Esophageal cancer, EC

Notes
  • The two most common malignant tumors in esophagus are squamous cell carcinoma (at the proximal two 2/3 of the esophagus) and adenocarcinoma (at the distal 1/3 of the esophagus). Other types of tumors that affect esophagus are: spindle cell carcinoma, verrucous carcinoma and pseudosarcoma, among others.
  • The risk factors for EC are: alcohol, tobacco, obesity, achalasia, human papillomavirus, sclerotherapy and irradiation of the esophagus among others.

Statistics: Global distribution of EC - 80 - 85% in developing country; males to females ratio of EC- 15 to 1; the most affected age 65 to 74 yrs.   

Symptoms
  • Mainly asymptomatic, especially at the early stage.
  • Chronic gastroesophageal reflux disease (GERD) and reflux esophagitis, especially in adenocarcinomas arising from Barrett esophagus.
  • Dysphagia with or without odynophagia (pain on swallowing). This is graded as follows;

Grade 0: Normal swallowing

Grade 1: Difficulty with solids

Grade 2: Difficulty with semi solids

Grade 3: Difficulty with liquids

Grade 4: Total dysphagia

  • Vomiting and sometimes hematemesis
  • Melena
  • Aspiration
  • Anemia
  • Dehydration
  • Chest pain
  • Weight loss
  • Vocal cord paralysis and hoarseness.
  • Spinal pain
  • Hiccups
  • Persistent cough
  • Lung abscess and pneumonia (arising from Fistulas between the esophagus and tracheobronchial tree)
  • Symptoms of metastasis to the lungs, liver, bones and other tissues.
Diagnosis
  • Endoscopy with biopsy (and subsequent histology and iodine staining)
  • Endoscopic ultrasound
  • CT (of the chest to assess the spread of tumor)
  • Barium x-ray (an obstructive lesion may be evident)
  • Chest x-ray
  • Routine tests that include: Complete Blood Count, electrolytes, and liver function tests.
Differential
  • Achalasia
  • Compression of the oesophagus from external sources such as enlarged lymph glands or bronchial carcinoma.
  • Gastric cancer
  • Intramural benign tumours
  • Metastatic tumours (mainly breast)
  • Oesophageal stricture
  • Barrett's oesophagus
Prevention
  • Avoid alcohol
  • Avoid tobacco
  • Watching the weight
Management
  • Supportive treatment include management of fluid, electrolyte and nutrition.
  •  
  • In a low-resource limited settings the prognosis of EC is poor due to the late diagnosis and treatment of the disease.
  • Patients should be reviewed regularly (at 3-6 months interval).
  • Surgery in stages 0, I, and II of esophageal cancer is usually curative while that in Stage III is palliative.
  • Radiotherapy: preoperative radiotherapy is advised for stages II and III to shrink tumour and make it amenable to surgery.

Preoperative radiotherapy is recommended for stages II and III to shrink tumour and render it amenable to resection

  • Chemotherapy:

In a low-resource limited settings the standard regimen is a combination of 5FU and cisplatin with or without radiotherapy

When resources are available, a platinum compound such as cisplatin and a taxane such as paclitaxel or docetaxel can be used.

Other drugs that can be used include: vinblastine, epirubicin, interferon alpha-2a, irinotecan and vinorelbine.

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