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A 79-year-old retired teacher with progressive dysphagia was diagnosed with carcinoma esophagus. Learn about differential diagnosis, risk factors, staging, investigations, and management options for this condition.
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79-YEAR OLD GENTLEMAN WITHPROGRESSIVE DYSPHAGIA………………………………………………………………………………………………………………………………………………………………………………………………………………………………. FAISAL GHANI SIDDIQUI MBBS; FCPS (GENERAL SURGERY); PG DIPLOMA-BIOMEDICAL ETHICS; MCPS-HPE; FICLS; (MHPE) HEAD, SURGICAL UNIT-I PROFESSOR OF SURGERY CHAIRMAN, DEPARTMENT OF SURGERY & DIRECTOR, DEPARTMENT OF MEDICAL EDUCATION LIAQUAT UNIVERSITY OF MEDICAL & HEALTH SCIENCES faisalghani@lumhs.edu.pk
CASE REPORT A 79-year-old retired teacher was admitted in the surgery ward with H/O: • Increasing difficulty in swallowing • Initially could swallow soft diet but now can tolerate fluids only • Weight loss of 5 kg in last one month On examination, he appears cachectic WHAT IS THE MOST LIKELY DIAGNOSIS?
DIAGNOSIS CARCINOMA ESOPHAGUS
DYSPHAGIA -difficulty in the progression of bolus from the mouth to the stomach due to dysfunction of: oropharynx esophagus
CARCINOMA OF THE OESOPHAGUS PATHOLOGY
TYPES OF CARCINOMA ESOPHAGUS 25% 75 %
SPREAD OF CARCINOMA OESOPHAGUS ACROSS THE WALL LONGITUDINALLY THROUGH SUBMUCOSAL LYMPHATICS TO THE REGIONAL LYMPH NODES • LIVER • LUNGS • BONE
Carcinoma Esophagus disseminates early! Symptoms are often absent until tumour becomes advanced poor prognosis at the time of diagnosis!
WHY ME? RISK FACTORS
SMOKING • ALCOHOL • HOT BEVERAGES • CORROSIVE INJURY • ACHALASIA CARDIA • OBESITY --> REFLUX • SMOKING
CASE REPORT A 79-year-old man admitted in the surgery ward with H/O: • Increasing difficulty in swallowing • Initially required soft diet but now can tolerate fluids • Weight loss of 5 kg in last one month On examination, he appears cachectic HOW WILL YOU INVESTIGATE THIS PATIENT?
ENDOSCOPY • First-line investigation • Site/size/extent/ histology of lesion • Disadvantage: only mucosal surfaces biopsied
SQUAMOUS CELL CARCINOMA OF THE MID ESOPHAGUS NORMAL MUCOSA OF THE ESOPHAGUS
HISTOPATHOLOGY SHOWS SQUAMOUS CELL CARCINOMA WHAT NEXT?
HOW TO INVESTIGATE PATIENT WITH DYSPHAGIA? 1 Local tumour and regional nodes (T, N) • Endoscopic ultrasound Metastases (M) • CT / PET scan (lung; liver; bones; distant nodes) • Laparoscopy (peritoneal metastases) 3 2 • Anemia • Tests for malnutrition
MANAGING A PATIENT WITH SUSPICIOUS SYMPTOMS ADVANCED CURATIVE TREATMENT
EARLY DISEASE T1/T2, N0 LOCALLY ADVANCED DISEASE T3/T4, N1 INCURABLE DISEASE Any T, N2/N3, M0
CASE REPORT A 79-year-old man admitted in the surgery ward with H/O: • Increasing difficulty in swallowing • Initially required soft diet but now can tolerate fluids • Weight loss of 5 kg in last one month On examination, he appears cachectic CONCLUSION: This case report demonstrated the importance of a timely upper endoscopy. It carries major impact on primary care physicians who serve as the first tier in managing patients with ‘red flag’ features.
. . . IN SUMMARY • Squamous cell affects the upper two-thirds; adenocarcinoma affects the lower third • Common etiological factors are tobacco and alcohol (squamous cell), GORD and obesity (adenocarcinoma) • Dysphagia is the most common presenting symptom • Accurate pretreatment staging is essential in patients thought to be fit to undergo ‘curative’ treatment