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Esophageal Cancer

This case is of interest to dietitians, chaplains, social workers, radiation therapists, speech therapists, and respiratory therapists.

Prerequisite Concepts

A medical vocabulary, cachexia, dysphagia, gastroesophageal reflux disease (GERD), loss/depression, nutritional needs, oral care. The user should also be able to classify obese patients and tobacco users.

This case helps the user appreciate the complexity of needs that a tumor in the esophagus creates, and appreciate the need for multidisciplinary team approach.
Objectives

* Describe the risk factors for .
* Select and use a nutritional assessment tool.
* Recognize the need for speech therapy and respiratory therapy input with esophageal malignancy.
* Recognize need for support with anticipatory grief.
* Recognize needs of caregivers in family units.

Concepts Discussed in the Case

Anticipatory grief, cachexia, esophageal , invasive tumors, malnutrition, metastasis, nutritional support, quality of life, staging of malignant disease, supportive care, and treatment for .

Arden is a 37-year-old white male who presents to his family doctor and is referred to the radiation oncology department for consultation.

Chief complaint: Heartburn for “a long time” and difficulty swallowing during the past 4 or 5 months. Occasionally food seems to “hang up” in his throat. He points to the upper portion of his neck, directly beneath his chin. Pain immediately below the sternum that feels like “a gnawing or burning.”

Other complaints: Weight loss of 33 pounds in the past 6 or 7 months, weakness, coughing at night. (Usual weight: 230 pounds).

Other information: Does not use tobacco; alcohol intake does not exceed 2 cans of beer per week. Has treated stomach pain with otc (over the counter) medications for acid stomach.

Students should identify: dysphagia, gastric reflux, cachexia, respiratory component, habits.

Define and describe GERD.

Identify structures surrounding or in close proximity to the distal esophagus that could be involved in this disease.

What is the relationship of weight loss to prognosis in malignant diseases?

What are acceptable hypotheses?

Patient History

* Fractured left leg age 14
* Usual childhood illnesses, immunization status unknown
* Wears glasses for myopia

Family History

* Negative heart disease, diabetes, mental illness
* Mother died of liver cancer at age 59
* father is alive and well

Social History

He is married and is employed as a carpenter.

Arden is self employed in the building industry. He does not have health insurance, but has $10,000 in life insurance. He married at age 36 and does not have a large support group because he was emancipated from his family of origin for a long time and developmentally is late in establishing a family.

Self care measures did not include consulting a physician until he is highly morbid.

What are the key points made so far?

* Family history of cancer
* He will likely need familial support

Appearance: Pale, malnourished, distressed
Vital signs: 132/92; 88
Temperature: 98.4°
Respirations: 14
Height: 6 feet (183 cm)
Weight: 62 kg

Joints appear prominent with evidence of some muscle wasting Epigastric tenderness on palpation

What are your differential diagnoses?

What global nutritional assessments can Arden take?

What Tests Should Be Ordered?

1. Chest x-ray.
2. Barium esophagram can show mucosal irregularities, displacement, narrowing, and strictures. (If cancer is diagnosed, a CT scan will be useful for staging because it will show node involvement and invasion of adjacent structures.)
3. Endoscopy and biopsy. Bronchoscopy will be indicated to rule out involvement of the left main stem bronchus if a tumor is found in the middle third of the esophagus. CT scan of the liver and bone may be recommended depending on metastasis.

Staging a cancer is important for determining appropriate treatment and prognosis. If the disease is limited to the area of origin (primary site) it is considered an earlier stage disease than one that has spread to lymph nodes and adjacent viscera.

Blood tests are not useful for identifying the disease because there are no known “tumor markers” for esophageal cancer. Tumor markers are chemicals characteristic of specific tissues; when they are elevated, disease is suspected and further tests are indicated. For example, the PSA (prostate specific antigen) is specific for prostate cancer, and although not diagnostic of prostate cancer, is a useful indicator of prostate health.

What preparation does Arden need for barium esophagram and endoscopy studies?

Diagnosis

From findings during endoscopy, pathology report on the biopsy, and the results of a barium swallow, Arden was found to have cancer of the gastroesophageal junction or GE junction.

What information rules out other diagnoses?

Treatment

What are the most important concepts to understand about the management plan:

1. Staging of the disease.
2. Performance status:

Karnofsky scores

ECOG score
3. Nutritional status: He needed nutritional support prior to beginning intensive therapy so he increased his intake, particularly protein, by using high calorie protein liquid supplements.
4. Preoperative radiation therapy to reduce the size of the tumor, aid in swallowing.
5. Esophagectomy by either left thoracoabdominal approach for a esophagogastrectomy or transhiatal esophagectomy.
6. Chemotherapy for systemic disease.

How is performance status related to treatment for cancer?

What assessments related to nutritional status need to be made? What is his nutritional risk?

What is the relationship of weight loss and prognosis in cancer patients?

What are some issues for caregivers?

What are the issues of anticipatory grief?

Discuss any alternatives: Macrobiotic diet, an alternative therapy, does not cure the disease. This diet may be used as complimentary to medical treatment and provide some patient satisfaction because of patient involvement in self care; however, the diet is fairly stringent and unfamiliar to most Americans.

Conclusion

Arden’s disease recurred after treatment with radiation therapy, surgery and chemotherapy. Early in the treatment course, his wife became pregnant, and he died 2 weeks after the birth of his little girl. His widow is employed as a waitress.

Arden presented after months of symptoms with invasive disease that had spread microscopically. In the remaining 13 months of his life, he had periods of good quality of life (by his own definition), as well as periods of distress from pain and fatigue.

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