Transcript Esophageal Cancer

Subsection D2
Rivera-Santos
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Chief Complaint: DYSPHAGIA
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History of Present Illness
5 months
PTA
4 months &
3 weeks PTA
• Experienced dysphagia and vomiting after eating
solid food
• Felt there was a lump in substernal area
• No chest pain
• Persistence of symptoms with weight loss of 10 lbs.
• Consulted a family physician
• Omeprazole, domperidone, disflatyl= did not
provide any relief
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History of Present Illness
4 months &
1 week PTA
4 months &
2 days PTA
• Persistence of symptoms lead him to seek consult at
UST OPD GI-MED
• Advised to stop previous medication and have an
esophagram
• Patient was non-compliant.
•
•
•
•
Progressive dysphagia
Unable to ingest soft meals
Difficulty in drinking fluids
Persistence of symptoms+ body weakness= sought
consult and was admitted to our institution (medicine)
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Jan.22- Feb.21
 EGD: circumferential, nodular, partially obstructing and friable mass
from 35 cm level of esophagus down to the cardia (41cm level)
 Biopsy of esophageal mass: well differentiated squamous cell
carcinoma
 Biopsy of cardia of stomach esophageal mass: revealled esophageal
mucosa with severe dysplasia can’t totally rule out invasive squamous
cell carcinoma
 Endoscopic guided insertion of NGT done
 CT Scan of chest and upper abdomen: soft tissue mass noted on the
esophagus from the distal third up to the gastroesophageal junction
causing significant narrowing of its lumen (1/26/09)
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 35th hospital day=started 1st cycle of radiotherapy and
chemotherapy (cisplatin & 5-FU)
 CT Scan of whole abdomen: circumferential wall
thickening in the included distal esophagus and adjacent
gastric cardia with thickness ranging from 7-16mm. A
solitary lymphadenopathy is seen in the
perigastroesophageal region measuring 1.8x1.4 cm.
(4/18/09, other hospital)
 CT Scan of the chest: esophageal new growth involving
the middle and lower 3rd of portion with slight regression
(5/6/09)
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History of Present Illness
2 months
PTA
May 10,
2009
• Continued 2nd cycle chemotherapy
& 26th session of radiotherapy
• Subsequently discharged
• Admitted for surgery
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Past Medical History
 (+) for Polio in 1958 at age 3
 (+) for TB in 1980, 3 months treatment
 2002 - laceration right upper quadrant, sutured
without any complications
 (-) HPN, DM, allergies, goiter, asthma
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Family History
 (+) for colon cancer, sister
 (+) asthma- siblings, mother, grandmother
 (+) for DM- mother
 (+) for PTB- father
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Personal & Social History
 23 pack years of smoking, stopped 3 months now
 Alcoholic beverage drinker (brandy TID, 1 long neck
for 23 years), stopped 5 months now
 (+) for substance use- tried few sessions of marijuana
and shabu, but denied addiction
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Review of Systems
 General: (‐) fever/ sweats/anorexia/ weakness
 HEENT: (‐) visual dysfunction/redness/ itchiness/ pain/ lacrimation, (‐) deafness/
 Tinnitus/ discharge, (‐) bleeding gums/ sores/ fissures/tongue abnormalities/ dental
 caries, (‐) sore throat/ tonsillitis, (‐) stiffness/ limitation of motion/ masses/
 adenopathy/ sensation of lump in the throat
 Pulmonary: (‐) dyspnea/ shortness of breath/ cough/ sputum production/ hemoptysis/
 wheezing/ back pain/ chest wall abnormality
 Cardiac: (‐) chest pain/ easy fatigability/orthopnea/ nocturnal dyspnea/ palpitations/
 syncope/edema/ HPN
 Vascular: (‐) phlebitis/ varicosities/ claudication
 Gastrointestinal: (‐) nausea/ vomiting/ GI bleeding/ flatulence
 Genito‐urinary: (‐) urinary frequency/ urgency/ hesitancy/ dysuria/ hematuria/
 nocturia/ urine stream flow abnormality/ flank pain/ stones/urethral discharge/
 genital lesions/testicular mass/ perineal pain/ impotence/ vaginal discharge/
 abnormal bleeding
 Musculoskeletal: (‐) joint stiffness/ pain/ swelling/ muscle pain/ weakness
 Endocrine: (‐) heat‐cold intolerance/ thyroid problems/ polyuria polydipsia polyphagia
 Psychiatric: (‐) anxiety/ depression/ interpersonal relationship difficulties
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Physical Exam
 BP (mmHg): 90/60
 Pulse rate / character: 80 bpm, regular
 Respiratory rate / pattern: 18 cpm, regular
 Temperature (°C): 36.6°C
 Wt. (kg.): 43.5
 Ht. (cm): 158.5
 BMI: 17.4
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 GENERAL SURVEY: conscious, coherent, ambulatory
notcardio‐pulmonary distress
 SKIN: warm, moist dry skin, no active dermatoses
 HEENT: pale palpebral conjunctiva, anicteric sclera
 Pupils 2‐3 mm round and ERTL No alar flaring, no
naso‐aural d/c. (+) NGT right Nostril. No impacted
cerumen, intact tympanic bilateral membrane, nasal
septum midline, (‐) tenderness, inflammation (‐)
bleeding, ecchymosis (‐) anosmia, (‐) facial
asymmetry. Moist buccal mucosa, non‐hyperemic
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 NECK: supple neck, lymph nodes non‐palpable
cervical LN
 Thyroid gland not enlarged, no other masses
 THORAX / LUNGS: symmetrical chest expansion, no
retractions, no lagging, equal tactile fremiti, resonant
lung fields, breath sounds with expiratory wheeze on
both upper lung fields more prominent right
 CARDIOVASCULAR: adynamic precordium, AB 5th
LICS MCL,
 S1>S2 apex, S2 > S1 at the base, no murmurs
 All pulses normal
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 ABDOMEN: scaphoid abdomen, (+) 6 cm diagonal
scar at RUQ, normoactive bowel sounds, tympanitic
on percussion, Traube’s space not obliterated, no
direct or rebound tenderness, spleen not palpable (‐)
fluid wave
 (‐) CVA tenderness
 MUSCULOSKELETAL: Asymmetric lower extremities
(left longer and thinner than the right), (‐) tenderness,
(‐) swelling
 NEUROLOGIC EXAM: normal
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Salient Features
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53 years old
Male
BMI: 17.4 (N: 18.5-23)
Progressive dysphagia to solids and liquids
Vomiting
Body weakness
(+) family history of colon CA
23 smoking pack years, stopped 5 months ago
Alcoholic
 Brandy TID
 1 long neck for 23 years, stopped 5 months ago
 (+) substance abuse: marijuana,shabu
 (-) lymphadenopathies
 (-)anorexia
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Salient Features
 EGD:
 circumferential, nodular, partially obstructing and friable mass
from 35cm level of esophagus down to the cardia (41cm level)
 Biopsy of esophageal mass
 Squamous cell carcinoma well differentiated.
 Biopsy of cardia of stomach esophageal mass
 Revealed esophageal mucosa with severe dysplasia cannot totally
rule out invasive squamous cell cacinoma (well
differentiated)
 Endoscopic guided insertion of NGT
 CT Scan of chest & upper abdomen
 soft tissue mass noted in the esophagus from the distal third up to
the gastroesophageal junction causing significant narrowing of its
lumen
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Salient Features
 CT scan of whole abdomen
 circumferential wall thickening in the included distal
esophagus and adjacent gastric cardia, with thickness
ranging from 7‐16 mm. A solitary lymphadenopathy is
seen in the perigastroesophageal region measuring 1.8 x
1.4 cm.
 CT scan of chest
 esophageal new growth involving the middle and lower
third of portion with slight regression
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Esophageal Cancer
(Squamous Cell Ca)
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Dysphagia
• Difficulty in swallowing, the primary symptom of
esophageal disorders.
• Sensation of sticking or obstruction of the passage of food
through the mouth, pharynx, or esophagus
Reference: Harrison’s Principles of Internal Medicine 17th ed. pp 237-239
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Dysphagia
 Mechanical due to large bolus or narrow lumen
 Motor due to weakness of peristaltic contractions or
impaired deglutitive inhibition causing nonperistaltic
contractions and impaired sphincter relaxation
Reference: Harrison’s Principles of Internal Medicine 17th ed. pp 237-239
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Dysphagia
Mechanical
Oropharyngeal
Esophageal
Motor
Oropharyngeal
Reference: Harrison’s Principles of Internal Medicine 17th ed. pp 237-239
Esophageal
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Dysphagia
Mechanical
Oropharyngeal
Esophageal
Motor
Oropharyngeal
Reference: Harrison’s Principles of Internal Medicine 17th ed. pp 237-239
Esophageal
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Esophageal Dysphagia
 Normally can be distended up to 4cm in diameter
 Dysphagia to solid food <2.5cm
 Dysphagia to fluids <1.3cm
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.
Harrison’s Principles of Internal Medicine, 17th ed
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Squamous Cell Carcinoma of the
Esophagus
 Most common type of carcinoma of the esophagus –
90%
 Age > 50
 Most symptomatic tumors are quite large by the time
they are diagnosed and have already invaded the wall
or beyond
 20% -upper third, 50% - middle third, and 30% - lower
third of the esophagus
Reference: Robbins and Cotran Pathologic Basis of Disease, 7th ed.
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Squamous Cell Carcinoma of the
Esophagus
 Most squamous cell carcinomas are moderately to well
differentiated
 Rich lymphatic network in the sub mucosa promotes
extensive circumferential and longitudinal spread
 Areas of metastasis
 Upper third - cervical lymph nodes
 Middle third - mediastinal, paratracheal, and
tracheobronchial nodes
 Lower third - gastric and celiac groups of nodes
Reference: Robbins and Cotran Pathologic Basis of Disease, 7th ed.
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Pathogenesis of Esophageal Carcinoma
Injury
stratified squamous Epithelium
Ulcer
Hyperplasia
Cell Death
Inflammation
Gastric Metaplasia
Dysplasia
Glandular
Dysplasia
Carcinoma
Adenocarcinoma
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Pathogenesis of Squamous Cell Carcinoma
Injury
Stratified squamous Epithelium
Ulcer
Hyperplasia
p53 gene
mutation
Squamous Cell
Carcinoma
Cell Death
Inflammation
Dysplasia
Carcinoma
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Clinical Features
 Insidious in onset
 Produces dysphagia and obstruction gradually and late
 Patient progressively alters their diet from solid to
liquid foods
 Extreme weight loss
 Debilitation
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Risk Factors
 Alcohol consumption increases the risk of
squamous cell cancer 10 to 25 times
 Combined cigarette use and alcohol consumption
can increase the risk of squamous cell cancer up to
100-fold
 Ingestion of nitrosamines
 Contamination of food by specific fungi
 Temperature of ingested fluids
 Presence of mechanical irritants to the esophagus
 Silica
 Crushed seeds
Reference: Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001
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 Chronic injury to the esophagus due to:
 Caustic ingestion
 Stasis of foodstuffs in patients with achalasia
 Gastroesophageal acid reflux disease
 Familial abnormality that is associated with squamous
cancer of the esophagus
 Tylosis A, which carries a 25 percent lifetime risk
Reference: Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001
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Reference: Enzinger et al NEJM 2003.
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DIAGNOSTIC TOOLS
OBJECTIVE: To identify and locate the problem, as well as
determine the extent of the diseasE
1.) CBC, PT/APTT, Electrolytes, TPAG
2.)12 lead ECG
3.)Spirometry
4.)Chest Xray
5.)CT scan
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Diagnostic Tools
 CBC - may show anemia secondary to iron deficiency or
chronic disease.
 PT and aPTT - may demonstrate hepatic insufficiency or
nutritional deficiencies; also detects abnormalities in blood
clotting
 Electrolytes – should be obtained to determine imbalances,
changes in fluid volume occur pre-op, intra op and post op
 Spirometry - measures lung function, specifically the
measurement of the amount (volume) and/or speed (flow)
of air that can be inhaled and exhaled.
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Diagnostic Tools
 12 lead ECG – a non invasive device that records
electrical activity of the heart as well as detects
possible abnormalities
 Chest X-ray – to determine the condition of the heart
and other adjacent structures.
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 CT scan - best tool for staging; to exclude the presence
of metastases (M staging) to the lungs and liver;
determines if adjacent structures have been invaded.
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Primary
tumor
Regional
Lymph nodes
Distal
Metastasis
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•
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Tis in situ
T1 Lamina propria,submucosa
T2 Muscularis propria
T3 Adventitia
T4 Adjacent strictures
• N0 none
• N1 Involved
•
•
•
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M0 none
M1 Distant
M1a Cervical/Celiac LN
M1b Other distant metastasis
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Reference: Enzinger et al NEJM 2003.
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Esophageal Cancer
 6th most frequent tumor disease worldwide
 Characterized by rapid development and fatal
prognosis in most cases
 Occurrence increases with age with the highest
incidence in the age group 50–70 years
 The disease is diagnosed more frequently in males
than in females (3:5)
 Most frequent histological type is squamous cell
carcinoma.
Reference: Helena Kollarova et al. 2007. Epidemiology of Esophageal Cancer – An Overview Article.
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Incidence
 Esophageal cancer incidence worldwide
 462 117 in the year 2002
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315 394 cases were diagnosed in males
146 723 cases in females
 In males, the incidence is approximately three times
higher than in females.
Reference: Helena Kollarova et al. 2007. Epidemiology of Esophageal Cancer – An Overview Article.
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Reference: Posner et. al., 2001. Cancer of the Upper Gastrointestinal Tract.
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Reference: Posner et. al., 2001. Cancer of the Upper Gastrointestinal Tract.
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Reference: Posner et. al., 2001. Cancer of the Upper Gastrointestinal Tract.
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Mortality
 Mortality rates represent roughly 90 % of the incidence rates of the
disease.
Reference: Helena Kollarova et al. 2007. Epidemiology of Esophageal Cancer – An Overview Article.
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 Philippines: Mortality (1998)
 Male 252 per 100 000 (0.7%)
 Females 139 per 100 000 (0.4%)
Source:World Health Organization. 1998.
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Squamous Cell Carcinoma
 Squamous cell cancers represent the single most
common malignancy of the esophagus worldwide.
 Endemic areas for squamous cell cancer of the
esophagus:
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Northern littoral in Iran
Linxian
China
Regions of South Africa, where the incidences are as high as
150 cases per 100,000 population.
Reference: Posner et. al., 2001. Cancer of the Upper Gastrointestinal Tract.
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 In the United States:
 Incidence rate of squamous cell cancers is about 3 per
100,000 population,
 Mortality: 12,000 deaths from squamous cell esophageal
cancer in 1998.
 Men are more commonly affected than are women.
 Highest incidence occurs during the sixth through
eighth decades of life.
Reference: Posner et. al., 2001. Cancer of the Upper Gastrointestinal Tract.
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Reference: Posner et. al., 2001. Cancer of the Upper Gastrointestinal Tract.
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Complications
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Weight Loss
Nutritional Deficiencies
Dysphagia
Solid food impaction
 Severe stenosis
 Requires endoscopic intervention for disimpaction.
 Regurgitation of food or oral secretions
 Significant luminal obstruction
 Halitosis
 Food stasis
 Regurgitation
Reference: James C. Chou et.al. American Medical Network: Esophageal Cancer.
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 Pulmonary complications from aspiration
 Pneumonia
 Pulmonary abscess
 The tumor mass
 Compression
 Obstruction of the tracheobronchial tree

Leading to dyspnea, chronic cough, and at times
postobstructive pneumonia.
 Esophagoairway fistula may develop with tumor
invasion of the trachea or bronchus.
 Airway fistulas are severely debilitating and are
associated with significant mortality owing to the high
risk of pulmonary complications such as pneumonia and
abscess.
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TREATMENT
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1. Surgical Management (curative)
 Treatment of Choice for early cancer
 Primary goal is complete resection of tumor and involved lymph
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nodes.
Anyone with disease up to T3 N1
Must be used with other management to improve survival
Esophagectomy: approaches include transthoracic, transhiatal,
transoral route
Radical Resection - Surgical resection that takes the blood
supply and lymph system supplying the organ along with the
organ.
Thorascopic tools, laparoscopic tools
Gastric/colonic mobilization
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Radiation Therapy
 The medical use of ionizing radiation as part of cancer treatment
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to control malignant cells
Radiotherapy may be used for curative or adjuvant cancer
treatment.
May be used as the primary therapy.
Radiation therapy works by damaging the DNA of cells.
The damage is caused by a photon, electron, proton, neutron, or
ion beam directly or indirectly ionizing the atoms which make
up the DNA chain.
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Chemotherapy
 Treatment of cancer through chemicals
 Refers to antineoplastic drugs used to treat cancer or the
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
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combination of these drugs into a cytotoxic standardized
treatment regimen.
Chemotherapy acts by killing cells that divide rapidly, one of the
main properties of cancer cells.
Most chemotherapeutic drugs work by impairing mitosis.
It also harms cells that divide rapidly under normal
circumstances which results in the most common side-effects of
chemotherapy.
Some drugs cause cells to undergo apoptosis or programmed cell
death.
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2. RADIATION & CHEMOTHERAPY
 CURABLE DISEASE
 Combined is superior to radiation alone
 Achieved overall survival rates that equal or exceed
those of historical surgical cohorts (though no trials
comparing them)
 Cisplatin and fluorouracil
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 Radiation with chemotherapy
 75% local control rate : improve swallowing
 30% actuarial disease free survival rate
 18% overall survival rate
 High Morbidity from adverse effects
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3. Neoadjuvant therapy
 Preoperative radiation and chemotherapy then resection
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PALLIATIVE THERAPY
 Most patients with esophageal cancer have advanced
stage at time of initial medical consultation.
 <20% survive in 1st year
 Goal of Palliation:
 Improvement of dysphagia
 Pain Management
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PALLIATIVE THERAPY
 DISPLACEMENT THERAPY
 ABLATIVE THERAPY
 Dilation therapy
 Contact thermal
 Stenting
 Noncontact Thermal
 Cytotoxic injection
 Photodynamic therapies
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DILATION
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STENT
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PALLIATIVE THERAPY
 Bleeding and esophageal fistula are the most common
adverse effects.
 No improvement of pain and anorexia
 Esophageal stent placement can well manage fistulas
from primary malignancy.
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Enteral Nutrition
 Enteral feeding when feasible
 Attempt to improve functional status before and after
surgery, during chemoradiation
 Oral route: precluded by anorexia, gastric dysmotility,
and generalized debilitation
 Surgical jejunostomy
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Prognosis
 The prognosis of esophageal cancer is generally
unfavorable.
 Long-term survival is only approximately 5 % of
patients.
 Of patients who undergo radical esophagectomies,10–20
% survive 5 years.
 In patients with inoperable cancer, the median survival
is 13–29 months.
Reference: Helena Kollarova et al. 2007. Epidemiology of Esophageal Cancer – An Overview Article.
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