SEER Training Modules
Case #2
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Physical Exam
2 month history of dysphagia and weight loss. Neck: no adenopathy. Abdomen: no masses, non-tender.
Imaging
4/16/XX
Esophagogram and UGI: Mass defect in upper third of the esophagus, 3 cm in size; remainder of UGI normal.
4/16/XX
Chest X-ray: Normal.
4/18/XX
Chest CT: Mucosal thickening within the esophagus c/w malignancy. No hilar or mediastinal adenopathy seen.
Laboratory
04/18/XX
LFTs: slightly elevated.
Scopes
04/28/XX
EGD with biopsy: Esophageal tumor at 12 cm from the incisors approximately 3.5 cm in size; no disease beyond the upper third of the esophagus.
Pathological Reports
04/28/XX
Esophageal biopsy: moderately differentiated squamous cell carcinoma.
Treatment
05/10/XX
Radiation: Began beam radiation total dose 3200 cGy to anterior and posterior chest 6MV photons and 3400 cGy to spinal cord 6MV photons
