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 done: Investigations 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 2 nd day post admission which was drained by a chest tube. right chest tube was removed but 6 th 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 oxygen 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 on 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