Post on 07-Apr-2018
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CANCER OF ESOPHAGUS
OGINDA DICKSON MED IV
LUCY LYANDA MED IV
GEORGE BIKETI MED VI
GEORGE NGARE MED VI
MODERATOR: PROF. B. OTSYULA
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DEMOGRAPHIC DATA
NAME: SIMON KIPKORIR T
AGE : 36 yrs
GENDER: Male
RESIDENCE : KABIYET
OCCUPATION: farmer
D.O.A :18/02/2010 WARD 6
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CHIEF COMPLAINTS Difficulty in swallowing x6/52
Headache and dizziness x1/7
HISTORY OF PRESENTING ILLNESS
Gradual onset
Felt food sticking in the chest followed by regurgitation
First solid foods, then liquids eventually saliva
Hx of post- prandial vomiting Hx of pain on swallowing.
Hx of hot foods and beverage consumption
Had appetite but food could not pass.
Hx of dull pain at epigastric region. Non- radiating and aggravated byingestion of food.
No hx of alcohol intake or cigarette smoking
No hx of PUD in the patient
No family hx of such an illness
Hx of weight loss
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HPI cont.
May 2009 thoracotomy and insertion of
celestine tube
Jan 2010 hx of vomiting blood and passing
of black stool
No hx of cough
No hx of change of voice
Hx of deviation of mouth to the left for thelast 1 yr
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PAST MEDICAL HISTORY
3RD admission
2nd adm Jan 2010- hematemesis transfusion
of 3 units
1st admMay 2009- surgery for insertion of a
celestine tube
No hx of DM, HTN, asthma or TB
NKFDA
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FAMILY & SOCIAL HX
Married to 1 wife with 2 children all a/w
No hx of a similar problem in the family
No hx of DM, hypertension,asthma or TB in
the family
REVIEW OF SYSTEMS
CNS: headache and dizziness. No convulsions,
no confusions.
GUT: No dysuria,
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REVIEW OF SYSTEMS CNS: No loss of consciousness, headache or
blurring of vision M/S : no muscle pain
GUT: no hematuria, or dysuria
SUMMARY
Simon Kipkorir is a 36 yr old ca esophagus
patient with a celestine tube in situ who
presented with chest pain for 3/7 and
dizziness for 1/7.
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PHYSICAL EXAMO/E
Young man in FGC, P++, J0,C0,Pedal oedema0,LD0, or
dehydration Vitals- p= 86 beats/min
R= 24 b/min
T= 36.50 C
BP=130/70 mmHgRESP
Rate of respiration = 24 b/m
Trachea central
Chest bilaterally moving with respiration equally Normal tactile fremitus
No palpable masses
vesicular breath sounds
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PER ABDOMEN Abdomen with normal fullness. Moving
symmetrically with respiration. Umbilicus central and inverted.
Surgical scar extending to the back, to 8th rib
and to epigastric region (curvilinear) Non tender on palpation
Liver and spleen not palpable
Tympanitic on percussion
Normal bowel sounds.
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CNS Oriented in person, place and time.
CN VII-mouth deviated to the left
- cannot blow air in the mouth- no wrinkling of forehead
- nasolabial folds absent on the right side.
Other CN intact.
Normal bulk, tone and reflexes. Power grade 5 Can perceive touch and pain in trunk & extremities.
No cerebellar dysfunctions
CVS
Pulse rate =86 b/m Bp =130/70 mmHg
Neck veins not distended
Normal s1 and s2 sounds heard.
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IMPRESSION Anaemia 2o to ca esophagus/upper GI
bleeding. 7th cranial nerve palsy. (LMNL).
PLAN
FHG- Hb 6.0g/dl GXM 3 units- O+ve both donor and recipient
Transfuse 3 units of blood.
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ESOPHAGEAL CANCER
PRESENTED BY GEORGE BIKETI
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Def: neoplasm of the esophagus,mainly of epithelial origin.
Epidem:12/100,000 varies withgeographical location.
Risk factors
Tobacco
Alcohol consumption
GE reflux
Achalasia, lye strictures,tylosis, HPV
Nitrosamines in soil
Fungal contamination of food-
Geotrichium candidum,Yeast(produce mutagens),
ingestion of very hot foods
Very hot tea
Roasted maize?, traditionalbrews,
Vitamin deficiencies,anemia, poor oralhygienechronic
Classification
Squamous cell carcinoma
Adenocarcinoma
Others:
Ca esophagus
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Barrets esophagus
Plummer- Vinson syndrome
Leukoplakia
Achalasia
Caustic injuries to esophagus
Scleroderma
Reflux esophagitis
Irradiation esophagitis
Premalignant disorders
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95% is squamous cell ca, 2.5-8%
adenocarcinoma,others: small cell ca,
malignant melanoma.
Squamous cell ca most common in upper and
middle 1/3 of esophagus, adenocarcinoma
most common at the GE junction
Common growth patterns: fungating(60%),
ulcerative(25%), infiltrative(15%)
Pathology
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Early disease may have no clinical features and dx is
on endoscopy for other conditions e.g.
GERD/screening for Barrets esophagus
advanced disease: Dysphagia: occurs when >than 60% of esophagus is
infiltrated with cancer. progressive
Respiratory symptoms resulting from aspiration or fistula
into the trachea/bronchus.
Wgt loss, cachexia
CLINICAL FEATURES
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Hoarseness due to recurrent laryngeal nerve palsy
.
Palpable lymphadenopathy in the neck.
Clinical features(cont.d)
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HISTORY
Progressive dysphagia (grade 0-4)
Odynophagia
Choking (ToF)
Hoarseness
Regurgitation and vomiting Difficulty in breathing and coughing
Progressive weight loss
Chest pain
H/o predisposing factors: smoking, alcohol etc
Horners syndrome Superior venacava syndrome
DIAGNOSIS
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IMPORTANT Hx
Loss of weight: poor feeding/ malignancy
Anaemia: Ca. stomach or PV syndrome Change of voice:- due to refluxed material irritating the
vocal cords or recurrent. laryngeal nerve palsy.
Cough or dyspnoea:- due to tracheal aspiration.
Haematemesis or melena: peptic eosophagitis & hiatushernia
Family Hx of Ca. oesophagus or stomach
Smoking and Alcohol
Cardiac drugs
Neurological changes: diplopia, dysarthria
Rheumatologic: mm weakness, skin disorders
PHYSICAL EXAMINATION
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PHYSICAL EXAMINATION
1. General Survey: Dehydration, Jaundice, Pallor (PV/ Ca. stomach),L. nodes (Lt. supraclavicular- Virchows node in Ca. stomach-Troisiers sign), Koilonychia, Pitting of palms and feet (tylosis
palmaris et plantaris), Dyspnoea & Difference in radial pulses(Aortic aneurysm), Emaciation.
2. Neck: Gurgling mass- watch pt. during meals, goitre, tracheal tug
3. Oropharynx: tonsillitis, candidiasis, retropharyngeal abscess, testsoft palate and vocal cords for paralysis
4. Resp. Sys: signs of secondaries or aspiration pneumonia
5. CVS: pericardial effusion, cardiomegally
6. Abdominal: previous surg., abdominal mass, Ca. stomach,hepatomegaly, ascites (peritoneal involvement)
7. DRE and VE: Kruckenburg tumour in POD
8. CNS: Cranial nerve palsies, lateralizing signs
9. Psychiatric exam: in a pt. with neurotic symptoms
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Is by TNM staging
Tis: carcinoma insitu
T1: lamina propria
T2: muscularis propria
T3: adventitia (periosophageal tissue)
Nx: lymphnodes
No: no lymphodes involved
N1: regional lymphnodes
STAGING
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Mo: no distant metastases
M1: distant metastases to coeliac axis nodes
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Differentials
Malignant tumours
SCC
Adenocarcinoma
lymphoma
carcinoid tumour
sarcomas
Benign esophageal tumors
leiomyomafibroma
lymphangioma
squamous papillomas-condylomas
inflamatory polyps
Pre cancerous lesions
Berretts oesophagus
Lye strictre
Tylosis
Plummer vinsons syndrome
Zenkers diverticulum
Achalasia
Chagas disease
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Investigations
1. Barium swallow
used to localize tumour strictures
intraluminal masses
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2. Endoscopy / esophagoscopy
for direct visualisation
- -for biopsy
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3. Endoscopic/ tracheoesophageal ultrasound
-depth of penetration of the tumor (T staging)
-the presence of enlarged periesophageal lymph nodes (N staging).
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4. Bronchoscopy
-for cancers of the middle and upper third of the thoracic
esophagus to help exclude invasion of the trachea or bronchi.
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5. Metastatic workup
CT scan Abdominal, pelvis and chest
LFTs
Coagulation profile -Prothrombin time and activated partialthromboplastin time coagulation.
Bone scan
Laparoscopy and thoracoscopy have a greater than 92%
accuracy in staging regional nodes
positron emission tomography scanning, which can helpelucidate hypermetabolic foci of disease activity.-newstaging modality
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Others:
Complete blood cell count
Electrolytes- hypercalcemia.
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IMPROVE QUALITY OF LIFE.
ATTEMPT RESTORE NUTRITIONAL INTAKE.
ATTEMPT TO PROLONG LIFE IF APPLICABLE.
MULTIDISCIPLINE APPROACH IDEAL.
MANAGEMENT OBJECTIVES
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Treatment options:
A) Multimodal:
Combines chemotherapy radiotherapy and surgeryMay be used for cure and palliation
Survival rates are higher than surgery alone
B: Surgery:
(i) esophagectomy
is resection of the esophagus
Done through a transhiatal or transthoracic approach (THE or TTE)
Stomach is often used for reconstruction where it is transposed and
esophagogastric anastomosis in the chest or neck done
Colonic or small gut interpostion to restore continuity
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OPTIONS FOR OESOPHAGECTOMY
ALL APPROACHES THROUGH ABDOMEN WITH
ADDITIONAL EXPOSURE AS NEEDED.
TWO STAGE
THORACOTOMY AND LAPARATOMY.
THREE STAGE
THORACOTOMY AND LAPARATOMY AND NECK
DISSECTION.
SINGLE STAGE
THORACOABDOMINAL INCISION.
TRANS HIATAL OESOPHAGECTOMY.
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SELECTION OF OPERATION
SITE OF TUMOUR.
ADHERENCE TO SURROUNDING TISSUE.
PRESENCE OF LYMPHADENOPAHY.
PLANNED CONDUIT.
CONCERNS OF BILE REFLUX.
EXPERIENCE OF SURGEON.
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Contraindications for esophagectomy
Invasion of the tracheobronchial tree
Invasion of the great vessels and pericardium Supraclavicular, lateral thoracic and coeliac nodes
Comorbid states eg. CVS and Resp disease
Decreased cardiac and respiratory function
Advanced nutritional debilitation.
Widespread metastasis.
Malignant effusion or ascites.
Recurrent laryngeal n. Palsy.
Superior vena cava syndrome.
Tracheo-oesophageal fistula.
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(ii) Paliative resection
- controversial instead use EBR
(iii) Intubationeither Souttar, celestine, Atkinson, Procter-Livingstone
(iv) stenting
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C) RADIOTHERAPY
Used for unresectable tumours
Where the expected survival time is shortGives relief to 67%/ >50% patients with dysphagia
Not allowed for tumours involving the stomach
Radiation dose of ~= 45 Gy
D) CHEMOTHERAPY
used either alone or in combination with other modalities
highlighted agents- 5FU and cisplatin
functions : - reduce bulk of tumour
- eradicate tumour in nodes- may reduce tumour dissemination
- to asses tumour responsiveness
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OTHER OPERATIVE MODALITIES
(PALLIATIVE)
DILATATION.
CRYOTHERAPY.
CHEMICAL ABLATION.
LASER THERAPY.
PHOTODYNAMIC THERAPY.
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SURGICAL PRE-OPERATIVE
CONSIDERATIONS
Correct any malnutrition.
Preoperative antibiotics.
Bowel preparation.
Nasogastric tube.
Postoperative analgesia. Peri-operative anticoagulation.
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POSTOPERATIVE FEEDING
Feeding after methylene blue, gastrografin ordilute barium test on day seven
Prior to chest tube removal.
Retain tube for 24 hours after.
Early nasogastric feeding on day three
Nasogastric tube well down into duodenum area.
POSTOPERATIVE COMPLICATIONS
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POSTOPERATIVE COMPLICATIONS
Anastomotic leak (11.3% - 19.5%).
Haemorrhage.
Chylothorax. Pulmonary infection (50% - KNH).
Pleural effusion.
Recurrent laryngeal nerve injury.
Benign stricture (4.6% for KNH). Malignant stricture.
Gastric emptying (21.3% - KNH).
DVT ( sudden death).
Postoperative confusion.
Sepsis.
Fluid electrolyte imbalance.
Diabetes .
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prognosis
Generally poor because of late presentation
5-8% operative death rate
5 year survival rate 9% (SCC) and