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|04-21-2008, 11:05 AM||post no: 1|
Cancer Oesophagus (Predisposing factors - Pathology - Clinical Picture - Investigations - Treatment
¦Site: Common at anatomical narrowing with that order of frequency, the commonest at middle 1/3 (provided adenocarcinoma of the lower 1/3 is excluded, otherwise lower 1/3 will be the commonest site).
¦Predisposing factors (Precancerous conditions):
1. Chronic irritation by tobacco, alcohol.
3. Plummer-Vinson syndrome which predispose to CA of the upper 1/3.
4. Achalasia of the cardia.
1) Annular " infiltrate type" common in the lower 1/3 & highly malignant.
2) Ulcerative type with raised everted edge.
3) Fungating mass.
1) Squamous cell carcinoma.
2) Adenocarcinoma " rare" only in lower 1/3 usually of gastric origin or over Barrett's oesophagus
Direct: Through oesophageal surroundings:
In the neck ® Lt. recurrent laryngeal nerve ® hoarseness.
Thorax ® trachea & left bronchus.
Abdomen ® Stomach & other abdominal organs.
Cervical part ® cervical L.N.
Thoracic part ® Tracheal, Tracheobronchial, post. mediastinal and diaphragmatic L.N.
Abdominal Part® Lt. gastric ® coeliac L.N.
Blood: Not rare to the liver.
1) Dysphagia which is progressive, of short duration , 1st for solid then for both.
2) Regurgitation which is rare due to absence of dilatation because of:
a) Short duration. b) Anorexia.
c) Malignant sclerosis of wall prevent dilatation.
3) Late symptoms:
a) Progressive loss of weight ® cachexia.
b) Accumulation of saliva ® Inhalation pneumonia.
c) Perforation into ® Mediastinum ® Mediastinitis.
® Aorta ® Fatal hge.
® Left bronchus ® Broncho-oesophageal fistula.
That of other causes of oesophageal obstruction, especially achalasia.
1) Barium swallow:
q Infiltrative carcinoma ® Annular stricture which is irregular with typical shouldering and no or slight dilatation above stricture site. In CA. lower 1/3 dilatation may occur but irregular stricture help in differential diagnosis from achalasia.
q Cauliflower mass or malignant ulcer® Filling defect.
2) Oesophagoscoy and biopsy.
q Abdominal ultrasonography to detect liver 2ries.
q Transoesophageal endoscopic ultrasonography to detect degree of invasion of the tumour to the oesophageal wall but not to surroundings.
4) C.T. Scanning : to assess operability. how? It may show:
q Infiltration to irresectable organs e. g. aortic arch.
q Distant Lymphatic spread.
q Distant metastases.
m Treatment of Cancer Oesophagus:
I) Inoperable : (Unfortunately, most of cases are inoperable).
Signs of inoperability
General : q Bad general condition.
q Distant metastases.
Local : q Infiltration to irresectable organ.
q Lymphatic spread to main L. N. group.
Lines of treatment :
1) Palliative radiotherapy:
But, perforation may occur if tumour involve whole wall thickness.
2) Palliative Bypass operations:
a) Sauttar tube or Celestin or Nottingham tube which inserted through the tumour tissue.
b) Tunneling of the tumour can be done by laser probe.
c) Oesophago- jejunonostomy with or without Roux-en Y loop.
d) Stomach tube.
Part of greater curvature with its intact blood supply (Lt. gastro epiploic) is isolated and used for anastomosis as a tube to the oesophagus.
e) Colon bypass: Segment of colon with intact blood supply connecting hypopharynx with stomach.
· This segment can be put either retrosternal (intrathoracic) or antesternal (Subcutaneous). The last is preferred as it need no thoracotomy and the patient can assist himself in swallowing by milking. The intrathoracic bypass is restricted to young ages.
f) Gastrostomy is the worst palliative bypass operation why? as accumulation of saliva will cause aspiration pneumonia. Proximal oseophagostomy may be done in combination to divert saliva to the neck stoma.
1) Post cricoid carcinoma:
a) Surgery: Total pharyngeolaryngectomy with gastric pulling or colon transposition "Difficult operation"
b) Radiotherapy: Gives better results than surgery.
2) CA. Upper 1/3 of oesophagus:
a) Surgery: Total oesophagectomy with pulling stomach to the neck in 3 steps. 3 steps operation (Mc Keown operation).
b) Radiotherapy: common in use in CA upper 1/3 than surgery.
3) CA. Middle 1/3 of oespohagus:
a) Surgery: Partial oesophago-gastrectomy with pulling stomach to chest in 2 steps operation (Ivor Lewis operation).
1st step is abdominal midline epigastric incision to:
Explore the abdomen to assess operability.
‚ To mobilize the stomach.
ƒ To do pyloroplasty as vagotomy is mandatory during oesophagectomy.
2nd step is Rt.5th space thoracotomy why in Rt. side? due to:
Middle 1/3 of oesophagus lie in Rt. side.
‚ Azygos vein can be ligated easily.
ƒ To avoid aortic arch in Lt. side.
Some preferre "3 steps total oesophagectomy" in cancer middle 1/3 as it remove whole organ containing malignancy and anastomosis done in the neck which prevent mediastinitis if leakage occur.
3rd step is neck incision. Some prefere left side as the oesophagus is present at the left side, But, others prefere right neck exposure to avoid injury of the thoracic ductat.
· The three steps can be done through abdominal and cervical incisions. The dissection of the thoracic part is done through the abdomen. This maneuver is limited to benign conditions.
b) Radiotherapy: There is increasing tendency to use it instead of surgery in cancer middle 1/3.
4) CA. Lower 1/3 oesophagus:
a) Surgery: Partial oesopago-gastrectomy through Lt. 8th space thoraco-abdominal incision. We remove tumour + 5 - 7 cm safety margin from oesophagus + large portion of stomach + tail of pancreas and spleen in some cases, then, we anastomose remaining part of stomach with that of oesophagus.
b) Radiotherapy: Has a minor role in CA. lower 1/3.
m Causes of death in cancer oesophagus:
Pneumonia due to * Aspiration.(commonest cause of death)
* Perforation to bronchial tree.
‚ Progressive cachexia & dehydration.
ƒ Mediastinitis from perforation into mediastinum.
„ Erosion of aorta.® Fatal hge. (rare).
SOURCE: DR. AYMAN SALEM'S BOOK
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