WELCOME WELCOME

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WELCOME WELCOME

TOTO

WEEKLY CLINICAL MEETING WEEKLY CLINICAL MEETING

ONON

80 YEARS MALE WITH DYSPHAGIA, WEIGHT LOSS 80 YEARS MALE WITH DYSPHAGIA, WEIGHT LOSS

AND COUGH AND COUGH

A DIAGNOSTIC DILEMMA.

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Chairperson Chairperson

Dr. Md. Safiul Alam Dr. Md. Safiul Alam Associate Prof. & Head Associate Prof. & Head

Dept. of Radiotherapy Dept. of Radiotherapy

Presented by Presented by

Dr. Muhammad Masudul Hassan ArupDr. Muhammad Masudul Hassan Arup Department of Radiotherapy

Department of Radiotherapy

Mymensingh Medical College and Hospital Mymensingh Medical College and Hospital

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PARTICULARS OF THE PATIENT PARTICULARS OF THE PATIENT

NameName :: Md. Salim Uddin.Md. Salim Uddin.

Age

Age :: 80 years.80 years.

Gender

Gender : : MaleMale.. Occupation

Occupation : : X-X-Businessman.Businessman.

Religion

Religion : : Islam.Islam.

Marital status

Marital status :: Married. Married.

Address

Address : : Vill: Chota Moheshpur Vill: Chota Moheshpur Upazilla-MuktagachaUpazilla-Muktagacha Dist.– Mymensingh.Dist.– Mymensingh.

Date of Examination

Date of Examination ::18.05.11.18.05.11.

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PRESENTING COMPLAINTS PRESENTING COMPLAINTS

1.1. Difficulties in swallowing for 8 months.Difficulties in swallowing for 8 months.

2.2. Occasional cough for 6 months.Occasional cough for 6 months.

3.3. Gradual weight loss for 6 months.Gradual weight loss for 6 months.

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HISTORY OF PRESENT ILLNESS HISTORY OF PRESENT ILLNESS

 According to the statement of the patient all According to the statement of the patient all his sufferings started 8 months back as he his sufferings started 8 months back as he noticed progressive difficulties in noticed progressive difficulties in swallowing. Initially he had problem with swallowing. Initially he had problem with solid food only but for last 2 months, it solid food only but for last 2 months, it increased in severity and developed increased in severity and developed swallowing difficulties with liquid also. More swallowing difficulties with liquid also. More over it was associated with regurgitation and over it was associated with regurgitation and retro sternal burning sensation. But he did retro sternal burning sensation. But he did

not give any history of vomiting.

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HISTORY OF PRESENT ILLNESS HISTORY OF PRESENT ILLNESS cont.

cont.

 In addition to this he had occasional cough In addition to this he had occasional cough for last 6 months. It was non productive, non for last 6 months. It was non productive, non periodic and not accompanied by chest pain periodic and not accompanied by chest pain or did not have any relation with posture. The or did not have any relation with posture. The cough did not aggravate during taking food cough did not aggravate during taking food either solid or liquid. He never coughed up either solid or liquid. He never coughed up

blood or blood stained sputum.

 He also complaints of marked weight lossHe also complaints of marked weight loss and generalized weakness for same duration.

and generalized weakness for same duration.

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HISTORY OF PAST ILLNESS HISTORY OF PAST ILLNESS

 H/O pulmonary tuberculosis in the year 1988.H/O pulmonary tuberculosis in the year 1988.

 H/O peptic ulcer disease with occasional regurgitation H/O peptic ulcer disease with occasional regurgitation and heartburn for 10 yrs.

and heartburn for 10 yrs.

 No H/O of Diabetes, Hypertension or Bronchial No H/O of Diabetes, Hypertension or Bronchial Asthma.

Asthma.

 Never suffered from any major disease other than PTB.Never suffered from any major disease other than PTB.

 Never underwent any major surgeryNever underwent any major surgery..

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TREATMENT HISTORY TREATMENT HISTORY

 He took anti tubercular drugs for 9 months but no He took anti tubercular drugs for 9 months but no document is available.

document is available.

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FAMILY HISTORY FAMILY HISTORY

 No one of his family member ever suffered from this No one of his family member ever suffered from this type of illness.

type of illness.

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SOCIOECONOMIC HISTORY SOCIOECONOMIC HISTORY

 Socioeconomically he belongs to a middle class Socioeconomically he belongs to a middle class family

family..

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PERSONAL HISTORY PERSONAL HISTORY

 Smoking:Smoking:

H/O smoking over last 60 years.H/O smoking over last 60 years.

Used to smoke 10 sticks per day.Used to smoke 10 sticks per day.

Started smoking with Biri. Started smoking with Biri.

For last 10-15 years he is taking For last 10-15 years he is taking

cigarettes.cigarettes.

 Betel leaf chewing:Betel leaf chewing:

He has also habit of betel leaf chewing He has also habit of betel leaf chewing

with betel nut and jarda.with betel nut and jarda.

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PERSONAL HISTORY PERSONAL HISTORY

cont.

 Diet:Diet: Use to take conventional Bangladeshi diet.Use to take conventional Bangladeshi diet.

 Sleep: Sleep: Normal.Normal.

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GENERAL EXAMINATION GENERAL EXAMINATION

 AppearanceAppearance:: Ill looking.Ill looking.

 Body builtBody built:: Average. Average.

 DecubitusDecubitus:: On choice. On choice.

 Nutritional statusNutritional status:: Poor.Poor.

 Anemia:Anemia: Mildly Anemic. Mildly Anemic.

 JaundiceJaundice:: Absent. Absent.

 CyanosisCyanosis:: Absent. Absent.

 ClubbingClubbing:: Absent. Absent.

 KoilonychiaKoilonychia:: Absent. Absent.

 LeukonychiaLeukonychia:: Absent. Absent.

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GERNERAL EXAMINATION GERNERAL EXAMINATION

cont.

 DehydrationDehydration:: Some sign of dehydration.Some sign of dehydration.

 OedemaOedema:: Absent. Absent.

 PulsePulse:: 78 beats/ min.78 beats/ min.

 BPBP : : 100/80 mm of Hg.100/80 mm of Hg.

 TempTemp:: Normal. Normal.

 Neck veinNeck vein:: Not engorged. Not engorged.

 Thyroid glandThyroid gland:: Normal. Normal.

 LNLN : : Not enlarged. Not enlarged.

 Skin conditionSkin condition:: Normal. Normal.

 Hair distributionHair distribution:: Normal. Normal.

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SYSTEMIC EXAMINATION SYSTEMIC EXAMINATION

 Examination of oral cavity, oropharynx:Examination of oral cavity, oropharynx:

Normal findings.Normal findings.

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SYSTEMIC EXAMINATION SYSTEMIC EXAMINATION cont.

cont.

 Abdominal examinationAbdominal examination::

InspectionInspection

Shape-Shape- Shunken. Shunken.

Movement with respiration-Movement with respiration- Normal. Normal.

Position of umbilicus-Position of umbilicus- centrally placed. centrally placed.

Flank-Flank- Not full. Not full.

Visible swelling-Visible swelling- Absent. Absent.

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cont.

 Hernial orifice-Hernial orifice- intact intact. .

 Visible peristalsis-Visible peristalsis- Absent. Absent.

 Scar mark-Scar mark- Absent. Absent.

 External genitalia-External genitalia- Normal findings.Normal findings.

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cont.

Palpation Palpation

Normal temperature.Normal temperature.

No muscle guard or rigidity.No muscle guard or rigidity.

No mass.No mass.

No organomegaly.No organomegaly.

Abdomen is nontender.Abdomen is nontender.

Hernial orifice is intact.Hernial orifice is intact.

External genitalia is normal. External genitalia is normal.

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cont.

 PERCUSSIONPERCUSSION

Shifting dullness is negative.Shifting dullness is negative.

Note is tympanatic.Note is tympanatic.

 AUSCULTATIONAUSCULTATION

Bowel sound present.Bowel sound present.

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RESPIRATORY SYSTEM RESPIRATORY SYSTEM

No Abnormality Detected No Abnormality Detected

CARDIOVASCULAR SYSTEM CARDIOVASCULAR SYSTEM

NERVOUS SYSTEM NERVOUS SYSTEM

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SALIENT FEATURE SALIENT FEATURE

 Md. Salim Uddin, an 80 years old Md. Salim Uddin, an 80 years old X-Businessman, hailing from Chota X-Businessman, hailing from Chota Moheshpur of Muktagacha Upazilla of Moheshpur of Muktagacha Upazilla of Mymensingh district was presented with the Mymensingh district was presented with the complaints of progressive dysphagia for 8 complaints of progressive dysphagia for 8 months, occasional cough for 6 months and months, occasional cough for 6 months and gradual weight loss for same duration.

gradual weight loss for same duration.

Initially he had swallowing difficulties with Initially he had swallowing difficulties with solid food only but later on found difficulties solid food only but later on found difficulties with liquid also. He had occasional with liquid also. He had occasional regurgitation though there was no history of regurgitation though there was no history of

vomiting.

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 In addition to this he has been suffering from In addition to this he has been suffering from occasional cough for last 6 months. It was occasional cough for last 6 months. It was non productive, non periodic and not non productive, non periodic and not associated with chest pain. The cough was associated with chest pain. The cough was not aggravated by adopting any particular not aggravated by adopting any particular posture or during ingestion of food or posture or during ingestion of food or drinking of water. He never coughed up drinking of water. He never coughed up blood or blood stained sputum. He never felt blood or blood stained sputum. He never felt breathing difficulties during his course of breathing difficulties during his course of

illness.

 He also complaints of marked weight loss.He also complaints of marked weight loss.

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^cont.^cont.

 In his past illness he gave history of PTB in the In his past illness he gave history of PTB in the year 1988 for which he took anti tubercular year 1988 for which he took anti tubercular drugs. He had also peptic ulcer disease with drugs. He had also peptic ulcer disease with occasional regurgitation and heartburn for 10 occasional regurgitation and heartburn for 10 yrs.yrs.

 He was a smoker for last 60 years. Also He was a smoker for last 60 years. Also habituated to betel leaf chewing.

habituated to betel leaf chewing.

 On general examination he is found, ill looking, On general examination he is found, ill looking, cachexic, dehydrated and mildly anaemic.

cachexic, dehydrated and mildly anaemic.

Otherwise he is non icteric, acyanosed and Otherwise he is non icteric, acyanosed and non-oedematous. There is no clubbing, non-oedematous. There is no clubbing, koilonychia, leuconychia or palpable lymph koilonychia, leuconychia or palpable lymph nodes. His temperature is normal, pulse rate is nodes. His temperature is normal, pulse rate is

78 beats / min and BP 100/80 mm of Hg.

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SALIENT FEATURE SALIENT FEATURE cont.

cont.

His systemic examination of abdomen, His systemic examination of abdomen, respiratory system, cardiovascular system respiratory system, cardiovascular system and nervous system revealed normal and nervous system revealed normal

findings.

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CLINICAL DIAGNOSIS CLINICAL DIAGNOSIS

??

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CLINICAL

CLINICAL DIAGNOSIS DIAGNOSIS

NEOPLASM OF OESOPHAGUS WITH LUNG METASTASIS NEOPLASM OF OESOPHAGUS WITH LUNG METASTASIS

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DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS

??

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DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS

Malignant Neoplasm of Lung with Oesophageal Malignant Neoplasm of Lung with Oesophageal

involvement.

Mediastinal Neoplasm with Oesophago- Mediastinal Neoplasm with Oesophago-

Tracheo/Bronchial involvement.

Neoplasm of oesophagus with pulmonary TB.

Benign Oesophageal condition with primary Benign Oesophageal condition with primary

infection or reactivation of pulmonary TB.

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INVESTIGATIONS INVESTIGATIONS

Routine Hematological Tests Routine Hematological Tests

TCTC – 11,500 / cu mm. – 11,500 / cu mm.

DCDC - - Neutrophils – 70%. Neutrophils – 70%.

Lymphocytes – 25%.Lymphocytes – 25%.

Monocytes – 04%.Monocytes – 04%.

Eosinophils – 01%.Eosinophils – 01%.

Basophils – 00%.Basophils – 00%.

Hb%Hb% - 70% . - 70% .

ESR - ESR - 40 mm in 140 mm in 1^st^st Hour Hour

Total Platelet CountTotal Platelet Count – 2,30,000/ cu mm. – 2,30,000/ cu mm.

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INVESTIGATIONS INVESTIGATIONS cont.

cont.

 Biochemical Tests:Biochemical Tests:

S. CreatinineS. Creatinine – 0.8 mg/dl. – 0.8 mg/dl.

Blood Urea – 30 mg/dl.Blood Urea – 30 mg/dl.

S. BilirubinS. Bilirubin – 0.4 mg/dl. – 0.4 mg/dl.

S. ALTS. ALT – 32 U/L. – 32 U/L.

S. ASTS. AST – 44 U/L. – 44 U/L.

S. Alkaline Phosphatase - 160 U/LS. Alkaline Phosphatase - 160 U/L..

RBS RBS – 6.5 mmol/L.– 6.5 mmol/L.

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cont.

Barium Swallow X-ray of oesophagus

Barium Swallow X-ray of oesophagus (11.5.11)(11.5.11)

 Barium has passed down the oesophagus Barium has passed down the oesophagus without obstruction.

without obstruction.

 Margin is regular.Margin is regular.

 No Filling defect, abnormal dilatation or No Filling defect, abnormal dilatation or shouldering effect Seen.

shouldering effect Seen.

 Mucosal pattern is normal. Mucosal pattern is normal.

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Barium Swallow X ray of Barium Swallow X ray of

oesophagus oesophagus

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cont.

ENDOSCOPY OF UPPER GIT (15.5.11) ENDOSCOPY OF UPPER GIT (15.5.11)

OESOPHAGUS

OESOPHAGUS:: An An Ulcero-ProliferativeUlcero-Proliferative growth at the growth at the lower end of oesophagus which is continuous with the lower end of oesophagus which is continuous with the

growth below in the stomach.

STOMACH

STOMACH: : Whole of the cardia is occupied by an Whole of the cardia is occupied by an Ulcero-Proliferative

Ulcero-Proliferative growth. growth.

DEODENUM

DEODENUM: : NormalNormal

BIOPSY

BIOPSY: : Taken from the growth Taken from the growth

COMMENTS

COMMENTS: : Ca. Gastro-Oesophageal JunctionCa. Gastro-Oesophageal Junction

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ENDOSCOPY OF UPPER GIT ENDOSCOPY OF UPPER GIT

ENDOSCOPIC PHOTOGRAPH OF LOWER END OF OESOPHAGUS AND CARDIA OF STOMACH SHOWING AGGRESSIVE LOOKING ULCERO-PROLIFERATIVE LESION

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cont.

CYTOPATHOLOGY OF SPUTUM

CYTOPATHOLOGY OF SPUTUM (10.5.11) (10.5.11) Negative for Malignant Cells

Negative for Malignant Cells AFB: Not Found

AFB: Not Found

MTMT (10.5.11) (10.5.11) : Negative : Negative

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cont.

USG OF WHOLE ABDOMEN (12.5.11) USG OF WHOLE ABDOMEN (12.5.11)

Normal Study Normal Study

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INVESTIGATIONS INVESTIGATIONS

CXR P/A View CXR P/A View

CXR showing an CXR showing an irregular oval opacity irregular oval opacity occupying rt. lower occupying rt. lower

lung field.

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BIOPSY BIOPSY

Endoscopic Biopsy was done on 17.5.11 Endoscopic Biopsy was done on 17.5.11

Histopathology Report Revealed:

Adenocarcinoma of gastric origin. Adenocarcinoma of gastric origin.

Grade: III (poorly differentiated)Grade: III (poorly differentiated)

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CT Guided FNAC of Lung Lesion CT Guided FNAC of Lung Lesion

23.05.2011 23.05.2011

CYTOLOGY Revealed CYTOLOGY Revealed::

Sq. Cell Carcinoma Sq. Cell Carcinoma

Grade: II Grade: II

Slide of CT guided FNAC

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OTHER INVESTIGATIONS OTHER INVESTIGATIONS

CT Scan of Chest and upper abdomen CT Scan of Chest and upper abdomen

Bronchoscopy Bronchoscopy

Endoscopic USG Endoscopic USG

S. Electrolytes S. Electrolytes PETPET

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CONFIRM DIAGNOSIS CONFIRM DIAGNOSIS

Double Malignancy:Double Malignancy:

1. Adenocarcinoma of Gastro-1. Adenocarcinoma of Gastro- Oesophageal Junction

Oesophageal Junction

2. Squamous cell ca. of Right Lung 2. Squamous cell ca. of Right Lung (Lower lobe)

(Lower lobe)

Staging: Could not be done.Staging: Could not be done.

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TREATMENT PLAN TREATMENT PLAN

IMPROVEMENT OF GENERAL IMPROVEMENT OF GENERAL

CONDITION CONDITION

CHEMOTHERAPY CHEMOTHERAPY RADIOTHERAPY RADIOTHERAPY

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IMPROVEMENT OF GENERAL CONDITION IMPROVEMENT OF GENERAL CONDITION

Endoscopic NG Tube Intubation was done Endoscopic NG Tube Intubation was done for feeding purpose on 25.05.2011

for feeding purpose on 25.05.2011..

Correction of Dehydration and Electrolytes Correction of Dehydration and Electrolytes Imbalance by iv infusion.

Imbalance by iv infusion.

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CHEMOTHERAPY CHEMOTHERAPY

Systemic Chemotherapy with following schedule Systemic Chemotherapy with following schedule

Inj. 5FU (500 mg) – D

Inj. 5FU (500 mg) – D₁₁-D-D₄₄

Inj. Etoposide (100 mg) – D

Inj. Etoposide (100 mg) – D₁₁-D-D₄₄ Inj. Cisplatin (25 mg) – D

Inj. Cisplatin (25 mg) – D₁₁-D-D₄₄.. [ 4 Weekly cycle[ 4 Weekly cycle ] ]

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CHEMOTHERAPY CHEMOTHERAPY

Details of Chemotherapy Details of Chemotherapy::

CYCLE DURATION TOXICITY

1^ST 28.05.11-01.06.1128.05.11-01.06.11 Nausea G II Diarrhoea G I 2^ND 25.06.11-28.06.1125.06.11-28.06.11 Nausea G I

Anaemia G II 3^RD 23.07.11-26.07.1123.07.11-26.07.11 Nausea G I

Vomiting G II 4^TH 20.08.11-23.08.1120.08.11-23.08.11 Nausea G I

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CHEMOTHERAPY RESPONSE CHEMOTHERAPY RESPONSE

After 3 Cycles of CT Before Treatment

R

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NEXT TREATMENT PLAN NEXT TREATMENT PLAN

After completion of chemotherapy our next After completion of chemotherapy our next plan of treatment is External Beam plan of treatment is External Beam Radiotherapy to the Gastro-oesophageal Radiotherapy to the Gastro-oesophageal Junction Neoplasm as well as the site of Junction Neoplasm as well as the site of

lung lesion sequentially.

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MESSAGE TO HOUSE MESSAGE TO HOUSE

Solitary metastatic lesion must be Solitary metastatic lesion must be evaluated with caution and care for evaluated with caution and care for detection of synchronous primary detection of synchronous primary

lesion.