DIAGNOSIS AND MANAGEMENT ESOPHAGEAL CANCER

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 (12-103yrs) Prevalent region - Central Nyanza province Predisposing factors Contribute to repeated long term minimal trauma a)Lifestyle 1.Smoking - SCC 2.Alcohol excess – SCC -Betel chewing b).Diet 3- Hot foods 4- Deficiency of antioxidants which have been found to inhibit carcinogenesis, including selenium, vitamins C and E, retinoids, & β-carotene, & plant sterols. 5-Exposure to N-nitroso compounds (from Nitrates & Nitrites converted by bacteria in the body) 6-Charred meat, Smoked fish C)Disorders of esophagus 7.Achalasia 8.Long standing oesophageal strictures 9.Post-irradiation 10. Paterson-Brown-Kelly (Plummer-Vinson) Syndrome - Post cricoid web + IDA 11. Barrett's oesophagus - there is a 44-fold ↑ risk of Adenocarcinoma if severe reflux for 10yrs d)Genetics 12. Tylosis (Palmar hyperkeratosis) 13. Coeliac disease - Predisposes to Adenocarcinomas 14-Epidrmolysis bullosa 15-P53 and RB genes Pathology Types; Squamous cell carcinoma- Most common worldwide Adenocarcinoma - Most common in most Westernised countries Oat cell carcinoma Site; 20% - Upper ⅓ - Squamous cell carcinoma 50% - Middle ⅓ - Squamous cell carcinoma 30% - Lower ⅓ - Adenocarcinoma Spread; 1. Local-regional - Occurs through submucosal infiltration of the wall of the oesophagus into adjacent structures, along the length of the oesophagus in the submucosal lymphatics & to regional lymph nodes. This is often discontinuous i.e. distant regional lymph nodes may be invaded even when local nodes are free of tumour, & there may be satellite nodules in the oesophagus proximal to the History Symptomatology -Progressive dysphasia initially to solids then to liquids. -Associated odynophagia- involvement of somatic structures. -Associated choking while eating-possibility of Tracheo- esophageal fistula -Hoarseness of voice-involvement of recurrent laryngeal nerve -Associated regurgitation and vomiting-colour-no bile pigment. (Due to the obstruction) -History of hematemesis or hemoptysis -Difficulty in breathing, cough-pulm. mets -Progressive weight loss, generalized fatigue and night sweats. -Steady deep chest pain often indicates mediastinal invasion. Predisposing factors. - Cigarette smoking or smoking in immediate family and alcohol intake. -ingestion of corrosive liquids-strictures -peptic ulcer and GERD-predispose adenocarcinoma -chronic drug intake-esophagitis -Consumption of chemically preserved vegetables-nitrates Smoked fish or meat -Chest irradiation-therapeutic or otherwise -cancer in patient or Family history of similar illness Physical Examination Usually non-revealing: General examination- 1. Anemia- chronic disease or Plummer Vinson syndrome Also check glositis and angular stomatitis 2. Dehydration and wasting –malnutrition 3.Oedema-malnutrition 4.Supraclavicaulr lympadenopathy-Virchows node -Examination of Chest crucial because of tumor infiltration. -Trachea central, air entry. -Resp exam-TOF creates effusion and pneumonia. INVESTIAGTIONS Laboratory 1. FHG-Anemia can be due to bleeding or nutritional deficiency or can be secondary to chronic disease and pre op preparation 2. U/E/C pre op 3. Liver function tests Serum protein levels (albumin, prealbumin, and transferrin) may be low, reflecting the extent of malnutrition. -Abnormal liver function tests may indicate liver metastases Imaging 1. Esophagoscopy and biopsy-Gold standard Allows visualization histological (or cytological) confirmation of suspected carcinoma. It is important to measure the length of the lesion and the distance from 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 organ can be involved 2.Barrium swallow-incase OGD absent Done early in course of dysphagia. Characteristic findings include 1.Rat tail appearance 2. Proximal dilatation. 3.Sholdering effects areas should be performed. 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. -Esophageal carcinoma is treated by surgery, radiotherapy, chemotherapy, or a combination of these methods. - It is important to stage the lesion as accurately as possible before deciding on the treatment plan. -Resectability of the primary lesion must first be determined. Nonresectability