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 4.Mucosal erosion/defects 3.CXR a) Check for mediastinal widening-invasion by tumor or lymphadenopathy b) Pleural effusion indicate pleural dessimination c) TOF pneumonic process features of aspiration pneumonia. d) The diaphragm doming in involvement of phrenic nerve causing paralysis. e) Lung nodules-lung metastasis or lung abcess e)An esophageal air-fluid level-obstruction 3. Endoscopic ultrasonography -Endoscopic ultrasound improves the ability to determine wall penetration and suggested by: 1. Direct spread to the trachea-bronchial tree or aorta 2.Angulation of esophageal axis. 3. Tracheoesophageal fistula 4. Hoarseness associated with vocal cord paralysis 5.Primary tumors larger than 10 cm are rarely resectable A.SURGERY Mucosal resection at endoscopy-CIS For the carcinoma in situ Types of Curative Subtotal Oesophagectomy; 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 correspond to the mucosa, lamina propria, muscularis mucosa, muscularis propria, and adventitia. Carcinoma appears as an irregular hypoechoic mass.Depth of penetration of the wall can be accurately assessed. The ability to detect regional lymph-node involvement may be further enhanced by the use of endoscopic, ultrasonographically guided fine-needle aspiration, which has an accuracy of more than 90 percent at many centers level of the tumour. The three most common approaches currently in use are: 1. Grey –Turner’s Transhiatal oesophagectomy 2. Lewis’ laparotomy and right thoracotomy 3.Sweets’ left thoraco-abdominal 1.Grey –Turner’s Trans-hiatal oesophagectomy 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. Other investigations a) Bronchoscopy should be done in lesions of the upper or middle ⅓, where there is potential for tracheo-bronchial invasion. b) Staging laparoscopy is useful for assessing Adenocarcinoma of the distal oesophagus, particularly if it is likely to extend below the phreno-oesophageal A laparotomy is performed first and the abdomen is explored. The stomach is prepared as an oesophageal substitute. The stomach is mobilized on the right gastric and gastroepiploic arteries. The omentum is divided, preserving the right gastroepiploic artery. The left gastric artery is double ligated. The gastrohepatic omentum is divided with care taken to identify accessory 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 1. Benign papillomas, polyps, or granulomatous masses Pinotti. This facilitates exposure of the distal oesophagus almost to the level of 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 4. Mediastinal tumours-Lymhoma Staging TNM Staging Tis Carcinoma-in-situ T1 invading lamina propria/submucosa the oesophagus can be dissected under direct vision.Cancerous portio of oesophagus is removed and the stomach is brought up through the posterior mediastinal oesophageal bed and a cervical anastomosis performed. 2. Lewis’ laparotomy and right thoracotomy Best for mid- or lower-third lesions. 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 T4 invasion of adjacent structures NX, N0, N1 M0 no distant spread M1 distant metastasis; Spread to the coeliac axis nodes from a lesion in the intrathoracic oesophagus - Regarded as metastatic (M) rather than nodal (N) disease in the TNM classification. 3.-3 stage McKeown operation - As Ivor Lewis (above) but a third incision on the right of the neck is made to complete the cervical anastomosis. A neck incision is required if;  lymph node dissection is to be done  there are technical difficulties with an anastomosis at the thoracic inlet hiatus to prevent compression of the stomach when it is brought into the chest. Patient is then positioned for right thoracotomy.The stomach is then elevated u into the chest and a high intrathoracic anastomosis is made at the apex of the ri chest. Complications of tubes a) Dislodged b) Blocked with food c) Overgrown and blocked by tumour d) Aggravation of chest pain. e) Haemorrhage f) Perforation -Furthermore, concomitant radiotherapy increases the complications of tubes e bleeding, perforation.  For upper & middle ⅓ tumours -Therefore, intubation should be reserved for patients with extensive disease an 3. Sweets’ left thoraco-abdominal Best employed for gastro-oesophageal junction carcinomas or low oesophageal carcinomas. Tumours 35 cm or more from the incisors are ideally suited to this approach. The patient is placed in the right lateral decubitus position. An oblique left upper quadrant laparotomy is performed to explore the gastro-oesophageal junction area and the liver. Then a thoracoabdominal incision through the sixth or seventh interspace is performed. The diaphragm is incised circumferentially to avoid injury to the phrenic nerve branches. The stomach is mobilized as above.