Esophageal cancer

Esophageal cancer: Excerpt from Professional Guide to Diseases (Eighth Edition)

Esophageal cancer is a malignant tumor that occurs in the esophagus, the muscular tube that propels food from the mouth to the stomach. It's difficult to treat, but can be cured if the cancer is confined to the esophagus. For patients whose cancer has spread beyond the esophagus, cure generally isn't possible; treatment is directed toward symptom relief.

Causes and incidence

The cause of esophageal cancer is unknown, but among predisposing factors are chronic irritation caused by heavy smoking and excessive use of alcohol, stasis-induced inflammation, nutritional deficiency, and diets high in nitrosamines. A genetic link has been proposed concerning an overexpression and mutation of the p53 tumor suppressor gene. Esophageal tumors are usually fungating and infiltrating. Most arise in squamous cell epithelium. However, the number of adenocarcinomas is greatly rising in the United States. Melanomas and sarcomas are few.

Regardless of type, esophageal cancer is usually fatal, with a 5-year survival rate of approximately 10% and regional metastasis occurring early via submucosal lymphatics. Metastasis produces such serious complications as tracheoesophageal fistulas, mediastinitis, and aortic perforation. Common sites of distant metastasis include the liver and lungs. (See Staging esophageal cancer.)

Esophageal cancer most commonly develops in men older than age 60 and is nearly always fatal. This disease occurs worldwide, but incidence varies geographically. It's most common in Japan, China, the Middle East, and parts of South Africa.

Signs and symptoms

Dysphagia and weight loss are the most common presenting symptoms. Dysphagia is mild and intermittent at first, but it soon becomes constant. Pain, hoarseness, coughing, and esophageal obstruction follow. Cachexia usually develops.

Diagnosis

X-rays of the esophagus, with barium swallow and motility studies, reveal structural and filling defects and reduced peristalsis.

CONFIRMING DIAGNOSIS  Endoscopic examination of the esophagus (esophagogastroduodenoscopy), punch and brush biopsies, and exfoliative cytologic tests confirm esophageal tumors. Usually, magnetic resonance imagining of the chest and thoracic computed tomography are helpful in determining disease staging. Positron emission tomography is useful in determining disease staging and whether surgery is possible.

Treatment

Multimodal therapy is usually indicated. Whenever possible, treatment includes resection to maintain a passageway for food. This may require such radical surgery as esophagogastrectomy with jejunal or colonic bypass grafts. Palliative surgery may include a feeding gastrostomy. Chemotherapy with 5-fluorouracil or cisplatin may be used. Insertion of prosthetic tubes to bridge the tumor alleviates dysphagia. Other treatments to improve the patient's ability to swallow include endoscopic dilation of the esophagus (sometimes with placement of a stent) and photodynamic therapy.

Treatment complications may be severe. Surgery may precipitate an anastomotic leak, a fistula, pneumonia, and empyema. Rarely, radiation may cause esophageal perforation, pneumonitis and pulmonary fibrosis, or myelitis of the spinal cord. Prosthetic tubes may dislodge and perforate the mediastinum or erode the tumor.

Special considerations

❑Before surgery, answer the patient's questions and let him know what to expect after surgery, such as gastrostomy tubes, closed chest drainage, and nasogastric suctioning.

❑If surgery included an esophageal anastomosis, keep the patient flat on his back to avoid tension on the suture line.

❑Promote adequate nutrition and assess the patient's nutritional and hydration status to determine the need for supplementary parenteral feedings.

❑Prevent aspiration of food by placing the patient in Fowler's position for meals and allowing plenty of time to eat. Provide high-calorie, high-protein, “blenderized” food, as needed. Because the patient will probably regurgitate some food, clean his mouth carefully after each meal. Keep mouthwash handy.

❑If the patient has a gastrostomy tube, give food slowly — by gravity — in prescribed amounts (usually 200 to 500 ml). Offer something to chew before each feeding to promote gastric secretions and a semblance of normal eating.

❑Instruct the family in gastrostomy tube care (checking tube patency before each feeding, adequate flushing after feedings and medications, providing skin care around the tube, keeping the patient upright during and after feedings).

❑Provide emotional support for the patient and his family; refer them to appropriate organizations such as the American Cancer Society.

❑When all treatments have failed, concentrate on keeping the patient comfortable and free from pain, providing as much psychological support as possible. If the patient is going home, discuss continuing care needs with the caregiver or refer the patient to an appropriate home health care agency or hospice. Encourage the patient and caregiver to express their feelings and concerns. Answer their questions honestly, with tact and sensitivity.

Pictures

Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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