|Year : 2015 | Volume
| Issue : 2 | Page : 144-146
Esophageal carcinoma in an elderly female Nigerian
Francis Osita Okpala
Department of Radiology, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria
|Date of Web Publication||21-Nov-2015|
Francis Osita Okpala
Department of Radiology, Federal Teaching Hospital Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
The evaluation of patients with esophageal complaints starts with barium swallow and/or endoscopy examinations. This report is about a 78-year old female whose barium esophagogram showed evidence of advanced esophageal cancer. The aim of this report is to highlight the need for a high index of suspicion, and early use of barium swallow, in evaluating esophageal complaints in patients of middle age and above, especially in developing countries like Nigeria where endoscopy may not be widely available. An earlier diagnosis may improve the mortality and morbidity from this very lethal tumor which is relatively rare.
Keywords: Barium swallow, dysphagia, esophageal carcinoma
|How to cite this article:|
Okpala FO. Esophageal carcinoma in an elderly female Nigerian. Afr J Med Health Sci 2015;14:144-6
| Introduction|| |
In Nigeria, esophageal carcinoma (EC) is rare, with a reported incidence of <0.7% of all cancers. ,,, This report is about an advanced EC, which was demonstrated in a barium swallow examination of a 78-year-old female.
| Case report|| |
A 78-year-old female patient presented with dysphagia to solid food for 3 months and liquids for 2 months. She had associated vomiting and weight loss, but no history of cough, hemoptysis, hematemesis and melena, ingestion of corrosive liquid, cigarette smoking or significant intake of alcohol. She was an hotelier and cooked for 30-40 years with firewood.
Apart from significant weight loss, the rest of her physical examination was unremarkable.
Blood investigation showed a packed cell volume of 36%, plasma glucose of 7.1 mmoL/L (normal range: 3.6-6.7), total protein of 65 g/L (Normal range: 62-80), serum albumin of 31 g/L (normal range: 30-50), and serum globulin of 34 g/L (normal range: 18-30). The serum electrolytes, urea, and creatinine were all normal.
Barium swallow and meal examination showed a mid-esophageal stricture with abrupt shouldered ends [Figure 1] and [Figure 2]; the distal esophagus, gastro-esophageal junction, stomach, and duodenum were normal. Chest radiograph and abdomino-pelvic sonogram were unremarkable.
|Figure 1: Lateral esophagram showing abrupt and irregular narrowing of the mid-esophagus and almost complete obstruction|
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|Figure 2: Antero-posterior oblique esophagram showing an abrupt narrowing of the mid-esophagus, with a shoulder in the proximal aspect of the narrowed segment. The mucosa in the narrowed segment is destroyed. Note the dilatation of the part of the esophagus proximal to the narrowed segment|
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A working diagnosis of EC was made. At Stamm gastrostomy done 2 weeks after admission, normal stomach, liver, and transverse colon were observed. On the 23 rd day after the Stamm gastrostomy, she had trans-thoracic subtotal esophagectomy and esophagostomy.
Histology of the excised esophageal specimen showed very well differentiated squamous cell nests/sheets, with heavy infiltration of the muscularis mucosa, thus confirming esophageal squamous cell carcinoma (ESCC).
She finally had colon by-pass surgery during which a "new esophagus" was fashioned out by using a segment of her colon. Following an unremarkable postoperative recovery, she was discharged for follow-up in the outpatient clinic.
| Discussion|| |
An EC is typically a carcinoma that arises from the esophageal epithelium.  It is one of the most lethal tumors because by the time the first symptoms like dysphagia start manifesting, half of the esophageal lumen is obstructed, by which point the tumor is fairly large. 
In most countries, EC is 3-4 times more common among males than females, probably due to increased incidence of cigarette smoking and/or alcohol consumption in males,  but in Nigeria, the male:female ratio is 1:1. , The most common site is the mid-esophagus ,,, while the upper third is least commonly affected.  In general, the most common histological variant is squamous cell carcinoma (SCC). However, in the United States and most Western countries, adenocarcinoma (AC) occurs more frequently.
Cigarette smoking and alcohol consumption are the two major causes of all types of EC, but they are more closely correlated with SCC than AC. SCC constitute about 90% of cases of EC in the highest risk regions, and though the reasons for this predominance are not well understood, they are thought to include poor nutritional status, low intake of fruits and vegetables, and drinking beverages at high temperatures. In low-risk areas like the United States and several Western countries, smoking, and excessive alcohol consumption account for about 90% of the total cases of ESCC. Smoking, overweight and obesity, and chronic gastroesophageal reflux disease, which triggers Barrett's esophagus, are thought to be the major risk factors for esophageal AC in the United States and some Western countries. Smokeless tobacco products and betel liquid (with or without tobacco) have been found as risk factors for EC in some parts of Asia.  Our patient had no history of major risk factors of EC like cigarette smoking and significant alcohol consumption, but since she was an hotelier and cooked for 30-40 years with firewood, whether the exposure of her esophageal mucosa to smoke from firewood was a causative factor remains conjectural.
Incidence varies from place to place, reflecting exposure to specific environmental factors that are still poorly defined, with the highest rates found in Southern Africa, East Africa, and Eastern Asia, and lowest rates observed in West Africa, Middle Africa, and Central America in both genders. , Nigeria, a West African nation, is in the lowest risk region. EC is rare in Nigeria with a reported incidence of <0.7% of all cancers. ,,,
Esophageal squamous cell carcinoma develops as the result of a sequence of histopathological changes that typically involves esophagitis, atrophy, mild to severe dysplasia, carcinoma in situ and finally, invasive cancer. Genetic changes associated with the development of ESCC include mutation of the p53 gene, disruption of cell-cycle control in G1 by several mechanisms (inactivation of p16MTS1, amplification of cyclin D1, alterations of RB), activation of oncogenes (e.g., epidermal growth factor receptor, c-MYC) and inactivation of several tumor suppressor genes.  The limitation in testing for genetic markers is that p53 and other mutations may be detected in precursor dysplastic lesions. However, coexpression of p63 and CK5/6 is specific for squamous origin in poorly differentiated tumors. 
Most patients with EC present during the sixth and seventh decades, and the incidence increases with advancing age.  This patient was 78 years old and therefore within the age group for EC. The clinical features of EC include dysphagia (most common), weight loss (second most common), epigastric or retrosternal pain, bleeding, hoarseness, and persistent cough.  Dysphagia corresponds in most cases to the advanced lesion with poor prognosis, and together with weight loss, are frequently observed in patients in at least stage II disease. Our patient had dysphagia and weight loss.
In the evaluation of a patient with esophageal complaints, barium swallow and/or endoscopy are the first examinations. Barium swallow is a useful initial examination because it allows the assessment of esophageal morphology and motility.  It remains the study of choice for the characterization of esophageal strictures.  On barium esophagrams, early EC lesions tend to be depressed, polypoid or plaque-like, while most advanced lesions are strictures with abrupt shouldered ends (i.e., annular or apple-core lesions).  Our patient had dysphagia as a symptom and barium swallow features of a mid-esophageal annular lesion. This would place her as a patient with advanced disease; thus, the prognosis could be expected to be poor. If there had been a high index of suspicion of EC, perhaps, she would have been offered a barium swallow exam much earlier in life, and the EC might have been discovered at an earlier stage when the prognosis could be expected to be better. Early detection, when the cancer is superficial, improves survival to 75%, compared to 25% for curative resection for patients at an advanced stage.  However, early detection remains the elusive but essential goal of research. 
Esophageal endoscopy permits direct inspection and biopsy of the esophageal mucosa for histologic diagnosis.  Endoscopy was not done in this patient as it was unavailable. However, the histology of excised esophageal specimen (from subtotal esophagectomy) showed very well differentiated squamous cell nests/sheets, with heavy infiltration of the muscularis mucosa, thus confirming ESCC because SCC are usually moderate to well-differentiated (based on mix of undifferentiated/primitive basal cells, large flat squamous cells, and keratinized foci).  About 90-95% of EC in Nigeria are SCC. ,,, For EC staging, Endoscopic ultrasonography, contrast-enhanced computed tomography, and positron emission tomography each offer unique information. 
Although some patients can be cured, the treatment for EC is protracted, diminishes the quality of life, and is lethal in a significant number of cases.  Only surgical resection at a very early stage has been shown to improve survival rates in EC patients.  Surgery has traditionally been the treatment for EC.  Primary treatment modalities include surgery alone, or with chemotherapy, or radiation therapy.  Palliative care options for patients who are not candidates for surgery include chemotherapy, radiotherapy, laser therapy, and stents.  Our patient was treated with only surgery: Stamm gastrostomy, followed 23 days later by trans-thoracic subtotal esophagectomy and esophagostomy. This was justifiable because effective palliation of dysphagia is the goal in the majority of patients with esophageal cancer. 
In 2001-2007, the overall 5-year survival rate for EC was 19% and most patients die within the 1 st year of diagnosis.  In 2008, an estimated 482,300 new cases and 406,800 deaths occurred worldwide. The majority of new cases occur in developing countries, accounting for 83% of cases and 86% of deaths. 
| Conclusion|| |
In evaluating esophageal complaints in adults, especially in developing countries where endoscopy may not be widely available, a high index of suspicion and early use of barium swallow examination are advised, because they could help in reducing the high morbidity and mortality currently associated with EC.
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[Figure 1], [Figure 2]