1. Describe the clinical features, diagnosis and management of cancer oesophagus.

Patients with cancer oesophagus manifest with:

a.Difficulty in swallowing

b. Painful swallowing.

Usually dysphagia is the most common symptom. Initially dysphagia is pronounced for solid food. Fluids and semisolid diet are better tolerated.

c. These patients manifest with excessive loss of weight which could be due to:

Difficulty in swallowing

Reduced appetite due to malignancy.

d. Heart burns – These patients characteristically complain of burning pain in the midline of the chest. This type of pain progressively gets worse and is made still worse by the act of swallowing.

e. Voice change – This is usually due to involvement of recurrent laryngeal nerves causing paralysis of vocal folds. Right recurrent laryngeal nerve is commonly involved in these patients. During early stages these patients may have varying degrees of aspiration. Sometimes aspiration may be severe enough to cause aspiration pneumonitis.

f. Disruption of peristalsis – The sheer bulk of tumor present intraluminally within the oesophagus may cause disruption of normal peristalsis. This could cause nausea, vomiting and food regurgitation.

g. Haematemesis – If the tumor is friable it can cause intraluminal bleeding leading on to hematemesis.

h. Compression symptoms – Increasing bulk of oesophageal mass can cause compression of local structures. It can cause compression to trachea leading on to upper airway obstruction. Another area of compression is at the level of superior vena cava causing superior vena caval syndrome. Erosion of trachea may lead to troublesome tracheo oesophageal fistula.

Symptoms caused by superior vena cava syndrome include:

1. Dyspnoea
2. Swelling of the face / upper extremities
3. Headache
4. Orthopnoea
5. Nasal stuffiness
6. Light headedness

Symptoms caused by metastatic lesions:

Hepatic metastasis can lead to jaundice, ascitis.

Lung metastasis could cause shortness of breath, pleural effusion.

Diagnosis:

Radiology:

Barium swallow / meal can reveal occlusal mass in the oesophagus.

CT scan imaging will reveal the extent of the lesion, compression to adjacent structures if any.

Metastatic lesions can also be identified by performing CT scan.

PET scans can be used to identify and ascertain whether the lesion is active and metabolically active.

Upper GI endoscopy:

This is the standard in the diagnosis of oesophageal cancer. It helps in identifying the exact location of the lesion, biopsying the lesion. The location of the tumor is generally measured from the incisor.

Histopathology:

This offers the final diagnosis. Adenocarcinoma is common in the lower oesophagus while squamous cell carcinoma is prevalent in the upper third of oesophagus.

Management:

The ideal management modality is determined by:

1. Cellular type of cancer
2. Stage of the disease
3. General condition of the patient

Priority should be given to the nutritional needs of the patient.

Manitenance of good oral hygiene.

As a first step in ensuring adequate nutrition to the patient naso gastric feeding can be resorted to.

To alleviate oesophageal obstruction stenting could be resorted to. Stents are usually used to keep the lumen of oesophagus patent. They also play a vital role in occluding tracheo oesophageal fistulas if present.

Surgical management:

This can be classified into therapeutic and palliative procedures.

If the tumor is resectable then segemental resection of the involved segment of the oesophagus can be performed. The shortened oesophagus can be corrected by interposing stomach / jejunal flaps.

Types of oesophagectomy:

Types of esophagectomy:

• Thoracoabdominal approach- which opens the abdominal and thoracic cavities together.
• Two stage Ivor Lewis (also called Lewis-Tanner) approach- with an initial laparotomy and construction of a gastric tube, followed by a right thoracotomy to excise the tumor and create an esophagogastric anastomosis.
• Three stage McKeown approach- where a third incision in the neck is made to complete the cervical anastomosis.Describe the clinical features, diagnosis and management of cancer oesophagus.

Endoscopic resection of oesophageal tumors:

1. This procedure is safe
2. Less invasive
3. Useful to treat early lesions

Patients who can undergo endoscopic resection are those with early lesions which does not involve the muscularis mucosa. Lasers can be used to assist in these resections.

Chemotherapy is reserved for advanced lesions. It also depends on the histological type of the tumor. The drugs used include:

Cisplatin

5-flurouracil.