Download 2. Prescribe additional examinations

MINISTRY OF HEALTH OF UKRAINE
VINNITSA NATIONAL PIROGOV MEMORIAL MEDICAL
UNIVERSITY
"CONFIRM"
at the methodical meeting
Department of Ray diagnostics,
Ray therapy and Oncology
Head of the department
As. of Prof., M.S.D. Kostyuk A.G.
________________________
"______" ________ 2013 year
METHODICAL GUIDELINES
For self-study for students in preparing for the practical (seminary) lessons
Subject of Study
Oncology
Module No.
Content Module No.
Topic of Lesson
3
Esophageal cancer.
Risk factors. Classification by TNM. Methods of
diagnostics. Clinics. Treatment: surgery, radiotherapy,
chemotherapy, combined.
Course
5
Faculty
General Medicine
1. Background.
Esophageal cancer (or oesophageal cancer) is malignancy of the esophagus.
There are various subtypes, primarily squamous cell cancer (approx 90–95% of all
esophageal cancer worldwide) and adenocarcinoma (approx. 50–80% of all
esophageal cancer in the United States). Squamous cell cancer arises from the cells
that line the upper part of the esophagus. Adenocarcinoma arises from glandular cells
that are present at the junction of the esophagus and stomach.
Esophageal tumors usually lead to dysphagia (difficulty swallowing), pain and
other symptoms, and are diagnosed with biopsy. Small and localized tumors are
treated surgically with curative intent. Larger tumors tend not to be operable and
hence are treated with palliative care; their growth can still be delayed with
chemotherapy, radiotherapy or a combination of the two. In some cases chemo- and
radiotherapy can render these larger tumors operable. Prognosis depends on the extent
of the disease and other medical problems, but is generally fairly poor.
2. Specific goals.
1. To know the etiology of esophageal cancer and the role of endocrine
pathology in the development of these diseases, their prevalence among different
groups of the population, the overall results of a special treatment ( = I)
2. To know the main cause of esophageal cancer, histologic classification and
classification system for TNM, clinical manifestations, depending on the stage of the
main methods of diagnosis and principles of radical and symptomatic treatment. (  =
II)
3. To be able to examine patients with esophageal cancer, registering patients at
the dispensary into the registration Form 30. (=III)
4. To be able to interpret the exfoliating cytology and biopsy in patients with
esophageal cancer.
5. To be able to define a differentiated treatment policy in patients with
different stages of esophageal cancer. ( = III)
6. To acquire a deontological view when working with patients with esophageal
cancer and those who have complications which is the manifestation of the underlying
disease.
7. Develop a sense of responsibility for the timeliness proper medical diagnosis
and the correct choice of treatment tactics in this pathology.
3. Basic knowledge, skills, abilities, necessary for studying the topic (interdisciplinary integration).
Preceding Subject
Normal anatomy
Normal physiology
Biochemistry
Physiopathology
Morbid anatomy
General Surgery
To know
Operative
surgery
and
topographic anatomy of the
external and internal anatomy
of esophagus, the characteristic
features of their structure,
blood supply (both arterial and
venous flow characteristics)
innervation.
Humoral and neuro-endocrine
regulation. The role of the
lymphoid tissue of esophagus
was normal.
The major classes of oral
hormones, their synthesis and
degradation.
Pathogenesis of endocrine
disorders in patients with
esophageal cancer.
Macroscopic
forms
of
esophageal cancer. Histological
classification of esophageal
cancer.
Methods of examination of
patients
with
esophageal
cancer: a survey, physical
To be able
Featuring a look of
esophagus and his parts.
Determine the stage of
esophageal
cancer
according
to
the
histological
classification
and
classification TNM.
Conduct a focused and
systematic collection of
examination.
Additional studies: endoscopy,
CT-scan, MRI, cytology and
biopsy.
Operative Surgery and The main types of surgery in
topographical anatomy
patients
with
esophageal
cancer.
Resection
of
esophagus:
indications, contraindications,
technique execution.
Esophagectomy: indications,
technique execution.
Lymphodysection: indications,
contraindications,
technique
execution.
Interdisciplinary
Key diagnostic symptoms of
Intergation
esophageal cancer.
complaints and medical
history of patients with
suspected esophageal
cancer.
Conduct
physical
examination
patients
with
esophageal cancer.
Surgical approaches to
define the line of the
face and oral wall
during these operations.
Identify
specific
manifestations
in
patients
with
esophageal
cancer,
interpretable additional
methods of examination
in these diseases.
4. Tasks for independent work in preparation for the occupation.
4.1. Theoretical issues to employment:
1. The spread of esophageal cancer.
2. Histological classification and TNM classification system of esophageal cancer.
3. Mandatory and special methods of examination.
4. Differential diagnosis of esophageal cancer.
5. Surgical treatment of esophageal cancer.
6. Indications and contraindications for surgery.
7. Technique of radical surgery in patients with esophageal cancer.
8. Palliative surgery.
9. Preoperative preparation of patients, post-operative treatment and postoperative
complications.
10. Long-term results of treatment of esophageal cancer.
11. Combined treatment of esophageal cancer. Forecast.
12. Question dispensary patients on esophageal cancer.
4.2. Practical work (jobs) that need to perform in class:
1. Carefully collect history. Determine the history of symptoms of esophageal cancer;
2. Physical examination the patient: palpation and assessment of lymph nodes,
including regional of the neck and mediastinum, palpation of the abdomen, liver;
3. Determine the methods of investigation: Ultrasound, chest radiography,
laboratory tests of blood and urine, endoscopy, CT-scan, MRI, cytology and biopsy;
4. Determine the stage of disease in patients with esophageal cancer;
5. Identify complications of esophageal cancer;
6. The indications for surgery, radiation, chemotherapy and combined treatments;
7. Assess the condition of the patient in the early postoperative period.
4.3. Content of the topic
Esophageal cancer is a cancerous (malignant) tumor of the esophagus, the
muscular tube that moves food from the mouth to the stomach.
Causes
Esophageal cancer is not very common in the United States. It occurs most
often in men over 50 years old.
Two main types of esophageal cancer exist: squamous cell carcinoma and
adenocarcinoma. These two types look different from each other under the
microscope.
Squamous cell esophageal cancer is linked to smoking and alcohol
consumption.
Barrett's esophagus, a complication of gastroesophageal reflux disease
(GERD), increases the risk for adenocarcinoma of the esophagus. This is the more
common type of esophageal cancer. Other risk factors for adenocarcinoma of the
esophagus include:

Male gender

Obesity

Smoking
Symptoms

Backwards movement of food through the esophagus and possibly mouth
(regurgitation)

Chest pain unrelated to eating

Difficulty swallowing solids or liquids

Heartburn

Vomiting blood

Weight loss
Dysphagia (difficulty swallowing) and odynophagia (painful swallowing) are
the most common symptoms of esophageal cancer. Dysphagia is the first symptom in
most patients. Odynophagia may also be present. Fluids and soft foods are usually
tolerated, while hard or bulky substances (such as bread or meat) cause much more
difficulty. Substantial weight loss is characteristic as a result of reduced appetite, poor
nutrition and the active cancer. Pain behind the sternum or in the epigastrium, often of
a burning, heartburn-like nature, may be severe, present itself almost daily, and is
worsened by swallowing any form of food. Another sign may be an unusually husky,
raspy, or hoarse-sounding cough, a result of the tumor affecting the recurrent
laryngeal nerve.
The presence of the tumor may disrupt normal peristalsis (the organized
swallowing reflex), leading to nausea and vomiting, regurgitation of food, coughing
and an increased risk of aspiration pneumonia. The tumor surface may be fragile and
bleed, causing hematemesis (vomiting up blood). Compression of local structures
occurs in advanced disease, leading to such problems as upper airway obstruction and
superior vena cava syndrome. Fistulas may develop between the esophagus and the
trachea, increasing the pneumonia risk; this condition is usually heralded by cough,
fever or aspiration.
Most of the people diagnosed with esophageal cancer have late-stage disease,
because people usually do not have significant symptoms until half of the inside of
the esophagus, called the lumen, is obstructed, by which point the tumor is fairly
large.
If the disease has spread elsewhere, this may lead to symptoms related to this:
liver metastasis could cause jaundice and ascites, lung metastasis could cause
shortness of breath, pleural effusions, etc.
Exams and Tests
Tests used to help diagnose esophageal cancer may include:

Barium swallow

Chest MRI or thoracic CT (usually used to help determine the stage of the
disease)

Endoscopic ultrasound (also sometimes used to determine the stage of disease)

Esophagogastroduodenoscopy (EGD) and biopsy

PET scan (sometimes useful for determining the stage of disease, and whether
surgery is possible)
Stool testing may show small amounts of blood in the stool.
Treatment
When esophageal cancer is only in the esophagus and has not spread, surgery is
the treatment of choice. The goal of surgery is to remove the cancer.
See:

Esophagectomy

Esophagectomy - minimally invasive
Sometimes chemotherapy, radiation, or a combination of the two may be used
instead of surgery, or to make surgery easier to perform.
If the patient is too ill to have major surgery or the cancer has spread to other
organs, chemotherapy or radiation may be used to help reduce symptoms. This is
called palliative therapy. In such cases, the disease is usually not curable.
Other treatments that may be used to help the patient swallow include:

Endoscopic dilation of the esophagus (sometimes with placement of a stent to
keep the esophagus dilated).

Photodynamic therapy, in which a special drug is injected into the tumor and is
then exposed to light. The light activates the medicine that attacks the tumor.
Support Groups
Patients can often ease the stress of illness by joining a support group of people
who share common experiences and problems. See cancer - support group.
Outlook (Prognosis)
Esophageal cancer is usually not curable. When the cancer has not spread
outside the esophagus, surgery may improve the chances of survival.
Radiation therapy is used instead of surgery in some cases where the cancer has
not spread outside the esophagus.
For patients whose cancer has spread, a cure is generally not possible.
Treatment is directed toward relieving symptoms.
Possible Complications

Difficulty swallowing

Pneumonia

Severe weight loss from not eating enough

Spread of the tumor to other areas of the body
When to Contact a Medical Professional
Call your health care provider if you have difficulty swallowing with no known
cause and it does not get better, or if you have other symptoms of esophageal cancer.
Prevention
The following may help reduce your risk of squamous cell cancer of the
esophagus:

Avoid smoking

Limit or do not drink alcoholic beverages
People with symptoms of severe gastroesophageal reflux should seek medical
attention.
Screening with EGD and biopsy in people with Barrett's esophagus may lead to
early detection and improved survival. People who are diagnosed with Barrett's
esophagus should consider getting regular checkups for esophageal cancer.
5. Tests for self evaluation.
A. Tests for self evaluation (test problem)
1. Which tumour of the esophagus is the epithelial derivation ?
1) The hemangioma
2) The myoma
3) The fibroma
4) The neurinoma
5) *The polyp
Correct answer: 5.
2. Where is found the Bernar-Gorner’s syndrome for esophageal cancer?
1) implant of recurrent nerve
2) penetration of adventitial tunic
3) penetration of diaphragmatic nerve
4) *penetration of sympathetic ganglion
5) penetration of vagus nerve
Correct answer: 4.
3. The most frequent benign tumor of esophagus
1) *Leiomioma
2) Fibroma
3) Adenoma
4) Lipoma
5) Lymphangioma
Correct answer: 1.
4. What is Schnitzler metastasis is metastasis in
1) Ovary
2) Umbilicus
3) *Peritoneum of small pelvis
4) Supraclavicular lymphatic node
5) Liver
Correct answer: 3.
5. What tumour of the liver is epithelial provenance?
1) Hemangioma
2) Fibroma
3) Lipoma
4) *Adenoma
5) Limphangioma
Correct answer: 4.
B. Situation tasks for self-control:
Task 1.
The male 65 y.o. alcohol abused in past, complaint of progressive disphagia for 2
monthes. The last 2 weeks have fluid diet only. During 3 days complaint for bad
cough after several sip of fluid. Temperature was increased, breath was complicated.
By fibrogastroscopy- at 26 cm circular constriction, by biopsy- planocellular cancer.
1. Provisional diagnosis
2. Prescribe additional examinations
3. Treatment tactics
6. Literature.
Basic.
1. Sorcin V, Popovich A, Dumanskiy Yu, et al. Clinical oncology.
Simferopol, 2008; 192 p.
2. Schepotin IB, Evans SRT. Oncology. Kiev, 2008; 235 p.
Additional.
1. National Comprehensive Cancer Network. NCCN Practice Guidelines in
Oncology: Esophageal cancer Screening. v. 2012.
2. National Cancer Institute. Esophageal Cancer Treatment PDQ. Updated
2012.
3. Das A. Tumors of the esophagus. In: Feldman M, Friedman LS, Brandt LJ,
eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 9th ed.
Philadelphia, Pa: Saunders Elsevier; 2010: 46 p.
4. Wong A, Fitzgerald RC Epidemiologic risk factors for Barrett's esophagus
and associated adenocarcinoma. Clin. Gastroenterol. Hepatol. 2005; 3: 1–10.
Methodical guidelines written
by Assistant oncology department
PhD. Lysenko S.A.