Esophageal Carcinoma
Description
● Introduction
Esophageal carcinoma has a terrible prognosis and is a very aggressive disease. It is one among the top 10 causes of cancer death worldwide. There are two predominant histology types:
More prevalent in industrialised nations, esophageal adenocarcinoma (EAC) usually develops in the gastro-oesophageal junction (GEJ) or distal oesophagus.
The most common kind of esophageal squamous cell carcinoma (SCC) is found in the upper or mid-esophagus and is particularly common in Asia, Africa, and South America.
The growing prevalence of obesity, Barrett's oesophagus (BE), and GERD coincides with the increased incidence of EAC. For early detection and prevention, it is essential to comprehend how it progresses from benign reflux to intestinal metaplasia and ultimately cancer.
● Case Presentation
A 64-year-old man Caucasian retiree who worked as an accountant showed up with:
➣Chief complaint: The main complaint was four months of progressive dysphagia, starting with solids and moving on to liquids.
➣Associated symptoms: Associated symptoms include chronic heartburn and inadvertent weight loss of 25 pounds.
➣Medical history: OTC antacids were used to treat chronic GERD.
➣Lifestyle: No illegal drug usage, moderate alcohol use (two beers per week), and nonsmoking.
➣Family/social background: Married, has three healthy adult children, and likes to travel, play golf, and garden.
➣Results of the examination: BMI = 30 (obese despite weight decrease), vitals constant.
No hepatosplenomegaly or lymphadenopathy.
Unremarkable systemic examination.
● Investigations
➣ Endoscopy
Four centimetres of fungating bulk at the gastro-oesophageal junction.
Mucosa that is salmon in colour and close to the mass is indicative of Barrett's oesophagus.
➣ The study of histopathology
• Mass biopsy: Adenocarcinoma, hyperchromatic nuclei, unusual mitoses, and infiltrating back-to-back irregular glands.
• Squamous-to-columnar transition with goblet cells → intestinal metaplasia (Barrett's oesophagus) with dysplasia is revealed by an adjacent mucosa biopsy.
● Pathophysiology
➣Chronic acid reflux disease, or GERD, damages the squamous epithelium.
➣Metaplasia → Goblet cells (Barrett's oesophagus) replace the columnar epithelium.
➣Genetic changes that accumulate as a result of dysplasia include TP53 mutation, CDKN2A inactivation, EGFR, and ➣Cyclin gene changes.
➣The development of invasive adenocarcinoma from carcinoma.
➣The metaplasia–dysplasia–carcinoma route is the name given to this sequence.
● Risk Factors
➣According to Barrett's Esophagus/Adenocarcinoma
•Chronic GERD Obesity, especially in the central region
•Caucasian ethnicity, male sex
•Over 50 years of age
•BE/EAC family history
➣For Carcinoma of Squamous Cells
•Alcohol and smoking
•Poverty and inadequate diet
•Nitrosamine-rich diet and very hot drinks
•Exposure to polycyclic hydrocarbons in the environment
•HPV infection (difference by area)
● Differential Diagnosis
•Benign strictures/webs/rings – slow progression, no major weight loss
•Functional motility disorders – achalasia, diffuse spasm (uncoordinated motility)
•Esophagitis – infectious (Candida, HSV, CMV), eosinophilic, GERD-related
•Other malignancies – lymphoma, metastatic disease, SCC of esophagus
Protocol
● Management
➣Diagnostic/Staging Workup
•Endoscopic ultrasonography (invasion depth).
•For locoregional spread, use CT/MRI.
•PET scan for metastases that are far away.
➣Treatment
•Radiofrequency ablation combined with endoscopic mucosal resection (EMR) is the treatment for early illness (T1a).
•Localised yet sophisticated: Surgical resection of the oesophagus plus neoadjuvant chemotherapy and radiation treatment.
•Advanced/unresectable: combination chemotherapy (cisplatin-based regimens, FolFOX).
•Targeted/Immunotherapy: trastuzumab for HER2+ tumours, PD-1 inhibitors (nivolumab, pembrolizumab).
•Palliative: Enteral feeding assistance and stent insertion for dysphagia.
➣Prognosis
•5-year survival rate overall: 15–25%.
•Multimodal treatment has a >40% survival rate for localised illness.
•Metastatic/advanced: poor prognosis (less than 10%).
● Management of Nursing
➣Diagnoses in Nursing
•Unbalanced diet: less than what the body needs for weight reduction and dysphagia.
•swallowing difficulties brought on by esophageal blockage.
•pain, either acute or chronic, associated with tumour invasion and treatment.
•Aspiration risk associated with esophageal dysfunction.
•Fear and anxiety around the diagnosis and treatment of cancer.
•lack of knowledge about illness, therapy, and self-care.
➣Interventions in Nursing
•The Diagnostic/Pre-Treatment Stage
•Evaluate weight patterns and swallowing capacity.
•Offer nutritional assistance in the form of soft or semi-solid foods, high-calorie diets, and short, frequent meals.
•Inform the patient's relatives about available treatments and diagnostic procedures.
•Psychological support: promote the sharing of concerns and fears.
● During Treatment
➣Chemotherapy/Radiotherapy:
•Keep an eye out for nausea/vomiting, oesophagitis, and mucositis.
•Use mouthwashes with analgesics and practise good oral hygiene.
•Promote soft, bland meals and plenty of water.
➣Surgical (Esophagectomy):
•Post-operative airway management, chest physiotherapy.
•lung exercises and early mobilisation.
•Keep an eye out for infection, strictures, and anastomotic leaks.
•Reintroducing the oral diet gradually (liquid → soft → solid).
➣Palliative Care:
•Palliative radiation and opioids for pain control.
•nutritional assistance (parenteral feeding if necessary, PEG tube).
•prevention of aspiration and swallowing rehabilitation.
•spiritual and emotional support; include family in the care process.
➣Pain and Discomfort Problem:
unbearable pain or discomfort during hospitalization is prevalent, impacting recovery and well-being.
•Interventions: Using approved measures, do routine pain evaluations.
prompt administration of analgesics as directed and assessment of their efficacy.
non-pharmacological methods of managing pain, such positioning and relaxation techniques.
•Result: Better patient comfort and efficient pain management.
➣Anxiety and Psychological Stress Issue: Patients frequently suffer anxiety, which can have an impact on results, particularly when dealing with serious diseases or preterm labour.
•Interventions: Nursing treatment that focusses on relaxation, such as stress-reduction methods and guided breathing exercises.
•Reducing dread of the unknown by offering continuous information on procedures and emotional support.
recommending expert counselling if necessary.
•Result: Better health outcomes, decreased cortisol levels, elevated contentment, and decreased anxiety.
➣Pressure ulcer risk (also known as bed sores)
•Problem: Patients who are bedridden or immobilised run the danger of getting pressure ulcers.
•Interventions: Repositioning patients often to reduce pressure on sensitive regions.
use of supportive surfaces, such as pads or customised mattresses.
Frequent evaluations of the skin and quick action if a breakdown is detected.
•Result: A lower prevalence of pressure ulcers and their related problems.
➣Fall Risk Issue: Elderly individuals in hospitals or those recovering from surgery are vulnerable to falls, which can cause harm.
•Interventions: Assessing fall risk both upon admission and on a frequent basis after that.
teaching families and patients about safety measures including using assistive technology and call bells.
ensuring that there are no risks in the area, such as wires or slick flooring.
•Result: Injury prevention and a decrease in fall rates.
Notes
For more details visit https://pmc.ncbi.nlm.nih.gov/articles/PMC6977094/
