DYSPAHGIA AND

OESOPHAGEAL
CANCER
PRESENTER: DR SINKALA YIZUKANJI
PRESENTATION LAYOUT
• Anatomy and physiology of the oesophagus
• Physiology
• Dysphagia
• Oesophageal cancer
• Risk factors
• Symptoms
• Physical findings
• Investigations
• Mechanism of spread
• Staging
• Treatment options
• Complications
• Prognosis
• Conclusion
• references
ANATOMY AND PHYSIOLOGY OF
THE OESOPHAGUS
• The oesophagus is a fibromuscular tube that connects the mouth to the
stomach.
• Location: posterior mediastinum
• Spans from the cricopharyngeal sphincter to the Cardiac sphincter of
the stomach.
• Length: 25cm and 4cm of this length is below the diagram
• The upper 1/3 is striated muscle which fades into the lower 2/3 which is
smooth muscle.
• It is lined by squamous epithelium except the lower 3cm which has
specialised epithelium( simple columnar)
CONSTRICTIONS OF THE
OESOPHAGUS
PHYSIOLOGY
• Passage of food from mouth
• Starts by contraction of oropharyngeal muscles with closure of nasal
and respiratory passages.
• Initial phase by striated muscles is voluntary.
• Completed by the involuntary smooth muscles.
• The process of swallowing automatically relaxes the gastroesophageal
sphincter.
• The lower oesophagus has a physiological sphincter working with
other anatomic mechanisms to prevent reflux of gastric content.
• The physiological sphincter is controlled by gastrointestinal hormones.
It can also be influenced by anticholinergic drugs and smoking.
• The upper sphincter at rest or after swallowing is closed to prevent
regurgitation.
The normal GOJ is about 3-4 cm with a closing pressure of about
30cmH20.
DYSPHAGIA
• Difficulty swallowing, including oral, pharyngeal, and
oesophageal phases.
• Oral pharyngeal dysphagia being difficulties in initiating
swallowing.
• Oesophageal dysphagia in passage of food bolus beyond the
oesophagus after successfully swallowing.
• Affects approximately 15% of the population
• Can lead to malnutrition, dehydration, and reduced quality of life
DYSPHAGIA
• IT is a major symptom for both benign and malignant conditions of
the oesophagus. Other associated symptoms include
• Odynophagia
• Heartburn
• Vomiting
• Chest pain
• Chocking
• Weight loss
• An auxiliary presentation for benign conditions of the
oesophagus will be shared for you to read
OESOPHAGEAL CANCER
• It is the 8th most common cancer worldwide
• 5th most common cancer in Zambia and third among cancer related
deaths.
• More common in males than female in the ratio of 3.5: 1
• 5 times more common in African men than white men.
• Adenocarcinoma predominates in high income countries while
squamous cell carcinoma predominates in middle and low icome
countriesn
RISK FACTORS
• Bullet points:
• Smoking
• Alcohol consumption
• Barrett’s oesophagus
• Gastroesophageal reflux disease (GERD)
• Family history
• Age (>55 years)
• Other underlying oesophageal disease( achalasia, caustic strictures
SYMPTOMS
• Dysphagia
• Odynophagia
• Heartburn
• Vomiting
• Chest pain
• Chocking
• Weight loss
• Hoarseness
• Fatigue
PHYSICAL FINDINGS
• Finding are typically normal unless there is metastatic
disease.
• Findings are more likely to be associated to sites of spread
and may include:-
• Cervical and supraclavicular lymphadenopathy
• Hepatomegaly if liver involved and often indicates
unresectable disease.
• Diagnosis is largely dependent on history and investigation.
This is so because of its location in the chest cavity.
DIAGNOSTITIC INVESTIGATIONS
• Endoscopy
• Biopsy
• Barium swallow
• Imaging
• CT,
• PET
• MRI
SUPPORTIVE
• FBC/DC
• Liver F.TS
• KFTs
• Lung F.T
• Chest X-Ray
• Abdominal U/S
BIOPSY :- HISTOLOGICAL TYPES
MECHANISMS OF METASTASIS
1. Direct spread: lack of serosa on the supradiaphragmatic
oesophagus favours local spread.
• In upper 1/3 it spreads to the trachea, bronchus, laryngeal nerve and aorta and its
branches.
• May perforate and cause mediastinitis
• Fistulation with trachea, bronchus and aorta in rare cases
2. Haematogenous: liver, lungs, bones and brain
3. Lymphatic(70%): supraclavicular nodes above the chest,
oesophageal nodes, tracheobronchial lymph nodes and
subdiaphragmatic lymph node in the thoracic cavity, coeliac nodes
in the abdomen
STAGING
 TEATMENT OPTIONS
1. Stage 1; Surgery for local disease
2. Stage2: Surgery with neoadjuvant or Adjuvant chemotherapy
Surgery is contraindicated in metastatic disease
3. Stage 3 & 4: Targeted therapy and immunotherapy
• Anti EGFR therapy
• Anti PI3K/mTOR therapy: Copanlisib, Idelalisib, Umbralisib, Duvelisib and
Alpelisib)
• Immunotherapy
Palliation: Patient comfort, Psychological support, nutritional support in
form of parenteral feeding, feeding gastrostomy/jejenostomy
ESMO Guidelines
COMPLICATIONS OF
OESOPHAGEAL CANCER
• Dysphagia
• Weigh loss
• Anaemia
• Tumour related anorexia
• Mediastinitis
• Metastatic complication
COMPLICATIONS OF CANCER
TREATMENT
• Anastomotic leak
• GORD
• Mediastinitis
• Empyema
• Hair loss
• Susceptibility to infection
• Bone marrow suppression
• Diarrhoea
• Radiation pneumonitis
• Pulmonary fibrosis
• Cardiac events
PROGNOSIS
• Poor prognosis due to early spread, longitudinal lymphatics,
aggressiveness, late presentation and lack od serosa in the
supradiaphragmatic oesophagus.
• Nodal involvement signals bad prognosis
• Has a 5 years survival rate of 10%
CONCLUSION
• Squamous cell carcinoma and Adenocarcima > 90%
• History and investigations and little physical finding if without mets.
• Early local and lymphatic spread
• Poor prognosis
• Surgery not indicated in stages 3 & 4
• Surgery, radiotherapy, chemotherapy, targeted therapy and
immunotherapy.
• Palliation in case of advanced disease.
REFERENCES
Acharya.R, Mahapatra .A, Verma H.K & Bhaskar. L.V.K, (2023), Unveiling
Therapeutic Targets for Esophageal Cancer: A comprehensive review,
Current oncology journal, volume 30.
Samson shumba et al (2023) Oesophageal cancer cases recorded in the
Zambia National Cancer Registry: A cross sectional study, Pan Africa
Medical Journal. 2023; 44(128).
Yang. Y.M, Hong P, Xu W.W He. Q.Y, Li B (2020) Advances in Targeted
Therapy for Oesophageal cancer. Signal Transduct. Target Therapy.
Stah .m, Marriette .C, Houstermans .K, & Anold .D,
(2013),Oesophageal cancer: ESMO Clinical Practice
Guidelines for diagnosis, treatment and follow-up.