Cancers

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Key points of Oesophageal CA

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• Alcohol, tobacco, and human papillomavirus infection are risk factors for squamous cell carcinoma; Barrett esophagus due to chronic reflux (often related to obesity) is a risk factor for adenocarcinoma. • Early-stage cancer is typically asymptomatic; initial symptoms are usually progressive dysphagia, which results from significant encroachment on the lumen, and sometimes chest discomfort. • Overall, survival is poor (5-yr survival: < 5%) because many patients present with advanced disease. • Surgery for cure is extensive and often poorly tolerated by older patients and patients with comorbidities. • Palliation may involve stenting or endoscopic laser therapy to reduce obstruction and allow oral intake.

* appetite is good significantly.

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All about Oesophageal CA

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The most common malignant tumor in the proximal two thirds of the esophagus is squamous cell carcinoma; adenocarcinoma is the most common in the distal one third. Symptoms are progressive dysphagia and weight loss. Diagnosis is by endoscopy, followed by CT and endoscopic ultrasound for staging. Treatment varies with stage and generally includes surgery with or without chemotherapy and radiation. Long-term survival is poor except for patients with local disease.

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The primary risk factors for esophageal cancer are

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• Alcohol ingestion • Tobacco use (in any form)

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Other risk factors for squamous cell carcinoma of the oesophagus

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achalasia, human papillomavirus, lye ingestion (resulting in stricture), sclerotherapy, Plummer-Vinson syndrome, irradiation of the esophagus, and esophageal webs. Genetic causes are unclear,

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Adenocarcinoma of the esophagus

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Adenocarcinoma occurs in the distal esophagus. Its incidence is increasing;

Alcohol is not an important risk factor, but smoking is contributory. Adenocarcinoma of the distal esophagus is difficult to distinguish from adenocarcinoma of the gastric cardia invading the distal esophagus.

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What has Barrett oesophagus got to do with adenocarcinoma of oesophagus

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Most adenocarcinomas arise in Barrett esophagus, which results from chronic gastroesophageal reflux disease and reflux esophagitis.

In Barrett esophagus, a metaplastic, columnar, glandular, intestine-like mucosa with brush border and goblet cells replaces the normal stratified squamous epithelium of the distal esophagus during the healing phase of acute esophagitis when healing takes place in the continued presence of stomach acid.

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Obesity is associated with a 16-fold increased risk of esophageal adenocarcinoma, probably because obesity is a contributing factor to reflux.

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Metastatic cancer

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Metastatic cancer constitutes 3% of esophageal cancer. Melanoma and breast cancer are most likely to metastasize to the esophagus;

others include cancers of the head and neck, lung, stomach, liver, kidney, prostate, testis, and bone. These tumors usually seed the loose connective tissue stroma around the esophagus, whereas primary esophageal cancers begin in the mucosa or submucosa.

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Symptoms and Signs

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Early-stage esophageal cancer tends to be asymptomatic.

When the lumen of the esophagus becomes constricted to about < 14 mm, dysphagia commonly occurs.

Chest pain may be present, usually radiating to the back. Weight loss, even when the patient maintains a good appetite, is almost universal. Compression of the recurrent laryngeal nerve may lead to vocal cord paralysis and hoarseness.

Nerve compression may cause spinal pain, hiccups, or paralysis of the diaphragm. Malignant pleural effusions or pulmonary metastasis may cause dyspnea.

Intraluminal tumor involvement may cause odynophagia, vomiting, hematemesis, melena, iron deficiency anemia, aspiration, and cough.

Fistulas between the esophagus and tracheobronchial tree may cause lung abscess and pneumonia.

Other findings may include superior vena cava syndrome, malignant ascites, and bone pain.

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The patient first has difficulty swallowing solid food, then semisolid food, and finally liquid food and saliva; this steady progression suggests a growing malignant process rather than a spasm, benign ring, or peptic stricture.

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Lymphatic spread to internal jugular, cervical, supraclavicular, mediastinal, and celiac nodes is common. The tumor usually metastasizes to lung and liver and occasionally to distant sites (eg, bone, heart, brain, adrenal glands, kidneys, peritoneum).

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•Endoscopy with biopsy•Then CT and endoscopic ultrasonography

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What is the screening test for Oesophageal CA

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There are no screening tests. Patients suspected of having esophageal cancer should have endoscopy with cytology and biopsy. Although barium x-ray may show an obstructive lesion, endoscopy is required for biopsy and tissue diagnosis

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Patients in whom esophageal cancer is identified require CT of the chest and abdomen to determine extent of tumor spread. If CT results are negative for metastasis, endoscopic ultrasonography should be done to determine the depth of the tumor in the esophageal wall and regional lymph node involvement. Findings guide therapy and help determine prognosis.

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Basic blood tests, including CBC, electrolytes, and liver function, should be done.

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What is the prognosis

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Prognosis depends greatly on stage, but overall is poor (5-yr survival: < 5%) because many patients present with advanced disease. Patients with cancer restricted to the mucosa have about an 80% survival rate, which drops to < 50% with submucosal involvement, 20% with extension to the muscularis propria, 7% with extension to adjacent structures, and < 3% with distant metastases.

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•Surgical resection, often combined with chemotherapy and radiation.

Esophageal cancer treatment decisions depend on tumor staging, size, location, and the patient’s wishes (many choose to forgo aggressive treatment)

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Patients with stage 0, I, or IIa disease (see Table: Staging Esophageal Cancer*) respond well to surgical resection; preoperative chemotherapy and radiation provide additional benefit.

Patients with stages IIb and III have poor survival with surgery alone; response and survival are enhanced by preoperative (neoadjuvant) use of radiation and chemotherapy to reduce tumor volume before surgery. Patients unable or unwilling to undergo surgery may receive some benefit from combined radiation and chemotherapy. Radiation or chemotherapy alone is of little benefit.

Patients with stage IV disease require palliation and should not undergo surgery.

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After treatment, patients are screened for recurrence by endoscopy and CT of the neck, chest, and abdomen at 6-mo intervals for 3 yr and annually thereafter.Patients with Barrett esophagus require intense long-term treatment for gastroesophageal reflux disease and endoscopic surveillance for malignant transformation at 3- to 12-mo intervals depending on the degree of metaplasia.

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Preoperative chemotherapy combined with radiation therapy can improve survival after surgical resection of thoracic esophageal cancer. Chemotherapy without radiation therapy followed by surgery may also be considered

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Complications of surgery include anastomotic leaks, fistulas, and strictures; bilious gastroesophageal reflux; and dumping syndrome.

The burning chest pain of bile reflux after distal esophagectomy can be more annoying than the original symptom of dysphagia and may require subsequent Roux-en-Y jejunostomy for bile diversion. An interposed segment of small bowel or colon in the chest has a tenuous blood supply, and torsion, ischemia, or gangrene of the interposed bowel may result.

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Palliation is directed at reducing esophageal obstruction sufficiently to allow oral intake. Suffering caused by esophageal obstruction can be significant, with salivation and recurrent aspiration.

Options include manual dilation procedures (bougienage), orally inserted stents, radiation therapy, laser photocoagulation, and photodynamic therapy.

In some cases, cervical esophagostomy with feeding jejunostomy is required.

Relief provided by esophageal dilation rarely lasts more than a few days.

Flexible metal mesh stents are more effective at maintaining esophageal patency.

Some plastic-coated models can also be used to occlude malignant tracheoesophageal fistulas, and some are available with a valve that prevents reflux when the stent must be placed near the lower esophageal sphincter.

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Endoscopic laser therapy can palliate dysphagia by burning a central channel through the tumor and can be repeated if needed. Photodynamic therapy uses an injection of porfimer sodium, a hematoporphyrin derivative that is taken up by tissues and acts as a photosensitizer. When activated by a laser beam directed on the tumor, this substance releases cytotoxic oxygen singlets that destroy tumor cells. Patients receiving this treatment must avoid sun exposure for 6 wk after treatment because the skin is also sensitized to light.

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Nutritional support by enteral supplementation enhances the tolerability and feasibility of all treatments. An endoscopically or surgically placed feeding tube provides a more distal route for feeding when the esophagus is obstructed.Because many cases of esophageal cancer are fatal, end-of-life care should always aim to control symptoms, especially pain and inability to swallow secretions .

At some point, many patients need substantial doses of opioids. Patients should be advised to make end-of-life care decisions early in the course of disease and to record their wishes in an advance directive.