E.3 Esophageal Cancer

What is the five year survival rate?

less than 20%

The majority of esophageal cancers are:

adenocarcinoma (from glands lining the esophagus)

Incidence is higher in:

men
increases w/ age 70-84 yrs

What is the prognosis?

Poor b/c usually not diagnosed until is advanced

Risk factors include:

barrett's metaplasia (GERD), smoking, excessive alcohol, obesity.
Injury to esophageal mucosa is the greatest risk

Achalasia

Delayed emptying of the lower esophagus and associated w/ squamous cell cancer.

where are most of the tumors located?

Middle and lower portion of the esophagus.

Appear as ulcerations, may penetrate the muscular layer and extend outside the wall.

What is the most common symptom of esophageal cancer?

progressive dysphagia - may be described as substernal feeling with food not passing

occurs first with meat, then w/ soft foods and eventually with liquids

Later s/sx include:

pain (substernal, epigastric, or back and can radiate to neck, jaw, ears, and shoulders).
Increases w/ swallowing

Weight loss without trying

regurgitation of contents with blood flecks

Hemorrhages if cancer erodes into the aorta

Perforation w/fistula formation into lung or trachea

The tumor may cause obstruction in later stages

if the tumor is in the upper third of the esophagus what s/sx are common?

sore throat, choking, and hoarseness

How does it spread?

via lymph system

Where does the cancer most commonly spread?

liver and lungs

What are the dx studies for esophageal cancer?

Endoscopic biopsy (for definite dx)
Endoscopic ultrasonography (EUS)
Esophagram (Barium swallow)

Barium swallow shows:

narrowing at the tumor site

What is the gold standard for Barrett's esophagus?

EGD

Albumin and Pre-albumin tell us...

about the patients nutritional status and how well they are absorbing nutrients

An endoscopic biopsy is done to...

make a definitive diagnosis of carcinoma by identifying malignant cells

Endoscopic ultrasonography is important to..

stage esophageal cancer

what are the tx options for esophageal cancer?

Depends on location, invasion, and metastases
Best results: multimodal approach

pre-surgery radiation and chemo

surgery resection

esophageal dilation and stenting

Why would radiation and chemo want to be done before surgery?

if you take the esophagus out first, the surgery is going to cause more complications due to the shortening of the esophagus than radiation and chemo would

Radiation and chemo are administered for...

palliation of sx (e.g. dysphagia) and to increase survival

combination drugs are normally used

Esophagectomy is the..

remove all or part of the esophagus and replaced with a dacron graft

esophagogastrostomy -

resection of a portion of the esophagus and anastomosis of the remaining part to the stomach

Esophagoenterostomy -

resection of a portion esophagus and anastamosis of a segment of the colon to the remaining portion

Dilation and stenting is done as..

palliative care to restore the swallowing function and maintain nutrition and hydration.

Allows liquid & food to pass thru stenotic area

stenting is done by:

self expandable metal stents

Stents are placed before surgery to do what?

improve nutrition status

How are these done?

endoscopically

What is photodynamic therapy?

Pt receives IV injection (Porfimer Na =photofrin)
Light is directed to the tumor using fiber passed thru endoscope

Light reacts w/photofrin and destroys cancer cells

Avoid direct sunlight up to 4 weeks after procedure

what are three complications of esophageal resection?

severe dumping syndrome

acid would reflux into the esophagus

malnutrition

What are the six components of post surgical care for esophageal cancer to pay attention too?

NG tube (DO NOT MANIPULATE)
Respiratory (mantain airway)
Semi-fowlers position (b/c aspiration & reflux)
IV fluids
Pain management
Nutritional support

The NGT is in place to do what two things? what do you have to know about it?

drain bloody discharge (may occur for 8-12 hrs before changing to a yellow greenish) and promotes bowl rest until everything heals

** DO NOT reposition the NG tube at any time

Why should be the respiratory status be monitored and what should be done?

surgery was just done near the airway

deep breathing and turning every two hours; incentive spirometry

What will their diet be like?

TPN; once they are ready to eat they will have smaller, bland meals, more throughout the day

30-60 mL of fluids an hour with progression to small, frequent, bland meals

If TPN leaks into the mediastinum, what s/sx would be present?

pain, increased temperature, dyspnea

What is post-op nutritional care?

sit up-right
eat 6-8 meals per day w/ fluid
manage diarrhea

What is an important lab value to monitor? why?

calcium - hypercalcemia

the body is not absorbing calcium because the stomach is not secreting the stuff needed to absorb it; abnormal production of PTH

How should we monitor for a GI bleed?

check the stool for bright red blood, if they are vomiting blood, H&H will drop, fatigue, O2 drops

To prevent hypovolemic?

assess BUN and creatinine

assess BP

Administer IV fluids

How often should incentive spirometry be done?

every hour 10x

Why is oral care essential post op and how often should it be done?

what specific liquid helps?

4x a day

prevent infection; the mouth is a passageway to the esophagus so you want to keep it as germ free as possible

milk of magnesia helps to remove crust format n

Chemo

single or combine
Carboplatin + paclitaxel, cisplatin + 5FU
ECF
DCF
cisplatin w/ capecitabine + oxaliplatin w/ either 5FU or calpecitabine

Single: bleomycin, mitomycin, methotrexate, vinorelbine (Navelbine), topotecan, and irinotecan (Camptosar)

Target Tx

targets HER 2 protein in the esophagus (this helps cancer grow) if there is too much.

Trastuzamab
Ramucirumab