cancer of esophagus

8/3/2019 Cancer of Esophagus

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CANCER OF ESOPHAGUS

OGINDA DICKSON MED IV

LUCY LYANDA MED IV

GEORGE BIKETI MED VI

GEORGE NGARE MED VI

MODERATOR: PROF. B. OTSYULA


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DEMOGRAPHIC DATA

NAME: SIMON KIPKORIR T

AGE : 36 yrs

GENDER: Male

RESIDENCE : KABIYET

OCCUPATION: farmer

D.O.A :18/02/2010 WARD 6


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CHIEF COMPLAINTS Difficulty in swallowing x6/52

Headache and dizziness x1/7

HISTORY OF PRESENTING ILLNESS

Gradual onset

Felt food sticking in the chest followed by regurgitation

First solid foods, then liquids eventually saliva

Hx of post- prandial vomiting Hx of pain on swallowing.

Hx of hot foods and beverage consumption

Had appetite but food could not pass.

Hx of dull pain at epigastric region. Non- radiating and aggravated byingestion of food.

No hx of alcohol intake or cigarette smoking

No hx of PUD in the patient

No family hx of such an illness

Hx of weight loss


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HPI cont.

May 2009 thoracotomy and insertion of

celestine tube

Jan 2010 hx of vomiting blood and passing

of black stool

No hx of cough

No hx of change of voice

Hx of deviation of mouth to the left for thelast 1 yr


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PAST MEDICAL HISTORY

3RD admission

2nd adm Jan 2010- hematemesis transfusion

of 3 units

1st admMay 2009- surgery for insertion of a

celestine tube

No hx of DM, HTN, asthma or TB

NKFDA


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FAMILY & SOCIAL HX

Married to 1 wife with 2 children all a/w

No hx of a similar problem in the family

No hx of DM, hypertension,asthma or TB in

the family

REVIEW OF SYSTEMS

CNS: headache and dizziness. No convulsions,

no confusions.

GUT: No dysuria,


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REVIEW OF SYSTEMS CNS: No loss of consciousness, headache or

blurring of vision M/S : no muscle pain

GUT: no hematuria, or dysuria

SUMMARY

Simon Kipkorir is a 36 yr old ca esophagus

patient with a celestine tube in situ who

presented with chest pain for 3/7 and

dizziness for 1/7.


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PHYSICAL EXAMO/E

Young man in FGC, P++, J0,C0,Pedal oedema0,LD0, or

dehydration Vitals- p= 86 beats/min

R= 24 b/min

T= 36.50 C

BP=130/70 mmHgRESP

Rate of respiration = 24 b/m

Trachea central

Chest bilaterally moving with respiration equally Normal tactile fremitus

No palpable masses

vesicular breath sounds


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PER ABDOMEN Abdomen with normal fullness. Moving

symmetrically with respiration. Umbilicus central and inverted.

Surgical scar extending to the back, to 8th rib

and to epigastric region (curvilinear) Non tender on palpation

Liver and spleen not palpable

Tympanitic on percussion

Normal bowel sounds.


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CNS Oriented in person, place and time.

CN VII-mouth deviated to the left

- cannot blow air in the mouth- no wrinkling of forehead

- nasolabial folds absent on the right side.

Other CN intact.

Normal bulk, tone and reflexes. Power grade 5 Can perceive touch and pain in trunk & extremities.

No cerebellar dysfunctions

CVS

Pulse rate =86 b/m Bp =130/70 mmHg

Neck veins not distended

Normal s1 and s2 sounds heard.


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IMPRESSION Anaemia 2o to ca esophagus/upper GI

bleeding. 7th cranial nerve palsy. (LMNL).

PLAN

FHG- Hb 6.0g/dl GXM 3 units- O+ve both donor and recipient

Transfuse 3 units of blood.


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ESOPHAGEAL CANCER

PRESENTED BY GEORGE BIKETI


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Def: neoplasm of the esophagus,mainly of epithelial origin.

Epidem:12/100,000 varies withgeographical location.

Risk factors

Tobacco

Alcohol consumption

GE reflux

Achalasia, lye strictures,tylosis, HPV

Nitrosamines in soil

Fungal contamination of food-

Geotrichium candidum,Yeast(produce mutagens),

ingestion of very hot foods

Very hot tea

Roasted maize?, traditionalbrews,

Vitamin deficiencies,anemia, poor oralhygienechronic

Classification

Squamous cell carcinoma

Adenocarcinoma

Others:

Ca esophagus


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Barrets esophagus

Plummer- Vinson syndrome

Leukoplakia

Achalasia

Caustic injuries to esophagus

Scleroderma

Reflux esophagitis

Irradiation esophagitis

Premalignant disorders


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95% is squamous cell ca, 2.5-8%

adenocarcinoma,others: small cell ca,

malignant melanoma.

Squamous cell ca most common in upper and

middle 1/3 of esophagus, adenocarcinoma

most common at the GE junction

Common growth patterns: fungating(60%),

ulcerative(25%), infiltrative(15%)

Pathology


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Early disease may have no clinical features and dx is

on endoscopy for other conditions e.g.

GERD/screening for Barrets esophagus

advanced disease: Dysphagia: occurs when >than 60% of esophagus is

infiltrated with cancer. progressive

Respiratory symptoms resulting from aspiration or fistula

into the trachea/bronchus.

Wgt loss, cachexia

CLINICAL FEATURES


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Hoarseness due to recurrent laryngeal nerve palsy

.

Palpable lymphadenopathy in the neck.

Clinical features(cont.d)


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HISTORY

Progressive dysphagia (grade 0-4)

Odynophagia

Choking (ToF)

Hoarseness

Regurgitation and vomiting Difficulty in breathing and coughing

Progressive weight loss

Chest pain

H/o predisposing factors: smoking, alcohol etc

Horners syndrome Superior venacava syndrome

DIAGNOSIS


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IMPORTANT Hx

Loss of weight: poor feeding/ malignancy

Anaemia: Ca. stomach or PV syndrome Change of voice:- due to refluxed material irritating the

vocal cords or recurrent. laryngeal nerve palsy.

Cough or dyspnoea:- due to tracheal aspiration.

Haematemesis or melena: peptic eosophagitis & hiatushernia

Family Hx of Ca. oesophagus or stomach

Smoking and Alcohol

Cardiac drugs

Neurological changes: diplopia, dysarthria

Rheumatologic: mm weakness, skin disorders

PHYSICAL EXAMINATION


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PHYSICAL EXAMINATION

1. General Survey: Dehydration, Jaundice, Pallor (PV/ Ca. stomach),L. nodes (Lt. supraclavicular- Virchows node in Ca. stomach-Troisiers sign), Koilonychia, Pitting of palms and feet (tylosis

palmaris et plantaris), Dyspnoea & Difference in radial pulses(Aortic aneurysm), Emaciation.

2. Neck: Gurgling mass- watch pt. during meals, goitre, tracheal tug

3. Oropharynx: tonsillitis, candidiasis, retropharyngeal abscess, testsoft palate and vocal cords for paralysis

4. Resp. Sys: signs of secondaries or aspiration pneumonia

5. CVS: pericardial effusion, cardiomegally

6. Abdominal: previous surg., abdominal mass, Ca. stomach,hepatomegaly, ascites (peritoneal involvement)

7. DRE and VE: Kruckenburg tumour in POD

8. CNS: Cranial nerve palsies, lateralizing signs

9. Psychiatric exam: in a pt. with neurotic symptoms


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Is by TNM staging

Tis: carcinoma insitu

T1: lamina propria

T2: muscularis propria

T3: adventitia (periosophageal tissue)

Nx: lymphnodes

No: no lymphodes involved

N1: regional lymphnodes

STAGING


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Mo: no distant metastases

M1: distant metastases to coeliac axis nodes


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Differentials

Malignant tumours

SCC

Adenocarcinoma

lymphoma

carcinoid tumour

sarcomas

Benign esophageal tumors

leiomyomafibroma

lymphangioma

squamous papillomas-condylomas

inflamatory polyps

Pre cancerous lesions

Berretts oesophagus

Lye strictre

Tylosis

Plummer vinsons syndrome

Zenkers diverticulum

Achalasia

Chagas disease


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Investigations

1. Barium swallow

used to localize tumour strictures

intraluminal masses


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/


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2. Endoscopy / esophagoscopy

for direct visualisation

- -for biopsy


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3. Endoscopic/ tracheoesophageal ultrasound

-depth of penetration of the tumor (T staging)

-the presence of enlarged periesophageal lymph nodes (N staging).


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4. Bronchoscopy

-for cancers of the middle and upper third of the thoracic

esophagus to help exclude invasion of the trachea or bronchi.


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5. Metastatic workup

CT scan Abdominal, pelvis and chest

LFTs

Coagulation profile -Prothrombin time and activated partialthromboplastin time coagulation.

Bone scan

Laparoscopy and thoracoscopy have a greater than 92%

accuracy in staging regional nodes

positron emission tomography scanning, which can helpelucidate hypermetabolic foci of disease activity.-newstaging modality


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Others:

Complete blood cell count

Electrolytes- hypercalcemia.


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IMPROVE QUALITY OF LIFE.

ATTEMPT RESTORE NUTRITIONAL INTAKE.

ATTEMPT TO PROLONG LIFE IF APPLICABLE.

MULTIDISCIPLINE APPROACH IDEAL.

MANAGEMENT OBJECTIVES


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Treatment options:

A) Multimodal:

Combines chemotherapy radiotherapy and surgeryMay be used for cure and palliation

Survival rates are higher than surgery alone

B: Surgery:

(i) esophagectomy

is resection of the esophagus

Done through a transhiatal or transthoracic approach (THE or TTE)

Stomach is often used for reconstruction where it is transposed and

esophagogastric anastomosis in the chest or neck done

Colonic or small gut interpostion to restore continuity


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OPTIONS FOR OESOPHAGECTOMY

ALL APPROACHES THROUGH ABDOMEN WITH

ADDITIONAL EXPOSURE AS NEEDED.

TWO STAGE

THORACOTOMY AND LAPARATOMY.

THREE STAGE

THORACOTOMY AND LAPARATOMY AND NECK

DISSECTION.

SINGLE STAGE

THORACOABDOMINAL INCISION.

TRANS HIATAL OESOPHAGECTOMY.


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SELECTION OF OPERATION

SITE OF TUMOUR.

ADHERENCE TO SURROUNDING TISSUE.

PRESENCE OF LYMPHADENOPAHY.

PLANNED CONDUIT.

CONCERNS OF BILE REFLUX.

EXPERIENCE OF SURGEON.


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Contraindications for esophagectomy

Invasion of the tracheobronchial tree

Invasion of the great vessels and pericardium Supraclavicular, lateral thoracic and coeliac nodes

Comorbid states eg. CVS and Resp disease

Decreased cardiac and respiratory function

Advanced nutritional debilitation.

Widespread metastasis.

Malignant effusion or ascites.

Recurrent laryngeal n. Palsy.

Superior vena cava syndrome.

Tracheo-oesophageal fistula.


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(ii) Paliative resection

- controversial instead use EBR

(iii) Intubationeither Souttar, celestine, Atkinson, Procter-Livingstone

(iv) stenting


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C) RADIOTHERAPY

Used for unresectable tumours

Where the expected survival time is shortGives relief to 67%/ >50% patients with dysphagia

Not allowed for tumours involving the stomach

Radiation dose of ~= 45 Gy

D) CHEMOTHERAPY

used either alone or in combination with other modalities

highlighted agents- 5FU and cisplatin

functions : - reduce bulk of tumour

- eradicate tumour in nodes- may reduce tumour dissemination

- to asses tumour responsiveness


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OTHER OPERATIVE MODALITIES

(PALLIATIVE)

DILATATION.

CRYOTHERAPY.

CHEMICAL ABLATION.

LASER THERAPY.

PHOTODYNAMIC THERAPY.


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SURGICAL PRE-OPERATIVE

CONSIDERATIONS

Correct any malnutrition.

Preoperative antibiotics.

Bowel preparation.

Nasogastric tube.

Postoperative analgesia. Peri-operative anticoagulation.


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POSTOPERATIVE FEEDING

Feeding after methylene blue, gastrografin ordilute barium test on day seven

Prior to chest tube removal.

Retain tube for 24 hours after.

Early nasogastric feeding on day three

Nasogastric tube well down into duodenum area.

POSTOPERATIVE COMPLICATIONS


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POSTOPERATIVE COMPLICATIONS

Anastomotic leak (11.3% - 19.5%).

Haemorrhage.

Chylothorax. Pulmonary infection (50% - KNH).

Pleural effusion.

Recurrent laryngeal nerve injury.

Benign stricture (4.6% for KNH). Malignant stricture.

Gastric emptying (21.3% - KNH).

DVT ( sudden death).

Postoperative confusion.

Sepsis.

Fluid electrolyte imbalance.

Diabetes .


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prognosis

Generally poor because of late presentation

5-8% operative death rate

5 year survival rate 9% (SCC) and

cancer of esophagus

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