed equipment to continue to operate. We rearranged the hospital so the incoming patients go to the school, triage, and over to the hospital for x-ray and surgery, recovery and back to the school. The school has two sides and a back with a large paved yard between. It is perfect for triage on one side and post op on the other. We managed to do 24 cases today. At 8:30 p.m. I said that was enough for the day because the staff was stressed and the team so worn out that they were getting short and could begin to make errors. We have not lost anyone yet and have a remarkable anesthetist, Rick. He is able to run three rooms at once, do spinals, drop gas, conscious sedation and not get ruffled. I cannot say enough about our team. They are all doing their jobs and never complaining. They are wonderful!

Wednesday, January 20, 2010 I woke up this morning thinking someone was really snoring and shaking the house, but it was another quake, a 6.9. After the quake and breakfast, we went over to the hospital to get the day started. Got two rooms going and then reorganized the triage area and opened another OR to do minor surgery, such as debridment and minor amputations. We managed to get some of the major cases done and I did an ORIF of a tibia and an amputation after dinner that started out as a debridment, but the bone was dead and we had to convert to a BK. We did l8 major cases and another two teams arrived with lots of equipment. We were overjoyed. At 6 p.m. we had a meeting and tried to fill in the new arrivals about all the problems. The meeting was great and all has been a wonderful cooperative effort. I can’t express how unselfish and giving everyone is on the team. They are all wonderful people.

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The people of Milot have been wonderful. They have been putting people up in their homes and the other day I was walking by a lady making a large pot of stew, and I mean LARGE. I found out she was making it and giving to those who were hungry. It’s 2:30 p.m. and I just got to lunch and am taking a sanity break. This morning after getting the cases started, we made rounds on all the surgical patients, changing dressings, scheduling wash out for open wounds, and evaluating others for surgery. Other teams arrived, orthopedists, general surgeons, anesthetists and nurses. We are pretty well organized and put them to work. Now we have someone to organize equipment and relieve those who are worn out. Our triage was not getting the patients to surgery, so we changed the system so they would go to triage, x-ray, be seen by an orthopedist again with their x-rays and then a decision would be made whether they go to surgery immediately or to holding. Then I began to organize the depot so we could find things. But I heard they were evacuating up to 100 more patients today so I had to stop this project because two or three helicopters were landing. We managed to get 29 cases done and finished by 10:30 p.m. I think I finally have the system down. I converted the clinic into a mash unit; two rows of beds and cots, eight cots and six beds. That way we can evaluate the patients in triage and send them to x-ray or the mash unit and those in x-ray get seen and those needing surgery go to the mash unit. We have those preped for surgery ready in the room next to the OR. It is working! Everyone is trying to work in the system, and I am proud of them. We now have nine orthopedists and everyone is great.

Friday, January 22, 2010 It was a short nights rest, but thankfully no tremors. After going to Mass, began organizing 8 a.m. and then a the trip to the Citadel and beach for those who had been working day and night for a week. It was like herding cats; first getting the docs and staff together and then arranging the transportation. In the process, they could not find the keys to the vehicle. After that I went to hospital where my son, John, was rocking and rolling with all the new surgeons that had Insert

“It has been an incredible father/son experience.” come in. He got twenty cases done in the morning. I was running around putting out fires, finding equipment, evaluating patients and keeping ahead of the schedule. I watched the helicopters bring in more patients. We had multiple helicopters land, sometimes three at a time. At about 1p.m. I noted that the OR staff was decompensating and could not handle it. There were over 20 cases. I stopped surgery for an hour and told everyone to take a 30-minute rest in shifts. I got the nicest smile, and they took a box and propped up their feet. I waited for my son to return to take over the board and begin surgery at 2 p.m. Then I went to lunch and back to the cast room, but an emergency case developed. A boy had fallen off a roof and broken both wrists and had a head contusion. He was in a lot of pain. We did a hematoma block. When the block set, the patient calmed down and we reduced both radial epiphysis fractures. He was so happy, but we kept him overnight to observe him because of soft tissue swelling in his head. The crew that went to the Citadel and beach came back relaxed and had a great time, so I put them back to work. We did about as many cases in the evening, but not as severe. We did 39 cases today and it is 11:45 p.m. and time to call it a day. All the staff and visiting teams are fatigued. They are tired in body but strong in spirit. My son, John, has done a wonderful job. It makes me proud as a parent. It has been an incredible father/son experience, I respect his judgment and he mine. We may differ in opinion, but we work it out amicably. We have laughed and cried together and shared an experience that few fathers and sons ever get.

Saturday, January 23, 2010 It is 6 a.m. and the rooster is crowing. I had to get up to get my team oﬀ. It sure will not be the same without them. I thought, “It is going to be a long day,” and it was. A lot of old trauma patients came in and one new patient arrived who had been hit by a car and had a head injury. I was running the operating rooms and when I got there someone had moved the x-rays and we had to begin searching to get the cases started. On top of it, we had two C-sections, so we lost one room. We managed to get the other rooms started and the cast room. By lunch we had done 12 cases and we did 13 in the afternoon. The boy hit by a car was on a respirator and the only way to keep him going was by hand ventilation or an anesthesia machine. (Special thanks to Phillips that donated monitors at 30g a copy and ventilators, about a dozen of each and sent two techs to install them. What a gift. It has made everyone’s job easier) We arranged to transfer the boy to the USS Comfort ship, and they sent a helicopter. We now have about 50 volunteers, have received about 300 patients and done over 160 surgeries. It is a bit staggering considering that we have been here about a week. We went back to get the pre-ops ready for tomorrow and ﬁnally headed home about 11 p.m. I hope my son and those returning to the states with him got home safely.

Sunday, January 24, 2010 I got to sleep until 6:30 a.m. and really needed it. There seem to be less roosters crowing in the a.m. Could it be because we are eating a lot of chicken? Just a thought. I headed to the OR and they were Insert

getting the cases started. I really feel good about the system we set up. It allows patients to be there the night before and ready to go in the morning. What I did is set up a pre-op area in the old clinic in the front of the hospital and numbered the spaces, and then drew a picture on exam paper and taped it to the wall. I made a similar one next to the posting board and a list below. When the patients come in, they are put in a slot, their name is put on the board and a slip added on the schedule. The visuals help because of the difficulty communicating in another language. It took several reminders to change the staff’s way of doing things, but it works. We use the walkie talkies to talk to the other areas and find patients and send them to the OR. By the end of the day it was running pretty smoothly, and we were able to post the cases for tomorrow. I also got to do my last case. There was a little old lady in pre-op that had a broken hip and no one felt comfortable doing the surgery. Since I was running board, I walked by her all day. Each time she lifted her finger and beckoned me. By today, the fourth for her on the stretcher, I was so moved that I insisted on doing the case over some resistance from others. Jeff and I did a open Richards screw;Posterior lateral approach, removed the hematoma, drilled the femur, placed the side plate, reduced, placed guide wire, removed side plate and put compression screw on side plate, reapplied and screwed the plate to the femur and screwed the compression screw into the head. Looked good and was stable on range of motion and done in 1 ½ hours with no x-ray. I really felt good about it. (Jeff Keen, a senior resident in the UF Shands program gave up his vacation to come and has been a valuable team member. He pitches in everywhere and does any surgery assigned to him and he asks for help when he needs it - which is not very often) We got to lunch early between cases, and we were talking when a helicopter came in needing help to unload patients. We ran over, it landed and they signaled us to come. In the Navy chopper I spotted a infant in the crew’s arms and pointed that I wanted it. The little baby girl was passed if off to me and I took her to a nurse anesthetist, Marty, who got in the front seat of the ambulance, and I passed her the child. The little one was listless and her eyes were rolling back. After surgery ,I checked on her and she was better hydrated and stable. The story I got was that she was just found in the rubble. One cannot conclude a journal such as this without thanking the staff at Sacred Heart Hospital, volunteer medical teams, those who served as interpreters, medical equipment and supply companies, U.S. hospitals and groups who donated money and supplies and, of course, my wife, son and daughter. So many put their lives on hold to help Haiti, but without them this effort would not have been a success. So just what was accomplished in one week? We accepted over 300-400 patients, took around 180 cases to surgery, collected many donations (the value is hard to calculate) and all felt good about being able to participate. Of course, our bodies are fatigued, but our spirits are high and unshakeable, knowing that we have given our best effort to make a difference in others’ lives. All of that helps to ease the anguish of the tragic situation and demanding but rewarding experience. Northeast Florida Medicine

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“...an aftershock...the people yelled, ‘shake, shake, shake’...ran to our one-room clinic.” Haiti Journal Bobi Wall, NP (Team member with Dr. Joan Huffman & others) I found out Saturday, January 16 that I had been approved to go with a team of thirteen others to help with Haiti earthquake relief. I just had two days to pack and prepare for this unique and challenging experience. The others on the team were: an anthropologist from New York, an LSW, an MPH, two security people from Wisconsin, one PA from Colorado and another from Jacksonville, a first year resident from Brown University, one trauma surgeon from UF Shands, (better known to journal readers as Dr. Joan Huffman, Editor-in-Chief ) one trauma psychologist, two nurses and me, the NP. Some of our team had been to Haiti before and had worked at clinics there. Some were new to the whole experience, like me. We worked on arranging medical supplies through Project Blessing before we drove on Tuesday, January 19 to Miami for a chartered flight to Haiti. One week after the earthquake, we were on a flight headed to Haiti to provide much needed relief assistance. Flying in we could not see much due to dust clouds. As we landed, the airport scene was overwhelming. Military helicopters were everywhere. There were tents erected Iran, Mexico, and France and many Brazilian planes. We passed through the airport building and I noticed water all over the floor as well as cracks and sagging ceilings. As we approached the other side of the building, hundreds of faces lined the perimeter of the fence. All of those people were shouting to get the job of helping arriving relief workers with their bags. Pallets of supplies lined the runway, and we lost our 10 boxes of medical supplies in the disorder. All we had left were the supplies we each brought, our surgical instruments and a saw for amputations. We took a van to the clinic at Hospice St. Joseph. At first I thought the destruction seemed mild, but as we left the airport area I saw the destruction was rampant. When we got to St. Joseph’s, the courtyard where we were to set up and clinic and work was too small and it was filled with trees and a cracked cement slab. The clinic location had to change. We also changed our sleeping accommodations from an apartment floor to inflatable mats outside on the ground. There were too many aftershocks, so a clear space on the ground was safer. The first day of clinic, we found some bags of meds. One PA stayed at the courtyard and set up a clinic while one surgical group went out in the surrounding area looking for those needing medical care. We had acquired 12 volunteers for first responders and translators at St. Joseph’s from the pool of their workers who all lost their homes. Many also lost family. I was a part of the second team (an intern, a nurse, and some volunteers). We hiked about a mile. We found people who had numerous infected wounds and fractures. Someone had done a lot of these people a disservice and sutured the wounds closed. Much of my day was spent cutting sutures, debriding, cleaning and redressing wounds. There were lots of infected scalp wounds. I mobilized a volunteer to cut bamboo and make me some splints for fractures. We wrapped them with ace bandages, had canes made

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out of bamboo and sent the people on their way with ibuprofen. We did not send anyone away without giving them some medicine. We had to decrease the frequency of administration as our supplies were limited at this point. I also utilized the psychologist after I saw some folks who had great need of him. The temperature was in the 90’s to 100 during the heat of the day. At one point an aftershock occurred and the people yelled,”shake, shake, shake” and ran into our one-room clinic. The people waiting to see us were endless. We saw over 200 at this clinic that day. One of the most frustrating parts was the flies crowding the wounds as we tried to treat them. At 3 p.m. we wrapped up our clinic, packed our supplies, and set off to return to Hospice St. Joseph. The route was uphill and considerably dusty through tent cities. I wore a mask and Vicks to filter the dust as well as the odor of decay. As I climbed I began to wheeze considerably. Taking off the mask did not help. Finally I was given a chair at one of the tent camps and I sat and wheezed while the intern ran to try to retrieve an inhaler. At one point I thought I might be left here until after sunset to try to walk again. Unfortunately, we had no inhalers, which as the days went on, was an absolute essential for a lot of the children. The van made it part way, and I was able to scramble to its safety after a brief rest. We rethought day two as the surgical team did not see as many people. Dr. Huffman did amputate two fingers from a lady, using only local anesthetic. We combined the two teams and headed en masse to our original site. Now we had two tent coverings. This freed us up to concentrate more in each of our own areas and to consult quickly with one another. We started to see more children with headaches and dehydration. We had rehydration packs for children and children’s Tylenol. Both days clinic was cut short as we ran out of our own water supply. It was hard to keep track of our supplies and the water kept disappearing. The team members started to get chills, weakness and headaches. We all avoided diarrhea by taking 1 Cipro 500mg every day. We also took a daily acidophilus and malranone to prevent malaria. I got some intense mosquito bites sleeping in the open at night. We did have coils and clip on fans with repellent which helped but did not eliminate mosquitoes. And the end of the second day of clinic we got a ride back to the hospice. When we arrived, we were welcomed with a Haitian meal of pasta and Creole sauce, cole slaw with vinegar dressing, plantains, tomatoes, and lettuce. Most people were eating now, and we paid them to help their economy, to cook for us. Yes we ate right along with them. They cleaned their vegetables with potable water and two drops of Clorox which is a standard for them. This night turned out to be more troubling than most. We were blessed with a couple nite lites because of a revived generator which made sleep easier. The team all slept on the cement slab of ground and the Haitian volunteers also on the ground on the other side of the cement steps. Our dog, a resident mutt, chased rats away at night and the cat chased bugs. The next day was full and we were very tired. The clinic changed to another site. We passed a much worse hit area of the city just continued on page 10

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“I am not ready or able to process all that happened to me in Haiti.” continued from page 8

beyond a soccer field and another massive tent city into a gated courtyard run by the sisters of Mother Theresa’s group. Stench of death was much stronger in this area. En route to this area we passed a canal with minimal water filled with rubbish which would serve as a reservoir for multiple diseases when the rains came. Large numbers of children and families came to the clinic. Today’s complaints, in addition to the ubiquitous wounds, were cough, fever, and stomach aches. Many people had not eaten in days. They had water but not much. Dust was everywhere. A lot of people also complained they were unable to sleep. Every day there were aftershocks. We had to be more creative in dealing with these complaints. Babies were listless. We started multiple IVs. On one patient we could not get an IV started so I did the old hypodermaclysis. I also saw a younger lady that had lost continence, so I referred her to Dr. Huffman and the lady was transported to the MASH hospital. Today we began to feel more overwhelmed. The needs were so immense just for the basics of food and water. If we had those they would relieve some of the headaches and stomach aches. We also needed masks to filter dust. I am beginning to feel like I cannot make a difference. Saturday evening, January 23, we heard Haitians singing hymns until late in the night. Even with all that has happened to them, they are steadfast in their faith. On Sunday we decided to take a break as most Haitians will not come to clinic and will observe the Sabbath instead. But even today a few needy people straggled in to the clinic. We had a girl come with an external fixator on one leg, it needed debrided, and the bone was showing through. So several of us helped Dr. Huffman debride it and cover. We only had local anesthetic, so during the procedure the girl passed out. I was holding her head and as I turned to look behind me, I was inches from the edge of a cement cliff. We all got through today. There were a couple more days the same as before and then we mobilized the whole team and left Haitian first responders to manage the base clinic. Today we found out the newborn baby who had been in our clinic a few times, died. We are all saddened. Our last night arrives, so we must organize some of the inventory for the next group arriving to provide medical relief. They should be in by the end of the week. We pack little of our own items and leave most of what we brought for the Haitian people. As we return to the airport on January 26, we see the airport building is no longer open. We were given pills to deworm us before we left. The team got split up in the C17 airplane. We slept the 2-hour flight to Orlando. The Red Cross was waiting to help us. I got a tangerine from them…sooo good. We rented a car and drove to Jacksonville.

Blessures (Kreyòl for wounds)

In an instant, a grave blessure tore through Haiti tumbling its fragile infrastructure, toppling its buildings, terrifying its people. Victims with blessures crowded our makeshift clinic. Crushed limbs, swollen and split, rouge and raw, crawling with ﬂies, jaune and gris, creeping with maggots. Hollow-eyed souls, burdened with blessures of loss, family and friends baking in concrete crematories; homes crumbled, schools and shops demolished, and futures uncertain. We humbly entered the world of blessures climbing through rubble to remote tent cities working hand in hand with Haitian helpers dressing weeping wounds, splinting broken hands and hearts, putting Band-Aids on gaping need. Joan Huﬀman © 02/04/2010

After returning, I was still on hyper alert. Diarrhea set in and my thoughts are disorganized. I cannot bring myself to download pictures yet. Some moments I want to sob. I left behind new Haitian friends. Some moments I just wish I could purge my body of this tragedy, but I make plans to return to work and my life. Yet, I am not ready or able to process all that happened to me in Haiti.

Go to www.bobiwall.com, click “My Galleries” for more Haiti photos.

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‘Operation Walk Haiti’ Shows Jacksonville Cares Jacksonville Orthopaedic Institute (JOI) along with Raven Transport, Baptist Health, and Solantic Baptist Urgent Care made a “community call” for used orthopaedic equipment which resulted in a huge tractor trailer being filled to the brim on January 23 and January 24. Caring citizens donated dozens of orthopaedic boots and braces, walkers, thousands of crutches and canes, and more than 50 wheelchairs for those in desperate need after the earthquake in Haiti. JOI staff and volunteers from the participating organizations coordinated the intake of the equipment and supplies, and they met more than 500 individuals, families and friends throughout the community who drove to the collection site to donate to the cause. Pat Hutton, MD, JOI - Orange Park/Clay County, and president of the Florida Orthopaedic Society, along with his wife, Marge, president of the Clay County Chamber, led a caravan of three completely filled trucks and two cars to the drop-off site at Baptist Outpatient Center. The American Legion in Middleburg led a motorcade of more than a dozen caring individuals who connected with VFWs, nursing homes and other organizations resulting in hundreds of pieces of ortho equipment being collected and brought in as they rallied around the cause. JOI physician and DCMS Immediate Past-President R. Stephen Lucie, MD, helped to communicate to many DCMS physicians and organizations the need for supplies, including expired drugs. The filled truck drove down to Fort Lauderdale early the following Monday morning and was off-loaded into a warehouse in coordination with Carlos Lavernia, MD, founder of Operation Walk Haiti and Chief of Orthopaedics at Mercy Hospital (Miami). Many of the needed items were airlifted to Haiti by Monday afternoon. Michael Scharf, MD, president of JOI, thanks Steve Silverman of Raven Transport, Hugh Greene and Diane Raines of Baptist Health, and Karen Bowling of Solantic for their immediate support of this successful effort. Photos at left taken January 24 during the “Operation Walk Haiti” at the JOI collection site.

These eﬀorts prove, once again, that Jacksonville is a very caring community!

St. Vincent’s Healthcare Teams Oﬀer Continuous Haiti Relief

CRUDEM Foundation Supports Haiti Relief Eﬀorts

When the large earthquake shook Haiti on January 12, 2010, that Third World country and its needy people were not strangers to the physicians and staﬀ at St. Vincent’s Healthcare in Jacksonville, FL. For years teams from St. Vincent’s, Baptist Medical Center, Memorial Hospital and Baptist Medical Center South have been making 10 trips annually to St. Boniface Hospital in the village of Fond des Blancs. With over 100 employees, this hospital is the only source of healthcare for a population of 250,000 rural poor over 107 square miles. DCMS members have been part of these medical teams. They include: Eugene R. Bebeau, Jr., MD; William L. Cody, MD; Ronald P. Carzoli, Jr., MD; Theodore S. Felger, MD; Kenneth D., Hagan, MD; and Javier Herrera, MD.

John Mazur, MD, recipient of the 2009 DCMS Clyde M. Collins Award, is assisting Carol Fipp (daughter of the late Dr. George Fipp) to coordinate local Haiti relief efforts for the CRUDEM (Center for the Rural Development of Milot). They are forming teams to fly to Haiti so they can provide medical assistance at the Scared Heart Hospital in Milot, Haiti. This is the same hospital where Dr. John Lovejoy volunteers, and his Jacksonville support group sends three orthopaedic teams to Milot annually. A massive relief effort is going on at the hospital. (see “Haiti Response Journal,” p. 5)

Jack Logue, Chairman of the Board for the St. Boniface Haiti Foundation and on the St. Vincent’s Healthcare staﬀ at the Spirituality Center said in light of the disasterous quake, teams have been forming to go and assist with relief eﬀorts. The Foundation is working with the USNS Comfort, UNICEF, Ministry of Health, World Health Organization and CRS on behalf of the Haitian people. Donations are being received by the Foundation and are used to purchase needed medical supplies. The hospital in Fond des Blancs is accepting patients who have had to migrate from Port au Prince. Mr. Logue encourages anyone who wants to know more about the Foundation to got to www.Haitihealth.org and click on “St. Boniface Haiti Foundation or call him at 904-308-7303.

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The hospital’s system is being strained, so contributions are appreciated. Go to www.crudem.org to donate. Fortunately, the Sacred Heart Hospital sustained little damage during the quake and it remains full operational and self sufficient with its own power and water system. The 73-bed hospital normally treats over 65,000 patients a year, but that number will be significantly higher because of the refuge influx of patients. Extra medical assistance will be needed for some time. Healthcare professionals who are interested in volunteering to go Milot and help at the hospital can contact Dr. John Mazur at jmazur@nemours.org. There is a special need for orthopedists, surgeons, general surgeons and anesthesiologists. Please contact Leora Legacy, (llegacy@dcmsonline.org) with news of any other Haiti relief efforts by DCMS members.

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THE US DEPT. OF HEALTH AND HUMAN SERVICES SAYS:

“All physicians should

strongly

advise every patient who smokes to quit because evidence shows that provider advice to quit smoking increases abstinence rates.” The National Cancer Institute projects that if providers assisted even 10% of their tobacco-using patients in quitting, the number of tobacco users in the U.S. would drop by 2 million people annually.

Northeast Florida AHEC offers FREE training to help providers effectively Ask, Advise, and Refer patients to appropriate cessation programs. UPCOMING FREE CME/CE PROGRAMS AT THE COMFORT SUITES AT WORLD GOLF VILLAGE:

Motivational Interviewing (March 11th, 2010) and Nicotine Replacement Options (May 13th, 2010) FREE On-line training modules are also available

TRAINING TOPICS INCLUDE:

• Brief Intervention Training • Motivational Interviewing • NRT Options

Northeast Florida AHEC

CONTACT: NE Florida AHEC Tobacco Training 1107 Myra St., Suite 250 Jacksonville, FL 32204 Ph: (904) 482-0189 • Fax: (904) 482-0196

www.northfloridaahec.org www.quitsmokingnowfirstcoast.com

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with more advanced disease. Patients found to have bulky nodal metastases by CT scan are not felt to be candidates for MIE and consideration is given to either an open operation or deﬁnitive chemoradiation.

MIE vs. Open Resection Data comparing MIE with open surgery are accumulating. Most of these data are in the form of single-institution studies using historical controls for comparison. In the only published study comparing open surgery with MIE, Nguyen et al found that MIE was associated with less blood loss, shorter length of surgery, and shorter length of stay in the intensive care unit.26 A large meta-analysis review was performed demonstrating the widening application of minimally invasive approaches to esophagectomy. Twenty three articles concerning the topic met the stringent requirement for review and included 1398 patients. Overall mortality (2.3%), morbidity (46%), and leak rate (7.7%) were similar to open procedures and confirm the safety and feasibility of the technique. Lymph node yield for an R0 resection (complete surgical excision) for these patients was similar to published results of open series.27 Patient quality of life following MIE has been assessed in only one study of 220 patients. Their postoperative scores were comparable with those of the norm of the population, and their quality of life was preserved after surgery.28 Long-term follow up is needed to confirm that these values translate into satisfactory oncologic outcomes. Adequate randomized data is not currently available to statistically confirm quality-of-life improvement from a minimally invasive approach in direct comparison with open approaches.

Complications of MIE The main tasks during the immediate postoperative period are to detect complications early and to minimize their adverse contributions to final outcomes in patients. The complications seen after MIE are no different from those seen after an open procedure, consisting mainly of gastric graft failure, pneumonia, other septic complications, and chylothorax. Failure of the gastric conduit can occur in either of two ways. Failure can occur in the form of catastrophic gangrene involving the entire gastric tube, which is a rare, but devastating complication. Patients become acutely ill hours after surgery and the condition is confirmed by endoscopy and imaging. Immediate reoperation is necessary to remove the gangrenous stomach, establish a cervical esophagostomy (“spit fistula”), and treat the patient for sepsis. Continuity of the digestive tract is reestablished only months or years later, after the patient has completely recovered. The other type of graft failure is more subacute and manifests itself by leakage of saliva from the new gastroesophageal anastomosis, usually 3 to 5 days after surgery. Anastomotic leaks are treated by opening the cervical wound at the bedside and initiating dressing changes. The patient can swallow water to wash out the wound. Once the amount of water exiting the leak is small, the patient begins a soft diet while applying pressure to the cervical wound. A 46-French www . DCMS online . org

Maloney dilator is passed at the bedside before discharge to decrease the chance of anastomotic stricture and to ensure that there is no distal obstruction. 29 The majority of leaks heal spontaneously in 2 to 3 weeks; however, approximately 50% of cases lead to anastomotic stricture and the need for chronic dilatation. 29 Adverse pulmonary events represent a major source of postoperative complications and occur in as high as 50% of patients after open esophagectomy. Patients are monitored closely after surgery for pulmonary complications, mainly for the development of pneumonia and acute respiratory distress syndrome (ARDS). Typically, ARDS develops after a period of relative well-being 3 to 5 days after the surgery. The trigger mechanisms for the development of ARDS after esophagectomy are poorly understood but ominous, and it is impossible to predict which patients are likely to develop the complication. 30,31 Radiation-induced pneumonitis, aspiration, and the trauma of surgery are all factors thought to predispose patients to develop post esophagectomy ARDS (30,31). Injury to the recurrent nerve signiﬁcantly increases the incidence of major pulmonary complications after esophagectomy as well. Such injury must be avoided by atraumatic neck dissection when the anastomosis is created in the left side of the neck and by keeping the dissection at the thoracic inlet immediately on the esophagus to avoid injury to the right recurrent nerve.

Conclusion Minimally invasive resection of the esophagus for the management of esophageal cancer is relatively feasible and safe. Based on the limited knowledge available today, short-term outcomes after MIE are at least comparable with, if not better than, outcomes associated with open procedures. Whether MIE is superior to the time honored open techniques as an oncologic surgical procedure remains to be determined. Experience with abdominal surgeries has shown that minimally invasive techniques eventually prevail over open techniques. This should hold true for MIE as long as the procedures do not jeopardize the basic principle of oncologic surgerycomplete resection of the tumor and its lymph-node bearing territories.

References 1.

Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 2003;349:2241-52.

Kato H, Fukuchi M, Miyazaki T, et al. Surgical Treatment for Esophageal Cancer. Dig Surg 2007;24:88-95.

Pennathur A, Luketich JD. Resection for Esophageal Cancer: Strategies for Optimal Management. Ann Thorac Surg 2008;85: S751-6.

Atkins BZ, Shah AS, Hutcheson KA, et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 2004;78:1170-6; discussion 1176.

Ferguson MK, Durkin AE. Preoperative prediction of the risk of pulmonary complications after esophagectomy for cancer. J Thorac Cardiovasc Surg 2002;123:661-9.

Northeast Florida Medicine Vol. 61, No. 1 2010 25

Windsor A, Braga M, Martindale R, et al. Fit for surgery: an expert panel review on optmising patients prior to surgery, with a particular focus on nutrition. Surgeon 2004;2(6):315-9.

24. Millikan K, Silverstein J, Hart V et al. A 15-year review of esophagectomy for carcinoma of the esophagus and cardia. J Am Coll Surg 1999; 118: 328-32.

Gibbs J, Cull W, Henderson W, et al. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134(1):36-42.

25. Atkins B, Shah A, Hutcheson K et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 2004; 78: 1170-6.

Lin J, Iannettoni MD. Transhiatal Esophagectomy. Surg Clin N Am 2005; 85: 593-610

Wright CD: Esophageal cancer surgery in 2005. Minerva Chir 2005; 60: 431-444.

10. Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy: clinical experience and reﬁnements. Ann Surg 1999;230:392- 400; discussion 400-3. 11. Boyle MJ, Franceschi D, Livingstone AS. Transhiatal versus transthoracic esophagectomy: complication and survival rates. Am Surg 1999;65:1137-42. 12.

Martin LW, Swisher SG, Hofstetter W, et al. Intrathoracic leaks following esophagectomy are no longer associated with increased mortality. Ann Surg 2005;242(3):392-9 [discussion: 399-402].

13. Rentz J, Bull DA, Harpole D, et al. Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients. J Thorac Cardiovasc Surg 2003;125:1114-20. 14. Pommier RF, Vetto JT, Ferris BL, Wilmarth TJ: Relationships between operative approaches and outcomes in esophageal cancer. Am J Surg 1998; 175: 422-425. 15. Hulscher JBF, Tijssen JGP, Obertop H, et al. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg 2001; 72: 306-313. 16. Hagen JA, DeMeester SR, Peters JH, Chandrasoma P, DeMeester TR. Curative resection for esophageal adenocarcinoma: analysis of 100 en bloc esophagectomies. Ann Surg 2001; 234:520-30; discussion 530. 17. Goldminc M, Maddern G, Le Prise E, et al. Oesophagectomy by a transhiatal approach or thoracotomy: a prospective randomized trial. Br J Surg 1993; 80: 367-370. 18. Chu KM, Law SY, Fok M, Wong J: A prospective randomized comparison of transhiatal and transthoracic resection for lowerthird esophageal carcinoma. Am J Surg 1997; 174: 320-324. 19. Hulscher JBF, van Sandick JW, Boer AGEM, et al: Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002; 347: 1662-1669. 20. Chang AC, Ji H, Birkmeyer NJ, et al. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg. 2008; 85:424-9. 21. Nishihira T, Hirayama K, Mori S. A prospective randomized trial of extended cervical and superior mediastinal lymphadenectomy for carcinoma of the thoracic esophagus. Am J Surg 1998;175:47-51. 22.

Lerut T, Nafteux P, Moons J, et al. Three-ﬁeld lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classiﬁcation in upperhalf esophageal carcinoma. Ann Surg 2004; 240: 962-972.

23. Altorki N, Kent M, Ferrara C, Port J: Threeﬁeld lymph node dissection for squamous cell and adenocarcinoma of the esophagus. Ann Surg 2002; 236: 177-183. 26 Vol. 61, No. 1 2010 Northeast Florida Medicine

26. Nguyen NT, Follette DM, Wolfe BM, et al: Comparison of minimally invasive esophagectomy with transthoracic and transhiatal esophagectomy. Arch Surg 2000; 135:920-955. 27. Gemmill EH, McCulloch P. Systematic review of minimally invasive resection for gastro–esophageal cancer. Br J Surg 2007; 94:1461-7. 28. Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al: Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg 2003; 238:486-494. 29. Orringer MB, Lemmer JH. Early dilation in the treatment of esophageal disruption Ann Thorac Surg 1986;42:536-9. 30. Wang SL, Liao Z, Vaporciyan AA, et al. Investigation of clinical and dosimetric factors associated with postoperative pulmonary complications in esophageal cancer patients treated with concurrent chemoradiotherapy followed by surgery. Int J Radiat Oncol Biol Phys 2006; 64:692-699. 31. Tandon S, Batchelor A, Bullock R, et al. Perioperative risk factors for acute lung injury after elective oesophagectomy. Br J Anaesth 2001; 86: 633-638.

Clinical Section on Esophageal Cancer continues after CME article, p. 33

Save the Date for the AMA Leadership Visit Cecil B. Wilson, MD, the current President-Elect of the American Medical Association (AMA), will visit Jacksonville April 2527, 2010. Dr. Wilson will become the 164th AMA President in June, 2010. While in the area, Dr. Wilson will speak at the April 26 DCMS Dinner Meeting at Epping Forest. Be sure to save that date and watch for a formal invitation.

April 26, 2010 - DCMS Dinner Meeting www . DCMS online . org

A Tale of Two Cities: Overcoming Barriers to Access Health Care

Background - Benefits that Matter! The Duval County Medical Society (DCMS) attempts to provide its members with the benefits that consistently meet your professional needs. One example of how this is being accomplished is by providing to DCMS members free Continuing Medical Education (CME) opportunities in the subject areas mandated/and or suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare (SVHC) Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). Helena Karnani, MD, Chair of the CME Committee; Betsy Miller, Director, Medical Staff, Quality Management; and Cindy Williamson, CME Coordinator, from SVHC deserve special recognition for their work on behalf of DCMS. This issue of Northeast Florida Medicine includes an article, “A Tale of Two Citieis: Overcoming Barriers to Access Health Care” authored by Mary K. Robinson, MD, (see pp. 27-30), which has been approved for 1.0 AMA PRA Category 1 credit(s).™ For a full description of CME requirements for Florida physicians (MD/DO), please visit the DCMS website (http://www.dcmsonline.org/ cme_requirements.aspx).

Faculty/Credentials: Mary Robinson, MD, is Medical Director at the Suzbacher Health Centers in Jacksonville, FL. Objectives for CME Journal Article 1. Deﬁne access to health care for uninsured and homeless persons 2. Identify barriers to access to health care in the uninsured and homeless persons population 3. Explore creative ways that the community can remove barriers to access to health care

Date of Release: March 15, 2010 Date Credit Expires: March 15, 2011 Estimated time to complete: 1 hr.

Methods of Physician Participation in the Learning Process 1. Read the “A Tale of Two Cities: Overcoming Barriers to Access to Health Care” article on pages 29-32 2. Complete the Post Test and Evaluation on page 26 3. Cut out & fax the Post Test and Evaluation to DCMS (FAX) 904-353-5848 OR members go to www.dcmsonline.org & submit test online

CME Credit Eligibility In order to receive full credit for this activity, a minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted if a passing score is not made on the ﬁrst attempt. DCMS members and non-members have one year to submit the post test and earn CME credit. A certiﬁcate of credit/completion will be emailed, faxed or USPS mailed within 4-6 weeks of submission. If you have any questions, please contact the DCMS at 355-6561, ext. 103, or llegacy@dcmsonline.org.

Faculty Disclosure Information Dr. Robinson reports no signiﬁcant relationships to disclose, ﬁnancial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee, and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare is accredited by the Florida Medical Association to provide continuing medical education for physicians. The St. Vincent’s Healthcare designates this educational activity for a maximum of 1.0 AMA PRA Category 1 credit(s) .TM Physicians should only claim credit commensurate with the extend of their participation in the activity.

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Northeast Florida Medicine Vol. 61, No. 1 2010 27

A Tale of Two Cities: Overcoming Barriers to Access Health Care

CME Questions & Answers (Circle Correct Answer) Free-DCMS Members/$50.00 charge non-members* (Return by March 15, 2011 by FAX: 904-353-5848, by mail: 555 Bishopgate Lane, Jacksonville, FL 32204 OR online: www.dcmsonline.org) 1. “Access to health care” is a term for a broad set of concerns centering on the degree to which individuals & groups can obtain needed services from the medical care system. a. True b. False 2.

An individual is examined & treated at an emergency room in Duval County. Barriers to follow-up outpatient care may include all of the following EXCEPT: a. Geographic b. Eligibility c. Racial d. Health literary

In the author’s opinion, the most formidable barriers to access to care are: (choose two) a. Geographic b. Eligibility c. Health literary d. Psychosocial

4. Volunteers in Medicine operates an outpatient practice that provides continuity care to employed persons who do not have health insurance. a. True b. False

All individuals & families whose income is 200% or below the federal poverty level are eligiable for Medicaid. a. True b. False

Sulzbacher Health Services provides access to care for homeless & persons living at 200% below the federal poverty level in the following specialties: a. Family Practice b. Dental Care c. Mental Health d. All of the above

7. In the Sulzbacher Center for the Homeless, a full time registered nurse provides all of the following EXCEPT: a. Links women & children to health care services b. Teaches nutrition, hygiene & self-care c. Teaches shelter staﬀ basic life support & AED use d. Admits patients who have intravenous lines & indwelling urinary catheters to the health service beds 8. The arrival of a physician executive director of We Care has facilitated improvement of the organization & helped with screening of potential specialty referrals. a. True b. False

Evaluation questions & CME Credit Information (Please evaluate this article. Circle one number using this scale: 1= Strongly Agree to 5= Strongly Disagree)

The article met the stated objectives: 1 2 3 4 5 The article was appropriate to my practice: 1 2 3 4 5 The topic was current and well presented: 1 2 3 4 5 Comments:_______________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ Name (Print)___________________________________________Email__________________________ Address/City/State/Zip_________________________________________________________________ Phone__________________________Fax_____________________DCMS Member (circle)

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A Tale of Two Cities: Overcoming Barriers to Access Health Care Mary K. Robinson, MD Editor’s Note: Due to production and space constraints, Figures 1-5 and Table 1 are not printed in the journal. They are available online at www.dcmsonline.org. Abstract: Access to Health Care is defined as the degree to which individuals are able to obtain needed services from the medical care system. A large percentage of individuals and families residing in the United States have either inadequate or no financial ability to access health care. As a result of reading this essay, readers will be able to enumerate geographic, eligibility, financial, health literacy, and psychosocial barriers to access to healthcare as they relate to patients in general and specifically to our local community. The reader will also learn of a number of ways in which the Duval County Medical Society and other local organizations are addressing access issues both in the provision of primary care and specialty care services. Finally, readers will learn how they themselves may participate in grassroots volunteer efforts to overcome obstacles to access to care for our neighbors in Duval County.

Introduction – Two Cities

“Those are the workers from our health center who drive around in the van with the big green letters on it?” “Oh them,” she replies indifferently, “I’ll take water or a hygiene kit now and then. They are good people, but I haven’t needed them until this toe started hurting. I was glad to see them today, though.” The patient is then offered a physical including a gynecological and breast examination, but she adamantly declines and responds, “I don’t want to know about any of that mess. I feel fine, except for this here toe.” Thinking of the fable of Androclese and the lion, the physician chooses to take care of this patient’s immediate concern, hoping to engender trust so that maybe one day she might avail herself of the early detection and preventive services that the health center has to offer.

Every community in the United States has a tale of two cities. The first “city” is comprised of individuals and families whose heads of household are employed and are able to afford private health (and sometimes dental) insurance as a benefit of their employment. These individuals and families enjoy a standard of living well above the federal poverty level and likely can identify their personal or family physician. The second “city” is made up of individuals and families who do not have private insurance and may not have health insurance at all. These individuals and families struggle financially below or just a little above the federal poverty level and often are unable to identify their personal or family physician.

Scenario Two: A sixty-year-old female arrives at the Sulzbacher Beaches Community Health Center actively seeking early detection primary preventive services and chronic disease management. She lost employment because of the recession about a year ago and could no longer aﬀord private care. She resorted to going to hospital emergency rooms to get a physician to write prescriptions for her several chronic problems including Diabetes, hypertension, and asthma. . This patient is eager to return to regularly scheduled visits. Further history reveals symptoms and signs of depression. She breaks down in tears when the physician suggests prescribing an antidepressant.

Two Scenarios

“Do you mean I can get care for depression, too? This clinic is a god-send!” she exclaims.

The dichotomy of “two cities” in health care is present in Jacksonville (Duval County), Florida as seen in the following two scenarios from homeless clients who came to the I.M. Sulzbacher Health Center. Scenario One: A fifty-five year-old female, looking older than her chronological age presents to clinic with a chief complaint of an ingrown toenail. She winces with pain when the great toe of her left foot is examined. Her sunburned and wind-wizened face sports a mouth with five or six tobaccostained teeth and a crooked nose that must have been fractured at least once. The physician orders a betadine footbath prior to excising the offending nail and also inquires how long she has been homeless in Jacksonville. Expecting to hear, “A few weeks, a month or so,” the physician is surprised when the patient says, “Twenty years.” “Do you know the HOPE team?” the physician questions. Address Correspondence: Mary K. Robinson, MD, Medical Director, Sulzbacher Health Centers, 611 East Adams Street, Jacksonville, FL 32202. Email: DoctorMaryKR@bellsouth.net.

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The physician then performs a complete physical including breast, gynecological, and rectal examinations. She ﬁlls out an application for “Tomorrow’s Rainbow,” a Florida Breast and Cervical Cancer Early Detection Program. She will leave with medications, an appointment for a mammogram and another appointment for a return visit to monitor medical interventions, and an invitation to attend a weekly diabetes education and support group held at the health center.

Health Care Access Deﬁned These two scenarios are examples of access to care. Simply stated, access to health care occurs whenever an individual is able to obtain information or direct services for the purpose of promoting the health and well being of the individual, and of the community in which he or she resides. It is also a “term used for a broad set of concerns that center on the degree to which individuals and groups are able to obtain needed services from the medical care system.”1 The majority of individuals living in nations such as the United States will access health care at various times in their

Northeast Florida Medicine Vol. 61, No. 1 2010 29

life cycles and for various reasons. Up to 90% of white women, but only about 70% of non-white women, receive prenatal care. Disparities in access to health care literally begin before we are born.2 Ideally infants should be given frequent access to health care at intervals that are optimal for assessment of growth, neurological development and psychosocial development and for primary prevention of disease aﬀorded by childhood immunizations. The National Health Interview Survey 2001 found that 95 % of responders had a regular source of pediatric care, indicating that we seem to have better access after we are born than before.3 Childhood immunization is a good example of access to care for both the good of the individual because it protects that particular child against deadly diseases and the good of the community since immunizing entire populations confers herd immunity. We learn and accept these principles from the moment we set foot in medical school, but upon entering the arena as licensed health care professionals, we face the reality that access to health care varies signiﬁcantly depending upon geographical location, health literacy, socioeconomic status and a number of other factors that will be explored in the following sections.

Healthcare Access Barriers Most individuals have encountered only inconveniences in health care. For example, an insured individual has almost run out of a prescription medication, and there are no more refills left because the medication was timed to be renewed at the next office visit, which the patient cancelled because of a personal scheduling conflict. The individual calls for an office visit to her personal physician and the next opening for an established patient is in three more weeks. The individual goes to an urgent care center where the provider prescribes enough medication to last until her regular provider can see her. This scenario does not illustrate a barrier to access to care, but only a temporary inconvenience. True barriers to access result in health care that is delayed or denied an individual and thus poses an imminent or potential threat that may result in impairment or death. Geographic Barriers – An individual’s location of residence, coupled with difficulty obtaining transportation to clinics or other outpatient care facilities (usually commingled with poor socioeconomic status) often constitute barriers to access to care. A Center for Health Statistics study entitled Health: Place Matters depicted Duval County in Northeast Florida divided into geographic Zones 1 through 6.4 (Figure 1, www.dcmsonline.org) Clinics that serve the uninsured along with public health outpatient facilities for primary care are mostly centered about the urban core Health Zone 1, the western part of Health Zone 2, and eastern part of Health Zone 4 all of which cluster around the core city on both sides of the St. Johns River. (Figure 2,www.dcmsonline.org) One Health Department clinic is located in Marietta, and provides Women’s Health Care, sexually transmitted infections detection and treatment, and children’s health, but no services 30 Vol. 61, No. 1 2010 Northeast Florida Medicine

for men with problems such as hypertension and diabetes.5 (Figure 3, www.dcmsonline.org) Citizens of Duval County who do not own and operate vehicles face transportation obstacles to care, especially in Health Zones that are located at distances of five to ten miles away from the urban core. Transportation barriers often cause financially indigent and elderly citizens to delay care that could have been provided in a less costly outpatient setting, choosing to use hospital emergency rooms after usual work hours when a friend or family member becomes available to provide transportation. Buses do provide transportation for patients seeking care, but some are unable to walk to bus stops and others fear being mugged and robbed when walking to and standing at bus stops. Most lack money for taxis. Eligibility Barriers – City and county subsidized health care comes with residence and other eligibility requirements. State-administered subsidized insurance (Medicaid or Reform Medicaid) is linked with Aid to Families with Dependent Children (AFDC), Supplemental Security Income (SSI), Institutional Medicaid (a plan that helps hospitals with the cost of catastrophic coverage for certain patients’ hospital stays), and coverage for skilled long-term care facilities i.e. “nursing homes.” A detailed discussion of how these various plans are administered and how patients may be eligible for a certain length of time and then lose eligibility is beyond the scope of this paper. Suffice it to say, large numbers of the most medically vulnerable of our residents are ineligible for city or state subsidized health care, specifically dental care, and other specialty health care such as optometry, ophthalmology, gynecology and urology services. Health Literacy Barriers – Of all the barriers to healthcare access for individuals and groups, poor health literacy is among the most formidable. Health Literacy may be defined as “an individual’s ability to read, understand and use health care information to make decisions and follow instructions for treatment.”6 Low health literacy has a negative impact on the treatment, outcome and safety of care delivery. Patients with low health literacy have a higher risk of prolonged hospitalization, are less likely to comply with treatment, are more likely to make errors with medication, and are more ill when they seek medical care.6 Healthy People 2010 defines health literacy as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.7 Such a perspective sees health literacy as the wide range of skills and competencies that people develop over their lifetimes to seek out, comprehend, evaluate and use health information and concepts to make informed choices, reduce health risks and increase quality of life. The four foundational underpinnings of this concept of health literacy include fundamental, scientific, civic, and cultural literacy. An inherent feature of this concept is that receivers of care and providers of care both participate in the foundational requirements.7

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Psychosocial Barriers – In this author’s opinion, the most formidable barrier to access to care and the most self destructive and costly to society is found in the area of mental health. The patient described in the first scenario of this article was restricted in health literacy, but had no geographic or eligibility barriers to care. Being homeless she certainly is eligible for federal Health Care for the Homeless (HCH) services provided in the Sulzbacher Health Center clinics, and she lives (albeit with no permanent roof over her head) within walking distance of these services. She even has a mobile outreach team who had been trying to coax her for years into accepting services. Her barrier to care is poor mental health with most likely substance abuse and dependence playing a role in her attitude of denial. Over 80% of homeless women are victims of severe physical/sexual assault, so chances are the Scenario One patient has been abused, often repeatedly and starting at a young age.8 She may be suffering from a unique kind of post-traumatic stress disorder that we see commonly in homeless women (and men, also). She may understand at a cognitive level that simple screening services such as the female examination with Pap smear is a reasonable offer, but at a deeper level she has been so beaten down by her life circumstances that she shuts out references to her future. Early detection of a disease that could happen, or might happen means nothing to her because of her pervasive loss of self-esteem, pessimism and mistrust of other people, even health care professionals. Often mental health professionals, on probing deeper when such patients do enter therapy, find that patients feel they “do not deserve to live,” and have few if any positive expectations about their future well-being or survival.9 Individuals who suffer from ongoing mental health disorders such as chronic or recurrent major depressive disorder, bipolar disease and schizophrenia are less likely to receive care for early detection or primary prevention, and are more likely to engage in cigarette smoking and other destructive substance abuse behaviors. They are also much less likely to adhere to treatment programs that include medication compliance, and participation in diet and exercise components.8 Financial Barriers – It goes without saying that persons and groups of low socioeconomic status delay or forego dental and medical care. Financial barriers are at work along with all of the other barriers listed above. Half of all personal bankruptcies in the United States result from health problems, and it is a short downhill slide from bankruptcy to eviction to homelessness.8

Overcoming Access to Care Barriers The response to helping individuals and groups overcome barriers to health care varies greatly depending upon numerous factors. Figures such as the familiar 49 million of 330 million Americans who do not have health insurance coverage are bandied about in the press and are the subject of legislation that is being considered nationally as of the writing of this article. Federal legislation may make health insurance more available to households in which the members have full time www . DCMS online . org

employment, but the unemployed and partially employed, “under the table” workers and aliens will probably be left out. Most medical professionals and their political action groups agree with some plan for health care reform. However, as members of the Duval County Medical Society, we do not have to wait for sweeping change to take place at a national level. Safety net providers are already in place and will be brieﬂy discussed below.

The Duval County Health Department The Duval County Health Department (DCHD) provides many services in a number of locations throughout the city (Figure 4, www. dcmsonline.org). In addition to ensuring the overall health of the community by implementing restaurant inspections, eliminating our community’s exposure to toxins such as asbestos and lead, and keeping track of a myriad of vital statistics, the DCHD also sponsors a number of direct care clinic sites. Visit its website www.dchd.net for an in depth description of its multiple services.

The University of Florida Clinics at Shands and its Satellites Shands Jacksonville, originally the Duval County Medical Center still contracts with the City of Jacksonville to provide low or no cost care for a large segment of the community. The primary care center located at the main campus of Shands on 8th Street accepts city contract patients. Some of the Shands satellite outpatient clinics accept city contract patients, and others do not. For a complete listing of these outpatient facilities go to their website at http://jax.shands.org/ and click on “primary care locations”, or “specialty care locations”.

Volunteers in Medicine The organization Volunteers in Medicine (VIM) operates an outpatient practice located in the city core in Health Zone 1. Physician, nurse and non-medical volunteers break down ﬁnancial, health literacy, and other barriers to access to health care by providing routine non-emergency medical services to clients who are employed but do not have health insurance and a home for medical care. A clear and concise fact sheet enumerating services and eligibility can be found online at www.dcmsonline.org/VIM-Jax.htm.

Volunteer Health Clinics Volunteer providers and staff also maintain the Volunteer Healthcare (“We Care”) clinics in various locations (Figure 5, www.dcmsonline.org) in Duval County on different days of the week and times of the day or evenings (Table 1, www. dcmsonline.org). Like the VIM practice, these clinics provide ongoing care to men and women (and in some cases children) who are in need of primary preventive and continuity of care for chronic disease management. Utilizing the Sulzbacher downtown clinic, the volunteer community Asthma program provides care for patients with asthma and related pulmonary diseases on the second Saturday morning of each month. The largest and most fully staffed are the Sulzbacher Health Centers. These centers are “hybrids” in that both Northeast Florida Medicine Vol. 61, No. 1 2010 31

volunteers and paid staff function to provide comprehensive care Monday through Friday, and one evening per week at the downtown location. The Sulzbacher Health Centers do not erect any age, sex, disease-specific or residence barriers to care. Recipients of care do not have to be employed or have an income at all, and they do not have to qualify through Aid to Families of Dependent Children as do those who are eligible for Medicaid. The Sulzbacher Centers provide a full range of Family Practice, dental, and mental health and substance abuse identification and recovery. Additionally, medical case managers help patients with a myriad of issues relating to health literacy and help break down psychosocial barriers to housing and a permanent medical home. In the Sulzbacher Center for the Homeless, a full time Registered Nurse links women and children to health care services and teaches nutrition, hygiene and self-care. She also educates and trains the shelter staff in areas such as basic life support and use of automatic defibrillators that are strategically placed in the dental and medical clinics and in the shelter. This RN is a major resource for improving health literacy among both shelter residents and staff. By patiently promoting awareness, she partners with local hospital discharge planners linking selected patients with temporary housing in the shelter. A small number of designated Health Service beds allow the shelter to serve as place for patients to recover from the illness or injury for which they required hospitalization. Sulzbacher health services employees are paid through Health Care for the Homeless Grants and other funding sources. In response to demographic studies and a substantial community effort, the center applied for and received funding to expand services to its new Beaches Community Health Center. Since opening early in January 2009, the Beaches Center has broken down geographic, financial, health literacy, and psychosocial barriers to access to care for residents of Jacksonville Beach and its surrounding areas. The clinicians and staff, both paid and volunteer, have already provided primary care and psychiatric services with 3,895 total patient visits, and 1,391 unduplicated visits from January through November 2009. By the time this piece reaches publication there should be at least part-time dental services available for our Jacksonville Beaches residents.

How You Can Help One word: volunteer! When you or your office manager hears from Dr. Sue Nussbaum, a physician and the Executive Director of WE CARE Jacksonville, agree to volunteer your services. Clients who access services through both Volunteers in Medicine and Volunteer Healthcare Clinics may truly need specialty care that they cannot afford. WE CARE Jacksonville focuses its efforts on recruitment of specialty physicians and also assists the Volunteer Healthcare clinics with medications, supplies, and additional staffing. The individuals who seek this care are your neighbors who “fall between the cracks” of eligibility for Shands’ specialty clinics and do not meet criteria for Medicaid coverage. Areas of critical need are: ophthalmology, especially for glaucoma and malignancies of

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the eyelid, otolaryngology, gynecology, (for evaluation and treatment of abnormal screening cytology and gynecological malignancies), and urology, for diagnosis and treatment of cancers of the prostate and urogenital tract (fortunately rare in this population). Invite your colleagues in other professions such as dental and podiatry to participate also. The We Care staﬀ and executive director carefully screen each request for specialty services, ensuring that only the most medically necessary pass through. Volunteer to provide care at Volunteers in Medicine or at one of the Volunteer Healthcare clinics. Ask your pulmonary and allergist colleagues who have been faithfully volunteering all of those Saturday mornings and others who started the Sulzbacher clinic when it was a small dispensary for shelter residents, or those who participate in VIM. They will tell you how rewarding it is to volunteer and how grateful patients will thank you for your willingness to give them medical attention. The Sulzbacher Beaches Community Health Center needs a rotation of physicians to provide an extended hours clinic at least one day per week. Donating just three hours of your time once a month or even every other month would allow the already overbooked clinic to extend its hours of availability. In summary, the size of Duval County is geographically daunting. All of the barriers to access to health care exist in Duval County as in other places in the United States. By cooperating with your Duval County Medical Society, you can collectively make a very big diﬀerence in the lives of your neighbors by removing barriers to access to care in your community.

References 1.

Access to Health Care in America http://books.nap.edu/ openbook.php?record 32 Accessed November 21, 2009.

Weirnick RM, Zuvekas SH, Drilea S. Research Findings #3: Access to Health Care, Sources and Barriers, 1996. 1.http:// meps.ahrq.gov. Accessed November 21, 2009.

National Health Care Disparities Report 2005 Institute of Medicine Access to Health Care in America. 31.www. ahqr.gov/QUAL/nhdr05/fullreport/ch3Ref.htm. Accessed Novenber 16th, 2009.

Health: Place Matters. Center for Health Statistics Study DCHD, Volume 7, Issue 1. March 2008, p. 2. Duval County Health Department Health Centers www dchd net/centers.htm Accessed November 16, 21, 25, 2009.6. U.S. Department of Health and Human Services: Quick Guide to Health Literacy. www.health.gov/communication/literacy/ quickguide accessed November 16th, 2009.

Nutbeam, D (2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15 (3) 259-267.

Kraybill, K and Olivet, J. Shelter Health, Essentials of Care for People Living in Shelter. National Health Care for the Homeless Council Washington D.C. 2008, pp. 11-13.

First, MB ed. Diagnostic and Statistical Manual of Mental Disorders DSM-IV Fourth edition, American Psychiatric Association Washington D.C. 1994, p 428.

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Esophageal Stenting in Patients with Advanced Esophageal Cancer Juan C. Munoz, MD Editor’s Note: Due to production constraints, Figures 1-6 are not printed in the journal. They are available online at www.dcmsonline.org as web illustrations. Abstract: Esophageal carcinoma is a common cause of cancer mortality. Most patients with esophageal and gastric cardia cancer are often diagnosed at an advanced incurable stage with a poor overall survival. Dysphagia and obstruction in patients with advanced esophageal and gastric cardia cancer lead to inability to handle oral secretions, recurrent episodes of aspiration pneumonia, nutritional compromise, weight loss, weakness, debility and severe chest pain, compromising the quality of life. Patients with locally unresectable tumor and metastatic disease are treated with palliative intent. In this article we are going to describe the use of self expandable stent (SES) as non surgical, minimally invasive treatment options in symptomatic patients with advanced esophageal and gastric cardia cancer, who are not candidates for surgery, chemo-radiation or who have recurrent dysphagia following deﬁnitive treatment.

Introduction Esophageal carcinoma is the sixth most common cause of cancer mortality. The most common esophageal cancer in developed countries including the U.S. is adenocarcinoma. China, Iran and parts of Africa have a high incidence of esophageal squamous-cell carcinoma.Most patients with esophageal and gastric cardia cancer are often diagnosed at an advanced incurable stage with a poor overall survival of less than 9 months and ﬁve-year survival rate of less than 20%.1, 2 Dysphagia and obstruction in patients with advanced esophageal and gastric cardia cancer lead to inability to handle oral secretions, nutritional compromise, weight loss, weakness, debility, recurrent episodes of aspiration pneumonia and severe chest pain, compromising the quality of life. Therefore, dysphagia and obstruction are considered two of the most distressing and debilitating symptoms in patients with advanced esophageal cancer (Figure 1, www.dcmsonline. org). Patients with locally unresectable tumor and metastatic disease are treated with palliative intent.3 The most important aspect in palliation is directed toward relieving dysphagia and obstruction, restoring oral diet to maintain nutrition and providing an acceptable quality of life.4 The use of self expandable stent (SES) under these circumstances may allow for the avoidance of more invasive procedures such as the placement of gastrostomy and jejunostomy tubes. There are a wide variety of palliative treatments considered to relieve dysphagia and obstruction, including Address Correspondence to: Juan C. Munoz, MD, Assistant Professor of Medicine, University of Florida College of Medicine, UF Gastroenterology, 653 W. 8th St., 3rd FL, Faculty Clinic, Jacksonville, FL 32209. Phone: (904-633-0797. Email: juan. munoz@jax.uﬂ.edu. www . DCMS online . org

chemotherapy (which has a limited role due to drug toxicity), external bean radiation therapy or local delivery radiotherapy also called brachytherapy (which do not provide immediate relief of the obstruction), or different endoscopic treatments including, injection ablative therapies (ethanol, cisplatin/ epinephrine), laser therapy, argon plasma coagulation and photodynamic therapy. 5-10 Self-expandable metal stent (SEMS) and self-expandable plastic stent (SEPS) have evolved since the early 1990s as a nonsurgical, minimally invasive treatment option in symptomatic patients who are not candidates for surgery, chemoradiation or who have recurrent dysphagia following definitive treatment. At the present time, placement of a SES is the most frequently used method for palliation for esophageal and gastric cardia cancer patients to relieve dysphagia and also has been indicated to occlude malignant esophago-respiratory fistula (ERF). Other indications for stent are phrenic or recurrent laryngeal nerve palsy.11 These patients may benefit from endoluminal implantation of SES, which dramatically relieves dysphagia and obstruction, therefore, improving patient quality of life with a restoration of natural alimentation. 1,2,12 SES can be carried out with a high technical success rate as a 20 minute outpatient procedure. SES has a low rate of stent placement complications and is considered an established part of palliative treatment; however, serious complication may occur.. The complications can be classified as in early (< 7 days after procedure), which has been subdivided in intra-procedural complications, post procedure complications, and late complications (> 7 days after procedure). These complications include cardiorespiratory, hemorrhages; perforation, stent misplaced, stent migration, atypical chest pain, trachea-bronchial stenosis, fever, hemorrhage, perforation, aspiration pneumonia, esophageal reflux, recurrent food impaction, fistula formation, and tumor growth.13

Types of Stents A variety of SES is available for the management of obstruction and ERF in patients with advanced esophageal and gastric cardia cancer. SES diﬀers in design and physical properties and will depend upon the individual manufacturer. Many of the available SEMS are covered to reduce the risk of tumor in-growth and seal ERF.14 In cases where the distal margin of the stent crosses the gastro-esophageal (GE) junction; there are now SEMS available with an anti-reﬂux mechanism.15 SEPS has the characteristics of being removable, save during neoadjuvant treatment, and would not interfere with EUS staging, re-staging and follow-up imaging such as CT scan, PET scan or MRI.16 Self expandable esophageal stent loaded with iodine 125 (I 125) has been described.17 Recently Northeast Florida Medicine Vol. 61, No. 1 2010 33

introduced, a biodegradable stent made of poly-l-lactic acid monoﬁlaments, which dissolve in a few months (3-4 mo), may be a good alternative in the near future.18 (Table 1).

Table 1 Self Expandable Stent Types • • • • • • • • • •

Alimaxx-E stent (Alveolus, Charlotte, NC) Biodegradable stent ( Ella-CS, Hradec Kradec Kralove, Czech Republic) Dual stent – anti reflux valve(Wilson Cook Medical, Winston – Salem, NC) Esophacoil (Medtronin/Instent Eden Prairie, Minnesota) Flamingo Wallstent II (Microvasive Boston Scientific Inc, Natick, MA) Gianturco Z-stent (Wilson Cook Medical, Winston – Salem, NC) Niti-S double stent (Taewoong Medical, Seoul, Korea) Polyflex stent ( Boston Scientific, Natick, MA) Ultra-flex stent ( Microvasive Boston Scientific Inc, Natick, MA) Wall Flex stent (Boston Scientific, Natick, MA)

No single study compares all the above models for cost, physical properties, technical success, complications, and assessment of long term benefits. However, studies suggest that stents are similar regarding dysphagia relief. Verschuur et al randomized placement of an Ultraflex stent, Polyflex stent or Niti-S stent in 125 patients with dysphagia from inoperable carcinoma of the esophagus or gastric cardia. They conclude all three stents are safe and offer adequate palliation of dysphagia from esophageal or gastric cardia cancer. However, Polyflex stents seems the least preferable as placement of this device is technically demanding and associated with high rate of stent migration.19 Conio et al in a randomized prospective study of 101 patients with unresectable esophageal cancer found no difference in palliation compared with partially covered Ultraflex (metal) stent and Polyflex (plastic) stent. However, there were significantly more complications with the Polyflex stents.20 Sabharwal et al in a prospective randomized study using Flamingo covered Wallstent or an Ultraflex covered stent in 53 patients with esophageal cancer localized in the lower third of the esophagus. In this study the two types of stents are equally effective in the palliation of dysphagia and the complication rates associated with their use are comparable.21

Technique Once the decision is made to place a stent, several questions must be answered by the endoscopist. They are: Which is best - General anesthesia or conscious sedation? At what esophageal level is the lesion localized? What type of stent should be used? Should the stent be covered or uncovered? Should the lesion be pre-dilated or not? And in patients with esophageal - respiratory ﬁstula, which stent should be placed ﬁrst, esophageal or respiratory (tracheal or bronchial) stent? The majority of esophageal SES can be performed under conscious sedation. This author prefers general anesthesia. No single study compares all the stent models and at present time there is no demonstrable superiority of one design. It depends on personal experience and preference. The patient is usually placed in the left lateral position. Tumor dilation is necessary in some cases. Dilation up to 10-12 mm is recommended 34 Vol. 61, No. 1 2010 Northeast Florida Medicine

prior to deployment of the stent for some manufacturers (Polyflex stent). For stricture dilation, Balloon, wire guided Bougie or a Savary-Guillard dilator over a guide wire can be used (Figure 2, www.dcmsonline.org). Dilation of the stricture is carried out under endoscopic, fluoroscopy guidance, or both (author prefers dual guidance). Dilation of the stricture is done under endoscopic, fluoroscopic and both guidance. Once the tumor is dilated, the length of the stenosis must be accurately measured. This can be accomplished endoscopically and/or fluoroscopically by visualization and documentation of distance measured from incisors, to the upper and lower margin of the tumor. Usually these margins are then marked using externally placed “paper clips” or internally placed hemoclips (used for hemostasis) prior the stent deployment. Once the SES is in a good position (stent covered at least 3-4 cm longer than upper and lower tumor margins), it is deployed under endoscopy, fluoroscopy or both guidance. The level of technical support from industry and the availability of expert physicians are important factors that contribute to successful stent placement 22(Figures 3-4, www.dcmsonline.org). All patients with a stent crossing the gastro-esophageal junction are informed of the likelihood of severe reflux for which Proton pump inhibitors (PPIs) may be prescribed. (Figure 5, www.dcmsonline.org) For patients with ERF and those with a tumor in the proximity of the airway (trachea or bronchi), it is recommended that a respiratory covered stent be placed first to avoid compression of the airway by esophageal stent and the patient be placed on indefinite suppressive antibiotics in an attempt to reduce morbidity from pneumonia.23-26 Patients are observed for a few hours before discharge. Difficult cases are admitted for overnight observation. Radiology confirmation of the stent position, reopening of the esophagus stricture and ERF closure is recommended (Figure 6, www. dcmsonline.org). The patient is advised to consume liquids and soft mechanical diet to avoid food impaction.

Indications of Self Expanding Stent Stent is probably one of the best options and is recommended in patients with dysphagia caused by esophageal or gastric cardia cancer and a life expectancy of 3 month or less.27 SES is generally seen as a palliative treatment since it has no ablative eﬀect on the tumor. Many sitting stents are used only when other treatments have failed for patients with poor prognosis. Indications for self expanding stent have two categories: absolute and relative as opposed to surgical resection. Absolute indications are: Advance esophageal cancer with distant metastasis; Tracheo - esophageal Fistula ( in conjunction with respiratory stent); Phrenic or recurrent laryngeal nerve palsy; and Patient not being candidate for radiotherapy/chemotherapy or other form of treatment. Relative indications are: Older age ( 80 or older); Extreme cachexia/malnutrition; Multiple medical co-morbidities and Esophageal stent as a bridge to surgery (and its potential eﬀect on the nutritional status prior to surgery, need to be studied).

Contraindications of Self Expanding Stent Self expanding stent has absolute and relative contraindications. Absolute contraindications are:Tumor involving the upper esophageal sphincter. Relative contraindications are: Extensive cancer involving gastric cardia and While patient is undergoing induction therapy (chemo-radiation). www . DCMS online . org

Complications Self expanding stents (SEMS and SEPS) are very attractive options in the management of patients with end-stage esophageal and gastric cardia cancer. Relief of the dysphagia is immediate (>90% of the cases). However, stent placement is not always easy to perform and is not free of complications. Traditionally, complications have been classified as early and late complications. Other authors classify them as an intra-procedural, post procedural or delayed complications. Overall 41.6% of patients had at least one complication after stent placement. The mortality is < 5% at 1 week and <30% at 30 days.28 Complications are also related to the site of the stent placement. For proximal stents the foreign body sensation and respiratory symptoms are the most common reported symptoms. For distal stents, mainly those placed through the GE-junction, intractable reflux requiring the use of proton pump inhibitors (PPIs) is the most common reported symptom. Additionally, each of the stents has its own complications; for instance self expanding plastic stent (SEPS) or Polyflex stent has been associated with high rates of migration, the lesion must be pre-dilated ( 10 to 12 FR) due to large delivery system, thus perforation is high in fibrotic and poorly distended lesions, mainly those who have been previously treated with chemo/ radiotherapy.29 There have been various types of SEMS with their own shortcomings. For instance, covered metallic stent has been shown to migrate more frequently than uncovered stent.30 Uncovered stents have been associated with increased rate of tumor ingrowths compared with covered metal stent. However the use of Photodynamic Therapy (PDT) to treat tumor in growth through self expanding metal esophageal stents has been described as effective and safe.8, 31 Recurrent dysphagia occurs in almost one-third of patients after stent placement. Repeat interventions for stent-related recurrent dysphagia are effective in over 90% of patients. 32 Prior irradiation and /or chemotherapy increase the risk of persistent chest pain after stent placement.33 There are early and post procedural complications. They are: Early complications (<7 days): A-1 Intra-procedural complications: Associated with sedation per se such as cardio-respiratory complications, iatrogenic perforation, hemorrhages or stent malposition or inadequate deployment (above superior esophageal sphincter, with a consequent foreign body sensation) and A-2 Post procedural complications: Hemorrhages, perforation, severe chest pain (atypical chest pain), respiratory compromise due to airway compression with resulting asphyxia. Late or delayed complications (> 7 days): Hemorrhages, perforation, severe recalcitrant esophageal reflux, stent migration, ulcerations, trachea-esophageal fistula, in-growth or overgrowth tumor and occlusion of the stent (food impaction).

Prognosis Survival of patients with esophageal cancer is often poor; ﬁve year survival is less than 20%.1, 2 Although SES has no direct anti-tumor activity, stenting the esophagus has dramatically improved the quality of life of patients with end-stage esophageal cancer.4,34 This application probably extends the survival of symptomatic, inoperable patients by preventing aspiration pneumonia, dehydration and improving nutritional intake. The median survival after SES placement www . DCMS online . org

ranges from 49 to 186 days 25,35,36,37 However, it is important to note that if anorexia is secondary to the presence of the tumor and not due to its mechanical implications, stenting is not likely to have a major impact on nutrition. Anorexic patients will beneﬁt from a feeding tube with a ﬁxed amount of caloric intake.

Summary and Recommendations SEMS and SEPS are nonsurgical, minimally invasive treatment options in symptomatic patients with advanced esophageal and gastric cardia cancer, who are not candidates for surgery, chemo-radiation or who have recurrent dysphagia following definitive treatment. Stents may also benefit patients with Esophageal-respiratory fistula (ERF) and phrenic or recurrent laryngeal nerve palsy. SEPS placement is safe, dysphagia score improve in a statistically significant manner. However, stent migration is a common event. Seps are removable, safe during neoadjuvant treatment, and would not interfere with EUS staging and follow-up imaging such as CT scan, PET scan or MRI. Esophageal stents related complications can be early (< 7 days after procedure) or late complications. These complications include cardio-respiratory, hemorrhages; perforation, stent misplaced, stent migration, atypical chest pain, tracheabronchial stenosis, fever, hemorrhage, perforation, aspiration pneumonia, esophageal reflux, recurrent food impaction, fistula formation, and tumor in-growth or overgrowth tumor. Stents crossing the gastro-esophageal junction can cause severe reflux and PPI maybe prescribed. For tumor or strictures in the upper third of the esophagus, the proximal end of the stent should be within or below the upper esophageal sphincter. Patients with ERF and those with tumor in the proximity of the airway (trachea or bronchi), should receive a respiratory covered stents first to avoid compression of the airway by the esophageal stents. Suppressive antibiotics are recommended to reduce morbidity from pneumonia. Self expandable esophageal stent loaded with iodine 125 (I 125) and the recently introduced biodegradable stent made of poly-l-lactic acid monofilaments, which dissolve in a few months can be a good alternative in the near future. Although SES has no direct anti-tumor activity, stenting the esophagus has dramatically improved the quality of life of patients with end-stage esophageal cancer.4, 33 The median survival after SES placement ranges from 49 to 186 days.

References 1.

Ries lag,Melbert D, Krapcho M, Stinchcomb DG, et al editors. SEER Cancer Statistics Review, 1975 – 2005. Bethesda, MD.: National cancer Institute. http://seer.cancer.giov/csr 1975 - 2005/, based on November 2007 SEER data submission, posted to the SEER website, 2008. (November 19, 2009)

Pultrum BB, Van Westreenen HL, Mulder NH. Outcome of palliative care regimens in patients with advanced esophageal cancer detected during explorative surgery. Anticancer res. 2006; 26:2289-2293.

Siersema, PD, Schrauwen, SL, Van Blankenstein, M. et al. Self-expanding metal stents for complicated and recurrent esophagogastric cancer. GastrointestEndosc. 2001; 54:579.

Paganin F, Schouler L, Cuissard L, et al. Airway and esophageal stenting in patients with advanced esophageal cancer and Northeast Florida Medicine Vol. 61, No. 1 2010 35

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pulmonary involvement. PLoS One. 2008 Aug 29;3(8):e3101. PMID: 18769726 [PubMed - indexed for MEDLINE] Fleisher D, Sivak MV Jr. Endoscopic Nd: YAG laser therapy as palliation for esophagogastric cancer. Parameters affecting initial outcome. Gastroenterology. 1985;89:827-31. Christiaens P, Decok S, Buchel O. et al. Endoscopic trimming of metallic stents with the use of argon plasma. Gastrointest. Endosc. 2008; 67:369-71. Homs MY, Eijkenboom WM, Siersema PD. Single-dose brachyotherapy for the palliative treatment of esophageal cancer. Endoscopy. 2005;37:1143-8. Okunaka T, Kato H, Conaka C, Yamamoto H, et al. Photodynamic therapy of esophageal carcinoma. Surg. Endosc. 1990;4:150-3. Burris HA3rd, Vogel CL, Castro D et al. Intratumoral cisplatin/epinephrine-injectable gel as a palliative treatment treatment for accessible solid tumors: a multicenter pilot study. Otolaryngol. Head Neck Surg. 1998; 118:496-503. Waldleigh RG, Abassi S, Korman L. Palliative ethanol injections of unresectable advanced esophageal carcinoma combined with chemoradiation. Am J. Med. Sci. 2006; 331:110-12. Russell E White, Robert K Parker, John W Fitzwater, Zachariah Kasepoi, Mark Topazian. Stents as sole therapy for oesophageal cancer: a prospective analysis of outcomes after placement. www.thelancet.com/oncology Published online February 17, 2009 DOI:10.1016/S1470-2045(09)70004-X) Schaer J, Katon RM, Ivancev K, et al. Treatment of malignant esophageal obstruction with silicone-coated metallic self-expanding stents. Gastrointest Endosc. 1992; 38:7-11. [PubMed]. McLoughlin MT, Byrne MF. Endoscopic stenting: where are we now and where can we go? World J Gastroenterol. 2008 Jun 28; 14(24):3798-80. PMID: 18609702 [PubMed - indexed for MEDLINE]. Uitdehaag M, Van Hooft J, Verschuur M.L, Rpici A, et al. A fully-covered stent (Alimaxx-E) for the palliation of malignancy dysphagia: a prospective follow up study. Gastrointestinal Endosc 2009. Dec;70(6):1082-9. Epub 2009 Jul 28. PMID: 19640521 [PubMed - in process]) Homs My;wahab PJ; Kuipers EJ; Steverberg EW, et al. Esophageal stents with antireflux valve for tumors of the distal esophagus and gastric cardia: a randomized trial. Gastrointestinal Endosc. 2004Nov;60(5):695-702. Alder D, Fang J, Wong R et al. Placement of polyflex stents in patients with locally advanced esophageal cancer is safe and improves dysphagia during adjuvant therapy. Gastrointestinal Endoscopy.2009. Article in Press. He Guo J, Jun Teng G, Yu Zhu G et al. Self-expandable Esophageal stent loaded with I 125 Seeds: Initial Experience in patient with Advanced Esophageal Cancer. Radiolog.y 2008 May;247(2):574 81. Epub 2008 Mar 18. PMID: 18349316 [PubMed - indexed for MEDLINE]). Vleggaar F. Stent placement in esophageal cancer as a bridge to surgery. Gastrointestinal Endoscopy. 2009, Oct;70(4):620-2. No abstract available. PMID: 19788979 [PubMed - indexed for MEDLINE]). Verschuur EM, Repici A, Kuipers EJ et al. New design esophageal stents for the palliation of dysphagia from esophageal or gastric cardia cancer: a randomized trial. Am J Gastroenterol. 2008 Feb;103(2):304-12. Epub 2007 Sep 25. Conio, M; Repici, A; Battaglia, G; et al. randomized prospective comparation of self expandable plastic stents and partially covered self-expandable metal stents in the palliation of malignant esophageal dysphagia. AM J Gastroenterology. 2007; 102; 2667.

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21. T Sabharwal, MS Hamady, S Cui, et al. A randomized prospective comparation of the Flamingo wallstet and Ultraflex stent for palliation of dysphagia associated with lower third esophageal carcinoma. Gut 2003 July; 52(7):922-92. 22. Pennnathur, A; Chang, A; McGrath K, et al. Polyflex Expandable stents in the Treatment of esophageal disease: Initial experience. Ann Thorac Surg. 2008;85:1968-73. 23. Paganin F, Scouler L, Cuissard L, et al. A. PLoS One Airway and Esophageal stenting in patients with Advanced Esophageal Cancer and pulmonary involvement. Research Article, published 29 Aug 2008 |doi:10.1371/journal.pone.0003101 Volume 3.issue 8 e301. Plos ONE www.plosone.org. 24. Lee K.E, Shin J.H, Song H.Y, Kim S.B, et al. Management of airway involvement of esophageal cancer using covered retrievable nitinol stents. Clinical Radiology. (2009) 64,133-141. 25. Christie NA, Buenaventura PO, Fernando HC, et al. results of expandable metal stents for malignant esophageal obstruction in 100 patients: short-term and long term follow up. Ann thorac Surg. 2001; 71:1797-801. 26. Rajiman, I, SiddiqueI, Ajani et al. Palliation of malignant dysphagia and fistulae with coated expandable metal stents: experience with 101 patients. Gastrointest Endosc 1998; 48:172. 27. Siersema PD. Treatment options for esophageal strictures. Nat Clin gastroenterol Hepatol. 2008,5:142-52. 28. Selinger CP, Ellul P, Smith P.A, et al. Esophageal stent insertion for palliation of dysphagia in a District general Hospital: experience from a case series of 137 patients. Q J Med. 2008; 101:545-548. 29. Vakil N, Morris AI, Marcon N et al. A prospective, randomized controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction. Am. J Gastroenterl. 2001; 96: 1791-6. 30. Johnson E, Enden T, Noreng HJ, et al survival and complications after insertion of self expandable metal stents for malignant esophageal stenosis. Scand J Gastroenterol. 2006 Mar;41(3):252-6. PMID: 16497610 [PubMed - indexed for MEDLINE]) 31. Scheider DM, Siemens M, Cirocco M, et al. Photodynamic therapy for the treatment of tumor ingrowth in expandable esophageal stent. Endoscopy.1997.May; 29(4):271-4. 32. Homs MY, Steyerberg EW, Kuipers EJ et al. Causes and treatment of recurrent dysphagia after self-expanding metal stent placement for palliation of esophageal carcinoma. Endoscopy.2004 Oct; 36(10):880-6. 33. Iraha Y, Murayama S, Toita T. Self expandable metallic stent placement for patients with inoperable esophageal carcinoma: Investigation of the influence of prior radiotherapy and chemotherapy. Radiat Med (2006) 24:247-252. 34. Madhusudhan C, Saluja SS, Pal S, Ahuja V, Saran P, Dash N, Sahni P, Chattopadhyay T. Palliative stenting for relief of dysphagia in patients with inoperable esophageal cancer: impact on quality of life. Disease of the Esophagus (2009) 22,331-336. 35. Cwikiel W, Tramberg KG, Cwikiel M, et al. Malignant dysphagia: Palliation with esophageal stents- long term results in 100 patients. Radiology 1998; 207:513-18. 36. White R, Parker R, Fitzwater J, etal. Stents as a sole therapy for esophageal cancer: a prospective analysis of outcomes after placement. Lancet Oncol. 2009;10:240-46.www.thelancet. com/oncology. 37. Thompson A, Baron Todd. Esophageal stents; One size does not fit all. J Gastroentero Hepatol. 2009; 24:114-119.

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Advanced Imaging and Ablation for the Endoscopic Detection and Treatment of Barrett’s Disease Abraham M. Panossian, MD; Lois L. Hemminger, NP-C; and Herbert C. Wolfsen, MD Abstract: Barrett’s esophagus develops as a result of the chronic, pathological reﬂux of gastro-duodenal contents into the esophagus and occurs in 1-2% of the US population with increasing prevalence.1-7 The clinical importance of un-treated Barrett’s disease is related to the associated risk for progression to dysplasia and neoplasia, as evidenced by the continuing increase in the rate of esophageal cancer, especially in southern states such as Florida. Endoscopic mucosal resection, usually performed at the time of endoscopic ultrasound examination, removes suspicious mucosal irregularities and permits quantitative and qualitative histologic analysis. Endoscopic ablation of remaining metaplastic and dysplastic tissue is necessary to prevent the development of metachronous disease.

Introduction Barrett’s esophagus (BE) is a common premalignant condition that is characterized by a change of the normal esophageal stratified squamous epithelium into intestinal-type specialized columnar metaplasia related to the chronic reflux of gastroduodenal contents into the esophagus. It has been recognized as the most important risk factor for the development of esophageal adenocarcinoma. The incidence and subsequent mortality of esophageal cancer has risen at a dramatic rate in the Western world, particularly in the South. Barrett’s esophagus may proceed through a degenerative path with progression from non-dysplastic specialized intestinal metaplasia to low-grade dysplasia (LGD), high-grade dysplasia (HGD), and finally invasive adenocarcinoma. At one time esophagectomy was considered the only available treatment option in most medical centers for patients with Barrett’s high-grade dysplasia and early adenocarcinoma while endoscopic imaging was reserved for initial diagnosis and surveillance of early BE. Over the past 15 years, new and exciting endoscopic technologies have been developed that have enhanced not only the accuracy of detection of BE and staging of high grade lesions, but have also provided endoscopic options for the complete eradication of advanced BE and early adenocarcinoma.

Endoscopic Treatment/Programmatic Approach The safe and effective use of any ablation device requires optimal endoscopic imaging for the early detection and characterization of disease and thereafter to guide therapy. There are several key endoscopic imaging studies in Barrett’s disease and esophageal cancer including the use of high-resolution endoscopy (HRE; also called high-definition endoscopy) with narrow-band imaging (NBI). NBI is a method of filtering Address Correspondence to: Herbert C. Wolfsen, MD, Division of Gastroenterology & Hepatology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224. Phone: (904) 953-2221. Fax: (904) 953-7260. Email: pdt@mayo.edu.

www . DCMS online . org

white light to remove the red-light component permitting blue green light to scan the mucosa to enhance the detection of mucosal glandular and vascular changes associated with dysplasia and neoplasia. Mayo Clinic recently published the results of tandem controlled study that found the use of HRE and NBI detected significantly more BE and higher grades of dysplasia in these patients while requiring the use of significantly fewer biopsies, compared with standard resolution white-light endoscopy (WLE).8 Other important endoscopic imaging studies are being done that investigate the use of advanced spectroscopic and laser-based imaging techniques such as auto-fluorescence imaging and confocal laser endomicroscopic imaging. Another important development has been the increased use of endoscopic mucosal resection (EMR) to remove any mucosal irregularities suspicious for the presence of neoplasia. This is an “excisional biopsy” technique for the endoscopic removal of mucosal and submucosal lesions up to several centimeters in diameter. The size of these specimens permits detailed histologic analysis for the presence of dysplasia and neoplasia at the lateral and deep tissue margins. Over the past five years in North America, the use of EMR has steadily increased with en bloc or piecemeal resections that use injected-assisted, cap-assisted or ligation-assisted devices.9 Advantages of EMR include removing high-risk mucosal lesions, recovering tissue specimens for quantitative and qualitative histologic analysis to determine the depth of disease invasion, and detecting locally advanced disease including lymphatic or neural involvement.10

Ablation Devices: Photodynamic Therapy Photodynamic therapy was the first endoscopic ablation technique used to treat patients with Barrett’s dysplasia as alternative to esophageal resection surgery. Photodynamic therapy (PDT) uses a photosensitizer drug such as porfimer sodium (Photofrin® Mont St. Hilaire, Quebec, Canada) that is activated by a high-power light energy device (using 630nm red light) to produce ablation of the gut epithelium (Ps-PDT). Ps-PDT effects include the triggering of apoptosis and vascular inflammation with ischemia. The intensity of the photodynamic effect appears to be related to tissue photosensitizer and oxygen content rather than selective drug cellular uptake or elimination. Porfimer sodium is the most commonly used photosensitizer for PDT in North America and previously studied applications include Barrett’s dysplasia and carcinoma, esophageal squamous cell carcinoma, and cholangiocarcinoma.11-13 The most important Ps-PDT study (PHO BAR) was performed in patients with Barrett’s HGD.14 This multicenter Northeast Florida Medicine Vol. 61, No. 1 2010 37

prospective randomized trial included a reference laboratory to standardize the histological diagnosis of HGD. The study also included surveillance endoscopy with a rigorous biopsy protocol that documented progression to invasive carcinoma in 28% of the patients treated with omeprazole alone (no PDT). This demonstrated the serious risks associated with a surveillance endoscopy approach (“watch and wait”) for patients with a confirmed diagnosis of HGD. At 24 months follow-up after treatment, a mean 52% of Ps-PDT treated patients had complete resolution of Barrett’s disease (complete response for intestinal metaplasia, (CR-IM)) while 77% had complete elimination of HGD (CR-HGD). Most importantly, adenocarcinoma occurrence was significantly lower in the Ps-PDT group (13%) compared with the control group (28%).14 Although the study demonstrated that endoscopic therapy was a safe and effective treatment as an alternative to esophageal resection surgery, it was not a realistic portrayal of how Ps-PDT is used in clinical practice. The Mayo Clinic recently published a retrospective cohort study that compared the long-term outcomes of patients with BE and HGD treated with either Ps-PDT or esophagectomy between 1994 and 2000 with an average follow up of 5 years for both groups.15 The 129 Ps-PDT patients were older with significantly more cardiac disease and higher age-adjusted co-morbidity compared with the 70 patients who underwent surgery. Prior to ablation treatment, high-risk nodular lesions were removed in 80% of patients using endoscopic mucosal resection via band ligation or cap techniques. HGD was eliminated in 86% of patients treated with Ps-PDT, although 30 % of patients underwent subsequent endoscopic treatment for recurrent HGD, including 5.4 % of patients who progressed to carcinoma. Overall survival, however, was similar in both groups, with 9% mortality in the PDT group and 8.5% in the surgery group. There were no deaths related to esophageal cancer.15 A similar study in patients with early esophageal cancer (T1a mucosal adenocarcinoma) treated with either Ps-PDT (132 patients) or surgery (46 patients) also found equivalent overall survival.16 Recurrent carcinoma was detected in 12 % of patients in the Ps-PDT group that was successfully re-treated using endoscopic therapy without an impact on overall survival. These studies established the role of endoscopic ablation therapy for patients with Barrett’s HGD and early carcinoma.17, 18

Radio Frequency Ablation Radio Frequency Ablation (RFA) applies high power radiofrequency energy using bipolar electrodes that alternate electric and magnetic fields producing vibration of ions and water molecules in the target tissue with rapid heating (and thermal destruction). RFA produces a thin-layer destruction of the surface epithelium (mucosa). It is important, therefore, that all nodular and thickened dysplastic and neoplastic tissue be removed using endoscopic mucosal resection to permit controlled superficial ablation of endoscopically flat mucosa. Circumferential ablation uses electrodes wrapped around a 38 Vol. 61, No. 1 2010 Northeast Florida Medicine

catheter-based balloon device of varying diameters (Halo 360) while focal ablation is performed using an endoscopemounted device (Halo 90).19 A recent randomized, sham-controlled study conducted in 19 centers (including Mayo Clinic Florida) for the eradication of Barrett’s dysplasia and to reduce the risk of invasive carcinoma was recently published in the New England Journal of Medicine.10 Patients with high-risk nodular lesions underwent endoscopic mucosal resection prior to repeat biopsy and study randomization to either RFA or sham procedures (11 patients). All patients were maintained on twice daily esomeprazole 40 mg. All histopathology slides were reviewed by a centralized expert laboratory. There were a total of 127 patients with either LGD (64 patients) or HGD (63 patients). Overall, clearance of dysplasia was noted in 86% at one year (81% of HGD patients and 90% for LGD patients). All intestinal metaplasia was eradicated in 77% of patients. Progression from HGD to carcinoma was detected in 4/21 patients in the sham-treatment group versus 1/42 patients in the RFA group. Sub-squamous intestinal metaplasia was found in 5.1% of RFA patients compared with 40.0% in the control group. There were 298 total RFA procedures (mean 3.5 per patient over 12 months) but no perforations or procedure-related deaths. Strictures developed in five patients after RFA (6.0%) that were treated with endoscopic dilations (mean 2.6 procedures). Although, these results reflect 12 months follow-up data, the study demonstrates that RFA is more effective than surveillance biopsy protocol in HGD patients, and that surveillance is no longer acceptable strategy. And for patients with endoscopically flat HGD, RFA is the treatment of choice compared with other methods of ablation or surgery.20

Cryotherapy Cryotherapy uses freezing of the gut mucosa to induce cell death by extra-cellular ice crystal formation, producing fluid shifts and disruption of cellular membranes and organelles (solution-effect injury). Rapid freezing forms intracellular ice increasing cell kill by edema, ischemia, and mechanical disruption of cell membranes. There are commercially available cryogen systems, using either liquid nitrogen or carbon dioxide. These cryogens are delivered by endoscopically placed spray catheters alongside venting, decompression tubes to prevent gastric distention and perforation. Dosimetry studies suggest that spray freezing with liquid nitrogen (-196 ° C) or rapid expansion of carbon dioxide with induction of tissue hypothermia by the Joule-Thompson effect (-78 ° C) may produce tissue depth of injury of > 4mm, similar to that produced by Ps-PDT.21 There are no controlled trials available studying the use of cryotherapy. Recently our program contributed to a multicenter study using liquid nitrogen cryotherapy for BE HGD. At the time of analysis, 27/45 patients had completed treatment (mean 4.3 sessions), with clearance of HGD in 93% and eradication of intestinal metaplasia in 56%. None of the patients progressed to carcinoma and there were no www . DCMS online . org

treatment-related adverse events.22 Mayo Clinic’s treatment results were also included in a multicenter study of patients treated with liquid nitrogen cryotherapy for palliative treatment of esophageal carcinoma.23 Canto et al. recently reported an uncontrolled single center experience with CO2 cryotherapy in 44 patients with Barrett’s HGD or intramucosal carcinoma. For those patients completing treatment, clearance of HGD and intestinal metaplasia was greater than 90% at median follow-up of 11.8 months.24 These three early stage studies suggest that cryotherapy is safe and useful although we await the results of comparative trials.

Treatment Center In 1995 Mayo Clinic Florida established a comprehensive endoscopic ablation center (the Center) that uses photodynamic therapy with a laser-activated photosensitizer drug (porfimer sodium) to destroy esophageal dysplasia and neoplasia. Since 2005 the Center has used radiofrequency energy (BARRx® procedure) for mucosal ablation in patients with Barrett’s disease. Other ablation modalities used in the program include endoscopically-delivered spray liquid nitrogen cryotherapy (2007) and carbon dioxide (CO2) cryotherapy (2009). Cryotherapy uses rapid freezing and thawing cycles produce cell death of the abnormal target mucosa. The ideal use of these complex endoscopic diagnostic and therapeutic technologies requires a comprehensive program providing detection, treatment and follow-up of esophageal dysplasia and neoplasia is necessary to ensure the successful endoscopic treatment of Barrett’s disease. Figure 1 demonstrates the rapid increase in the number of endoscopic resection and ablation procedures in the Center over the past five years. Endoscopic mucosal resection and ablation of Barrett’s dysplasia and non-invasive esophageal carcinoma has become first-line therapy at Mayo Clinic Florida, as an alternative to esophageal resection surgery.

Figure 1 Increase of Endoscopic Resection and Ablation Procedures

Conclusion Well done studies with Ps-PDT and RFA have deﬁnitely established the role of endoscopic ablation therapy in the treatment of patients with BE HGD and early cancer in expert centers. To maintain this record of treatment success, www . DCMS online . org

it is critically important that ablation centers have an entire program in place for the detection, treatment and follow up of esophageal dysplasia and neoplasia.25 There should be a detailed clinical evaluation of each patient followed by a careful endoscopic examination using advanced endoscopic imaging modalities such as high-resolution endoscopy with autoﬂuorescence and narrow band imaging for the detection of all areas of dysplasia and neoplasia, especially nodular highrisk lesions. This procedure should be followed by endoscopic ultrasound evaluation to detect malignancy invading the deeper layers of the esophageal wall or extending to regional lymph nodes, followed by endoscopic mucosal resection to remove areas suspicious for malignancy. After complete mucosal healing with high doses of acid blocker medication, ablation of all the residual Barrett’s mucosa (typically 3-4 sessions within 12 months) is recommended to prevent the development of metachronous dysplasia or neoplasia. Thereafter, it remains important to continue life-long aggressive acid suppression therapy (or anti-reﬂux surgery). Long-term surveillance endoscopy is also recommended to monitor the esophageal lining, especially the distal esophagus and esophageal junction areas for the early detection and removal of any mucosal abnormality suggestive of residual or recurrent disease.26 Careful attention to these endoscopic and clinical practices has resulted in the successful treatment of Barrett’s dysplasia and early carcinoma without requiring esophageal resection surgery.

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Peters J H, Hagen J A,DeMeester S R. Barrett’s esophagus. J Gastrointest Surg. 2004;8:1-17.

Eisen G M. Ablation therapy for Barrett’s esophagus. Gastrointest Endosc. 2003;58:760-769.

Reid B J. Barrett’s esophagus and esophageal adenocarcinoma. Gastroenterol Clin North Am. 1991;20:817-834.

Shaheen N,Ransohoff D F. Gastroesophageal reflux, Barrett esophagus, and esophageal cancer: scientific review. JAMA. 2002;287:1972-1981.

Rex D K, Cummings O W, Shaw M, et al. Screening for Barrett’s esophagus in colonoscopy patients with and without heartburn. Gastroenterology. 2003;125:1670-1677.

Gerson L B, Shetler K,Triadaﬁlopoulos G. Prevalence of Barrett’s esophagus in asymptomatic individuals. Gastroenterology. 2002;123:461-467.

Wolfsen H C, Crook J E, Krishna M, et al. Prospective, controlled tandem endoscopy study of narrow band imaging for dysplasia detection in Barrett’s Esophagus. Gastroenterology. 2008;135:24-31.

Waxman I,Konda V J. Mucosal ablation of Barrett esophagus. Nat Rev Gastroenterol Hepatol. 2009;6:393-401.

10. Shaheen N J, Sharma P, Overholt B F, et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med. 2009;360:2277-2288. 11. Wolfsen H C. Uses of photodynamic therapy in premalignant and malignant lesions of the gastrointestinal tract beyond the esophagus. J Clin Gastroenterol. 2005;39:653-664.

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12. Wolfsen H C. Present Status of Photodynamic Therapy for High-Grade Dysplasia in Barrett’s Esophagus. J Clin Gastroenterol. 2005;39:189-202. 13. Prasad G A, Wang K K, Baron T H, et al. Factors associated with increased survival after photodynamic therapy for cholangiocarcinoma. Clin Gastroenterol Hepatol. 2007;5:743748. 14. Overholt B F, Lightdale C J, Wang K K, et al. Photodynamic therapy with porﬁmer sodium for ablation of high-grade dysplasia in Barrett’s esophagus: international, partially blinded, randomized phase III trial. Gastrointest Endosc. 2005;62:488498. 15. Prasad G A, Wang K K, Buttar N S, et al. Long-term survival following endoscopic and surgical treatment of high-grade dysplasia in Barrett’s esophagus. Gastroenterology. 2007;132:1226-1233. 16. Prasad G A, Wu T T, Wigle D A, et al. Endoscopic and Surgical Treatment of Mucosal (T1a) Esophageal Adenocarcinoma in Barrett’s Esophagus. Gastroenterology. 2009; 17. Panjehpour M,Overholt B F. Porﬁmer sodium photodynamic therapy for management of Barrett’s esophagus with high-grade dysplasia. Lasers Surg Med. 2006;38:390-395. 18. Wolfsen H. Endoluminal Therapy for Esophageal Disease: An Introduction. Gastrointest Endoscopy Clin N Am. January 2010;20:1-10. 19. Van Vilsteren F,Bergman J. Endoscopic Therapy Using Radiofrequency Ablation for Esophageal Dysplasia and

Carcinoma in Barrett’s Esophagus. Gastrointest Endoscopy Clin N Am. 2010;20:[In Press]. 20. Van Vilsteren F, Pouw R, Seewald S, et al. A multi-center randomized trial comparing stepwise radical endoscopic resection versus radiofrequency ablation for Barrett esophagus containing high-grade dysplasia and/or early cancer. (Abstract 939) Gastrointest Endosc. 2009;69 AB133. 21. Halsey K,Greenwald B. Cryotherapy in the Management of Esophageal Dysplasia and Malignancy. Gastrointest Endoscopy Clin N Am. 2010;20:[In Press]. 22. Shaheen N, Greenwald B, Dumot J, et al. Safety and efficacy of endoscopic spray cryotherapy for Barrett’s esophagus with high-grade dysplasia (Abstract W1387) Gastrointest Endosc 2009;69:AB357. 23. Greenwald B, Dumot J, Abrams J, et al. Endoscopic spray cryotherapy for esophageal cancer: safety and efficacy (Abstract W1352). . Gastrointest Endosc. 2009;69 AB349. 24. Canto M, Gorospe E, Shin E, et al. Carbon dioxide cryotherapy is a safe and effective treatment of Barrett’s esophagus (BE) with HGD/intramucosal carcinoma (Abstract W1323). Gastrointest Endosc. 2009;69 AB341. 25. Bergman J J. Radiofrequency ablation--great for some or justified for many? N Engl J Med. 2009;360:2353-2355. 26. Panjepour M, Overholt B, Phan-Brooks M,Overholt A. Photodynamic therapy (PDT) for Barrett’s esophagus with dysplasia: long-term follow-up of gastroesophageal junction area is recommended (Abstract W1317). . Gastrointest Endosc 2009;69 AB339.

2nd Annual Quality and Safety Conference May 7, 2010 at the University of North Florida University Center/7:30 a.m. - 3:00 p.m. Special Keynote Address by Brent James, MD Chief Quality Oﬃcer, Executive Director, Institute for Health Care Delivery Research, Intermountain Healthcare, Salt Lake City, Utah

Special Feature: First report from the newly operational Quality Collaborative of Northeast Florida

$50.00 Registration Fee Register now at www.unf.edu/brooks/center

40 Vol. 61, No. 1 2010 Northeast Florida Medicine

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A Word of Thanks to Our Physicians Volunteers in Medicine Jacksonville (VIM-Jax), a volunteer-run primary care clinic, wishes to thank the following physicians who give of their time to allow access to care for the working uninsured of Greater Jacksonville: Dr. Ted Montgomery Dr. Dawn Mussallem Dr. Photis Nichols Dr. Dinesh Pubbi Dr. Prithviraj Rai Dr. Douglas Robins Dr. Renato Romero Dr. Howard Rose Dr. Eric Rosemund Dr. Neil Sager Dr. Timothy Schneider Dr. Chris Scuderi Dr. Mona Shah Dr. D.M. Shetty Dr. Edward Smith Dr. Timothy Sternberg Dr. Robert Van Cleve Dr. Timothy Woodward

Dr. Kenneth Adams Dr. Vaqar Ali Dr. Leonardo Alonso Dr. Youssef Al-Saghir Dr. Majdi Ashchi Dr. Leslie Beadling Dr. Richard Beck Dr. JeďŹ&#x20AC;rey Brink Dr. James Burt Dr. Vincent Caracciolo Dr. Alan Cleland Dr. Gerardo Colon Dr. Cynthia Flanders Dr. John Foster Dr. Salim Ghazi Dr. Sanjiva Goyal Dr. David Grech Dr. A.L. Green Dr. Jack Groover Dr. Kevin Hayes Dr. Howard Hogshead Dr. Margaret Johnson Dr. Yazan Khatib Dr. Sumant Lamba Dr. Kirk Landau Dr. JeďŹ&#x20AC;rey Levenson Dr. Michael Lutz Dr. John Mazur Dr. Charles McIntosh Dr. Dennis McDonagh

Volunteers in Medicine - Jacksonville VIM-Jax requests physician volunteers. They can volunteer as little as 4 hours a month at our newly renovated facility at 41 E. Duval Street. VIM-Jax also has specialty care, both at our clinic and to outside providers. Primary care/internal medicine volunteers are an ongoing need. Please visit our website, www.vim-jax.org for more information. You may also contact Catie Wallace at 904-3992766 x103 or cwallace@ vim-jax.org.

Volunteers in Medicine - Jacksonville Serving the working uninsured 41 E. Duval Street, Jacksonville, FL 32202 Phone: (904) 399-2766 Fax: (904) 549-8300 Website: www.vim-jax.org 42 Vol. 61, No. 1 2010 Northeast Florida Medicine

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LIVE & SILENT AUCTIONS

DCMS Membership Applications These physicians’ applications for membership in the Duval County Medical Society are now being processed. Any information or opinions you may have concerning the eligibility of the applicants listed here may be directed to Ashley Booth Norse, MD, DCMS Membership Committee Chair (904-2444106 or Barbara Braddock, Membership Director (904-355-6561 x107). Joanne L. Adkison, MD Pediatrics Nemours Children’s Clinic 807 Children’s Way Medical Degree: University of Chicago College of Medicine Residency: University of Florida College of Medicine Jacksonville Nominated by: UFJP Shachie V. Aranke, MD Neurology The Neuroscience Institute at Shands 580 W. 8th St. 9th FL Tower I Medical Degree: Medical College of Georgia Medical School Residency: University of Minnesota Medical School Fellowship: University of Michigan Medical School Nominated by: UFJP Agnes E. Aysola, MD Pathology UF Pathology 655 W. 8th St. 1st FL Clinical Center Medical Degree: Semmelweis University of Medicine Residency: Conemaugh Valley Memorial Medical Center Fellowship: Institute for Transfusion Medicine Nominated by: UFJP Edmund Z. Brinkis, MD Orthopedic Surgery UF Bone & Joint Center at Emerson 4555 Emerson Exwy. #100 Medical Degree: New York Medical College Residency: State University of New York Fellowship: Thomas Jefferson University Hospital Nominated by: UFJP Nauman A. Chaudary, MD Pulmonary Medicine UF Pulmonary 555 W. 8th St. Pavilion 4th FL N. Medical Degree: Army Medical College Residency: Marshall University School of Medicine Fellowship: West Virginia University School of Medicine Nominated by: UFJP Elizabeth L. Devos, MD Emergency Medicine UF Emergency Medicine 655 W.8th St. 1st FL Clinical Center Medical Degree: Northeastern Ohio Universities Residency: University of Florida Health Science Center/Jacksonville Fellowship: George Washington University Medical School Nominated by: UFJP Elliot L. Dimberg, MD Neurology Mayo Clinic

4500 San Pablo Rd. Medical Degree: Tulane University School of Medicine Residency/Fellowship: University of Virginia Medical School Fellowship: May Clinic Nominated by: Kevin Boylan, MD; Kathleen Kennelly, MD; Elizabeth Shuster, MD Brenda L. Figueroa, MD Pediatrics/Adolescent Pediatrics San Jose Pediatrics & Adolescent Center 6271 St. Augustine Rd. Medical Degree: Universidad Autonoma de Guadalajara Medical School Internship: New York Medical College Fifth Pathway Program Residency: Children’s Hospital at Sinai Hospital Nominated by: UFJP Anna Gajda, MD Family Medicine Commonwealth Family Practice Center 761 Edgewood Ave. N. Medical Degree: Medical Academy in Lodz Residency: University of Florida Health Science Center Nominated by: UFJP Samir L. Habashi, MD Gastroenterology UF Beaches Digestive & Liver Specialists 570 Jacksonville Dr. Medical Degree: Ain Shams University Residency/Fellowship: University of Florida College of Medicine/Jacksonville Nominated by: UFJP Matthew S. Hale, MD Emergency Medicine UF Emergency Medicine 655 W. 8th St. 1st FL Clinical Center Medical Degree: Medical University of South Carolina Residency: University of Florida Health Science Center/Jacksonville Nominated by: UFJP Hary T. Katz, MD Allergy, Asthma & Immunology Family Allergy & Asthma Consultants 4123 University Blvd. S. #B Medical Degree: University of Miami School of Medicine Residency: Ohio State University Medical Center Fellowship: The Cleveland Clinic Nominated by: Sunil Joshi, MD; Sudhir Prabhu, MD; J. Dale Schrum, MD Parveen Khanna, MD Anesthesiology Center for Pain Management 655 W. 8th St. Pavilion 2nd FL Medical Degree: Lady Harding Medical College Residency: University of Nebraska Medical School

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Fellowship: University of Florida College of Medicine Nominated by: UFJP Laila Samiian, MD General/Oncology Surgery UF Surgery 655 W. 8th St. 3rd FL Faculty Clinic Medical Degree: University of Miami School of Medicine Residency: Henry Ford Hospital Fellowship: Stanford University School of Medicine Nominated by: UFJP Saurin J. Shah, MD Anesthesiology UF Anesthesiology 655 W. 8th St. 2nd FL Clinical Center Medical Degree: Virginia Commonwealth University Medical School Residency: Virginia Commonwealth University Medical School Nominated by: UFJP Carmela L. Tardo, MD Pediatrics Developmental Pediatrics 6271 St. Augustine Rd. #1 Medical Degree: Tulane University School of Medicine Internship/Residency: Johns Hopkins University School of Medicine & University of California School of Medicine Fellowship: Columbia Presbyterian Medical Center Nominated by: UFJP Kristin J. Taylor, MD Diagnostic Radiology UF Radiology 655 W. 8th St. 2nd FL Clinical Center Medical Degree: University of South Florida College of Medicine Residency: University of Florida College of Medicine Jacksonville Nominated by: UFJP Chika Ugorji, MD Pediatrics Shands Jacksonville/Newborn Nursery 655 W. 8th St. 3rd FL Clinical Center Medical Degree: SUNY Downstate Medical Center College of Medicine Residency: University of Florida College of Medicine/Jacksonville Nominated by: UFJP Carmine Volpe, MD General/Oncology Surgery UF Surgery 655 W. 8th St. 3rd FL Faculty Clinic Medical Degree: Drexel University College of Medicine Residency: Drexel University College of Medicine Fellowship: Roswell Park Cancer Institute Nominated by: UFJP RESIDENTS/FELLOWS MAYO CLINIC HEMATOLOGY/ONCOLOGY Stephen H. Dyar, Jr., MD

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Be a Part of History 1853-2010 1853 – DCMS was founded, ﬁrst medical society in Florida 1888 – Yellow Fever epidemic 1911 – Small Pox vaccination campaign 1929 – DCMS Alliance was founded 1953 – DCMS celebrates 100 years of service 1988 & 2003 – Constititional Amendment Campaigns for tort reform

“Remaining True to Our Mission” is the working title of a new book to be published in 2010-2011 heralding the 157-year history of the Duval County Medical Society and the greater medical community on the First Coast.

From the Yellow Fever Epidemic of 1888 to the state Constitutional Amendment Campaign in 2003.

A special History Book Committee composed of DCMS members is being formed to oversee the Society’s historical content in the approximately 250-page volume. Working with the Committee will be DCMS EVP Jay Millson and the book’s author, Leora Legacy, Northeast Florida Medicine’s managing editor, who welcome ideas and suggestions for the book. John Compton, publisher and owner of Legacy Publishing Company in Birmingham, Alabama, will direct the book project and meet with local physician practices and healthcare institutions to secure underwriting for the project. This will provide an opportunity to highlight practice and institutional histories and accomplishments. Watch the DCMS website (www.dcmsonline.org) and “News You Need to Know” for further information as the book takes shape. Direct any questions to EVP Jay Millson at jmillson@dcmsonline.org or John Compton at the DCMS oﬃce.

The mission of the DCMS is to promote the delivery of and access to high quality, ethical medical care for the community, and to serve as an advocate for physician members and their patients. www . DCMS online . org

Northeast Florida Medicine Vol. 61, No. 1 2010 47

48 Vol. 61, No. 1 2010 Northeast Florida Medicine

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