High Incidence of High Incidence of Esophageal Squamous Cell Esophageal Squamous Cell Carcinoma in the Kalenjin Carcinoma in the Kalenjin

Population of KenyaPopulation of Kenya

Chris Huff, MDChris Huff, MD

PGY-3PGY-3

M.C.M.C.

54 yo female presents with worsening SOB and 54 yo female presents with worsening SOB and dry cough x 1 month. Also mild dysphagia with dry cough x 1 month. Also mild dysphagia with solids.solids.Denies chest pain, orthopnea, PND, LE swelling.Denies chest pain, orthopnea, PND, LE swelling.No fever, chills, night sweats, hemoptysisNo fever, chills, night sweats, hemoptysisPMH:PMH: none noneFam Hx:Fam Hx: NC NCSoc Hx:Soc Hx: no toxic habits no toxic habitsMeds:Meds: none noneAll:All: NKDA NKDA

M.C.M.C.

EXAM:EXAM:Gen:Gen: mild resp distress mild resp distressVS:VS: 36.8, P85, BP90/60, R26, 88% RA 36.8, P85, BP90/60, R26, 88% RAHeart:Heart: RRR, no m/r/g RRR, no m/r/gLungs:Lungs: coarse breath sounds throughout all lung coarse breath sounds throughout all lung

fields bilaterallyfields bilaterallyAbd:Abd: benign, no HSM benign, no HSMNode:Node: no palpable LAD no palpable LADExt:Ext: warm, no edema warm, no edema

M.C.M.C.

HCT 32HCT 32WBC 8WBC 8Plt 250Plt 250Creat 1.2Creat 1.2Na+ 128Na+ 128HIV (-)HIV (-)CXR – diffuse interstitial opacities bilat. CXR – diffuse interstitial opacities bilat. with mediastinal LADwith mediastinal LAD

M.C.M.C.

Hospital Course:Hospital Course:- Admitted to the medicine service and Admitted to the medicine service and

treated empirically with Rocephin, treated empirically with Rocephin, Azithromycin, and 4 drug TB therapyAzithromycin, and 4 drug TB therapy

- Worsened over the next few days, so Worsened over the next few days, so steroids and nebulizer initiatedsteroids and nebulizer initiated

- On HD #5 sats 35% on 15LOn HD #5 sats 35% on 15L

M.C.M.C.

- Patient transferred to the ICU with plan for Patient transferred to the ICU with plan for intubationintubation

- Pt intubated and after inflation of the cuff, Pt intubated and after inflation of the cuff, was discovered to have persistent air leakwas discovered to have persistent air leak

- Also stomach and chest both rising with Also stomach and chest both rising with baggingbagging

M.C.M.C.

- Patient was felt to most likely have Patient was felt to most likely have tracheo-esophageal fistula (TEF)tracheo-esophageal fistula (TEF)

- Gen Surg consulted for EGD and cancer Gen Surg consulted for EGD and cancer found in mid portion of esophagus with found in mid portion of esophagus with extension to the trachea, creating TEFextension to the trachea, creating TEF

- Pt made comfort care and expired 1 hr Pt made comfort care and expired 1 hr later from resp. failurelater from resp. failure

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Epidemiology:Epidemiology: - Most common cancer in Men and 3- Most common cancer in Men and 3rdrd most most

common in womencommon in women

- Incidence 200 per 100,000- Incidence 200 per 100,000- Male to female ratio of 1.5 to 1Male to female ratio of 1.5 to 1- Mean age at diagnosis 58.7 yrsMean age at diagnosis 58.7 yrs- 90% is squamous cell90% is squamous cell

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Tenwek Hospital Bomet KenyaTenwek Hospital Bomet Kenya

- - Retrospective Review of esophageal cancer diagnoses Retrospective Review of esophageal cancer diagnoses 1999-20071999-2007

- Esophageal cancer accounted for 914 (34%) of newly - Esophageal cancer accounted for 914 (34%) of newly diagnosed cancersdiagnosed cancers

- 6.3% of pts </= to 30yo, 1% </= to 20yo- 6.3% of pts </= to 30yo, 1% </= to 20yo

Dis Esophagus. 2009 May 15. Dis Esophagus. 2009 May 15.

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Risk Factors:Risk Factors:- Family historyFamily history

- EtOH and tobaccoEtOH and tobacco

- Corn and Wheat Diet (2 main hypotheses)Corn and Wheat Diet (2 main hypotheses)1) Deficiency of A, C, E, selenium, zinc1) Deficiency of A, C, E, selenium, zinc2) Exposure to the corn mold 2) Exposure to the corn mold Fusarium moniliforme Fusarium moniliforme SheldonSheldon3) Polycyclic Aromatic Hydrocarbons from food 3) Polycyclic Aromatic Hydrocarbons from food contaminated with smoke or sootcontaminated with smoke or soot

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Pathophysiology:Pathophysiology:- Arises from polyps, plaques, or denuded epitheliumArises from polyps, plaques, or denuded epithelium

- Usually occurs in the mid-esophagusUsually occurs in the mid-esophagus

- Early invasion of submucosa and extends in cephalad Early invasion of submucosa and extends in cephalad directiondirection

- Invades lymph nodes early b/c the lymphatics are Invades lymph nodes early b/c the lymphatics are located in the lamina proprialocated in the lamina propria

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Clinical Manifestations:Clinical Manifestations:- Dysphagia and weight loss most commonDysphagia and weight loss most common

- Vomiting and chest painVomiting and chest pain

- Iron deficiency anemia without melenaIron deficiency anemia without melena

- Respiratory symptoms if TEF developsRespiratory symptoms if TEF develops

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Tracheoesophageal Fistula: How rare?Tracheoesophageal Fistula: How rare?

- European study in 2008 264 of 2113 - European study in 2008 264 of 2113 patients with esophageal cancer were patients with esophageal cancer were found to have a TEFfound to have a TEF

- Incidence in KenyaIncidence in Kenya

unknownunknown

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Diagnosis of Esophageal Cancer:Diagnosis of Esophageal Cancer:

- Barium swallow can suggest, but need EGD with - Barium swallow can suggest, but need EGD with biopsy to make the diagnosisbiopsy to make the diagnosis

- On EGD can appear as plaque, stricture, - On EGD can appear as plaque, stricture, ulceration, or massulceration, or mass

- Diagnosis improves with number of biopsies - Diagnosis improves with number of biopsies taken: 1= 93%, 7=98%taken: 1= 93%, 7=98%

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Staging of Esophageal Cancer:Staging of Esophageal Cancer:

- TNM criteria – 5 yr survival related to - TNM criteria – 5 yr survival related to stage:stage:

I 60%I 60%

II 31%II 31%

III 20%III 20%

IV 4%IV 4%

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Staging of Esophageal Cancer:Staging of Esophageal Cancer:

- CT scan to evaluate for metastasis (M)- CT scan to evaluate for metastasis (M)

- EUS for locoregional staging (T & N)- EUS for locoregional staging (T & N)

- Possible PET to better eval for mets prior to surgery- Possible PET to better eval for mets prior to surgery

**EUS and PET not available in Western Kenya and **EUS and PET not available in Western Kenya and staging CT often not performed because of financial staging CT often not performed because of financial reasonsreasons

Esophageal SCC in Western KenyaEsophageal SCC in Western Kenya

Treatment: Depends on StageTreatment: Depends on Stage

- Neoadjuvant chemoradiation followed by - Neoadjuvant chemoradiation followed by surgery for stage I – IIIasurgery for stage I – IIIa

- Cisplatin/5-FU chemo recommended- Cisplatin/5-FU chemo recommended

- 60% unresectable at diagnosis- 60% unresectable at diagnosis

- Chemoradiation- Chemoradiation

- Palliative care (may include stenting)- Palliative care (may include stenting)

ConclusionsConclusions

Esophageal Cancer is common and occurs at an Esophageal Cancer is common and occurs at an early age in Western Kenyaearly age in Western Kenya

Risk factors are combination of genetic and Risk factors are combination of genetic and environmentalenvironmental

Diagnosis made with EGD and biopsyDiagnosis made with EGD and biopsy

In remote areas of Kenya treatment limited to In remote areas of Kenya treatment limited to surgical resection vs palliative caresurgical resection vs palliative care

ReferencesReferencesBalazs et al.Balazs et al. Eur J Cardiothorac Surg Eur J Cardiothorac Surg 2008;34:1103-1107 2008;34:1103-1107Parker et al. Frequent occurrence of esophageal cancer in young people in western Kenya Dis Esophagus. 2009 Parker et al. Frequent occurrence of esophageal cancer in young people in western Kenya Dis Esophagus. 2009 May 15May 15 Wakhisi et al. Esophageal cancer in north rift valley of Western Kenya. Afr Health Sci. 2005 Jun;5(2):157-63Wakhisi et al. Esophageal cancer in north rift valley of Western Kenya. Afr Health Sci. 2005 Jun;5(2):157-63 White et al. Esophageal Cancer: a common malignancy of young people in Bomet District, Kenya. Lancet. 2002 White et al. Esophageal Cancer: a common malignancy of young people in Bomet District, Kenya. Lancet. 2002 Aug 10;360(9331):462-3Aug 10;360(9331):462-3

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