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cancer esophagus
- 1. Ms Sujata Desai Ms Sarita Kumari Ms Shiney Sam
- 2. • Ms Sujata Desai • Chemotherapy • Anatomy Physiology • Radiation therapy • Definition • Palliative management • Epidemiology and incidence • Complications • Etiology • Ms Shiney Sam • Prevention and Screening • Pre operative management • Pathophysiology • Post operative management • Clinical Manifestations • Rehabilitation • investigations • Prognosis • TNM staging • Discharge planning • Ms Sarita Kumari • Follow up • Classification • Spread • Treatment :- • Surgery
- 5. Structure • 4 layers Mucosa Submucosa Muscularis propria Adventitia
- 6. Functions
- 8. Blood supply
- 14. Epidemiology Country Incidence Link US 6 cases/100,000 men/year (Black>white). China (HenanProvince) 0.9% in the population Nitrosamine in the soil and older than 30 years of age contamination of foods by fungi (Geotrichum candidum) and yeast, which produce mutagens India, Pakistan, and Sri Lanka 9000 cases/year in 6 Chewing tobacco , smoking cancer registry Singapore Hot beverages, Chinese tobacco and wine South African Bantus and Zulus Nitrosamine in the soil and contamination of food by molds, especially the Fusarium species Normandy, Brittany Alcohol and smoking
- 15. Incidence Squamous Adeno New cases per year 16980 12450 Male-to-female ratio 3:1 7:1 Black-to-white ratio 6:1 1:4 Most common locations middle distal Major risk factors smoking Barrett’s alcohol esophagus In TMH 1200 pts /year 2nd most common in men 4th most common in female M0re than 180 Sx /yr
- 16. Etiology • Unknown • Hereditary & Genetics • Smoking and alcohol
- 17. • Dietary factors • *N-nitroso compounds (animal carcinogens) *Pickled vegetables and other food-products *Toxin-producing fungi *Betel nut chewing *Ingestion of very hot foods and beverages (such as tea) • Obesity • Work place exposure
- 18. ACHALASIA
- 20. Hiatus Hernia
- 23. Tylosis
- 24. Esophageal Web
- 25. Others • Helicobacter pylori • h/o cancer • Injury : ingestion of • HPV acids or alkalines • Aspirin • Colic Disease • NSAIDS • Chronic peptic sore • Oral sepsis • Syphilis • Radiation Therapy
- 26. Prevention and screening • Counseling : Avoid alcohol and tobacco • Endemic mass screening programmes • Screening high risk factor • Surveillance Programme Barrett’s esophagus without dysplasia endoscopy 3 yearly Low grade Dysplasia: every year High Grade Dysplasia every 6months 4 quadrant biopsy 2cm apart
- 27. Pathophysiology
- 28. Clinical manifestation • Dysphagia • Odynophagia • Hoarseness of voice • Dysphonia • Central chest pain
- 29. • Wt loss • TEF • Chronic cough • haemoptysis • Malena or haematemesis • Nausea vomiting, regurgitation • Superior vena cava syndrome
- 30. Signs of Metastasis • Bone pain • Malignant ascites • Malignant pleural effusion • Jaundice • Supraclavicular and cervical lymphadenopathy • Diaphragmatic paralysis
- 31. Investigations • History and physical examination • Blood examinations: – CBC,LFT, RFT, Electrolytes • Tumor marker: Alkaline Phosphatase (20 to 140 IU/L) CEA (0 – 2.5ng/ml)
- 32. • Imaging Tests – Chest X ray – CT scan – CT guided needle biopsy – MRI – PET scan
- 33. • Barium Swallow
- 34. Esophagoscopy
- 35. • Endoscopy – Upper endoscopy – Endoscopic ultra sound – Bronchoscopy – Thoracoscopy and laparoscopy
- 36. • OTHERS • Biopsy • HER2 Testing
- 37. TNM Staging
- 38. Staging
- 40. Classification morphological histological Type I : polypoid Squamous carcinoma Type ll: ulcerated Adenocarcinoma Type lll: infiltrating ulcerated Mixed adenosquamous Type lV :diffuse undifferentiated Small cell carcinoma
- 41. Squamous cell carcinoma a) Upper thirds of esophagus-20% b) Middle thirds of esophagus-50% c) Lower thirds of esophagus-30%
- 42. Adenocarcinoma
- 43. Spread • Commonly spread by Lymphatic system (1) Local spread Trachea tracheoesophageal fistula Aorta Fatal hemorrhage Recurrent laryngeal nerve hoarseness of voice • (2) Lymphatic spread *Extensive submucosal lymphatic spread ( proximal line of resection should be 10cm proximal to the tumour). *Cervical ,mediastinal and coeliac LNs. • (3) Blood spread Lung, liver & brain.
- 44. Treatment modality • Surgery • Chemotherapy • Radiation therapy • Combination therapy • Palliative therapy
- 46. Surgery • 1877- Czerny first surgeon to successfully resect a cervical esophageal cancer • Initially the anastomosis was done by bringing out the ends subcutaneously with external plastic tubes, skin tubes and flaps • 1933- Ohsawa first stomach reconstruction • 1946- Ivor Lewis two staged approach (rt thoracotomy and separate laparotomy) • 1976- Mc Keown 3 stage operation • 1982 & 1994 vagus nerve preservation • 1997 – laparoscopic total esophagectomy
- 47. Management of early cancers
- 48. • Photodynamic Therapy (PDT) • Drug used: sodium porfirmer
- 49. Laser Ablation • Neodymium- :yttrium-aluminium- garnet(Nd:YAG)
- 50. Endoscopic Mucosal Resection(EMR) After resection proton Pump inhibitors are used
- 51. Radiofrequency Ablation Endoscopic balloon ablative device , kills cells by heating by electric current
- 52. Surgery
- 53. Operable tumors 1) Tumors below the carina (tracheal bifurcation) Ivor Lewis operation (2 phases ) 1st phase :laparotomy & mobilization of stomach. 2nd phase Rt thoracotomy through the 5th intercostal space resection of the tumor .LNs and 10cm of the oesophagus above the tumor & GE anastomosis.
- 55. Tumors above the carina Mc Keown operation (3 phases ) 1st phase :laparotomy & mobilization of stomach 2nd phase Rt thoracotomy through the 5th intercostal space :esophageal mobilization 3rd phase: neck incision : the oesophagus & stomach are delivered to the neck where resection is done and anastomosis of the stomach & cervical oesophagus is carried out.
- 57. VATS
- 58. 3) Tumors below the diaphragm (1 phase) • lt thracoabdominal incision: the stomach & lower oesophagus are removed with • Roux-en-Y esophagojujenostomy • .
- 59. • Other options Transhiatal esophagectomy Thoracotomy is avoided by mobilizing the oesophagus from the abdomen via the diaphragmatic hiatus and via the neck incision
- 60. 3 field lymph node dissection • Field I: abdominal field • Field II: Paraesophageal, parabronc hial, apical nodes, recurrent nodes, paratracheal • Field III: Cervical paraesophageal, supraclavi cular
- 61. • Endopscopic removal through laparoscopy & thoracoscopy
- 62. Reconstructions
- 64. Chemotherapy • Neoadjuvant • Two 4-day cycles, • 3 weeks apart • Cisplatin 80 mg/m2 by infusion over 4 h • fluorouracil 1000 mg/m2 daily by continuous infusion for 4 days. (MRC protocol) • Surgery performed two to four weeks after chemotherapy
- 65. Radiation therapy EBRT alone 64.8Gy / 33 - 36 fractions External beam radiotherapy and brachytherapy EBRT • Dose : 60 Gy / 28 fractions with reducing fields. ILRT Boost : 5 - 8Gy / 2-3 fractions (HDR), one week apart or single fraction 20Gy low dose rate (LDR).
- 66. Brachytherapy
- 67. Concomitant chemo radiation • 50Gy / 25 fractions over 5 weeks, • Cisplatin 75 mg/m2IV Day 1 of weeks 1, 5, 8, and 11, • Fluorouracil, 1g/m2 per day by continuous infusion day1 – day 4 week 1, 5, 8, and 11. (RTOG regimen)
- 68. Targeted Therapy • EGFR: Cetuximab • HER-2/neu:Trastuzumab • VEGF:Bevacizumab • Small molecule inhibitors: Imatinib
- 69. Palliative treatment • Inoperable Tumors ( 60% of the patients) * Local spread( e.g tracheoesophageal fistula,) * Distant spread • * Bad general condition • Options:- – Endoscopic Laser to core a channel through the tumor
- 70. Intubations – • Self expanding metal stents • Traction stents e.g. Celestine stent • Pulsion stents e.g. Soutter’ tube
- 71. Dilatation
- 72. – Radiotherapy for squamous cell ca – Dose : 3000cGy /10 fractions /2 weeks – Reduced field / boost : 2000cGy/10# / 2 weeks – ILRT alone or in combination with EBRT. – 5 - 8Gy/# in 2- 3 fractions, one week apart – Chemotherapy :5 FU + Cisplatin – 5Fu 1000mg/m2/day continuous IV infusion on day1- 5Cisplatin 100mg/m2 iv on day 1 – Repeat cycles on 1,5, 8, 11 wks
- 73. PEG
- 74. Complications • Anastomotic leak • Respiratory insufficiency • Wound infection • Gastric outlet obstruction • Pulmonary embolism • Radiation pneumonitis • Stricture • Fistula • haemorrhage
- 76. Nursing Management • Preoperative management • Post operative management
- 78. Psychological preparation Assess level of anxiety Answer the questions and concerns regarding surgery Allow time and privacy to prepare psychologically Provide support and assistance Cultural aspect need to be considered Discharge planning
- 79. Legal preparation Informed consent by surgeon No sedation should be administered Documentation
- 80. Nutritional support Aims : promote wt gain Interventions – Assess wt , nutritional assessment – Sr Albumin , protein – Assessment of swallowing capacity – High calorie high protein diet in liquid and soft form – Enteral nutrition: NG feeds – Parentral nutrition – Hydration – Adjust diet according to existing problems- constipation/diarrhea
- 81. Prevent pulmonary complications Patients are not able to clear secretions Head elevation Stent placement and dilatation
- 82. Physical and physiological preparation • Cleaning of surgical site • Shaving • Personal hygiene • Oral care • Nutrition: liquid diet x 3 days • Monitor vital signs • Intake /output chart • Antibiotics and regular medications NPO night before No enema and laxatives can be allowed
- 83. Pain management Explain to notify pain Pain medications will be prescribed Non invasive pain relieve techniques
- 84. Preoperative exercises Stop smoking Chest physiotherapy Incentive spirometry Football bladder exercises Coughing exercises Deep breathing Splinting Getting out of bed
- 85. Pre anesthetic work up All investigations & corrections to Co morbidities ECG PFT Arterial blood gas 2d echo Mouth opening Check list Send all equipments to OT
- 87. • Immediate • Intermediate • Extended
- 88. Immediate • Intensive care - 24 to 48 hrs • Care of ventilated pt : patent airway Suctioning • Care of drains • Cardiopulmonary monitoring
- 89. Intermediate
- 90. • Neurological Status • Assess neurological status every shift. • Any neurological change should be carefully watched and • Promptly reported
- 91. Pain Management Adequate pain control reduces the mortality and morbidity Asess the pain Initial pain management consist of morphine or bupivacaine given epidurally Patient-controlled analgesia with morphine, or a combination of both .Nothing by mouth for 5 to 7 days, intravenous or epidural pain medications are used.
- 92. Pain Management contd.. Oral pain medications are started on the fifth or seventh postoperative day The main classes : opoids, nonsteroidal anti-inflammatory drugs, and local anesthetics.
- 93. Non-pharmacological interventions Distraction Relaxation Positioning
- 94. Pulmonary Care Aggressive pulmonary toilet Pain control is paramount Patients are usually intubated after surgery monitor oxygenation closely (spo2) Suctioning Chest physiotherapy ,Nebulizers Coughing, deep breathing exercises, Incentive spirometer. Teach patients to splint their incision with a pillow. Early mobilization Monitor patients closely for fever
- 95. Chest tube care Assess the drainage every shift. Serosanguinous within a few hours. Not more than 100 to 200 ml/h on the first day. A sudden change in the color of chest tube : milky (chyle leak ) Check the chest tube site for drainage, Keep the chest tube dressing clean, dry, and intact. Keep the chest tube free of any kinks or dependent loops
- 96. Subcutaneous emphysema Palpate the surrounding area Due to an air leak from a pleural injury Additional suction or placement of a new chest tube New-onset may indicate a leak of the esophageal anastomosis. . Fever, tachycardia, and hypoxemia Esophageal leak can be confirmed by barium swallow Postoperative chest radiographs for pneumothorax and for placement of any chest tube. Monitor abrupt changes in oxygenation
- 97. Hemodynamics Intravenous maintenance fluid at a rate of 100 to 200 ml/h for the first 12 to 16 hours. Patients may require fluid boluses in the immediate postoperative period. Crystalloids or blood products may be used Interstitial pulmonary edema. Malnutrition and low protein levels can complicate the situation. A delicate balance between adequate fluid replacement and fluid overload. 30 ml/h of urine output Determination of body weight Meticulous skin care is necessary.
- 98. Nasogastric Tubes . Do not move, manipulate, or irrigate the nasogastric tube. Do not attempt to replace it. Monitor the tube for patency Assess the drainage for color and amount.
- 99. Gastrointestinal Care Restricted by mouth for 5 to 7 days Oral medications, are crushed and put down the nasogastric tube on the second day ; they are never swallowed. Diligent mouth care A jejunostomy feeding tube is often placed during surgery and is used from the first post op day for feeding Early enteral feeding helps in early healing Jejunostomy site care
- 100. At 5 to 7 days check the anastomosis for leaks Eat 6 to 8 small frequent meals each day, Avoid very hot or cold beverages and spicy foods. Protein supplements, high-energy foods, or a soft dysphagia diet Sit upright, chew slowly, and eat more than 3 hours before bedtime assists in reducing reflux. Drink fluids between meals rather than with meals Dumping syndrome, may arise in patients who have had their vagus nerves divided. After vagotomy is related to unregulated gastric emptying Minimizing liquids with meals Consumption of frequent, small, low-carbohydrate meals Discharged with plans for supplemental tube feeding.
- 101. Incision Care Keep dressings clean, dry, and intact. Change dressing 2 to 3 times a day Saliva leak out through the cervical incision. Can be managed by simple dressing Large volumes (>250 ml every 8 hours), application of a wound drainage bag The leak is allowed to seal on its own, Sealing could take several weeks.
- 102. Infection Risk Compromised nutritional status, They have invasive catheters Risk of infection at the surgical sites. Meticulous wound and skin care, Hand washing, Avoidance of cross-contamination Changing of invasive catheters Antibiotics Adequate nutrition.
- 103. Prophylaxis of deep vein thrombosis Heparin s/c BD TED stockings Early ambulation Leg and ankle exercises
- 104. Discharge planning
- 105. • Do’s Check surgical incision Maintain personal hygiene Incision site care Resume daily activities, work and sexual activities Drink fluid b/w meals Eat 3 hrs before bedtime Check wt
- 106. Contd… Take stool softeners Crush all medications Observe complications: tarry stool, progressive wt loss, diarrhea Keep follow up appointments
- 107. • Don’ts Avoid smoking (join stop smoking group) Avoid strenuous activity for 12 wks Avoid driving for 3 wks Avoid hot & cold beverages , spicy food Drink fluid in between meals
- 108. Rehabilitation Patient must sleep in a head high position Get adapted to small frequent meals Keep a difference of 2-3 hrs between meals and bed time Continue spirometer for 3 months Donot carry weight more than 5 kgs Resume daily activities
- 109. Prognosis
- 110. Follow up Every 6 months Plain X Ray, CBC , Biochemistry on visit If symptomatic CT, PET CT
- 111. Conclusion
- 113. Thank u