Esophageal Cancer

Manifestations
1. Onset of signs & symptoms is usually late in relation to the extent of the tumour (Lewis, 2014; Canadian Cancer Society, 2018)
  1. Symptoms
    1. Painful swallowing (odynophagia), pain the throat, chest or back
    2. Fatigue
    3. Malaise
    4. Nausea/ Vomiting
  2. Signs
    1. Progressive Dysphagia
    2. Weight loss
    3. Cough
    4. Reurgitation
      1. When esophageal stenosis is severe, regurgitation of blood-flecked esophageal contents is common (Lewis, 2014)
    5. Hiccups
    6. Hoarseness
    7. Indigestion
    8. Heartburn
    9. Loss of apetite
Main Causes/Risk Factors
1. Epidemiology (Mao, Zheng & Ling, 2011; Napier, Scheerer & Misra, 2014)
  1. Sex, Age and Race
    1. Men are more likely to be diagnosed with esophageal cancer than women
    2. Increases with age, with incidence rates peaking at 70 years of age.
    3. Incidence and mortality rates in African-American descent are higher than that in Caucasians
  2. Geographic Location
    1. Squamous Cell Carcinoma is most prevalent in parts of China, Iran, South America, France and Africa and low socioeconomic status is linked with it (Napier, Scheerer & Misra, 2014)
      1. Adenocarcinoma is most common in developed nations including Australia, Finland, France, United States and United Kingdom (Napier, Scheerer & Misra, 2014)
        The highest current incidence of EADC is in Great Britain
      2. More than 50% of the EC incidence in the world occur in China
      3. Referred to as "Asian esophageal cancer belt". The region extends from northeast China to the Middle East (Napier, Scheerer & Misra, 2014)
2. Cause of esophageal cancer is unknown but there are important risk factors (Lewis, 2018; Canadian Cancer Society, 2018)
  1. Long-term irritation of lining of the esophagus
    1. GERD (Gastroesophageal reflux disease)
      1. Contents of the stomach back up, or reflux into the esophagus and causes heartburn and discomfort
        GERD increases the risk of Barret's esophagus, which increases the risk of developing ADC.
    2. Barrett's esophagus
      1. A complication of GERD where stratified squamous epithelium is replaced by columnar epithelium (Johns Hopkins Medicine, n.d; Masab, 2018)
        It is estimated that 1 in 200 cases of Barrett's esophagus will progress to esophageal cancer (Lewis, 2014)
    3. Achalasia
      1. The nerves that control the normal rhythmic contractions in the esophagus and the lower esophagus sphincter doesn't work properly.
        The part of the esophagus above sphincter becomes enlarged, and results in difficulty swallowing food and liquid.
    4. Tylosis
      1. Rare inherited disease with scaly patches (hyperkeratosis) on hand and feet and also growths with finger-like projections, called paillomas in the esophagus (Canadian Cancer Society, 2018)
        Researchers have identified the tylosis esophageal cancer (TOC) gene.
    5. Plummer-vinson syndrome
      1. The mucous membranes of the mouth, throat and esophagus waste away and a thin member of tissue (known as esophageal web) can also grow anywhere along the esophagus, which causes problems swallowing (Canadian Cancer Society, 2018)
        A patient with a history of achalasia is at greater risk for squamous cell cancer (Lewis, 2014)
    6. Scarring from swallowing lye
      1. Lye that is found in strong cleaners like drain cleaners can burn and destroy esophageal cells (Lewis, 2014)
    7. HPV infection
      1. Studies have shown increased incidence of HPV infection in ESCC from Asian countries, South Africa, Alaska, and Australia (Mao, Zheng & Ling, 2011)
  2. Lifestyle risk factors
    1. Smoking
      1. Smoking and drinking are the primary risk factors and have synergistic effects. Alcohol is the major factor, but smoking may increase the carcinogenicity caused by alcohol (Napier, Scheerer & Misra, 2014; Zhang, 2013)
    2. Excessive alcohol intake
    3. Nutritional imbalance
      1. Over-nutrition
        Excessive carbohydrate intake and obesity (developed nations)
      2. Under-nutrition
        Low intake of micronutrients such as vitamin A, C, E, riboflavin, zinc, selenium and low intake of fresh fruits and vegetables (developing nations)
    4. Drinking very hot beverages
      1. Drinking green tea at high temperatures resulted in a six or seven times greater increase in the risk of ESCC in patients who were also smokers (Torres-Aguilera & Remes, 2018)
    5. Chewing of betel quid (paan)
      1. Common in India and China. Contains cancer-causing substances that increase the risk of developing SCC of the esophagus (Canadian Cancer Society, 2018)
    6. Obesity
      1. Three times more risk of EADC in overweight people (Zhang, 2013)
        Also a risk factor for GERD
Classifications
1. Adenocarcinoma (Canadian Cancer Society, 2018)
  1. develops in the lower third of the esophagus, often in an area containing Barrett’s esophagus
    1. Barett's Esophagus: a complication of GERD where stratified squamous epithelium is replaced by columnar epithelium (Johns Hopkins Medicine, n.d; Masab, 2018)
      1. Occurs due to chronic reflux of gastric acid and bile at gastroesophageal junction
        Progresses to adenocarcinoma
  2. Advanced adenocarcinoma of the esophagus often grows into the GE junction and can even grow into the upper part of the stomach
  3. Pathophysiology (Masab, 2018)
    1. Changes in gene structure, expression and protein structure leading to tumor growth
    2. Risk factor of obesity lead to hypertrophied adipocytes and inflammatory cells within fat deposits, creating an environment of low-grade inflammation and promote tumor development through the release of adipokines and cytokines
      1. Adipocytes supply energy production and support tumor growth and progression
2. Squamous Cell Carcinoma
  1. It can occur anywhere along the esophagus, but it is most common in the middle and upper part; occurs as one or more tumors (Canadian Cancer Society, 2018)
  2. Pathophysiology (Masab, 2018)
    1. Risk factors such as alcohol and carcinogens found in tobacco cause damage to cellular DNA
      1. Decrease metabolic activity within the cell to inhibit detoxification and increase oxidation
      2. Inflammation of squamous epithelium leads to dysplasia and in situ malignant transformation
        Dysplasia: appears as an accumulation of atypical cells (Mao, Zheng & Ling, 2011)
        Tumors usually present as fungating, ulcerating, or infiltrating lesions in the esophageal epithelium (Moa, Zheng & Ling, 2011)
  3. Most common type of esophageal cancer worldwide (Napier, Scheerer & Misra, 2014)
Treatment & Management
1. Surgical Interventions (Lewis, 2014)
  1. Esophagectomy
    1. Removal of part or all of the esophagus
  2. Esophagogastrostomy
    1. resection of a part of the esophagus and anastomosis of the remaining portion to the stomach
  3. esophagogastrostomy
    1. resection of a portion of the esophagus and anastomosis of a segment of colon to the remaining portion
  4. May be thoracic or both abdominal and thoracic
  5. Minimally invasive esophagectomy (laparoscopic vagal nerve–sparing) uses smaller incisions decreasing hospital stays, and fewer pulmonary complications
2. Radiation Therapy (Canadian Cancer Society, 2018)
  1. uses high-energy rays or particles to destroy cancer cells
  2. Commonly used to:
    1. shrink a tumour before other treatments such as surgery
    2. destroy cancer cells in the body (as a primary treatment)
    3. destroy adenocarcinoma cells left behind after surgery and reduce the risk of the cancer recurring
  3. may be used alone to relieve pain or control the symptoms of advanced esophageal cancer (palliative radiation therapy)
  4. Two Types
    1. External Beam
      1. a machine directs radiation through the skin to the tumour and some of the tissue around it
        Done 5x/week for several weeks
    2. Brachytherapy
      1. an internal radiation therapy that uses a radioactive material called a radioactive isotope. It is placed right into, or very close to, the tumour and the radiation kills the cancer cells over time.
3. Chemotherapy (Canadian Cancer Society, 2018)
  1. may be given before surgery (neoadjuvant chemotherapy) and after surgery (called adjuvant chemotherapy), or as the main treatment given (primary chemotherapy)
    1. Neoadjuvent chemotherapy: given to shrink an adenocarcinoma before surgery
    2. Adjuvent chemotherapy: to destroy cancer cells left behind and lower the risk that cancer will come back, or recur
    3. Primary chemotherapy: chemotherapy given as the main treatment; it may be used for stage 4 esophageal cancer or if person is not healthy enough to have surgery or chemoradiation
      1. Sometimes used to relieve pain or control the symptoms of advanced esophageal cancer; palliative chemotherapy
4. Chemoradiation
  1. Chemotherapy and radiation therapy are used at the same time for treatment
5. Molecular Targeted Therapy (Canadian Cancer Society, 2018)
  1. Uses drugs to target molecules that tell the cells to to grow or divide, thus stopping the growth and spread of cancer cells while limiting harm to normal cells
    1. Most commonly administered targeted drug is trastuzumab (Herceptin)
6. Endoscopic Mucosal Resection Canadian Cancer Society, 2018)
  1. used to remove small, early stage tumours that are only in the inner layer, or mucosa, of the esophagus and have not spread to the other layers of the esophagus
    1. After EMR, the healthy tissue removed along with the tumour is examined under a microscope. If cancer cells found in the tissue, more EMR or treatment with chemotherapy, radiation therapy or photodynamic therapy (PDT) may be needed to completely remove or destroy the cancer.
      1. PDT: treatment with drugs that make cells sensitive to light (called photosensitizers). Drug is taken up by cancer cells, then, endoscope is used to expose cancer cells to light
7. Palliative Therapy (Lewis, 2014)
  1. consists of restoration of swallowing and maintenance of nutrition and hydration
  2. Relieve obstruction
  3. Dilation: relieves dysphagia, allows for improved nutrition
  4. Stent Placement: may help when dilation is no longer effective. Stent is placed in esophagus so that food and fluids can pass through stenotic segment of esophagus
  5. Tube placement for nutritional support and pain management
Diagnostic Testing (Lewis, 2014; Canadian Cancer Society, 2018)
1. Upper GI endoscopy
  1. A flexible tube with a light and lens on the end passes through the mouth and down the throat into the esophagus.
    1. To check for bleeding, ulcers, tumours, inflammation or narrowing.
      1. Also done to take samples of tissue to be tested in the lab (biopsy).
        Endoscopy with biopsy is necessary to make a definitive diagnosis of carcinoma by identification of malignant cells (Lewis, 2014)
2. Endoscopic ultrasonography
  1. High-frequency sound waves to make images of structures in body.
    1. Uses an endoscope with an ultrasound probe. It provides detailed information about the location, size, depth of the tumour and if the cancer has spread to surrounding lymph nodes or tissues (Canadian Cancer Society, 2018).
      1. Important tool used to stage esophageal cancer (Lewis, 2014)
3. Biopsy
  1. Removal of tissue/ cell from the body to confirm malignancy
4. Other tests (Canadian Cancer Society, 2018; Lewis, 2014)
  1. CT scan
    1. CT and MRI makes 3-D pictures of the organs, tissues, bones and blood vessels. They are used to assess the extent of the disease (Lewis, 2018)
  2. PET scan
    1. Radioactive 3-d colour images to look for changes in the metabolic activity of body tissues
  3. MRI
  4. Pulmonary function tests
    1. Group of tests that measure how well the lungs are functioning
  5. Heart function tests
    1. ECG measures the electrical activity in the heart. Echocardiogram uses ultrasound to look at the structure and motion of the heart
  6. Thorascopy
    1. Procedure involving tube-like instrument with light to assess for cancer in lymph nodes and other organs near the esophagus (Canadian Cancer Society, 2018)
  7. Laparoscopy
    1. Procedures that uses endoscope to examine and remove internal organs and to accurately stage esophageal cancer
  8. Bronchoscopy
    1. Performed to detect malignant involvement of the lung (Lewis, 2018)
5. History and physical examination
6. Barium swallow
  1. Barium is a liquid that coats the inside of organs and shows their outline clearly on an x-ray.
    1. Often the first diagnostic test used to check for esophageal cancer.
      1. It can show ulceration, narrowing/ stricture of the esophagus, the location and general size of the tumour, abnormal opening from the esophagus into the trachea (tracheoesophageal fistula) and spread of cancer to the stomach (Canadian Cancer Society, 2018; Lewis, 2018).
7. Staging (Canadian Cancer Society, 2018; Napier, Scheerer & Misra, 2014)
  1. Squamous Cell Carcinoma
    1. Stage 0
      1. Tumour only within the epithelium of the inner lining of the esophagus. Precancerous condition.
    2. Stage 1A
      1. Tumour grown into the connective tissue or muscle layer of the mucosa
    3. Stage 1B
      1. Tumour grown into the connective tissue or muscle layer of: the mucosa/ surrounding the mucusa, thick outer muscle layer
    4. Stage 2A
      1. Tumour grown into the muscularis propria or connective tissue that supports and covers the outside of the esophagus or grown into the adventitia.
    5. Stage 2B
      1. Tumour grown into the adventitia.into the adventitia or connective tissue or muscle layer of the mucosa or into the submucosa. The cancer has also spread to 1 or 2 nearby lymph nodes.
    6. Stage 3A
      1. Tumour grown into the connective tissue or muscle layer of the mucosa or into the submucosa or the muscularis propria. Spread to 3-6 nearby lymph nodes
    7. Stage 3B
      1. Tumour grown into the muscularis propria or adventitia, or nearby areas such as pleura, pericardium, diaphragm, peritoneum or azygos vein.
    8. Stage 4A
      1. Tumour grown into nearby areas such as the pleura, pericardium, diaphragm, peritoneum, or azygos vein or main artery carring blood of the heart, vertebrae or trachea.
    9. Stage 4B
      1. The cancer has spread to other parts of the body (distant metastasis), such as to the lungs, liver, & stomach.
  2. Adenocarcinoma
    1. Stage 1A
      1. Tumour grown into the connective tissue or muscle layer of the mucosa
    2. Stage 1B
      1. Tumour grown into connective tissue or muscle layer of the mucosa or into the submucosa or the thick outer muscle layer (muscularis propria)
    3. Stage 1C
      1. Tumour has grown into the connective tissue or muscle layer of the mucosa or into the submucosa or the thick outer muscle layer (muscularis propria).
    4. Stage2A
      1. Tumour grown into the muscularis propria
    5. Stage 2B
      1. Tumour has grown into the connective tissue or muscle layer of the mucosa or into the submucosa or it has grown into the layer of connective tissue that supports and covers the outside of the esophagus (adventitia).
    6. Stage 3A
      1. Tumour grown into the connective tissue or muscle layer of the mucosa or into the submucosa or it grows into muscolaris propria.
    7. Stage 3B
      1. Tumour grown into the muscularis propria or the adventitia or into nearby areas such as the pleura, pericardium, diaphragm, peritoneum or vein that runs along the spinal column (azygos vein).
    8. Stage 4A
      1. Tumour grown into nearby areas such as the pleura, pericardium, diaphragm, peritoneum, or azygos vein or main artery carring blood of the heart, vertebrae or trachea.
    9. Stage 4B
      1. Cancer has spread to other parts of the body (distant metastasis) such as lungs, liver or stomach
    10. Stage 0
      1. Tumour only within the epithelium of the inner lining of the esophagus. Precancerous condition.
  3. Staging is essential to deciding appropriate treatment and interventions
8. Complete blood count
  1. Several laboratory tests to assess RBC, WBC, and platelets.
    1. To check for anemia and bleeding; set a baseline to compare with blood tests done during and after treatment to check the effects of therapies
Nursing Interventions/Care (Lewis, 2014)
1. Preoperative
  1. Assess for poor nutrition due to inability to ingest adequate amounts of food/ fluids
    1. High calorie, high protein diet
  2. Teach client/family how to keep intake/output records and assess for signs of fluid & electrolyte imbalance
  3. Meticulous oral care
2. Postoperatively
  1. Assess NG tube drainage
    1. May be bloody for first 8-12 hours, gradually becoming greeish-yelloe
  2. Monitor for respiratory complications
    1. Turning and deep breathing done every 2 hours; use Incentive spirometer
  3. Must place client in semi-Fowler or Fowler position to prevent reflux and aspirations of gastric secretions
    1. Maintain upright position for at least 2 hours after eating
3. continuous follow-up, encouragement and assisstence in maintaining nutrition
  1. May require a permanent gastrostomy
4. Help decrease client's fear/anxieties through therapeutic communication
5. Other patient outcomes
  1. Relief of pain
  2. maintain patent airway
  3. able to swallow comfortably
  4. understand prognosis of disease
Complications (Lewis, 2014)
1. Hemorrhage may occur if the cancer erodes through the esophagus and into the aorta.
2. Esophageal perforation with fistula formation into the lung or the trachea can sometimes develop
3. Could spread via lymph system. Liver and the lung are common sites of metastasis.
4. The tumour may enlarge enough to cause esophageal obstruction.

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Esophageal Cancer

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	Created by Sehar Khan over 5 years ago