Esophageal cancer – Flashcards

Esophageal tumors that are usually fungating and infiltrating and nearly always fatal Liver and lungs: common sites of metastasis If symptom-producing, cancer usually already spread to lymph nodes Includes two types of malignant tumors: squamous cell carcinoma (usually occurring in the middle to lower two-thirds of the esophagus) adenocarcinoma (usually beginning in the glandular tissue of the esophagus) squamous cell carcinoma (usually occurring in the middle to lower two-thirds of the esophagus) adenocarcinoma (usually beginning in the glandular tissue of the esophagus) Grim prognosis because usually not detected until it has progressed to advanced, incurable stage

Esophageal cancer begins in the mucosa and then invades the submucosal and muscular layers of the esophagus. Regional metastasis occurs early by way of submucosal lymphatics, commonly fatally invading adjacent vital intrathoracic organs. including the tracheobronchial tree, aorta, or the recurrent laryngeal nerve. (If the patient survives primary extension, the liver and lungs are the usual sites of distant metastasis; unusual metastasis sites include the bone, kidneys, and adrenal glands.)

Alcohol use Chronic exposure of the esophageal mucosa to noxious or toxic stimuli, resulting in dysplasia Chronic gastroesophageal reflux Tobacco use

Chronic irritation from heavy smoking Excessive use of alcohol Stasis-induced inflammation, as in achalasia or stricture Previous head and neck tumors Nutritional deficiency, such as in untreated sprue and Plummer-Vinson syndrome Human papilloma virus Gastroesophageal reflux disease Barrett esophagus (precursor to adenocarcinoma)

Esophageal cancer is most common in men during the 6th and 7th decades of life. It affects men three times more commonly than women. Blacks are three times more likely to develop esophageal cancer than Whites. Squamous cell cancer is more common in blacks; adenocarcinoma is more common in Whites and currently accounts for over 50% of newly diagnosed cases.

Direct invasion of adjoining structures Inability to control secretions Obstruction of the esophagus Loss of lower esophageal sphincter control (may result in aspiration pneumonia) Atelectasis, pleural effusion Cardiac arrhythmias Wound infection Anastomotic stricture, leaks

Feeling of fullness, pressure, indigestion, or substernal burning Dysphagia and weight loss; the degree of dysphagia varies, depending on the extent of disease Hoarseness Pain on swallowing or pain that radiates to the back Anorexia, vomiting, and regurgitation of food Bone pain (associated with organ metastasis)

Chronic cough (possibly from aspiration) Cachexia and dehydration Hemoptysis or hematemesis Malignant pleural effusion Lymphadenopathy in laterocervical or supraclavicular areas (associated with metastasis) Jaundice (associated with organ metastasis)

Complete blood cell count may reveal anemia secondary to iron deficiency. Serum calcium levels may be elevated in patients with squamous cell carcinoma.

X-rays of the esophagus, with barium swallow and motility studies, delineate structural and filling defects and reduced peristalsis. Computed tomography scan helps to diagnose and monitor esophageal lesions and assists with staging. Magnetic resonance imaging permits evaluation of the esophagus and adjacent structures. Positron-emission tomography scanning aids in primary detection and metastasis.

Esophagogastroduodenoscopy, punch and brush biopsies, and exfoliative cytologic tests confirm esophageal tumors. Bronchoscopy (usually performed after an esophagoscopy) may reveal tumor growth in the tracheobronchial tree. Endoscopic ultrasonography of the esophagus combines endoscopy and ultrasound technology to measure the depth of penetration of the tumor.

Surgery and other treatments to relieve disease effects Radiation therapy: external radiation, intraluminal brachytherapy, or both Photodynamic therapy Palliative therapy used to keep the esophagus open: Dilatation of the esophagus via balloon or expandable metallic stents Laser therapy Radiation therapy Installation of prosthetic tubes (such as Celestin's tube) Dilatation of the esophagus via balloon or expandable metallic stents Laser therapy Radiation therapy Installation of prosthetic tubes (such as Celestin's tube)

Liquid to soft diet, as tolerated High-calorie supplements

Chemotherapy: cisplatin with 5-fluorouracil as the standard combination therapy; paclitaxel Analgesics

Esophageal resection (esophagectomy) Radical surgery to excise tumor and resect esophagus or stomach and esophagus Gastrostomy or jejunostomy

Endoscopic laser treatment and bipolar electrocoagulation

Acute pain Anxiety Deficient fluid volume Fatigue Fear Grieving Imbalanced nutrition: Less than body requirements Impaired swallowing Risk for aspiration Risk for infection

express feelings of increased comfort and decreased pain express feelings of decreased anxiety maintain fluid volumes within the normal range express feelings of energy and decreased fatigue verbalize feelings related to the diagnosis and prognosis maintain weight within an acceptable range demonstrate the ability to swallow without coughing or choking remain free from aspiration show no evidence of infection.

Provide support, and encourage the patient and family to talk about their feelings, especially those related to the treatment and prognosis. Position the patient properly to prevent food aspiration, and provide oral suctioning as necessary. Institute aspiration precautions. Maintain a patent airway. Have suctioning equipment readily available at the bedside in case of aspiration; anticipate the need for an artificial airway. Administer tube feedings, as ordered. Obtain daily weights and daily calorie counts. Give prescribed drugs, such as analgesics for pain relief. Provide frequent rest periods. Institute energy conservation measures; cluster nursing care to promote rest. Check skin turgor. Assist the patient in managing the effects of radiation and chemotherapy. Obtain specimens for laboratory testing, such as serum electrolyte levels and complete blood counts. Prepare the patient and family physically and psychologically for surgery, if indicated.

Vital signs Airway patency Hydration and fluid balance Nutritional status Electrolyte levels Intake and output Surgical site, including signs and symptoms of postoperative complications Swallowing ability Pain control Coping strategies Effects of radiation therapy or chemotherapy

Blood pressure assessment Calculating and setting an IV drip rate Chemotherapeutic drug administration Chemotherapeutic drug preparation and handling Esophageal tube insertion, assisting Feeding tube insertion IV bag preparation IV bolus injection IV catheter insertion IV pump use Impaired swallowing and aspiration precautions Intake and output assessment Laser therapy, assisting Nutritional screening Pain management Postoperative care Preoperative care Preparing a patient for abdominal surgery, OR Pulse oximetry Pulse assessment Radiation therapy, external Respiration assessment Surgical wound dressing application Venipuncture Weight measurement

disease process, including possible causes and risk factors and the stage of disease proposed treatment plan, including the postoperative course if appropriate use of radiation or chemotherapy as treatment methods, including possible adverse effects measures for coping with adverse effects of treatment dietary needs and nutritional measures enteral feeding methods if appropriate aspiration precautions energy conservation measures, emphasizing the need for rest between activities postoperative care measures, such as incision site care signs and symptoms of possible complications, including the need to notify a practitioner if any occur.

Arrange for home care follow-up after discharge. Refer the patient to the American Cancer Society. Refer the patient for speech therapy to assist with swallowing and aspiration prevention, if appropriate. Arrange for referral for nutritional therapy and support, as indicated. Arrange for a referral to hospice and support services.