welcome to weekly clinical meeting on 80 years male with dysphagia, weight loss and cough 80 years...

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

A DIAGNOSTIC DILEMMA.A DIAGNOSTIC DILEMMA.

ChairpersonChairpersonDr. Md. Safiul AlamDr. Md. Safiul Alam

Associate Prof. & HeadAssociate Prof. & HeadDept. of RadiotherapyDept. of Radiotherapy

Presented byPresented 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

PARTICULARS OF THE PATIENTPARTICULARS 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.ReligionReligion : : 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.

PRESENTING COMPLAINTSPRESENTING 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.

HISTORY OF PRESENT ILLNESSHISTORY 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. not give any history of vomiting.

HISTORY OF PRESENT ILLNESSHISTORY 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. 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.

HISTORY OF PAST ILLNESSHISTORY 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..

TREATMENT HISTORYTREATMENT 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.

FAMILY HISTORYFAMILY 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.

SOCIOECONOMIC HISTORYSOCIOECONOMIC HISTORY

Socioeconomically he belongs to a middle class Socioeconomically he belongs to a middle class

familyfamily..

PERSONAL HISTORYPERSONAL 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.

PERSONAL HISTORYPERSONAL HISTORY cont. cont.

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

Sleep: Sleep: Normal.Normal.

GENERAL EXAMINATIONGENERAL 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.

GERNERAL EXAMINATIONGERNERAL EXAMINATION cont. 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.

SYSTEMIC EXAMINATIONSYSTEMIC EXAMINATION

Examination of oral cavity, oropharynx:Examination of oral cavity, oropharynx: Normal findings.Normal findings.

SYSTEMIC EXAMINATIONSYSTEMIC 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.


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.


PalpationPalpation 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.


PERCUSSIONPERCUSSION

Shifting dullness is negative.Shifting dullness is negative.

Note is tympanatic.Note is tympanatic.

AUSCULTATIONAUSCULTATION

Bowel sound present.Bowel sound present.

SYSTEMIC EXAMINATIONSYSTEMIC EXAMINATION

RESPIRATORY SYSTEMRESPIRATORY SYSTEMNo Abnormality DetectedNo Abnormality Detected

CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEMNo Abnormality DetectedNo Abnormality Detected

NERVOUS SYSTEMNERVOUS SYSTEMNo Abnormality DetectedNo Abnormality Detected

SALIENT FEATURESALIENT 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. vomiting.

SALIENT FEATURESALIENT FEATURE

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.illness.

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

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

SALIENT FEATURESALIENT 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.findings.

CLINICAL DIAGNOSISCLINICAL DIAGNOSIS

??

CLINICALCLINICAL DIAGNOSIS DIAGNOSIS

NEOPLASM OF OESOPHAGUS WITH LUNG METASTASISNEOPLASM OF OESOPHAGUS WITH LUNG METASTASIS

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

??

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Malignant Neoplasm of Lung with Oesophageal Malignant Neoplasm of Lung with Oesophageal involvement. involvement.

Mediastinal Neoplasm with Oesophago-Mediastinal Neoplasm with Oesophago-Tracheo/Bronchial involvement.Tracheo/Bronchial involvement.

Neoplasm of oesophagus with pulmonary TB.Neoplasm of oesophagus with pulmonary TB.

Benign Oesophageal condition with primary Benign Oesophageal condition with primary infection or reactivation of pulmonary TB.infection or reactivation of pulmonary TB.

INVESTIGATIONSINVESTIGATIONS

Routine Hematological TestsRoutine 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 1stst Hour Hour Total Platelet CountTotal Platelet Count – 2,30,000/ cu mm. – 2,30,000/ cu mm.

INVESTIGATIONSINVESTIGATIONS 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.


Barium Swallow X-ray of oesophagusBarium 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.

Barium Swallow X ray of Barium Swallow X ray of oesophagusoesophagus


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

OESOPHAGUSOESOPHAGUS:: 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. growth below in the stomach.

STOMACHSTOMACH: : Whole of the cardia is occupied by an Whole of the cardia is occupied by an Ulcero-Proliferative Ulcero-Proliferative growth. growth.

DEODENUMDEODENUM: : NormalNormal

BIOPSYBIOPSY: : Taken from the growth Taken from the growth

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

ENDOSCOPY OF UPPER GITENDOSCOPY OF UPPER GIT

ENDOSCOPIC PHOTOGRAPH OF LOWER END OF OESOPHAGUS AND CARDIA OF STOMACH

SHOWING AGGRESSIVE LOOKING ULCERO-PROLIFERATIVE LESION


CYTOPATHOLOGY OF SPUTUMCYTOPATHOLOGY OF SPUTUM (10.5.11) (10.5.11)

Negative for Malignant CellsNegative for Malignant Cells

AFB: Not FoundAFB: Not Found

MTMT (10.5.11) (10.5.11) : Negative : Negative


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

Normal StudyNormal Study

INVESTIGATIONSINVESTIGATIONS

CXR P/A ViewCXR P/A View

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

BIOPSYBIOPSY

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

Histopathology Report Revealed:Histopathology Report Revealed:

Adenocarcinoma of gastric origin. Adenocarcinoma of gastric origin.

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

CT Guided FNAC of Lung LesionCT Guided FNAC of Lung Lesion23.05.201123.05.2011

CYTOLOGY RevealedCYTOLOGY Revealed::

Sq. Cell CarcinomaSq. Cell Carcinoma

Grade: IIGrade: II

Slide of CT guided FNAC

OTHER INVESTIGATIONSOTHER INVESTIGATIONS

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

BronchoscopyBronchoscopy

Endoscopic USGEndoscopic USG

S. ElectrolytesS. Electrolytes

PETPET

CONFIRM DIAGNOSISCONFIRM DIAGNOSIS

Double Malignancy:Double Malignancy:

1. Adenocarcinoma of Gastro-1. Adenocarcinoma of Gastro-Oesophageal JunctionOesophageal 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.

TREATMENT PLANTREATMENT PLAN

IMPROVEMENT OF GENERAL IMPROVEMENT OF GENERAL CONDITIONCONDITION

CHEMOTHERAPYCHEMOTHERAPY

RADIOTHERAPYRADIOTHERAPY

IMPROVEMENT OF GENERAL CONDITIONIMPROVEMENT OF GENERAL CONDITION

Endoscopic NG Tube Intubation was done Endoscopic NG Tube Intubation was done

for feeding purpose on 25.05.2011for feeding purpose on 25.05.2011..

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


Systemic Chemotherapy with following scheduleSystemic Chemotherapy with following schedule

Inj. 5FU (500 mg) – DInj. 5FU (500 mg) – D11-D-D44

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

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

[ 4 Weekly cycle[ 4 Weekly cycle ] ]


Details of ChemotherapyDetails of Chemotherapy::

CYCLE DURATION TOXICITY

1ST 28.05.11-01.06.1128.05.11-01.06.11 Nausea G II Diarrhoea G I

2ND 25.06.11-28.06.1125.06.11-28.06.11 Nausea G I Anaemia G II

3RD 23.07.11-26.07.1123.07.11-26.07.11 Nausea G I Vomiting G II

4TH 20.08.11-23.08.1120.08.11-23.08.11 Nausea G I

CHEMOTHERAPY RESPONSECHEMOTHERAPY RESPONSE

After 3 Cycles of CTBefore Treatment

R

NEXT TREATMENT PLANNEXT 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.lung lesion sequentially.

MESSAGE TO HOUSEMESSAGE 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.lesion.

welcome to weekly clinical meeting on 80 years male with dysphagia, weight loss and cough 80 years...

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