History Chief Complaint My patient Mr D, a 76 years old gentleman presented to hospital on 19 th February 2017 with a complain of difficulty in swallowing for the past 4 months. History of Presenting Illness Mr D was previously well with no apparent symptoms. He first started to experience dysphagia was 4 months ago which is progressive. Initially, he had difficulty in swallowing solid food and then his condition worsen for about 10 weeks ago where he can only tolerate semi-solid food like porridge and fluids. He has no problem with swallowing his saliva. He also claimed that the food that he couldn’t swallow will then regurgitated and vomited out. The vomitus was told to be bitter and contained gastric contents of recently ingested food. It was non-projectile and it does not contain blood in it. He also complained of odynophagia when he forcefully trying to swallow solid food for the past 4 months. He also found that he has slight loss of appetite and loss of weight for the past 6 months. He was about 77kg and now he is 75kg which is not so significant. He also noticed a change in his bowel habit. The amount and frequency of stool were decreased for the past 6 months compared to his usual bowel habit previously. He used to defecate once daily but now it has decreased to 3 to 4 times per week. However, the stool was told to be brown in colour without blood stain or melena or watery stool. Otherwise, Mr D denies of any heart burn, epigastric pain or regurgitation of with unpleasant taste during night time. He also denies of any abdominal pain or distention of abdomen. He denies of coughing during swallowing or difficulty to initiate swallowing. He has no fever and the dysphagia is not relieved with repeated swallows. He also denies of any hematemesis. There is no complains of hoarseness of voice, hiccups or difficulty in breathing. He also did not complain of any weakness of limbs. On further questioning, Mr D seeks for medical attention when his son told him to go to hospital. He then visited Hospital FE on early January 2017 when he started to have difficulty in swallowing porridge. Esophagogastroduodenoscopy (OGDS) and CT-scan were done.
Transcript
History
Chief Complaint
My patient Mr D, a 76 years old gentleman presented to hospital on 19th February 2017 with
a complain of difficulty in swallowing for the past 4 months.
History of Presenting Illness
Mr D was previously well with no apparent symptoms. He first started to experience
dysphagia was 4 months ago which is progressive. Initially, he had difficulty in swallowing
solid food and then his condition worsen for about 10 weeks ago where he can only tolerate
semi-solid food like porridge and fluids. He has no problem with swallowing his saliva. He
also claimed that the food that he couldn’t swallow will then regurgitated and vomited out.
The vomitus was told to be bitter and contained gastric contents of recently ingested food. It
was non-projectile and it does not contain blood in it. He also complained of odynophagia
when he forcefully trying to swallow solid food for the past 4 months.
He also found that he has slight loss of appetite and loss of weight for the past 6 months. He
was about 77kg and now he is 75kg which is not so significant. He also noticed a change in
his bowel habit. The amount and frequency of stool were decreased for the past 6 months
compared to his usual bowel habit previously. He used to defecate once daily but now it has
decreased to 3 to 4 times per week. However, the stool was told to be brown in colour
without blood stain or melena or watery stool.
Otherwise, Mr D denies of any heart burn, epigastric pain or regurgitation of with unpleasant
taste during night time. He also denies of any abdominal pain or distention of abdomen. He
denies of coughing during swallowing or difficulty to initiate swallowing. He has no fever
and the dysphagia is not relieved with repeated swallows. He also denies of any hematemesis.
There is no complains of hoarseness of voice, hiccups or difficulty in breathing. He also did
not complain of any weakness of limbs.
On further questioning, Mr D seeks for medical attention when his son told him to go to
hospital. He then visited Hospital FE on early January 2017 when he started to have difficulty
in swallowing porridge. Esophagogastroduodenoscopy (OGDS) and CT-scan were done.
Besides, PET scan was also done in hospital KJ. He was then referred to Hospital FE on 27th
of January for further management of his condition.
Past Medical History & Past Surgical History
Mr D is a known hypertensive for 25 years. His blood pressure in under control with
medications and he goes for regular check-ups in a Klinik nearby his house. Otherwise, he
has no diabetes mellitus, gastric disease, asthma, cardiovascular diseases or any malignancy
diagnosed previously. He denied of any neuromuscular disease like stroke or poliomyelitis or
multiple sclerosis that may cause dysphagia.
Drug History
He is currently under the medications listed below:
1. Perindopril 4mg OD Tablet
2. Amlodipine Besylate 5mg OD Tablet
3. Simvastatin 20mg ON Tablet
Patient does not take any traditional medications and he has no known drug allergies.
Family History
Both of her parents are not alive. His father passed away many years ago due to diabetic
complications and his leg was amputated. His father was diagnosed with diabetes mellitus
and hypertension since around 48 years old. His mother was hypertensive, diagnosed about
the same age. However, patient does not remember the cause of death. Patient has 4 other
siblings and he is second youngest in the family. His eldest sister is also suffering with
cardiovascular disease and his second eldest sister has passed away due to breast cancer about
20 years ago. Whereas his third sister which is a known hypertensive since 50 years old was
diagnosed also with gynecological cancer, however she is still alive but refused treatment.
Patient claimed to be not close with his younger brother. There is a significant family history
of diabetes and hypertension running in the family. Two of his sisters also suffer with
gynecological cancer.
Mr D is married to his wife who is 70 years old and they have 4 children and they are all
healthy with no known medical illnesses
Social History
Mr D was previously a smoker for 32 years and about 10 sticks per day. His pack-years is
found to be 16. He stopped smoking at the age of 65 years old when his children managed to
convince him for smoking cessation.
Mr D does not consume any alcohol. Mr D denied usage of any recreational drugs, recent
travels as well as practicing any history of high-risk behaviours.
Review of Systems
General Health Status Has weight loss (2kg in 6 months) Decreased appetite No history of fall No lumps No lethargy No night sweats No alteration of sleeping pattern No fever No itch/rash No recent trauma No drastic change in mood
Nervous system
No significant finding
No headache No dizziness No seizure or syncopal attacks
No limbs numbness No limb weakness No visual disturbances No hearing problems No speech problems Normal level of memory, concentration and consciousness
Cardiovascular system No significant finding
No chest pain No palpitation No pain in legs when walking No ankle swelling No cyanotic spells
Respiratory system No significant finding
No shortness of breath No cough No wheezing No paroxysmal nocturnal dyspnea No orthopnea
Gastrointestinal system
Dysphagia Vomiting Change in bowel habits No oral ulcerations No nausea No diarrhea No abdominal pain No jaundice No abdominal mass No haematemesis No melena No haematochezia
Genitourinary system No significant finding
No incontinence No dysuria No urinary abnormalities Normal urinary frequency No terminal dribbling No nocturia or polyuria No incontinence No urethral discharge
Musculoskeletal system No significant finding
No joint swellings or pains No pain or stiffness of muscles No problem in moving No recent falls
Endocrine system No significant finding
No polydipsia, polyuria or excessive thirst No temperature intolerance No change in sweat pattern No alteration in voice No thinning of hair No swelling at neck No protrusion of eye balls No easy bruising
Ophthalmology
No blurring of vision No red eye
No significant finding No eye discharge Ear, Nose and Throat No significant finding
No ear discharge No difficulty in hearing No running nose No nasal block No post nasal dripping No mouth breathing No hoarseness of voice
Physical Examination
General Examination
On inspection, my patient is lying down comfortably on the bed in supine position with one
pillow at 30 degree without respiratory distress. Mr D is well built and not obese but he looks
tired. He is 75kg and 1.75m which gives her a BMI of 25.95 kg/m2. He was alert, conscious
and responsive to the surrounding. He was also oriented to time, place and person. There
were also no signs of dehydration. The patient did not appear to be pale or jaundiced. He also
has a cannula inserted into the dorsum of his left hand and an identification tag attached on
his right arm.
Vital signs
Body Temperature: 37 °C orally
Pulse rate: 75 beat per minute with normal rhythm and good volume. There was no
radio-femoral or radio-radial delay. Pulse is not collapsed in nature.
Respiratory rate: 20 breaths per min.
Blood pressure: 120/64 mmHg.
Partial Pressure of O2: 98% under room air
Hand examination
On examination, the palm is warm, mois, pink and has a normal capillary filling time of
(<2seconds) which suggest absence of anemia and dehydration.. There was no palmar
erythema and no sign of peripheral cyanosis on the fingers. There was tobacco stain on the
index finger of his right hand. No splinter hemorrhage was observed in the nails and there
were no sign of clubbing, no koilonychias, no tendon xanthoma, no Osler’s nodes, and no
scratch marks or scars on both upper limbs. Asterixis was absent. He did no elicit any fine
tremors at the time of examination.
Head and Neck examination
On examination, the palpebral conjunctiva was pinkish and sclera was white, showing
absence of anaemia and jaundice respectively. The pupils were normal and equal in size.
There was no signs of dehydration such as sunken eyeballs. However arcus senilis was
noticeable on the periphery of the iris in both eyes. There was no angular stomatitis nor
cracked lips. The lips were pink and moist. Oral hygiene was good with no central cyanosis.
The uvula was centrally placed and the pharyngeal wall was symmetrical. There was no
facial asymmetry, ptopsis or squinting of the eyes. All the cervical lymph nodes were not
palpable and non-tender. Both left and right sided supraclavicular lymph glands were not
enlarged or palpable. Thyroid gland was not enlarged. Carotid pulse was regular on both
sides and showed good volume. Jugular venous pulse was not raised. Lastly, trachea was
palpated and it is not deviated.
Leg examination
On examination of the lower limb, there was no visible scars, lesions or discolouration. No swellings, lumps or bumps were noted. Leg muscles were of normal size suggesting no wasting has taken place. Pitting oedema was absent in both legs. There was no signs of limb ischemia such as cold extremities, loss of hair, shiny skin, pigmentation or ulcer. Posterior tibial and Dorsalis pedis pulse was felt and it was regular and in good volume.
Systemic Examination
Gastrointestinal System
Inspection
The patient was in a supine position on the bed. The environment was well lit and conducive
for abdominal examination. The shape of the abdominal wall was slightly distended and
symmetrical. All quadrants of the abdominal wall moved synchronously along with
respiration. The umbilicus was centrally placed and inverted. There was no swelling seen
over the abdominal wall. There were no rashes, dilated veins (caput medusa), surgical scars,
visible peristalsis, or visible pulsations observed. However there are some spots of
hyperpigmentation at the area of lower abdomen.
Palpation
On superficial palpation, the abdomen was soft and non-tender on all 9 quadrants. There was
no evidence of guarding, rebound tenderness and no masses felt. On deep palpation, there
were no signs of hepatosplenomegaly and both kidneys were not ballotable. There was no
mass detected upon deep palpation. Liver span were measured to be a normal size which was
7.5 cm. Spleen is not palpable.
Percussion
All regions of the abdomen were tympanic on percussion.
Auscultation
Shifting dullness was absent which indicates the absence of ascites which may be suggestive
of metastases. Bowel sounds were normal and 2 times per minute heard at right iliac fossa
region.
I would further like to complete my abdominal examination by conducting per-rectal
examination and also examination of the external genitalia area. However, this was not done
to preserve the modesty of the patient.
Respiratory Examination (No Significant Findings)
Inspection
The chest wall of the patient was symmetrical in shape. It appeared to move symmetrically
with respiration. There were no deformities seen in the chest wall such as pectus excavatum
and pectus carinatum. No surgical scars seen. No visible pulsations were observed.
Palpation
There is no deviation of the trachea. Chest wall expansion was symmetrical. Vocal tactile
fremitus was performed and the results tabulated below.
Vocal fremitus on the right and left side in all the following areas :
Right Left
Supraclavicular Normal Normal
Infraclavicular Normal Normal
Supramammary Normal Normal
Inframammary Normal Normal
Axillary Normal Normal
Infra-axillary Normal Normal
Suprascapular Normal Normal
Interscapular Normal Normal
Infrascapular Normal Normal
Percussion
Resonant sound were heard in all areas of the lung field except for cardiac and liver dullness.
Auscultation
Vesicular breath sound were heard in all areas of the lung field.
Cardiovascular System
Inspection
No scars or pigmentations were noted on the chest wall. Chest expanded symmetrically with
respiration. No signs of precordial bulge and engorged veins seen. There was no surgical
scars and visible pulsations noted.
Palpation
Apex beat can be felt on the 6th intercostal space about 1cm to the left of mid-clavicular
line. No palpable thrills were and parasternal heaves felt.
Auscultation
S1 and S2 were heard clearly.
Peripheral vascular examination
Radial pulse was regular of 75 beats per minute with normal rhythm and good volume. No
collapsing pulse was noted
Brachial pulse beat was regular with good volume
Carotid pulse was regular with good volume
Femoral pulse was not able to be ascertained
Posterior tibial pulse was regular with good volume
Dorsalis pedis pulse was regular with good volume
Summary
Mr D is a 76 years old gentleman. He presented to Hospital FE with chief complain of
progressive dysphagia from solid to minimal semi-solid food for the past 4 months. The
dysphagia is followed by vomiting of food ingested. This is also associated with loss of
appetite and loss of 2kg in the duration of 6 months. Mr D was a chronic smoker with 16
pack-years and known hypertensive for 25 years.
Provisional Diagnosis
Oesophageal Carcinoma
Supporting statement:
Progressive dysphagia from solid to semi-solid food in 4 months duration
Vomiting and regurgitation after eating and also odynophagia
Vomitous contains gastric content of ingested food
Patient was a chronic smoker
Patient has loss of appetite and loss of weight
Positive family history of malignancies
Patient age is 76 years old which is also a risk factor
Differential Diagnosis
1. Achalasia
Supporting statements: Opposing statements:
Dysphagia
Vomiting, regurgitation
Loss of weight
Dysphagia is not relieved by severalattempts of swallowing
There is no aspiration symptoms likecough
There is no feeling of food sticking inthe esophagus
He did not complain of difficulty inswallowing saliva or liquid
There is no signs of aspiration inphysical examination
2. Oesophageal strictures
Supporting statements: Opposing statements: Dysphagia Weight loss Odynophagia
There was no history of heartburn orchest pain
Duration of dysphagia is too short tobe benign oesophageal stricture
No history of Gastroesophageal reflux No history of ingestion of corrosive
substance
3. Oesophageal web and ring
Supporting statements: Opposing statements: Dysphagia Weight loss
There was no history of heartburn orchest pain or GERD
Patient has no Plummer-Vinsonsyndrome
There is no iron deficiency anaemia
4. Oesophagitis
Supporting statements: Opposing statements: Dysphagia There is no previous history of
Analyse the white blood cell count to rule out presence of any infections.
Check for the haemoglobin level and red blood cell count to ensure anaemia is
absent.
To identify blood group and cross match blood in preparation for any
emergency procedures and blood transfusion.
ABO Group O
Rh (D) Group D Positive
Tests 19/2/2017 Interpretations
White blood cell 9.72 x 10^9/L Normal
Red blood cell 4.57 x 10^12/L Normal
Haemoglobin 13.9 g/dL Normal
Haematocrit 43.5 % Normal
Mean cell volume 95.3 fl Normal
Mean cell hemoglobin 30.4 pg Normal
Mean cell hemoglobin
concentration
31.9 g/dL Normal
Red cell distribution
width
12.9 % Normal
Platelet 290 x 10^9/L Normal
2. Renal Profile
To assess kidney function and to detect any abnormalities or possible kidney failure. This is
important as patient is a known hypertensive. Also to detect any electrolyte abnormalities that
may affect the surgery.
19/2/2017 Significance
Urea 7.9 mmol/L
Sodium 139 mmol/L Normal
Potassium 4.10 mmol/L Normal
Chloride 108 mmol/L Normal
Creatinine 77.0 µmol/L Normal
3. Bilirubin Test
A bilirubin test is used to detect an increased level in the blood. It may be used to help determine the cause of jaundice and/or help diagnose conditions such as liver disease, hemolytic anemia, and blockage of the bile ducts. However, the results are not significant for this patient.
19/2/2017 Interpretation Total Bilirubin 8.6 umol/L Normal Direct Bilirubin 3.9 umol/L Normal Indirect Bilirubin 4.7 umol/L Normal
4. Chest X-Ray
It can be used to evaluate if there is cardiomegaly due to long standing hypertension
in this patient. It is also necessary to screen all patient susing CXR above 50 years old
before operation as a preventive measure. Another significant value of doing chest X-
ray is also to rule out secondary metastases to lung. Besides, patient was a chronic
smoker so it is also useful to rule out any lung pathology.
Interpretation:
This is an erect PA chest X-ray of Mr D. The lung fields are clear.
5. Liver function testIt is done to evaluate the function of liver.
19/2/2017 Interpretation Total protein 75.0 g/L Normal Albumin 37 g/L Normal
Alkaline phosphatase 62 U/L Normal Alanine transaminase 37 U/L Normal
Interpretation: Liver is normal. Liver enzymes are not raised.
6. Fasting blood glucoseThis is done to evaluate patient’s glucose control or undiagnosed underlying diabetes mellitus
19/2/2017 Fasting Glucose 6.1 mmol/L
Interpretation: Patient’s fasting glucose is slightly higher than normal.
7. 24 hours urine
This is done because patient complained of dysphagia. This is to check the hydration status and urine output. Other than that, it can also be useful to rule out other kidney diseases.
20/02/2017 Interpretation 24 hours urine volume 1259.0 ml Normal 24 hours urinary urea 248 mmol/L/day Normal 24 hours urea 197.3 mmol/L Normal
8. Lipid profile
19/02/2017 Interpretation
Triglycerides 1.37 mmol/L Normal
HDL Cholesterol 0.93 mmol/L Normal
Cholesterol 2.94 mmol/L Normal
LDL Cholesterol 1.38 mmol/L Normal
9. PT/APTT test
This investigation is done to make sure we can foresee the bleeding tendency during
and after the surgery. The APTT is used to evaluate the intrinsic coagulation factors
XII, XI, IX, VIII, X, V, II (prothrombin), and I (fibrinogen) as well as prekallikrein
(PK) and high molecular weight kininogen (HK). A PT test evaluates the coagulation
factors VII, X, V, II, and I (fibrinogen). By evaluating the results of the two tests
together, a health practitioner can gain clues as to what bleeding or clotting disorder
may be present. The PTT and PT are not diagnostic but usually provide information
on whether further tests may be needed.
19/02/2017 Interpretation
Prothrombin time (PT) 12.90s Normal
International normalized
ratio (INR)
1.12 Normal
Activated Partial
Thromboplastin time
(APTT)
33.8s Normal
10. Oesophagogastroduodenoscopy (OGDS) with biopsy
The last OGDS was done on 27th of January 2017 in Hospital FE (outpatient department). It is exclusively important to perform this procedure in order for diagnosing esophageal carcinoma. Biopsy can also be taken when an abnormal looking area is found for further investigation.
Interpretation: Tumour is found in the distal third of esophagus. Tumour is visible at the level of the Esophagogastric junction (EGJ). It has no extension unto the fundus or lesser curvature. It almost encroaches the Esophago-Gastric Junction extending from 32 cm from incisors to the z-line at 38 cm where the demarcation line of squamocolumnar junction. It fits the classification of Siewart I where the tumor center located between 5 and 1cm proximal to the anatomical cardia. It is important because it has different approach on management. Biopsy was taken and confirmed that it is poorly differentiated adenocarcinoma of oesophagus. Therefore, it is distal oesophageal adenocarcinoma Siewart 1.
11. CT scan
It is most used to identify hematogenous metastases. Besides, it can also give a clearer picture of the tumor size and location. CT scan is also important for staging purpose to plan for further management of the patient. CT scan was done on the 8th of February.
Interpretation: CT scan shows irregular thickening of the oesophagus extending to gastroesophageal junction. It was measured to be 5.8cm in length with pericardioesophageal nodes. Besides, multiple well defined hypodense liver lesions likely cysts and multiple lucent
lesions in the iliac bone. The 2 key prognostic features of oesophageal cancer are the depth
of tumour infiltration into or through the oesophageal wall (T stage) and the presence or absence of visceral metastasis. T1 and T2 lesions generally show an oesophageal mass thickness between 5 mm and 15 mm, and T3 lesions show a thickness >15 mm. T4 lesions show invasion of contiguous structures on CT.
12. Positron emission tomography (PET) scan
A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. Staging of cancer also be done by using PET scan.
Interpretation: Unfortunately, PET scan result is not available.
13. Endoscopic Ultrasound / EUS (suggestive investigation)
It can be used to determine the depth of spread of a malignant tumour through the esophageal wall (T1-3), the invasion of adjacent organs (T4) and metastasis to lymph nodes. It can also detect contiguous spread downward into the cardia and left lobe of liver.
14. Bronchoscopy (suggestive investigation)
This is to assess if there is pulmonary invasion to lung structures.
15. Laparoscopy (suggestive investigation)
Laparoscopy can be useful to diagnose intra-abdominal and hepatic metastases, detect peritoneal tumour seedlings.
16. Barium swallow (suggestive investigation)
An x-ray is a way to take a picture of the inside of the body. Barium coats the surface of the esophagus, making a tumor or other unusual changes easier to see on the x-ray. It can also evaluate how much has the tumour causing obstruction hence dysphagia.
17. MRI (suggestive investigation)
MRI is an alternative to CT for the staging of oesophageal cancer. It is highly accurate for detecting distant metastases, especially to the liver and adrenals, and for determining advanced local spread (T4). However, it is less reliable in defining early infiltration (T1 to T3). MRI appears to be sensitive in predicting mediastinal invasion; the loss of signal in the vessels and the air-filled trachea and bronchi may provide a clear delineation between the
tumour and the aorta and the tracheobronchial tree.
Principle of Management
According to the Siewert classification for esophageal-gastric junction tumors, the details are
as follows:
Siewert Description Management
1 Tumor center between 5cm
and 1 cm proximal to the
anatomical cardia
Approach as esophageal
cancer
I Tumor center between 1cm
proximal and 2cm distal to
the anatomical cardia
Approach as esophageal or
gastric cancer
III Tumor center between 2cm
and 5cm distal to the
anatomical cardia
Approach as gastric cancer
This is based of the National Comprehensive Cancer Network Guidelines in Oncology. As
for this patient, he fits into the criteria of type I Siewert and he should be managed as
esophageal cancer. However the TNM staging for this patient is not known due to lack of
resources from the database. The prognostic factor of esophageal cancer depends on the depth
of tumor penetration through wall and also the involvement of the regional lymph node and
metastasis.
There are mainly 3 method of surgery. Modified Ivor-Lewis, McKeown and Transhiatal
esophagectomy. Lymphadectomy can be done as 1-field, 2-field and 3-field
lymphadenectomy. However, the complications of surgery must be discussed with the patient
like in intraoperative, it may causes respiratory complications due to thoracotomy, bleeding,
infection and for postoperatively, it may causes anastomotic leakage, chylothorax, injury to
recurrent laryngeal nerves causing hoarseness of voice and strictures.
Surgery alone is best for patients with TI, T2 esophageal cancer without nodal metastasis
(N0). However, neoadjuvant treatments before surgery may increases the operability and
improve survival in some patients.
For Siewert 1 tumors, transthoracic esophagetomy with 2 field lymph nodes (thoracic and
abdominal nodes) dissection is the procedure of choice. Neoadjuvant chemotherapy is useful
for this patient as it was too big to be resected initially. However, the drugs used for
chemotherapy was not available as patient does not remember and it was completed in
Hospital FE.
Lastly, palliative treatment can be offered to patient to overcome debilitating or distressing
symptoms to improve quality of life. For example, surgical resection and external beam
radiotherapy with endoscopic laser and brachytherapy can be offered. As for dysphagia, a
rigid tubes or expanding stents may be inserted to help the patient in swallowing as palliative
care.
Theoretical Discussion:
Esophageal cancer is the 6th most common cancer in the world. It usually occur in mid to late
adulthood with poor survival rate. Although there are multiple, rare esophageal cancer
histologies (e.g. gastrointestinal stromal tumors, leiomyosarcoma, and liposarcoma),
Adenocarcinoma and Squamous Cell Carcinoma are the two principle variants and account
for > 98% of esophageal cancer diagnoses. Squamous cell carcinoma has an increasing trend
due to tobacco abuse.
Adenocarcinoma is highly associated with obesity and gastroesophageal reflux disease
(GERD). It occurs at lower one-third of the esophagus with majority near gastro-esophageal
junction. Risk factors like besity increases the risk of developing GERD by approximately
twofold due to elevated intra-abdominal pressure and a resultant laxity in the lower
esophageal sphincter. GERD leads to chronic irritation of the distal esophagus and can
eventually cause metaplasia by the replacement of normal, squamous epithelium by columnar
epithelium and the formation of what is referred to as Barrett’s esophagus. The new,
secretory columnar cells are thought to be better-suited to withstand the erosive contents that
spill over from the gastroesophageal junction (GEJ), but unfortunately, this change also
increases the risk for dysplasia by sevenfold, with Barrett’s esophagus evolving to
Adenocarcinoma at a rate of approximately 1% per year.
Squamous Cell Carcinoma, on the other hand occurs mostly in the upper two-third of the
esophagus. It is almost always linked to tobacco and alcohol abuse. Current smokers have a
ninefold increased risk of developing SCC of the esophagus, while heavy drinkers of alcohol
have an increased risk. Combined, however, the synergistic effects of tobacco and alcohol
abuse lead to a 20-fold increased risk of developing esophageal cancer.
Siewert classification has described the most accepted classification scheme for
Adenocarcinoma at the Gastro-Esophageal Junction tumor: type I, AC arising from an area of
intestinal metaplasia of the esophagus, which can infiltrate the GEJ from above; type II, AC
arising from the cardia of the stomach; type III, subcardial gastric carcinoma that infiltrates
the GEJ from below. This is important to divide them into several different classification
based on the anatomical location as it affect the principle of management. Type I GEJ tumors
tend to have lymphatic drainage toward lower mediastinal and upper gastric lymph nodes,
whereas type II and III GEJ tumors are more likely to drain to celiac axis nodes. As such,
type I GEJ tumors are generally treated as distal esophageal cancer, whereas type II and III
GEJ tumors are viewed by many as gastric carcinomas.
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