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High Incidence of
Esophageal Squamous Cell
Carcinoma in the Kalenjin
Population of Kenya
Chris Huff, MD
PGY-3
M.C.
54 yo female presents with worsening SOB and
dry cough x 1 month. Also mild dysphagia with
solids.
Denies chest pain, orthopnea, PND, LE swelling.
No fever, chills, night sweats, hemoptysis
PMH: none
Fam Hx: NC
Soc Hx: no toxic habits
Meds: none
All: NKDA
M.C.
EXAM:
Gen: mild resp distress
VS: 36.8, P85, BP90/60, R26, 88% RA
Heart: RRR, no m/r/g
Lungs: coarse breath sounds throughout all lung
fields bilaterally
Abd: benign, no HSM
Node: no palpable LAD
Ext: warm, no edema
M.C.
HCT 32
WBC 8
Plt 250
Creat 1.2
Na+ 128
HIV (-)
CXR – diffuse interstitial opacities bilat.
with mediastinal LAD
M.C.
Hospital Course:
- Admitted to the medicine service and
treated empirically with Rocephin,
Azithromycin, and 4 drug TB therapy
- Worsened over the next few days, so
steroids and nebulizer initiated
- On HD #5 sats 35% on 15L
M.C.
- Patient transferred to the ICU with plan for
intubation
- Pt intubated and after inflation of the cuff,
was discovered to have persistent air leak
- Also stomach and chest both rising with
bagging
M.C.
- Patient was felt to most likely have
tracheo-esophageal fistula (TEF)
- Gen Surg consulted for EGD and cancer
found in mid portion of esophagus with
extension to the trachea, creating TEF
- Pt made comfort care and expired 1 hr
later from resp. failure
Esophageal SCC in Western Kenya
Epidemiology:
- Most common cancer in Men and 3rd most
common in women
- Incidence 200 per 100,000
- Male to female ratio of 1.5 to 1
- Mean age at diagnosis 58.7 yrs
- 90% is squamous cell
Esophageal SCC in Western Kenya
Tenwek Hospital Bomet Kenya
- Retrospective Review of esophageal cancer diagnoses
1999-2007
- Esophageal cancer accounted for 914 (34%) of newly
diagnosed cancers
- 6.3% of pts </= to 30yo, 1% </= to 20yo
Dis Esophagus. 2009 May 15.
Esophageal SCC in Western Kenya
Risk Factors:
- Family history
- EtOH and tobacco
- Corn and Wheat Diet (2 main hypotheses)
1) Deficiency of A, C, E, selenium, zinc
2) Exposure to the corn mold Fusarium moniliforme
Sheldon
3) Polycyclic Aromatic Hydrocarbons from food
contaminated with smoke or soot
Esophageal SCC in Western Kenya
Pathophysiology:
- Arises from polyps, plaques, or denuded epithelium
- Usually occurs in the mid-esophagus
- Early invasion of submucosa and extends in cephalad
direction
- Invades lymph nodes early b/c the lymphatics are
located in the lamina propria
Esophageal SCC in Western Kenya
Clinical Manifestations:
- Dysphagia and weight loss most common
- Vomiting and chest pain
- Iron deficiency anemia without melena
- Respiratory symptoms if TEF develops
Esophageal SCC in Western Kenya
Tracheoesophageal Fistula: How rare?
- European study in 2008 264 of 2113
patients with esophageal cancer were
found to have a TEF
- Incidence in Kenya
unknown
Esophageal SCC in Western Kenya
Diagnosis of Esophageal Cancer:
- Barium swallow can suggest, but need EGD with
biopsy to make the diagnosis
- On EGD can appear as plaque, stricture,
ulceration, or mass
- Diagnosis improves with number of biopsies
taken: 1= 93%, 7=98%
Esophageal SCC in Western Kenya
Esophageal SCC in Western Kenya
Staging of Esophageal Cancer:
- TNM criteria – 5 yr survival related to
stage:
I 60%
II 31%
III 20%
IV 4%
Esophageal SCC in Western Kenya
Staging of Esophageal Cancer:
- CT scan to evaluate for metastasis (M)
- EUS for locoregional staging (T & N)
- Possible PET to better eval for mets prior to surgery
**EUS and PET not available in Western Kenya and
staging CT often not performed because of financial
reasons
Esophageal SCC in Western Kenya
Treatment: Depends on Stage
- Neoadjuvant chemoradiation followed by
surgery for stage I – IIIa
- Cisplatin/5-FU chemo recommended
- 60% unresectable at diagnosis
- Chemoradiation
- Palliative care (may include stenting)
Conclusions
Esophageal Cancer is common and occurs at an
early age in Western Kenya
Risk factors are combination of genetic and
environmental
Diagnosis made with EGD and biopsy
In remote areas of Kenya treatment limited to
surgical resection vs palliative care
References
Balazs et al. Eur J Cardiothorac Surg 2008;34:1103-1107
Parker et al. Frequent occurrence of esophageal cancer in young people in western Kenya Dis Esophagus. 2009
May 15
Wakhisi et al. Esophageal cancer in north rift valley of Western Kenya. Afr Health Sci. 2005 Jun;5(2):157-63
White et al. Esophageal Cancer: a common malignancy of young people in Bomet District, Kenya. Lancet. 2002
Aug 10;360(9331):462-3
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Graham et al. Prospective evaluation of biopsy number in the diagnosis of esophageal and gastric
carcinoma.Gastroenterology 1982 Feb;82(2):228-31
Rationale of staging in cancer of the esophagus. In: International Trends in General Thoracic Surgery: Esophageal
Cancer, vol 4, Delarue, N, Wilkins, EW, Wong, J Eds), CV Mosby, St Louis 1988.
Mallery, S, Van Dam, J. Increased rate of complete EUS staging of patients with esophageal
cancer using the nonoptical, wire-guided echoendoscope. Gastrointest Endosc 1999; 50:53.
Bolton, JS, Fuhrman, GM, Richardson, WS. Esophageal resection for cancer. Surg Clin North Am
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