Medical-Surgical Nursing Note on Esophageal Cancer

1. CANCER OF ESOPHAGUS
JAISON THOMAS DANIEL
NURSING TUTOR
YFCON, RATNAGIRI

2. ESOPHAGEAL CANCER
• Esophageal cancer is a devastating disease.
• It is the 6th most common cause of cancer deaths worldwide.
• Although some patients can be cured, the treatment for esophageal cancer is protracted,
diminishes quality of life, and is lethal in a significant number of cases.
• The principal histologic types of esophageal cancer are
Squamous Cell Carcinoma (SCC)
Adenocarcinoma.

3. TYPES
• Squamous cells line the entire esophagus, so SCC can occur in any part of the
esophagus, but it often arises in the upper half.
• Adenocarcinoma typically develops in specialized intestinal metaplasia (Barrett
metaplasia) that develops as a result of gastroesophageal reflux disease (GERD); thus,
adenocarcinoma typically arises in the lower half of the distal esophagus and often
involves the esophagogastric junction.

4. RISK FACTORS FOR ESOPHAGEAL SQUAMOUS
CELL CARCINOMA
• The risk factors and etiologic associations for SCC of the esophagus include the
following:
• Smoking and alcohol use
• Diet
• Certain infections
• Tylosis

5. CLINICAL MANIFESTATIONS
• Dysphagia (most common); initially for solids, eventually progressing to include liquids
(usually occurs when esophageal lumen < 13 mm)
• Weight loss (second most common) due to dysphagia and tumor-related anorexia.
• Bleeding (leading to iron deficiency anemia)
• Epigastric or retrosternal pain
• Bone pain with metastatic disease
• Hoarseness (due to the involvement of the recurrent laryngeal nerve)

6. CLINICAL MANIFESTATIONS
• Persistent cough
• Intractable coughing or frequent pneumonia (due to tracheobronchial fistulas caused by
direct invasion of tumor through the esophageal wall and into the mainstem bronchus)
Physical findings include the following:
• Typically, normal examination results unless the cancer has metastasized
• Hepatomegaly (from hepatic metastases)
• Lymphadenopathy in the laterocervical or supraclavicular areas (reflecting metastasis)

7. DIAGNOSTIC EVALUATIONS
• Laboratory studies such as complete blood count (CBC) and comprehensive metabolic
panel (CMP) focus principally on patient factors that may affect treatment (eg, nutritional
status, renal function).
Imaging studies used for diagnosis and staging include the following:
• Esophagogastroduodenoscopy (EGD; allows direct visualization and biopsies of the tumor)
• Endoscopic ultrasonography (EUS; most sensitive test for T and N staging ; used when no
evidence of M1 disease)
• Computed tomography (CT) of the abdomen and chest with contrast (for assessing lung and
liver metastasis and invasion of adjacent structures)

8. DIAGNOSTIC EVALUATIONS
• Pelvic CT scan with contrast if clinically indicated
• Positron emission tomography (PET) scanning (for staging)
• Bronchoscopy (if tumor is at or above the carina, to help exclude invasion of the trachea
or bronchi)
• Laparoscopy and thoracoscopy (for staging regional nodes)
• Barium swallow (very sensitive for detecting strictures and intraluminal masses, but now
rarely used)

9. MANAGEMENT
• Treatment of esophageal cancer varies by disease stage, as follows:
• Stage I-III (locoregional disease) - Available modalities are endoscopic therapies (eg,
mucosal resection or ablation), esophagectomy, preoperative chemoradiation, and
definitive chemoradiation.
• Stage IV – Systemic chemotherapy with palliative/supportive care for patients with
ECOG performance score of 2 or less and palliative/supportive care only for patients
with ECOG performance score of 3 or more.
•

10. SURGICAL MANAGEMENT
• Ivor Lewis esophagogastrectomy (laparotomy plus right thoracotomy)
• McKeown esophagogastrectomy (right thoracotomy plus laparotomy plus cervical
anastomosis)
• Minimally invasive Ivor Lewis esophagogastrectomy (laparoscopic approach)
• Minimally invasive McKeown esophagogastrectomy (laparoscopic approach)
• Robotic minimally invasive esophagogastrectomy
• Transhiatal esophagectomy (THE)
• Transthoracic/transabdominal esophagectomy with anastomosis in chest or neck

11. ESOPHAGECTOMY

12. TYPES OF ESOPHAGECTOMY
• Transthoracic esophagectomy
Ivor Lewis esophagectomy (right thoracotomy and laparotomy)
McKeown esophagectomy (right thoracotomy followed by laparotomy and
cervical anastomosis)
• Transhiatal esophagectomy
• Minimally invasive esophagectomy
• Salvage endoscopic resection

13. TRANSTHORACIC ESOPHAGECTOMY

14. TRANSHIATAL ESOPHAGECTOMY

15. • Palliative care options for patients who are not candidates for surgery are as follows:
• Chemotherapy
• Radiotherapy
• Laser therapy
• Stents

16. CHEMOTHERAPY & RADIATION
• Chemotherapy and radiotherapy for esophageal cancer are delivered preoperatively.
• The aims of preoperative (neoadjuvant) chemotherapy and radiotherapy are to reduce
the bulk of the primary tumor before surgery to facilitate higher curative resection rates
and to eliminate or delay the appearance of distant metastases.
• Common chemotherapic agents using in the treatment of esophageal cancer are
alkylating, antimetabolite, anthracycline, and antimicrotubular agents,

17. • Stents
• Long-term palliation of dysphagia can be achieved with endoscopic, radiographic-
assisted insertion of expandable metal or plastic stents