DIAGNOSIS AND MANAGEMENT ESOPHAGEAL CANCER
DIAGNOSIS AND MANAGEMENT ESOPHAGEAL CANCER 0DIAGNOSIS AND MANAGEMENT ESOPHStAuvGiaE.cAoLm C- TAhNeCMEaRrketplace to BuyDaInAdGSNelOl ySoIuSr Study Material
Introduction, definition, age, pathology –Refer. Sex
M:F - 25:1
Age
Average age - 58.2yrs ...
diagnosis and management esophageal cancer diagnosis and management esophageal cancer 0diagnosis and management esophstauvgiaecaolm c tahnecmearrketplace to buydainadgsnelol ysoiusr study material
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DIAGNOSIS AND MANAGEMENT ESOPHAGEAL CANCER
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DIAGNOSIS AND MANAGEMENT ESOPHAGEAL CANCER
DIAGNOSIS AND MANAGEMENT ESOPHAGEAL CANCER 0DIAGNOSIS AND MANAGEMENT ESOPHStAuvGiaE.cAoLm C-
TAhNeCMEaRrketplace to BuyDaInAd GSNelOl ySoIuSr Study Material
Introduction, definition, age, pathology –Refer. History
Sex Symptomatology
M:F - 25:1 -Progressive dysphasia initially to solids then to liquids.
Age -Associated odynophagia- involvement of somatic
Average age - 58.2yrs (12-103yrs) structures.
Prevalent region - Central Nyanza province -Associated choking while eating-possibility of Tracheo- esophageal fistula
Predisposing factors -Hoarseness of voice-involvement of recurrent laryngeal nerve
Contribute to repeated long term minimal trauma -Associated regurgitation and vomiting-colour-no bile pigment. (Due to the
a)Lifestyle obstruction)
1.Smoking - SCC -History of hematemesis or hemoptysis
2.Alcohol excess – SCC -Difficulty in breathing, cough-pulm. mets
-Betel chewing -Progressive weight loss, generalized fatigue and night sweats.
b).Diet -Steady deep chest pain often indicates mediastinal invasion.
3- Hot foods Predisposing factors.
4- Deficiency of antioxidants which have been found to inhibit carcinogenesis, - Cigarette smoking or smoking in immediate family and alcohol intake.
including selenium, vitamins C and E, retinoids, & β-carotene, & plant sterols. -ingestion of corrosive liquids-strictures
5-Exposure to N-nitroso compounds (from Nitrates & Nitrites converted by -peptic ulcer and GERD-predispose adenocarcinoma
bacteria in the body) -chronic drug intake-esophagitis
6-Charred meat, Smoked fish -Consumption of chemically preserved vegetables-nitrates
C)Disorders of esophagus Smoked fish or meat
7.Achalasia -Chest irradiation-therapeutic or otherwise
8.Long standing oesophageal strictures -cancer in patient or Family history of similar illness
9.Post-irradiation Physical Examination
10. Paterson-Brown-Kelly (Plummer-Vinson) Syndrome - Post cricoid web Usually non-revealing:
+ IDA General examination-
11. Barrett's oesophagus - there is a 44-fold ↑ risk of Adenocarcinoma if 1. Anemia- chronic disease or Plummer Vinson
severe reflux for >10yrs syndrome Also check glositis and angular stomatitis
d)Genetics 2. Dehydration and wasting –malnutrition
12. Tylosis (Palmar hyperkeratosis) 3.Oedema-malnutrition
13. Coeliac disease - Predisposes to 4.Supraclavicaulr lympadenopathy-Virchows node
Adenocarcinomas 14-Epidrmolysis bullosa -Examination of Chest crucial because of tumor infiltration.
15-P53 and RB genes -Trachea central, air entry.
Pathology -Resp exam-TOF creates effusion and pneumonia.
Types; INVESTIAGTIONS
Squamous cell carcinoma- Most common worldwide Laboratory
Adenocarcinoma - Most common in most Westernised countries 1. FHG-Anemia can be due to bleeding or nutritional deficiency or can
Oat cell carcinoma be secondary to chronic disease and pre op preparation
Site; 2. U/E/C pre op
20% - Upper ⅓ - Squamous cell carcinoma 3. Liver function tests Serum protein levels (albumin, prealbumin,
50% - Middle ⅓ - Squamous cell carcinoma and transferrin) may be low, reflecting the extent of malnutrition.
30% - Lower ⅓ - Adenocarcinoma -Abnormal liver function tests may indicate liver metastases
Spread; Imaging
1. Local-regional - Occurs through submucosal infiltration of the wall of the 1. Esophagoscopy and biopsy-Gold standard
oesophagus into adjacent structures, along the length of the oesophagus in the Allows visualization histological (or cytological) confirmation of suspected
submucosal lymphatics & to regional lymph nodes. This is often discontinuous carcinoma.
i.e. distant regional lymph nodes may be invaded even when local nodes are free It is important to measure the length of the lesion and the distance from the
of tumour, & there may be satellite nodules in the oesophagus proximal to the incisors for staging and treatment planning.
main tumour. Typical tumours are friable and bleed easily. Multiple biopsies from suspicious
2. Systemic (Haematogenous) - Mainly to the liver & lungs, but practically any areas should be performed.
organ can be involved Bronchoscopy may be done to check invasion of the bronchi
MANAGEMENT
The goal of treatment in carcinoma of the oesophagus is twofold: palliation of
dysphagia and cure of the cancer. The standard of therapy is oesophageal
resection.
-However most patients present with advanced tumour which are unresectabe.
Palliative management to relieve the dysphagia is instituted.
2.Barrium swallow-incase OGD absent -Esophageal carcinoma is treated by surgery, radiotherapy, chemotherapy, or a
Done early in course of dysphagia. Characteristic findings include combination of these methods.
1.Rat tail appearance - It is important to stage the lesion as accurately as possible before deciding on
2. Proximal dilatation. the treatment plan.
3.Sholdering effects -Resectability of the primary lesion must first be determined. Nonresectability
, 4.Mucosal erosion/defects suggested by:
3.CXR
1. Direct spread to the trachea-bronchial tree or aorta 2.Angulation of
a) Check for mediastinal widening-invasion by tumor or lymphadenopathy
esophageal axis.
b) Pleural effusion indicate pleural dessimination
3. Tracheoesophageal fistula
c) TOF pneumonic process features of aspiration pneumonia.
4. Hoarseness associated with vocal cord paralysis
d) The diaphragm doming in involvement of phrenic nerve causing paralysis.
5.Primary tumors larger than 10 cm are rarely resectable
e) Lung nodules-lung metastasis or lung
A.SURGERY
abcess e)An esophageal air-fluid level- Mucosal resection at endoscopy-CIS
obstruction For the carcinoma in situ
3. Endoscopic ultrasonography
Types of Curative Subtotal Oesophagectomy;
-Endoscopic ultrasound improves the ability to determine wall penetration and
abnormal lymph nodes. The, main determinants of the operation chosen are the surgeon's preference an
- Used in pre-operative staging. Five distinct wall layers can be identified that level of the tumour.
correspond to the mucosa, lamina propria, muscularis mucosa, muscularis The three most common approaches currently in use are:
propria, and adventitia. Carcinoma appears as an irregular hypoechoic 1. Grey –Turner’s Transhiatal oesophagectomy
mass.Depth of penetration of the wall can be accurately assessed. 2. Lewis’ laparotomy and right thoracotomy
The ability to detect regional lymph-node involvement may be further enhanced 3.Sweets’ left thoraco-abdominal
by the use of endoscopic, ultrasonographically guided fine-needle aspiration, 1.Grey –Turner’s Trans-hiatal oesophagectomy
which has an accuracy of more than 90 percent at many centers Best used to remove upper-third or lower-third neoplasms
5.CT-Scan of the chest The operation is done in a supine position with a single lumen endotracheal tub
Local invasion of the tumour and extension. Used in staging of the tumour. A laparotomy is performed first and the abdomen is explored. The stomach is
prepared as an oesophageal substitute.
Other investigations The stomach is mobilized on the right gastric and gastroepiploic arteries. The
a) Bronchoscopy should be done in lesions of the upper or middle ⅓, where omentum is divided, preserving the right gastroepiploic artery. The left gastric
there is potential for tracheo-bronchial invasion. artery is double ligated.
b) Staging laparoscopy is useful for assessing Adenocarcinoma of the distal The gastrohepatic omentum is divided with care taken to identify accessory
oesophagus, particularly if it is likely to extend below the phreno-oesophageal arteries to the left lobe of liver.
ligament. Also, transperitoneal spread & liver metastasis The hiatus is dissected . It is helpful to open the hiatus anteriorly as described b
Differential diagnosis Pinotti. This facilitates exposure of the distal oesophagus almost to the level of
1. Benign papillomas, polyps, or granulomatous masses the carina.
2. Esophageal webs, rings and strictures The side of left neck is opened and the oesophagus exposed; The upper third
of
3. Achalasia cardia the oesophagus can be dissected under direct vision.Cancerous portio of
4. Mediastinal tumours-Lymhoma oesophagus is removed and the stomach is brought up through the posterior
Staging mediastinal oesophageal bed and a cervical anastomosis performed.
TNM Staging 2. Lewis’ laparotomy and right thoracotomy
Tis Carcinoma-in-situ Best for mid- or lower-third lesions.
T1 invading lamina propria/submucosa An upper midline laparotomy is performed and the upper abdomen explored.
T2 invading muscularis propria The stomach is mobilized as previously described. It is important to enlarge
the
T3 invading adventitia hiatus to prevent compression of the stomach when it is brought into the chest.
T4 invasion of adjacent structures Patient is then positioned for right thoracotomy.The stomach is then elevated
NX, N0, N1 u into the chest and a high intrathoracic anastomosis is made at the apex of the
M0 no distant spread ri chest.
M1 distant metastasis; Spread to the coeliac axis nodes from a lesion in the
intrathoracic oesophagus - Regarded as metastatic (M) rather than nodal (N) Complications of tubes
disease in the TNM classification. a) Dislodged
b) Blocked with food
c) Overgrown and blocked by tumour
3.-3 stage McKeown operation - As Ivor Lewis (above) but a third incision on d) Aggravation of chest pain.
the right of the neck is made to complete the cervical anastomosis. A neck e) Haemorrhage
incision is required if; f) Perforation
lymph node dissection is to be done -Furthermore, concomitant radiotherapy increases the complications of tubes e
there are technical difficulties with an anastomosis at the thoracic inlet bleeding, perforation.
For upper & middle ⅓ tumours -Therefore, intubation should be reserved for patients with extensive disease an
3. Sweets’ left thoraco-abdominal a life expectancy limited to 1-2 months.
Best employed for gastro-oesophageal junction carcinomas or low oesophageal -Patient should rest at 45 degrees to reduce reflux
carcinomas. Tumours 35 cm or more from the incisors are ideally suited to this -Should take meals at least 3 hours before sleeping.
approach. Drink pure pineapple juice.
The patient is placed in the right lateral decubitus position. An oblique left upper 2) Laser therapy - a core of tumour is vaporized, opening the lumen
quadrant laparotomy is performed to explore the gastro-oesophageal junction area without perforating the oesophagus.
and the liver. 3) Radiation therapy-For patients with unresectable disease and for poor
Then a thoracoabdominal incision through the sixth or seventh interspace is operative candidates, radiation therapy may afford significant short-term
performed. The diaphragm is incised circumferentially to avoid injury to palliation of pain and dysphagia. Better for upper third tumours which are
the phrenic nerve branches. The stomach is mobilized as above. mos squamous cell carcinoma.
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