S3 Productions Presents

CANCER ESOPHAGUS

Ms Sujata DesaiMs Sarita KumariMs Shiney Sam

• Ms Sujata Desai• Anatomy Physiology• Definition • Epidemiology and incidence• Etiology• Prevention and Screening• Pathophysiology• Clinical Manifestations• investigations• TNM staging

• Ms Sarita Kumari• Classification• Spread• Treatment :- • Surgery

• Chemotherapy• Radiation therapy• Palliative management• Complications

• Ms Shiney Sam• Pre operative management • Post operative management• Rehabilitation• Prognosis• Discharge planning• Follow up

Contents

Ms Sujata Desai

ANATOMY AND

PHYSIOLOGY

Structure• 4 layers Mucosa

Submucosa

Muscularis propria

Adventitia

Functions

Blood Supply and

Nerve Supply

Blood supply

Venous Drainage

Nerve Supply

Lymphatic drainage

Cancer Esophagus

Definition

Country Incidence LinkUS 6 cases/100,000 men/year (Black>white).

China (HenanProvince) 0.9% in the population older than 30 years of age

Nitrosamine in the soil and contamination of foods by fungi (Geotrichum candidum) and yeast, which produce mutagens

India, Pakistan, and Sri Lanka 9000 cases/year in 6 cancer registry

Chewing tobacco , smoking

Singapore Hot beverages, Chinese tobacco and wine

South African Bantus and Zulus Nitrosamine in the soil and contamination of food by molds, especially the Fusarium species

Normandy, Brittany Alcohol and smoking

Epidemiology

Incidence Squamous Adeno

New cases per year 16980 12450Male-to-female ratio 3:1 7:1Black-to-white ratio 6:1 1:4Most common locations middle distalMajor risk factors smoking Barrett’s

alcohol esophagusIn TMH 1200 pts /year2nd most common in men4th most common in femaleM0re than 180 Sx /yr

Etiology• Unknown• Hereditary & Genetics• Smoking and alcohol

• Dietary factors • *N-nitroso compounds (animal

carcinogens) *Pickled vegetables and other food-products *Toxin-producing fungi *Betel nut chewing *Ingestion of very hot foods and beverages (such as tea)

• Obesity• Work place exposure

ACHALASIA

Barrett’s Esophagus

Hiatus Hernia

Plummer Vinson Syndrome

EsophagitisAnemiadysphagia

Tylosis

Esophageal Web

• Helicobacter pylori• Injury : ingestion

of acids or alkalines

• Colic Disease• Chronic peptic

sore• Oral sepsis

• Syphilis• Radiation Therapy• h/o cancer• HPV• Aspirin • NSAIDS

Others

Prevention and screening

• Counseling : Avoid alcohol and tobacco• Endemic mass screening programmes• Screening high risk factor • Surveillance Programme

Barrett’s esophagus without dysplasiaendoscopy 3 yearly

Low grade Dysplasia: every yearHigh Grade Dysplasia every 6months

4 quadrant biopsy 2cm apart

PathophysiologyP53 gene located on chromosome 17p produce nuclear

phosphoprotein

Important for cell

growth & control the cell cycle

progression and

regulate the DNA repair

Mutation or

deletion of p53 genes

Alter p 53 activity

Disturb cell cycle control

Early esophageal cancer

Histologic changes

Clinical manifestation

• Dysphagia• Odynophagia• Hoarseness of voice• Dysphonia• Central chest pain

• Wt loss• TEF• Chronic cough • haemoptysis• Malena or haematemesis• Nausea vomiting, regurgitation• Superior vena cava syndrome

• Bone pain• Malignant ascites• Malignant pleural effusion• Jaundice• Supraclavicular and cervical

lymphadenopathy• Diaphragmatic paralysis

Signs of Metastasis

Investigations

• History and physical examination• Blood examinations: – CBC,LFT, RFT, Electrolytes

• Tumor marker:Alkaline Phosphatase (20 to 140 IU/L)CEA (0 – 2.5ng/ml)

• Imaging Tests– Chest X ray – CT scan– CT guided needle biopsy–MRI– PET scan

• Barium Swallow

Esophagoscopy

• Endoscopy– Upper endoscopy– Endoscopic ultra sound– Bronchoscopy– Thoracoscopy and laparoscopy

•OTHERS

• Biopsy •HER2 Testing

TNM Staging

Staging

Ms Sarita Kumari

morphological

Type I : polypoid

Type ll: ulcerated

Type lll: infiltrating ulcerated

Type lV :diffuse

Classification

Squamous cell carcinomaa) Upper thirds of esophagus-20%b) Middle thirds of esophagus-50%c) Lower thirds of esophagus-30%

Adenocarcinoma

Spread• Commonly spread by Lymphatic system

(1) Local spread Trachea tracheoesophageal fistula Aorta Fatal hemorrhage Recurrent laryngeal nerve hoarseness of voice

• (2) Lymphatic spread *Extensive submucosal lymphatic spread ( proximal

line of resection should be 10cm proximal to the tumour).

*Cervical ,mediastinal and coeliac LNs.

• (3) Blood spread Lung, liver & brain.

• Surgery• Chemotherapy• Radiation therapy• Combination therapy• Palliative therapy

Treatment modality

Management protocol

• 1877- Czerny first surgeon to successfully resect a cervical esophageal cancer

• Initially the anastomosis was done by bringing out the ends subcutaneously with external plastic tubes, skin tubes and flaps

• 1933- Ohsawa first stomach reconstruction

• 1946- Ivor Lewis two staged approach (rt thoracotomy and separate laparotomy)

• 1976- Mc Keown 3 stage operation

• 1982 & 1994 vagus nerve preservation

• 1997 – laparoscopic total esophagectomy

Surgery

Management of early cancers

• Photodynamic Therapy (PDT)

• Drug used: sodium porfirmer

• Neodymium-:yttrium-aluminium-garnet(Nd:YAG)

Laser Ablation

Endoscopic Mucosal Resection(EMR)

After resection protonPump inhibitors are used

Radiofrequency AblationEndoscopic balloon ablative device , kills cells by heating by electric current

Surgery

1) Tumors below the carina (tracheal bifurcation) Ivor Lewis operation

(2 phases ) 1st phase :laparotomy & mobilization of stomach. 2nd phase Rt thoracotomy through the 5th intercostal space resection of the tumor .LNs and 10cm of the oesophagus above the tumor & GE anastomosis.

Operable tumors

Mc Keown operation (3 phases ) 1st phase :laparotomy & mobilization of stomach 2nd phase Rt thoracotomy through the 5th intercostal space :esophageal mobilization 3rd phase: neck incision : the oesophagus & stomach are delivered to the neck where resection is done and anastomosis of the stomach & cervical oesophagus is carried out.

Tumors above the carina

Transthoracic Esophagectomy

VATS

• lt thracoabdominal incision: the stomach & lower oesophagus are removed with

• Roux-en-Y esophagojujenostomy

• .

3) Tumors below the diaphragm (1 phase)

• Other options Transhiatal esophagectomy Thoracotomy is avoided by mobilizing the oesophagus from the abdomen via the diaphragmatic hiatus and via the neck incision

• Field I: abdominal field• Field II: Paraesophageal,

parabronchial, apical nodes, recurrent nodes, paratracheal

• Field III: Cervical paraesophageal, supraclavicular

3 field lymph node dissection

• Endopscopic removal through laparoscopy & thoracoscopy

Reconstructions

Colonic transposition

• Neoadjuvant• Two 4-day cycles,• 3 weeks apart • Cisplatin 80 mg/m2 by infusion over 4 h • fluorouracil 1000 mg/m2 daily by

continuous infusion for 4 days. (MRC protocol)

• Surgery performed two to four weeks after chemotherapy

Chemotherapy

EBRT alone 64.8Gy / 33 - 36 fractionsExternal beam radiotherapy and brachytherapy EBRT• Dose : 60 Gy / 28 fractions with reducing

fields.ILRT Boost : 5 - 8Gy / 2-3 fractions (HDR), one week apart or single fraction 20Gy low dose rate (LDR).

Radiation therapy

Brachytherapy

• 50Gy / 25 fractions over 5 weeks, • Cisplatin 75 mg/m2IV Day 1 of weeks

1, 5, 8, and 11,• Fluorouracil, 1g/m2 per day by

continuous infusion day1 – day 4 week 1, 5, 8, and 11. (RTOG

regimen)

Concomitant chemo radiation

• EGFR: Cetuximab• HER-2/neu:Trastuzumab• VEGF:Bevacizumab• Small molecule inhibitors: Imatinib

• ;

Targeted Therapy

• Inoperable Tumors ( 60% of the patients)* Local spread( e.g tracheoesophageal fistula,)* Distant spread

• * Bad general condition• Options:-

– Endoscopic Laser to core a channel through the tumor

Palliative treatment

• Self expanding metal stents

• Traction stents e.g. Celestine stent

• Pulsion stents e.g. Soutter’ tube

Intubations

Dilatation

– Radiotherapy for squamous cell ca– Dose : 3000cGy /10 fractions /2 weeks– Reduced field / boost : 2000cGy/10# / 2 weeks– ILRT alone or in combination with EBRT. – 5 - 8Gy/# in 2- 3 fractions, one week apart– Chemotherapy :5 FU + Cisplatin– 5Fu 1000mg/m2/day continuous IV infusion on

day1-5Cisplatin 100mg/m2 iv on day 1– Repeat cycles on 1,5, 8, 11 wks

PEG

• Anastomotic leak• Respiratory insufficiency• Wound infection• Gastric outlet obstruction• Pulmonary embolism• Radiation pneumonitis• Stricture• Fistula • haemorrhage

Complications

Ms Shiney Sam

Nursing Management

• Preoperative management• Post operative management

Preoperative management

Psychological preparationAssess level of anxietyAnswer the questions and concerns regarding surgeryAllow time and privacy to prepare psychologicallyProvide support and assistanceCultural aspect need to be consideredDischarge planning

Legal preparation

Informed consent by surgeonNo sedation should be administered Documentation

Nutritional supportAims : promote wt gainInterventions– Assess wt , nutritional assessment– Sr Albumin , protein– Assessment of swallowing capacity– High calorie high protein diet in liquid and soft form– Enteral nutrition: NG feeds– Parentral nutrition– Hydration– Adjust diet according to existing problems-

constipation/diarrhea

Patients are not able to clear secretionsHead elevationStent placement and dilatation

Prevent pulmonary complications

Physical and physiological preparation

• Cleaning of surgical site• Shaving • Personal hygiene• Oral care• Nutrition: liquid diet x 3 days• Monitor vital signs• Intake /output chart• Antibiotics and regular medicationsNPO night beforeNo enema and laxatives can be allowed

Explain to notify pain Pain medications will be prescribedNon invasive pain relieve techniques

Pain management

Stop smokingChest physiotherapyIncentive spirometryFootball bladder exercisesCoughing exercisesDeep breathingSplintingGetting out of bed

Preoperative exercises

Pre anesthetic work upAll investigations & corrections toCo morbiditiesECGPFTArterial blood gas

2d echoMouth openingCheck listSend all equipments to OT

Post operative management

• Immediate• Intermediate• Extended

Immediate

• Intensive care - 24 to 48 hrs• Care of ventilated pt : patent airway

Suctioning

• Care of drains• Cardiopulmonary monitoring

Intermediate

• Neurological Status• Assess neurological status every

shift. • Any neurological change should be

carefully watched and• Promptly reported

Adequate pain control reduces the mortality and morbidity

Asess the pain Initial pain management consist of morphine or

bupivacaine given epidurally Patient-controlled analgesia with morphine, or a

combination of both .Nothing by mouth for 5 to 7 days, intravenous or

epidural pain medications are used.

Pain Management

Oral pain medications are started on the fifth or seventh postoperative day

The main classes : opoids, nonsteroidal anti-inflammatory drugs, and local anesthetics.

Pain Management contd..

Distraction RelaxationPositioning

Non-pharmacological interventions

 Aggressive pulmonary toilet Pain control is paramount Patients are usually intubated after surgery

monitor oxygenation closely (spo2) Suctioning Chest physiotherapy ,Nebulizers Coughing, deep breathing exercises, Incentive

spirometer. Teach patients to splint their incision with a pillow. Early mobilization  Monitor patients closely for fever

Pulmonary Care

Assess the drainage every shift.Serosanguinous within a few hours.Not more than 100 to 200 ml/h on the first day.A sudden change in the color of chest tube : milky (chyle leak ) Check the chest tube site for drainage, Keep the chest tube dressing clean, dry, and intact. Keep the chest tube free of any kinks or dependent loops

Chest tube care

Palpate the surrounding areaDue to an air leak from a pleural injury Additional suction or placement of a new chest tube New-onset may indicate a leak of the esophageal

anastomosis.. Fever, tachycardia, and hypoxemia Esophageal leak can be confirmed by barium

swallowPostoperative chest radiographs for pneumothorax

and for placement of any chest tube.Monitor abrupt changes in oxygenation

Subcutaneous emphysema

Hemodynamics

Intravenous maintenance fluid at a rate of 100 to 200 ml/h for the first 12 to 16 hours.  Patients may require fluid boluses in the immediate postoperative period. Crystalloids or blood products may be used Interstitial pulmonary edema. Malnutrition and low protein levels can complicate the situation.A delicate balance between adequate fluid replacement and fluid overload. 30 ml/h of urine outputDetermination of body weight Meticulous skin care is necessary.

. Do not move, manipulate, or irrigate the nasogastric tube.Do not attempt to replace it.  Monitor the tube for patency Assess the drainage for color and amount.

Nasogastric Tubes

Restricted by mouth for 5 to 7 days Oral medications, are crushed and put down the nasogastric tube on the second day ; they are never swallowed. Diligent mouth careA jejunostomy feeding tube is often placed during surgery and is used from the first post op day for feedingEarly enteral feeding helps in early healingJejunostomy site care

Gastrointestinal Care

At 5 to 7 days check the anastomosis for leaks Eat 6 to 8 small frequent meals each day, Avoid very hot or cold beverages and spicy foods. Protein supplements, high-energy foods, or a soft

dysphagia diet Sit upright, chew slowly, and eat more than 3 hours before

bedtime assists in reducing reflux. Drink fluids between meals rather than with meals Dumping syndrome, may arise in patients who have had

their vagus nerves divided. After vagotomy is related to unregulated gastric emptying

Minimizing liquids with meals Consumption of frequent, small, low-carbohydrate meals Discharged with plans for supplemental tube feeding.

Incision Care

Keep dressings clean, dry, and intact.Change dressing 2 to 3 times a daySaliva leak out through the cervical incision. Can be managed by simple dressingLarge volumes (>250 ml every 8 hours), application of a wound drainage bagThe leak is allowed to seal on its own,Sealing could take several weeks.

Compromised nutritional status, They have invasive catheters Risk of infection at the surgical sites. Meticulous wound and skin care, Hand washing, Avoidance of cross-contamination Changing of invasive catheters Antibiotics Adequate nutrition.

Infection Risk

Heparin s/c BDTED stockingsEarly ambulationLeg and ankle exercises

Prophylaxis of deep vein thrombosis

Discharge planning

• Do’sCheck surgical incisionMaintain personal hygieneIncision site careResume daily activities, work and sexual activities Drink fluid b/w mealsEat 3 hrs before bedtimeCheck wt

Take stool softenersCrush all medicationsObserve complications: tarry stool, progressive wt loss, diarrheaKeep follow up appointments

Contd…

• Don’tsAvoid smoking (join stop smoking group)Avoid strenuous activity for 12 wksAvoid driving for 3 wksAvoid hot & cold beverages , spicy foodDrink fluid in between meals

Patient must sleep in a head high position Get adapted to small frequent mealsKeep a difference of 2-3 hrs between meals and bed timeContinue spirometer for 3 monthsDonot carry weight more than 5 kgsResume daily activities

Rehabilitation

Prognosis

Every 6 monthsPlain X Ray, CBC , Biochemistry on visitIf symptomatic CT, PET CT

Follow up

Conclusion

Thank u