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Abstract Malignant dysphagia means difficullty in swallowing due to irreversible malignant strictures e.g :- primary oseophageal cancer , oseaphago gastric junction tumor .(1) Aim of the work:- Evaluation of oesophageal malignant dysphagia as regard the clinical presentation, methods of diagnosis , pathology of tumor and different measures of management . Anatomy of oseophagus:- The oesophagus is a muscular tube protected at its ends by the upper and lower oesophageal sphincters. It commences as a continuation of the pharynx at the lower border of the cricopharyngeus muscle, at the level of the sixth cervical vertebra (C6). The surface marking for this point is the lower border of the cricoid cartilage. It enters the chest at the level of the suprasternal notch and descends through the superior and posterior mediastinum along the front of the vertebral column. It passes though the oesophageal hiatus in the diaphragm at the level of the 10th thoracic vertebra to end at the gastro-oesophageal junction. The surface marking for this point is the left seventh costal cartilage. The oesophagus measures 25–30 cm in length although this varies according to the height of the individual and in particular the suprasternal–xiphoid distance(3). Pathogenesis of Cancer oseophagus:- The two most common histological types of esophageal carcinoma include SCC and adenocarcinoma. Less than 1% to 2% of all esophageal cancers are sarcomas or small cell carcinomas. Rarely lymphomas, carcinoids and melanomas may arise in the esophagus(19). ROUTES OF ESOPHAGEAL CANCER SPREAD:- Prognosis in esophageal cancer is greatly dependent on local invasion as well as spread to regional and distant structures within the body. Esophageal cancer is aggressive in nature, spreading by a variety of pathways including direct extension, lymphatic spread and hematogenous metastasis. The lack of serosa in the esophageal wall plays an integral role in the local extension of esophageal cancer. With no anatomical barrier, the primary tumor is able to extend rapidly into the adjacent structures of the neck and thorax including the thyroid gland, trachea, larynx, lung, pericardium, aorta and diaphragm(34). The lymphatic drainage of the esophagus is extensive. It is drained by two separate lymphatic plexuses, with one lymphatic plexus arising within the mucosal layer and a second plexus arising within the muscular layer. A majority of the lymphatic fluid from the upper two-thirds of the esophagus tends to flow upward, and the lymph from the lower third of the esophagus flows relatively downward, but all the lymphatic channels of the esophagus communicate. Therefore, lymphatic fluid from any portion of the esophagus may spread in either direction and spread to the intra-thoracic or intra-abdominal lymph nodes (35). Esophageal cancer also spreads hematogenously, in order of decreasing frequency, to the liver, lungs, bones, adrenal glands, kidney and brain. This method of spread is more common with more advanced stages of esophageal cancer (36). Staging of Cancer Oseophagus :- TNM system, specifically referring to depth of invasion in T staging(37) Category Description Tis Carcinoma in situ. T1 Tumors invade lamina propria or submucosa. T2 Tumors invade muscularis propria. T3 Tumors invade adventitia. T4 Tumors invade adjacent structures. N0 No regional lymph node metastasis. N1 Regional lymph node metastasis. M0 No distant metastasis. M1a, M1b Distant metastasis. Stage-specific protocols for treatment :- Stage Tumor Node Metastasis Operative options 0 Tis N0 M0 Local ablative therapy I T1 N0 M0 Surgery II A T2 T3 N0 N0 M0 M0 Surgery II B T1 T2 N1 N1 M0 M0 Neoadjuvant therapy with or without surgery III T3 T4 N1 Any N M0 M0 Neoadjuvant therapy with or without surgery IV A Any T Any N M1a Chemotherapy or radiation therapy with or without surgery IV B Any T Any N M1b Palliative treatment MANAGEMENT OF ESOPHAGEAL CANCER :- Because it can be difficult to diagnose esophageal cancer early and diagnosed at rather late stage, more than 30 percent of patients have metastatic disease at the time of presentation. So curative treatment has no benefit to this patients & most methods of treatment are palliative Palliative modalities for esophageal carcinoma :- (A)Endoscopic Techniques :- Stent placement. Laser therapy :- *Thermal (Nd:YAG). *Photodynamic therapy. Dilation. Electrocoagulation (BICAP probe). Chemical Injection Therapy. Nutritional Support :- *Nasoenteric feeding tube. *Percutaneous endoscopic gastrostomy (PEG). (B)Non-Endoscopic techniques :- Surgery. Radiation therapy. *External beam radiotherapy. *Intraluminal radiotherapy (brachytherapy). Chemotherapy. |