UCLA Medical Center

347-44-27 WW

TROESCHER, BONNIE

Outpatient Consultation

M EDICIN E/Gastroentero logy

Outpatient GE Consultation Note

Date of Service:

Tuesday, September 7,2004

Requesting Physician: Dr. Irwin S. Benowitz, D.O., Primary Care Physician, 2121 West Magnolia Blvd,

Burbank, CA 91506.

.

Identification: Ms. Troescher is a very pleasant 67-year-old Caucasian woman accompanied today by

her husband with the primary complaint of dysphagia believed secondary to adenocarcinoma of the

gastroesophageal junction.

History Of Present Illness: The patient states that she was asymptomatic from a gastrointestinal

standpoint until January of this year when she developed a rapidly progressive dysphagia associated with

weight loss. The patient specifically denies prior heartburn or regurgitation. In February she began

undergoing an extensive outpatient evaluation. An upper pan endoscopy by Dr. Balian was performed on

February 19, 2004. Unfortunately, we do not have outside records of this first endoscopic examination.

Endoscopy reportedly revealed a mass at the gastroesophageal junction. Apparently the endoscopist was

able to pass the scope into the stomach beyond the area of narrowing. Biopsies from the gastric fundus

were reportedly positive for adenocarcinoma. On the same day the patient underwent CTs of the chest,

abdomen and pelvis which were remarkable only for the gastroesophageal junction mass. There was no

definite lymphadenopathy nor any evidence of distant metastasis. No invasion of local structures was

noted. A PET scan performed on March 24, revealed hypermetabolic tumor in the gastric fundus but no

other hot lesions. On March 31 the patient underwent exploratory laparoscopy with placement of a J-tube

and a Port,A-Cath by Dr. Renner af St. Jos!3ph, Hospitc:ll.i,n,E3,urp~nk.

On ApFil 20 the, patient YP9t3rvvent ~ndosc:;opic ultrasound by [j'r.Nagaraja using a P,entax E~: 3630' UR

engoscopE:Llt does n?t~ppear th~f any FNAs of suspicious: lymphrlOdes wereobtarned at this tfme. The'

~Xarni'~ationreportedly revealed a T3primary rumor~ th~ ca'seYvasclassifiedasN2. There"is'some;note

of s,LJb'car1'nallymph nodes, quthornention Of definite celiac nodes. "fhe patient was ,told that on the! basis

oqhe staging examination that she had inoperable disease. She, therefore, underwent'20 of28

recommended cycles of radiation therapy. The total radiation dose is not clear from the documents

presented today. The patient also underwent two cycles with 5-FU and carboplatin. She was offered

further cycles of this or, as an alternative, tamoxifen plus carboplatin but she refused based on her

intolerance of side effects with the first two cycles of chemotherapy.

More recently following her course of chemoradiation therapy the patient has undergone repeat staging

examination and barium upper Glseries performed on July 16revealeda1~2 em narrowing at the'

gastroesophageal jUnctionbtttno Qtherdefiniteevidence of dis§8se.,There vvas no prO)(imaldHation of

the esophagus or stasis of thebatium noted. Des,pite this the'patiehthasnoticed that her dysphagia,

which improved slightly during initial treatment,has now become progressively worse again. A PET scan

performed on August 19shbwed diffuse hypermetabolic activity in the fundus. Although this might seem

to suggest persistent tumor, the radiologists's reading was equivocal as to whether or not this represented

inflammatory tissue versus possible residual tumor. The patient has apparently never entertained the

possibility of surgical therapy, however, she does have general reservations about Western medical

therapy. When we briefly discussed surgical options she said that she was concerned about the

excessive morbidity and mortality of the procedures. She has considered the possibility of undergoing a

stent procedure. At present her main complaints are of dysphagia and occasional bilious emesis. The

patieflt states thaJ she does not Irkeusing, her J-tul?~, o~, supplemental enteral nutrition because she feels

tied down .to feeding regimens. She is currently taking se~erar cans of Ensure during the day and a1 night.

'In'additionshe is taking various nutraceuticals, vitamins and has taken other compounds such as soy

protein. She understands that an esophageal stent might allow her to take oral nutrition but is concerned

about potential complications including GERD.

Dictated: 9/7/2004 18:09

By: Gareth Dulai, MD. (P14266)

Reference number: M1.409081 087602700

Transcribed: 9/8/2004 5:15

By: /EDIX

Reference number: 09087602.700

Received: 9/8/2004 5:07

Document ID'Numbero 2648233

Patient UI"Nutnber: 103165239

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Outpatient Consultation

MEDICINE/Gastroenterology Outpatient GE Consultation Note

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