Download Esophageal Cancer

Chief Complaint: DYSPHAGIA
History of Present Illness
5 months
PTA
4 months &
3 weeks PTA
• Experienced dysphagia and vomitting 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
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)
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)
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)
2 months
PTA
May 10,
2009
• Continued 2nd cycle chemotherapy
& 26th session of radiotherapy
• Subsequently discharged
• Admitted for surgery
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
 No HPN, DM, allergies, Goiter and Asthma
Family History
 + for colon cancer, sister
 + asthma- siblings, mother, grandmother
 + for DM- mother
 + for PTB- father
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
Review of Systems
 General: (‐) fever/ sweats/anorexia/ weakness
 HEENT: (‐) visual dysfunction/redness/ itchiness/ pain/ lacrimation, (‐) deafness/
 Hnnitus/ 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
Physical Exam
 BP (mm Hg): 90/60
 Pulse rate / character: 80bpm, regular
 Respiratory rate / pattern: 18cpm, regular
 Temperature (°C): 36.6°C
 Wt. (kg.): 43.5
 Ht. (cm): 158.5
 BMI: 17.4
 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
 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
 ABDOMEN: scaphoid abdomen, (+) 6 cm diagonal
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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 extremiHes
(leI
longer and thinner than the right), (‐) tenderness, (‐)
swelling
NEUROLOGIC EXAM: normal
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
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
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
Esophageal Cancer
(Squamous Cell Ca)
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
Harrison’s Principles of Internal Medicine 17th ed. pp 237-239
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
Harrison’s Principles of Internal Medicine 17th ed. pp 237-239
Dysphagia
Mechanical
Oropharyngeal
Esophageal
Motor
Oropharyngeal
Harrison’s Principles of Internal Medicine 17th ed. pp 237-239
Esophageal
Dysphagia
Mechanical
Oropharyngeal
Esophageal
Motor
Oropharyngeal
Harrison’s Principles of Internal Medicine 17th ed. pp 237-239
Esophageal
Esophageal Dysphagia
 Normally can be distended up to 4cm in diameter
 Dysphagia to solid food <2.5cm
 Dysphagia to fluids <1.3cm
.
Harrison’s Principles of Internal Medicine, 17th ed
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
Robbins and Cotran Pathologic Basis of Disease, 7th ed.
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
Robbins and Cotran Pathologic Basis of Disease, 7th ed.
Pathogenesis of Esophageal Carcinoma
Injury
Stratified squamous Epithelium
Ulcer
Hyperplasia
Cell
Death
Inflammation
Gastric Metaplasia
Dysplasia
Glandular
Dysplasia
Adenocarcinom
a
Carcinoma
Pathogenesis of Squamous Cell Carcinoma
Injury
Stratified squamous Epithelium
Ulcer
Hyperplasia
p53 gene
mutation
Squamous Cell
Carcinoma
Cell
Death
Inflammation
Dysplasia
Carcinoma
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
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
Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001
 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.
Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001
Enzinger et al NEJM 2003
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
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 preop, 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.
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.
CT scans - best tool for staging; to
exclude the presence of metastases (M
staging) to the lungs and liver;
determines if adjacent structures have
been invaded.
Primary
tumor
Regional
Lymph nodes
Distal
Metastasis
•
•
•
•
•
Tis in situ
T1 Lamina propria,submucosa
T2 Muscularis propria
T3 Adventitia
T4 Adjacent strictures
• N0 none
• N1 Involved
•
•
•
•
M0 none
M1 Distant
M1a Cervical/Celiac LN
M1b Other distant metastasis
(Enzinger et al NEJM 2003)
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
EPIDEMIOLOGY OF ESOPHAGEAL CANCER – AN OVERVIEW ARTICLE
Department of Preventive Medicine, Faculty of Medicine, Palacky University Olomouc, Hnevotinska 3, 775 15 Olomouc, Czech
Republic
Helena Kollarova et al; March 29, 2007;
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.
EPIDEMIOLOGY OF ESOPHAGEAL CANCER – AN OVERVIEW ARTICLE
Department of Preventive Medicine, Faculty of Medicine, Palacky University Olomouc, Hnevotinska 3, 775 15 Olomouc, Czech
Republic
Helena Kollarova et al; March 29, 2007;
Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001
Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001
Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001
Mortality
 Mortality rates represent roughly 90 % of the incidence rates of the
disease.
EPIDEMIOLOGY OF ESOPHAGEAL CANCER – AN OVERVIEW ARTICLE
Department of Preventive Medicine, Faculty of Medicine, Palacky University Olomouc, Hnevotinska 3, 775 15 Olomouc, Czech
Republic
Helena Kollarova et al; March 29, 2007;
 Philippines: Mortality 1998
 Male 252 per 100 000 (0.7%)
 Females 139 per 100 000 (0.4%)
from WHO www.who.int; 1998
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.
Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001
 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
Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001
Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001
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
American Medical Network: Esophageal Cancer; James C. Chou et.al
 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.
TREATMENT
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
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
Chemotherapy
 Treatment of cancer through Chemicals
 Refers to antineoplastic drugs used to treat cancer or the
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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
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
 Radiation with chemotherapy
 75% local control rate : improve swallowing
 30% actuarial disease free survival rate
 18% overall survival rate
 High Morbidity from adverse effects
3. Neoadjuvant therapy
 Preoperative radiation and chemotherapy then resection
PALLIATIVE THERAPY
 Most patient 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
PALLIATIVE THERAPY
 DISPLACEMENT THERAPY
 ABLATIVE THERAPY
 Dilation therapy
 Contact thermal
 Stenting
 Noncontact Thermal
 Cytotoxic injection
 Photodynamic therapies
DILATION
STENT
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
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
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.
EPIDEMIOLOGY OF ESOPHAGEAL CANCER – AN OVERVIEW ARTICLE
Department of Preventive Medicine, Faculty of Medicine, Palacky University Olomouc, Hnevotinska 3, 775 15 Olomouc, Czech
Republic
Helena Kollarova et al; March 29, 2007;