A 16 yr old boy with aggressive ca esophagus DR Ayunga A.O - - PowerPoint PPT Presentation

A 16 yr old boy with aggressive ca esophagus

DR Ayunga A.O Physician-Garisa PGH Associate Faculty Lecturer-UON Afya Bora Fellow in Global Health

Cancer of esophagus in a 16yr old

• Y.N 16 yr old boy
• unwell for the past 3 yrs with on and off dyspepsia and

hurtburn

• He was being managed for peptic ulcer disease.
• Pt presented to our hospital on the 28/7/12 with c/o
• of retrosternal and epigastric pain
• postprandial vomiting,
• hematemesis,
• progressive dysphagia.
• O/E patient was sick looking,wasted with epigastric

tenderness with no palpable masses or organomegally

Investigations

• Investigations done:

1.barium swallow 1yr back that demonstrated a distal 1/3 oesophageal stricture. 2.FHG which was normal. 3.h.pylori test –negative.

• Patient was referred to KNH for an OGD

,biopsy and CT scan which were done on 25/8/12 and showed :

• OGD: stricture at 30cm blocking lumen.
• Biopsy: necrotic tumor disposed in nests of

very pleomorphic squamous cells with a diagnosis of poorly differentiated SCC.

• CT scan: malignant stricture of esophagus at

T5-T10 with proximal dilatation,small subcentimetre mediastinal nodes.

• Pt advised to have surgery but could not afford at

the time and presented again on 17/10/12 with vomiting,inability to swallow and hotness of body.

• Patient was put on intravenous fluids and referred

to Nyeri for surgical management-ivor lewis esophagectomy was done on 6/11/12.

• Tumour was resected with 3cm free margin and was

transfused 6 pints of blood.

• Pt admitted in ICU post-op and developed ARF but

regained normal RF after 3 days of Rx.

• Discharged while he was able to feed and with

normal bowel movements.

• Patient was brought back to Garissa PGH 30 days

postop for palliative management.

• He was was markedly wasted with bilateral lower

limb pitting edema upto midleg and had a right chest tube draining purulent fluid.

• Patient developed left sided empyema thoracis 2nd

day post admission which was drained by a chest tube.

• right chest tube was removed but 6th post

admission day patient developed a right pneumothorax and a right chest tube was reinserted.

Further tests after readmission

• Investigations done:
• FHG: WBC 12.1 with granulocytes 88%,HB 13.9,MCV

and MCH normal,PLT 207.

• Electrolytes: k 3.59,Na 131.4,Cl 104.1.
• Creatinine:239.52.
• LFT:AST 41.75,ALP 346.4,GGT 181.05,Albumin

1.71,total protein 5.49,Direct bilirubin 6.56,total bilirubin 28.7.

• Pleural fluid M/C/S: gram stain heavy growth of

s.aureus with many intracellular G-ve diplococcic sensitive to linezolid and resistant to PenG,oxacillin,azithromycin and sporfloxacin.

• Patient was put on high protein diet,sc heparin

5000iu BD,IV flagyl and IV ceftriaxone.

• patient was doing well in the ward with mild

respiratory distress.

• On 17/12/12 patient developed severe respiratory

distress with a left chest tube insitu,Xray done showed bilateral pneumothorax,patient was put on

• xygen via nasal prongs(relatives declined via

mask).

• family declined chest tube reinsertion on the right

side.

• On th 18/12/12 morning patient was certified dead.

Discussion

• Esophageal cancer usually develops in persons

between 50 and 70 years of age.

• M:F 3:1.
• There are two histologic types: squamous cell

carcinoma and adenocarcinoma.

• Chronic alcohol and tobacco use are strongly

associated with an increased risk of squamous cell carcinoma.

• Other risks are Tylosis, achalasia, caustic-induced

esophageal stricture, and other head and neck cancers.

• SCC has a high incidence in certain regions of China

and Southeast Asia.

• 50% of all cases occur in the distal third of the

esophagus.

• Adenocarcinoma is more common in whites.
• The majority of adenocarcinomas develop as a

complication of Barrett's metaplasia due to chronic gastroesophageal reflux.

• Most adenocarcinomas arise in the distal third of

the esophagus

Symptoms

• Most pts with esophageal cancer present with

advanced, incurable disease.

• Over 90% have solid food dysphagia, which

progresses over weeks to months.

• Odynophagia is sometimes present.
• Significant weight loss is common.
• Local tumor extension into the tracheobronchial

tree may result in a TOF, characterized by coughing

• n swallowing or pneumonia.

• Chest or back pain suggests mediastinal

extension.

• Recurrent laryngeal involvement may produce

hoarseness.

• Physical examination is often unrevealing.
• The presence of supraclavicular or cervical

lymphadenopathy or of hepatomegaly implies metastatic disease.

investigations

• Lab-Non specific
• Anaemia of chronic disease
• Hypoalbuminemia due to malnutrion
• CXR-may show adenopathy, a widened

mediastinum, pulmonary or bony metastases, or signs of TOF.

• Barium esophagiogram fisrt study followed by

OGD with biopsy

DDX

• Achalasia
• Peptic stricture
• Adenocarcinoma of the gastric cardia with

esophageal extension

• Benign tumours

Staging

• Done to guide therapy
• CT scan of chest and liver to exclude

metastases,lympadenopathy or tumour extension

• Two most important predictors of poor

survival are lymph node involvement and adjacent mediastinal spread.

Treatment

• Depends on the stage
• IIIB- palliation-Combination radiation and

chemotherapy