Chief Complaint: DYSPHAGIA. History of Present Illness 5 months PTA Experienced dysphagia and...

Chief Complaint: DYSPHAGIA

History of Present Illness

Jan.22- Feb.21EGD- 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 doneCT 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)

Past Medical History+ for Polio in 1958 at age 3+ for TB in 1980, 3 months treatment2002, laceration right upper quadrant,

sutured without any complicationsNo HPN, DM, allergies, Goiter and Asthma

Family History+ for colon cancer, sister+ asthma- siblings, mother, grandmother+ for DM- mother+ for PTB- father

Personal & Social History23 pack years of smoking, stopped 3 months

nowAlcoholic 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 ExamBP (mm Hg): 90/60Pulse rate / character: 80bpm, regularRespiratory rate / pattern: 18cpm, regularTemperature (°C): 36.6°CWt. (kg.): 43.5Ht. (cm): 158.5BMI: 17.4

GENERAL SURVEY: conscious, coherent, ambulatory notcardio‐pulmonary distress

SKIN: warm, moist dry skin, no active dermatosesHEENT: pale palpebral conjunctiva, anicteric sclera,pupils 2‐3 mm round and ERTL No alar flaring, nonaso‐aural d/c. (+) NGT right Nostril. No impactedcerumen, intact tympanic bilateral membrane, nasalseptum midline, (‐) tenderness, inflammation (‐)bleeding, ecchymosis (‐) anosmia, (‐) facialasymmetry. Moist buccal mucosa, non‐hyperemic

NECK: supple neck, lymph nodes non‐palpable cervical LN

thyroid gland not enlarged, no other massesTHORAX / LUNGS: symmetrical chest expansion,

noretractions, no lagging, equal tactile fremiti,

resonantlung fields, breath sounds with expiratory wheeze

onboth upper lung fields more prominent rightCARDIOVASCULAR: adynamic precordium, AB

5th LICS MCL,S1>S2 apex, S2 > S1 at the base, no murmursAll pulses normal

ABDOMEN: scaphoid abdomen, (+) 6 cm diagonal scar at

RUQ, normoactive bowel sounds, tympanitic onpercussion, Traube’s space not obliterated, no

direct orrebound tenderness, spleen not palpable (‐) fluid

wave,(‐) CVA tendernessMUSCULOSKELETAL: Asymmetric lower

extremiHes (leIlonger and thinner than the right), (‐)

tenderness, (‐)swellingNEUROLOGIC EXAM: normal

Salient Features53 years oldMaleBMI: 17.4 (N: 18.5-23)Progressive dysphagia to solids and liquidsvomitingBody weakness(+) family history of colon CA23 smoking pack years, stopped 5 months agoAlcoholic

Brandy TID1 long neck for 23 years, stopped 5 months ago

(+) substance abuse: marijuana,shabu(-) lymphadenopathies(-)anorexia

Salient FeaturesEGD:

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 massRevealed 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 FeaturesCT 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

DysphagiaMechanical due to large bolus or narrow

lumenMotor due to weakness of peristaltic

contractions or impaired deglutitive inhibition causing nonperistaltic contractions and impaired sphincter relaxation


Esophageal DysphagiaNormally can be distended up to 4cm in

diameterDysphagia to solid food <2.5cmDysphagia to fluids <1.3cm

Harrison’s Principles of Internal Medicine, 17th ed.

Squamous Cell Carcinoma of the EsophagusMost common type of carcinoma of the

esophagus – 90% Age > 50Most 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 EsophagusMost squamous cell carcinomas are

moderately to well differentiatedRich lymphatic network in the sub mucosa

promotes extensive circumferential and longitudinal spread

Areas of metastasisupper third - cervical lymph nodesmiddle third - mediastinal, paratracheal, and

tracheobronchial nodeslower third - gastric and celiac groups of nodes

Robbins and Cotran Pathologic Basis of Disease, 7th ed.

Pathogenesis of Esophageal Carcinoma

Injury

Stratified squamous Epithelium

Cell Death

Hyperplasia

Gastric Metaplasia

Inflammation

Dysplasia

CarcinomaGlandular Dysplasia

Adenocarcinoma

Ulcer

Pathogenesis of Squamous Cell Carcinoma

Injury

Stratified squamous Epithelium

Cell Death

Hyperplasia

Inflammation

Dysplasia

CarcinomaSquamous Cell

Carcinoma

Ulcer

p53 gene mutation

Clinical FeaturesInsidious in onset Produces dysphagia and obstruction

gradually and latePatient progressively alters their diet from

solid to liquid foodsExtreme weight lossDebilitation

Risk FactorsAlcohol consumption increases the risk of

squamous cell cancer 10 to 25 timesCombined cigarette use and alcohol

consumption can increase the risk of squamous cell cancer up to 100-fold

Ingestion of nitrosaminesContamination of food by specific fungiTemperature of ingested fluids Presence of mechanical irritants to the

esophagusSilicaCrushed seeds

Cancer of the Upper Gastrointestinal Tract by Posner et. al., November 2001

Chronic injury to the esophagus due to:Caustic ingestionStasis of foodstuffs in patients with achalasiaGastroesophageal acid reflux disease

Familial abnormality that is associated with squamous cancer of the esophagusTylosis A, which carries a 25 percent lifetime

risk.


Enzinger et al NEJM 2003

DIAGNOSTIC TOOLSOBJECTIVE: 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 pre-op, 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.

(Enzinger et al NEJM 2003)

Esophageal Cancer6th most frequent tumor disease worldwideCharacterized by rapid development and fatal

prognosis in most casesOccurrence 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 carcinomaEPIDEMIOLOGY 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;

IncidenceEsophageal cancer incidence worldwide

462 117 in the year 2002 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;

MortalityMortality rates represent roughly 90 % of the incidence

rates of the disease.



Philippines: Mortality 1998Male 252 per 100 000 (0.7%)Females 139 per 100 000 (0.4%)

from WHO www.who.int; 1998

Squamous Cell CarcinomaSquamous cell cancers represent the single

most common malignancy of the esophagus worldwide.Endemic areas for squamous cell cancer of the

esophagus Northern littoral in Iran Linxian, China Regions of South Africa, where the incidences are

as high as 150 cases per 100,000 population.


In the United StatesIncidence 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

womenHighest incidence occurs during the sixth

through eighth decades of life


ComplicationsWeight LossNutritional DeficienciesDysphagiaSolid food impaction

Severe stenosisRequires endoscopic intervention for disimpaction.

Regurgitation of food or oral secretions Significant luminal obstruction

Halitosis Food stasisRegurgitation

American Medical Network: Esophageal Cancer; James C. Chou et.al

Pulmonary complications from aspiration PneumoniaPulmonary 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 cancerprimary goal is complete resection of tumor and involved

lymph nodesanyone with disease up to T3 N1must be used with other management to improve survivalesophagectomy: approaches include transthoracic,

transhiatal, transoral routeRadical Resection - Surgical resection that takes the blood

supply and lymph system supplying the organ along with the organ.

thorascopic tools, laparoscopic toolsgastric/colonic mobilization

Radiation TherapyThe medical use of ionizing radiation as part of cancer

treatment 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

ChemotherapyTreatment of cancer through ChemicalsRefers to antineoplastic drugs used to treat cancer or

the 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 DISEASECombined is superior to radiation aloneAchieved overall survival rates that equal or

exceed those of historical surgical cohorts (though no trials comparing them)

Cisplatin and fluorouracil

Radiation with chemotherapy75% local control rate : improve swallowing30% actuarial disease free survival rate18% overall survival rateHigh Morbidity from adverse effects

3. Neoadjuvant therapyPreoperative radiation and chemotherapy then

resection

PALLIATIVE THERAPYMost patient with esophageal cancer have

advanced stage at time of initial medical consultation

<20% survive in 1st yearGoal of Palliation:

improvement of dysphagiaPain Management

PALLIATIVE THERAPYDISPLACEMENT

THERAPY

Dilation therapyStenting

ABLATIVE THERAPY

Contact thermalNoncontact ThermalCytotoxic injectionPhotodynamic therapies

PALLIATIVE THERAPYBleeding and esophageal fistula are the most

common adverse effectsNo improvement of pain and anorexia

Esophageal stent placement can well manage fistulas from primary malignancy

Enteral NutritionEnteral 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

PrognosisThe 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.



Chief Complaint: DYSPHAGIA. History of Present Illness 5 months PTA Experienced dysphagia and...

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