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Clinical study of carcinoma of oesophagus.

INTRODUCTION: AIM OF THE STUDY: Incidence and analysis of certain aetiological factors in the causation of carcinoma of oesophagus among the patient population attending these referral hospital BTGH Gulbarga. To find out the relative incidence of presentation among our patients. To study the incidence of histipathological type of carcinoma in relation to the site of involvement in the oesophagus. T o study the diagnostic investigation modalities being preferred by the treating clinicians and assess their relative accurancy. To assess the various treatment modalities being offered at this renowned referrel centre with particular reference to the histopathological type and site of involvement.

MATERIALS AND METHODS: This study on carcinoma oesophagus includes 125 patients who were admitted in MR medical college govt general hospital and Basveshwar teaching and general hospital Gulbarga

The relevant details of individual cases were recorded in a proforma, which contains history, physical findings, laboratory data, specific diagnostic tests and modality of treatment undertaken

All the cases were thoroughly investigated. Chest xray was taken in all cases to rule out any associated diseases. Endoscopy was done in all cases to locate the exact site of tumor, its extension and more important to get a histological confirmation. This was the main modality adopted. Endoscopy was done in all cases irrespective of barium study. Bronchoscopy was done in some of the cases of upper and middle third tumors to find out tracheal and mediastinal involvement.

Ultrasonography of the abdomen was also done to assess the abdominal metastasis of liver and lymph node CT scan was done in few cases. CT scan being noninvasive and accurate in finding the lesions which are not large enough to be detected by ultrasound. A thorough investigation was done to find out any other alignments associated with carcinoma oesophagus

Treatment was planned taking into consideration of the site of tumor, operability and general condition of the patient. In the treatment plan, restoration of ability to swallow was the primary aim. Once the definite treatment is started, patient was monitored carefully to detect early signs of complications and its management. On discharge patients were asked to come for periodic review atleast once a month.

OBSERVATION: Analysis of 124 cases were done in detail. The actual incidence of carcinoma oesophagus in this hospital constitutes 4-4.5% of all cancer cases. This is the fourth commonest site of malignancy encountered in this hospital, other being oral cancers, carcinoma cervix and carcinoma breast.

The influence of certain etiological factors in the causation of carcinoma in this population is studied.
INFLUENCE OF AGE

AGE INTERVAL   NUMBER   PERCENT

10-20            1       0.8%
21-30            2       1.6%
31-40            5        4%
41-50            27      21.6%
51-60            49      39.2%
61-70            31      24.8%
71-80            9       7.2%
81-90            1       0.8%

INFLUENCE ON SEX

sex      Number   Percent
Male       84       67.2
Female     41       32.86


The male female ratio is 2:1.

Three main habits which influence the causation of disease is studied.
AETIOLOGICAL FACTORS

Habits        Number   Percent

Smoking         57       46%
Alcohol         39       31%
Pan chewing     68       54%
Snuff           15       12%


Pan chewing includes both the male and females

The relative incidence of the mode of presentations of the disease is shown below:
MODES OF PRESENTATION

SYMPTOMS                  NUMBER   PERCENT

Dysphagia                  115       92%
Significant weight loss     72       58
Loss of appetite            59       47
Heart burn                  55       44
vomiting                    48       38
Pain in the Epigastrium     33       26
Lymph nodes in the neck     29       23
regugitation                10        8
others                      20       16


A study in relation between blood groups and carcinoma oesophagus was also done
BLOOD GROUP AND CARCINOMA OESOPHAGUS

BLOOD GROUP   NUMBER   PERCENT
B POSITIVE      39       31
A POSITIVE      36       29
O POSITIVE      34       27
AB POSITIVE     16       13
RH NEGATIVE     14      11.2

MIDDLE THIRD OESOPHAGUS CARCINOMA: 61 CASES

                Number   Percent   Well
                                   Differentiation
Squamous cell     59      48.0           14
carcinoma
Adeno             2         1             0
carcinoma

                Moderately        Poorly
                Differentiation   Differentiation
Squamous cell         32                13
carcinoma
Adeno                  1                 1
carcinoma

LOWER THIRD OESOPHAGEAL CARCINOMA: 47 CASES

                NUMBER   Percent   Well
                                   differentiation

Squamous cell     32      25.6            9
carcinoma
Adeno             15      12.0            4
carcinoma

                Moderately        Poorly
                differentiation   differentiation

Squamous cell         14                 9
carcinoma
Adeno                  8                 3
carcinoma


The treatment modality offered approximately depends upon the site of the tumor, histopathology and cellular differentiation. Treatment consists of both curative and palliative. Two modalities are commonly used: surgery (Curative and palliative and radiotherapy).

Most of the cases with upper third lesions and middle third lesions were referred for radiotherapy to peripheral cancer institute, Gulbarga for favour of radiotherapy and for the follow up Surgery:

Upper one third: 47 cases, out of which 20 cases were subjected for resection and anastomosis and 27 were subjected for feeding gastrostomy and jejunostomy.

Out of 20 operated cases 8 cases were involving the lower third of the oesophagus and 12 cases were involving the lower end of oesophagus and stomach.

In all cases pyloromyotomy was done to facilitate the drainage of the stomach.

All the cut edges of the specimen were subjected for frozen section biopsy.

Anastomosis was done in two layers for all cases.

Out of 27 inoperable cases, metastasis in liver with fixity to the posterior abdomninal wall in 7 cases

Secondaries with ascites in 10 cases.

Tumor was fixed posterior abdominal wall in 5 cases.

Involvement of celiac group of lymph nodes with secondaries in liver and fixity of tumor in 5 cases.

Feeding gastrostomy was done in 17 cases and feeding jejunostomy was done in 10 cases. Post-operative complications:

Out of 20 cases 4 cases had anastomotic leak, out of which 2 cases had mild leak and treated conservatively;

2 cases of pleural effusion was aspirated

2 cases of pneumonitis were treated by antibiotics

3 cases had wound infection treated with antibiotics

Medial and upper third - subjected for radiotherapy

DISCUSSION: Incidence of carcinoma oesophagus in our country varies in different parts. In this series incidence is reported to be 4-4.2% of all cancer cases treated in this hospital. (1). Baruah in 1979 recorded the frequency rate of 9.8% in Assam. In Britain from 2-5%. Higher incidence is reported from Russia and Afghanistan 6-8%. (2,3)

A higher incidence of disease was found in males in comparison with females (4). The male to female ratio is 2:1. But some parts of the country showed higher incidence ratio. In Europe also higher incidence among males are reported except in finland where there is a marginal increase in female population

There are three main habitual factors namely: smoking, alcohol and pan chewing relevant in causation of carcinoma of oesophagus, in our study betal nut chewing with or without tobacco constituting of 54% appears to be a common factor. The next line in causation of carcinoma oesophagus in our study was smoking which constitutes abt 46% and the next is alcohol intake which constitutes 31%. (5,6,7)

Dysphagia is found to be most common presenting symptom. It constitutes 92%.significant weight loss noted in 58% of our cases which is not common in western countres. 47% of our patients presented with history of loss of appetite and 44% complained of heart burn. 23% of our study had lymph node involvement in the neck, it is high when compared to western series, thereby showing that patients seek medical advice only in late stages in our country.
SQUAMOUS CELL CARCINOMA OF OESOPHAGUS

               Number   Well   Moderate   Poorly
                                          differentiated

Upper third      17      4        8             5
Middle third     32      14       32            13
Lower third      59      9        14            9
Total           108      27       54            27

ADENO CARCINOMA OESOPHAGUS

               Number   Well   Moderate   Poorly differentiated

Upper third      0       0        0                 0
Middle third     2       0        1                 1
Lower third      15      4        8                 3
Total            17      4        9                 4


Squamous cell carcinoma was the commonest pathological type in our study. Nearly all the upper third and middle third lesions were Squamous cell carcinoma and majority were of moderately differentiated type as shown in the above table

In lower third tumours 65% were Squamous cell origin and the rest were adeno carcinomas. In some of the western series higher incidence of adencarcinoma has been reported.

The modalities of treatment were approximately used depending upon the tumous site (8,9,10,11), pathological type and general condition of the patient for tumours of upper third patients were reffered to peripheral cancer institute

In our study lower third growths were found to be common (48.6%). nearly all of them were found to be of Squamous cell in origin. the main modality adopted was radio therapy for majority of our patients reported to hospital with metastasis in liver and abdominal lymphnodes.

Curative surgery was done in lower third of lesions. And main palliative treatment followed was irradiation and for a new cases palliative chemotherapy done.

In our series, curative surgery was offered in 20 cases and palliative surgery for 27 cases in lower third tumours immediate post-operative period we lost 2 patients and 3 patients and stormy post-operative period, who were adequately treated and discharged in good health. Rest of the patients had a smooth post-operative period. In 28 patients who had irresctable growth with multiple secondaries palliative gastrostomy or jejunostomy was done

In patients who had inoperable carcinoma oesophagus who were not willing for radiotherapy, palliative chemotherapy was given. Chemotherapeutic drugs used includes Methotrexate, Cyclophosphamide, 5- flurouracil and cis platinum. These drugs are used either in combination or individually depending on the general condition of the patient.

CONCLUSION: The incidence of carcinoma oesophagus appears to be 5 to 6% of all cancer cases admitted in this hospital (M. R. Medical College)

Most common age group was between 51 to 60 yrs .average age in males is 59years and female is 51 years.the male female ratio is 2:1.

Pan chewing (betal nut) along with or without tobacco was the most common causative factor associated in our patients.

Dysphagia was the most common mode of presentation.

Lower third oesophagus the commonest site of involment of carcinoma. Sqamous cell carcinomas the predominant type of malignancy and few adenocarcinoma

Endoscopy was the commonly used modality for diagnosis of the lesion Surgery was the commonly used mode of treatment in our hospital for lower 1/3rd lesions Feeding gastrostomy and jejunostomy were the most commonly used palliative methods used in advanced carcinoma at our centre.

Palliativre chemotherapy was given for advanced carcinomas and radiotherapy for middle 1/3rd and lower 1/3rd cases.

DOI: 10.14260/jemds/2015/1957

BIBLIOGRAPHY:

(1.) Czerny Wangesteen: cancer of the oesophagus and stomach 2nd edition. American cancer society, 1956.

(2.) Torek: the first successful case of resection of the thoracic oesophageal carcinoma. sug. gynac. obst.16:614, 1913.

(3.) Jussawalla and Gangadharan: epidemiological study in India. Ind.j.surg.vol.41:437, 1979.

(4.) Bonosree c. deka: study of carcinoma Pesophagus in north Karnataka. Ind.j.cancer vol.15: 23-27, 1978.

(5.) Ashely D: journal of medical genetics 6:70, 1969.

(6.) Howel-evans: carcinoma oesophagus with Tylosis a study in two Failies. Br. Journal in medicine 27:413-429, 1958.

(7.) Simons: immunogenetic aspects of carcinoma oesophagus, cancer: 36: 786: 1973.

(8.) Desai P. B. Symposium on cancer problems in India. B. J. Medical College, Poona 1975.

(9.) Wynder E.C. and bross: a study of aetiological factors in cancer oesophagus cancer: 14-389, 1961.

(10.) Shanta and Krishnamoorthy: Role of epidemiologic factors in ca oesophagus. Ind. j. can 12-115, 1965.

(11.) Allison and Johnstu: Barretts ulcer and adeno carcinoma, Am. J. Path, 86-313, 1985.

Rajshekhar Patil [1], Jagdeesh [2], Palla Abhishek Reddy [3]

AUTHORS:

[1.] Rajshekhar Patil

[2.] Jagdeesh

[3.] Palla Abhishek Reddy

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of General Surgery, MR Medical Collage, Basweshwar Hospital, Gulbarga.

[2.] Post Graduate, Department of General Surgery, MR Medical Collage, Basweshwar Hospital, Gulbarga.

[3.] Post Graduate, Department of General Surgery, MR Medical Collage, Basweshwar Hospital, Gulbarga.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Rajshekhar Patil, Block No. 56, Swastik Nagar, Bilgundi Layout, Sedam Road, Gulbarga.

E-mail: drrjsp@gmail.com

Date of Submission: 10/09/2015.

Date of Peer Review: 11/09/2015.

Date of Acceptance: 21/09/2015.

Date of Publishing: 28/09/2015.
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Title Annotation:ORIGINAL ARTICLE
Author:Patil, Rajshekhar; Jagdeesh; Reddy, Palla Abhishek
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Sep 28, 2015
Words:2020
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