GASTROESOPHAGEAL

CANCER
Jeremy Paris
S140019

Case
49 year old Itaukei male referred from Valelevu
HS with 3 month history of worsening
- Dysphagia
- Vomiting soon after meals
- Weight loss
Progressively difficult to tolerate feeds (painful
regurgitation) w/ continuous vomiting for 1/52
Can only take fluids.
Weight loss: ~30kgs over the past 6 months
(>30% of TBW)
Vomitus: Mostly food, occasionally acidic. Often
yellowish but no blood
Lassitude: Unable to return to farm.
◦ (+) epigastric pain radiating to back
◦ GERD symptoms (>5 years)
◦ No known comorbidities
◦ No allergies
◦ No family history of a similar problem
◦ A subsistence farmer from Namosi, lives with
wife and 3 children (13,10,4).
◦ (+) Smoking 10 pack years
◦ (+) yaqona almost daily
◦ (+) alcohol occasionally
ROS:
(+)Coughing with yellow sputum production,
occasionally tinge of blood.
(+) melena but no other change in bowel habit
No betel nut use, neither chewing tobacco
O/E: Cachetic looking itaukei male vomiting ◦ Investigations:
yellowish fluids (no blood noted)
FBC: WCC 9,200 Hb 15.1 Hct 40 MCV 81
Vital Signs: Normal
CBG 6.4
HEENT: Pink mucosa, no icterus, no
palpable nodes Liver enzymes: AST 47 ALT 35

Chest: Some creps on Rt mid-lower zones. Bilirubin 0.5 Alb: 38 LDH 239
DHS, no murmurs U&E: Na 144 K 4.5 Cl 101 Urea 13 Cr 142
Abdomen: Scaphoid. Mild epigastric eGFR 98
tenderness. No organomegaly nor. Soft.
PSA 1.0 AFP 2.5 ESR 69
Ext: Warm, no edema
VDRL Neg HepB Neg HIV Neg
Endoscopy
Click icon to add picture

CT Scan
Assessment and Plan:
A- Gastroesophageal Adenocarcinoma
P - Aim: Curative (Locally invasive disease)

◦ Non Surgical: Optimise for theatre (nutrition) in the meantime, stabilse and make plans for referral for
radiotherapy +/- chemotherapy.

◦ Surgical: Total Gastrectomy

◦ Outcome: Developed complications, required a tracheostomy and later succumbed after 26 days of
admission.
Gastroesophageal Cancer
Epidemiology
◦ Globally: 8th most common cancer, 6th
most common cause of death from
cancer, 80% in the developing world.
◦ M:F ratio is 4:1. Very poor survival
rate, treads that follow the incidence.
◦ Fiji: 5 cases seen in the ward b/w July-
August 2018.
Types
 Associated Conditions
◦ GERD
Reflux of stomach contents causes troublesome
symptoms and/or complications
◦ Barretts Esophagus
Intestinal metaplasia of distal esophagus
Increased risk: 40-90x
Surveillence programmes
Ca may exist in >50% of subtotal
esophagectomies

◦ Plummer-Vinson Syndrome
Paterson and Brown Kelly – post-cricoid web
producing obstruction
Risk Factors:
 History Physical Examination
Presentation: Myriad of complaints. Often
present with advanced disease ◦ Cachexia

◦ Dysphagia (>90%) ◦ Anemia

◦ Worsening GERD symptoms (wks) ◦ Metastatic Disease

◦ Odynophagia (50%)
◦ Hoarseness/voice changes
◦ Weight loss
◦ Aspiration pneumonia
Also: Assymptomatic
Anemia
Other signs of Mediastinal invasion
(hiccups, airway obstruction etc)
Investigations
Support Diagnosis:
◦ Barium Swallow

Confirm Diagnosis:
◦ Endoscopy (Gold Standard) and biopsy
Transesophageal USS (for staging also)

Staging:
CT Scan
Bronchoscopy (proximal 2/3 tumors)
Staging Siewerts Classification

◦ Type I tumor (located between 5 and 1 cm

2017 AJCC/UICC (TMN)
proximal to the anatomical squamocolumnar
◦ Tumour epicentre involving GEJ: junction or Z-line (ie, Barrett's esophagus) and
that may infiltrate the EGJ from above.
No more 2cm into proximal stomach
= Esophageal Ca
◦ Type II tumor (located between 1 cm
Vs Beyond/ Not involving GEJ proximal and 2 cm distal to the anatomical Z-
= Stomach Ca. line) –"junctional carcinoma."

◦ Type III tumor (located between 2 and 5 cm

distal to the anatomical Z-line) – Subcardial
gastric ca - infiltrates the EGJ and distal
esophagus from below.
Treatment Options
◦ Depends on the stage of disease
◦ Aim to cure with potentially curable disease
and restore swallowing in the remainder.
◦ Complex to design
1. EMR (early)
2. Surgical
3. Chemotherapy
4. Radiotherapy
5. Combined modality therapy
Surgical Resection
◦ Confined to esophagus and those fit for Post Op:
surgery.
Feed (jejunostomony)
◦ No longer used a form of palliation due to
ICU care
development of other modalities.

Complications:
Approaches:
Early/Late
1. Ivor Lewis two-phase esophagectomy
Local/Systemic
2. Left thoracolaparotomy (GEJ)
Especially:
3. Transhiatal esophagectomy
Chest infections
Anastomotic leak (5-10%)
Surgical
◦ T1 to T3 lesions : potentially resectable. T4(a) involve the pericardium, pleura, or diaphragm are
potentially resectable. T4(b) disease precludes resection
◦ Unlikely Surgical Cure with Absence of systemic spread: “LENGTHS”

L Loss of weight >20%

E Esophageal ‘axis’ is abnormal on barium
N Nodes – multiple on CT
G Grade – invasive, poor differentiation
T Tumor length >8cm
H Horner’s Syndrome
Chemotherapy
◦ Part of multimodality therapy especially for Stage > II
◦ Many regimens suggested rom many trials.
◦ MAGIC Trial : ECF (Epirubicin, Cisplatin, continueous 5FU)
Perioperative ECF = 36% vs 23% (surgery alone)
Radiotherapy
◦ SCC are radiosensitive and potentially radiocurable.
Palliative Care
Often due to extensive disease cancers, often advanced disease aimed to improve quality of life (esp
dysphagia)
◦ Endoscopic dilation
◦ Stenting: Allows patient to eat on their own.
Prevention of aspiration pneumonia
◦ Lazer Ablation (1-2months)
◦ Radiotherapy and Chemotherapy – limited
◦ Analgesia and terminal care
Take home message
◦ Treat GERD
◦ Counsel appropriately
◦ Red flags
Questions?

Vinaka Surgery
Block II 2018