Difference between revisions of "Oesophageal Neoplasia"

Revision as of 11:39, 28 June 2010

Oesophageal neoplasia is very rare accounting for less than 0.5% of all cancer, except where Spirocerca lupi is endemic (Africa and South-eastern USA). The most frequently reported types of neoplasm are:

Squamous cell carcinoma - usually appears as an annualar thickening in the middle third of the oesophagus, anterior to the heart.
Leiomyosarcoma
Fibrosarcoma
Osteosarcoma
(Plasmacytoma)
(Local invasion of paraoesophageal tumours e.g. thryoid)
(Leiomyoma - benign, most frequently in the caudal oesophagus and cardia)

Signalment

Most are older in age
No sex predilection
No breed predilection

Description

In Africa and South-eastern USA the parasitic worm Spirocerca lupi can cause oesophageal fibrosarcomas and osteoasarcomas. This is most likely due to the parasite secreting a carcinogen. The aetiology of carcinomas in other areas is idiopathic though potentially ingestion of carcinogens may be involved.

Diagnosis

History and Clinical Signs

Indicative of partial or complete upper gastrointestinal obstruction

Signalment as above
Non-specific signs of general poor condition and weight loss
Dysphagia/Pain on swallowing
Regurgitation
Aspiration pneumonia (secondary to regurgitation)
Hypertrophic osteopathy as a paraneoplastic syndrome - particulary those with sarcomas with Spirocerca lupi aetiology

Plain Radiography

A mass, intra-luminal gas retention or oesophageal stricture with a cranial dilation are not always visible. Contrast studies may be required to define mucosal irregularities and strictures. Swallowing defects and regurgitation can be assessed via fluoroscopy.

Advanced Imaging Techniques

CT and MRI can be useful in defining the full extent of the lesion.

Endoscopy and Biopsy

Endoscopy can allow visualisation of the mass. Several biopsies should be taken.

Surgery and Biopsy

Samples can also be taken via thoracotomy or cervical exploration.

Faecal Analysis

Ova of Spirocerca lupi can be found in the faeces.

Treatment

Surgery

Complete tumour excision with oesophageal anastomosis is frequently problematic due to difficulties obtaining complete margins and complications of reconstruction. There can also be complications in the healing of particularly the thoracic oesophagus. One study of 6 dogs who underwent partial oesophagectomy due to Spirocerca-related oeophageal sarcomas reported a median survival of 267 days. 5 of the 6 cases also received doxorubcin. Another study of 4 dogs with oesophageal leiomyosarcoma reported potential long term resolution of clinical signs following marginal surgical resection despite incomplete margins if the tumour was low grade (all were grade 1). Oesophageal bouginage can reduce signs such as regurgitation. Oesophagotomy and gastrostomy tubes can also be used for short term palliation.

Chemotherapy

Rarely reported.

Radiotherpy

Limited in the thoracic oesophagus due to poor tolerance of the heart, lungs and other surrounding tissues.

Prognosis

Often poor as usually in advanced stages on time of diagnosis therefore limiting resection options. In addition, metastatic rate is high: malignant tumours are locally invasive and metastasis occurs via draining lymph nodes (Cervical and Prescapular lymph nodes in the cervical oesophagus and Mediastinal in the thoracic oesophagus) and haematogenous spread to distant areas.

References

Farese J.P, Bacon N.J et al, (2008), Oesophageal leiomyosarcoma in dogs: surgical management and clinical outcome of four cases, Vet Comp Oncol, Mar;6(1):31-8
Morris J, Dobson J (2001) Gastrointestinal Tract, in Small Animal Oncology, Blackwell Science, pp 125-127
Ranen E, Sharmier M. H, Shahar R. et al, (2004), Partial Esophagectomy with Single Layer Closure for Treatment of Oesophageal Sarcomas in 6 Dogs, Vet Surg 33:428-434
Liptak J. M, Withrow S.J, (2007), Cancer of the Gastrointestinal Tract, in Withrow and MacEwen's Small Animal Clinical Oncology, fourth edition, Eds Withrow S.J, Vail D.M, Missouri, Saunders Elsevier, pp 477-478

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-{{OpenPagesTop}}
+{{Unfinished}}
-==Introduction==
-Oesophageal neoplasia is very rare, accounting for less than 0.5% of all neoplasia in dogs.  It has a higher incidence in the areas where ''Spirocerca lupi'', a [[Helminths|helminth parasite]], is endemic in Africa and the south-eastern USA.  The most commonly reported forms of neoplasm are:
-*'''Squamous cell carcinoma''' - usually apparent as an annualar thickening in the middle third of the oesophagus, anterior to the heart base.
-*'''Leiomyosarcoma'''
-*'''Fibrosarcoma'''
-*'''Osteosarcoma'''
-*'''Plasmacytoma'''
-*Local invasion of paraoesophageal tumours is much more common than primary oesophageal neoplasia.  The most common metastatic tumours are '''thyroid carcinomas'''.
-*Benign '''leiomyomas''' may occur in the caudal oesophagus and gastric cardia.
-*'''Fibrosarcomas''' and '''osteosarcomas''' are the most common tumours caused by ''Spirocerca lupi'', probably due to the production of a carcinogen by the parasite.
-==Signalment==
+{{cat}}
-Most affected animals are middle-aged or older and there is no breed or sex predilection.
+{{dog}}
-==Diagnosis==
+Oesophageal neoplasia is very rare accounting for less than 0.5% of all cancer, except where ''Spirocerca lupi'' is endemic (Africa and South-eastern USA). The most frequently reported types of neoplasm are:
-===Clinical Signs===
+* Squamous cell carcinoma - usually appears as an annualar thickening in the middle third of the oesophagus, anterior to the heart.
-Signs are indicative of partial or complete upper gastro-intestinal obstruction:
+* Leiomyosarcoma
-*'''Regurgitation''' with '''hypersalivation'''.
+* Fibrosarcoma
-*'''Difficulty in swallowing''' (dysphagia) and '''pain on swallowing''' (odynophagia).  The animal will often appear to stretch its neck and make repeated efforts to swallow.
+* Osteosarcoma
-*'''Malnutrition''' due to chronic regurgitation and anorexia, resulting on poor body condition.
+* (Plasmacytoma)
-*As with any cause of chronic regurgitation, animals may develop '''aspiration pneumonia''' with signs of coughing, tachypnoea, dyspnoea and pyrexia.
+* (Local invasion of paraoesophageal tumours e.g. thryoid)
-*'''Hypertrophic osteopathy''' (Marie's disease) as a paraneoplastic syndrome, particulary in those animals with sarcomas with caused by ''Spirocerca lupi'' infection.
+* (Leiomyoma - benign, most frequently in the caudal oesophagus and cardia)
-===Diagnostic Imaging===
-====Radiography====
-Plain radiographs of the chest may show a mass of soft tissue opacity associated with the oesophagus, although apparent masses in the caudal oesopahagus could also represent hiatal hernias.  Some tumours (such as osteosarcomas) may contain areas of mineralisation.  There may be intra-luminal gas retention or an oesopageal stricture with cranial dilation.  It should be noted that there are numerous other causes of [[Oesophageal Stricture|oesophageal strictures]], including peri-oesophageal (thoracic) neoplasia and inflammatory lesions like abscesses and granulomata.
-'''Barium contrast studies''' may be used to define mucosal irregularities and strictures whereas dynamic lesions, such as swallowing defects and regurgitation, can be assessed by '''fluoroscopy'''.
-It may difficult to image the mass by '''ultrasonography''' but this technique may be useful if the mass lies in the cranial mediastinum or close to the diaphragm.
-'''Endoscopy''' can allow direct visualisation of the mass if it extends into the oesophageal mucosa and lumen.  Grab biopsies can also be taken via the endoscope.
+==Signalment==
+* Most are older in age
+* No sex predilection
+* No breed predilection
-====Advanced Imaging Techniques====
+==Description==
-'''Computed tomography''' (CT) and '''Magnetic resonance imaging''' (MRI) may be useful in defining the full extent of the lesion and for determining its exact relationship with the oesophagus.
+In Africa and South-eastern USA the parasitic worm ''Spirocerca lupi'' can cause oesophageal fibrosarcomas and osteoasarcomas. This is most likely due to the parasite secreting a carcinogen. The aetiology of carcinomas in other areas is idiopathic though potentially ingestion of carcinogens may be involved.
-===Biopsy===
+==Diagnosis==
-If the mass lies in the cranial mediastinum, samples could be obtaind by ultrasound-guided fine needle aspiration (as for a thymoma or thymic lymphoma).  Otherwise, excisional biopsies could be obtained by thoracoscopy.
+===History and Clinical Signs===
+Indicative of partial or complete upper gastrointestinal obstruction
+* Signalment as above
+* Non-specific signs of general poor condition and weight loss
+* Dysphagia/Pain on swallowing
+* Regurgitation
+* Aspiration pneumonia (secondary to regurgitation)
+* Hypertrophic osteopathy as a paraneoplastic syndrome - particulary those with sarcomas with ''Spirocerca lupi'' aetiology
+===Plain Radiography===
+A mass, intra-luminal gas retention or oesophageal stricture with a cranial dilation are not always visible. Contrast studies may be required to define mucosal irregularities and strictures. Swallowing defects and regurgitation can be assessed via fluoroscopy.
+===Advanced Imaging Techniques===
+CT and MRI can be useful in defining the full extent of the lesion.
+===Endoscopy and Biopsy===
+Endoscopy can allow visualisation of the mass. Several biopsies should be taken.
+===Surgery and Biopsy===
+Samples can also be taken via thoracotomy or cervical exploration.
 ===Faecal Analysis===
-Ova of ''Spirocerca lupi'' may be found in the faeces of affected animals.
+Ova of ''Spirocerca lupi'' can be found in the faeces.
 ==Treatment==
-===Surgical Management===
+===Surgery===
-Due to the advanced development of many oesophageal neoplasms at the time of diagnosis, complete surgical excision is often problematic.  The thoracic oesophagus may be approached by lateral thoracotomy on either side (retracting the brachiocephalic trunk if approaching from the left or ligating the azygos vein if from the right) or via a median sternotomy.  The affected portion of the oesophagus is isolated with loops of moist umbilical tape and moist laparotomy swabs are used to pack the oesopahgus off from the thorax.  The tumour is excised, together with the largest possible margin of normal tissue and an anastomosis is then created between the two ends of the incision.
+Complete tumour excision with oesophageal anastomosis is frequently problematic due to difficulties obtaining complete margins and complications of reconstruction. There can also be complications in the healing of particularly the thoracic oesophagus. One study of 6 dogs who underwent partial oesophagectomy due to Spirocerca-related oeophageal sarcomas reported a median survival of 267 days. 5 of the 6 cases also received doxorubcin. Another study of 4 dogs with oesophageal leiomyosarcoma reported potential long term resolution of clinical signs following marginal surgical resection despite incomplete margins if the tumour was low grade (all were grade 1). Oesophageal bouginage can reduce signs such as regurgitation. Oesophagotomy and gastrostomy tubes can also be used for short term palliation.
-Only 3-5 cm of the length of the oesophagus can be resected without risking dehiscence of the anastomosis and it is advisable to restrain the patient in a headcollar and side-reins after the procedure to prevent this site from coming under tension.  The oesophagus is especially prone to dehiscence because it is under constant tension (exacerbated by movement) and because it lacks a serosa which is responsible for the formation of an initial fibrin seal during healing of the rest of the gastro-intestinal tract.  To support a large resection, intercostal muscle flaps, omentum or synthetic meshes can be wrapped around an anastomotic site.  Tension on the oesophagus can also be released by sectioning the phrenico-oesophageal membrane (which attaches it to the diaphragm) or by making a circumferential incision through the outer longitudinal muscle layer.  Dehiscence of a surgical wound is one cause of [[Rupture of the Oesophagus|oesophageal rupture]].  [[Oesophageal Stricture#Surgical Management|Bougeinage]] may be used to prevent the formation of [[Oesophageal Stricture|strictures]] at the surgical site.  Gastrostomy tubes can be used for short-term palliation of cases with extensive tumours that have obliterated the oesophageal lumen.
-One study of 6 dogs that underwent partial oesophagectomy for treatment of ''S. lupi''-related oeophageal sarcomas reported a median survival of 267 days with adjunctive doxorubicin therapy<ref name="multiple">Ranen E, Sharmier M. H, Shahar R. et al, (2004), '''Partial Esophagectomy with Single Layer Closure for Treatment of Oesophageal Sarcomas in 6 Dogs''', ''Vet Surg'' 33:428-434</ref>.  Another study of 4 dogs with oesophageal leiomyosarcoma reported potential long term resolution of clinical signs following surgical resection (despite incomplete margins) if the tumour was of a low histological grade (all those in the study were of grade 1) <ref>Farese J.P, Bacon N.J et al, (2008), '''Oesophageal leiomyosarcoma in dogs: surgical management and clinical outcome of four cases''', ''Vet Comp Oncol'', Mar;6(1):31-8 </ref>.
 ===Chemotherapy===
-This approach has rarely been reported except as an adjunctive therapy to the surgical removal of ''S. lupi''-associated masses, where '''doxorubicin''' was used post-operatively <ref name="multiple">Ranen E, Sharmier M. H, Shahar R. et al, (2004), '''Partial Esophagectomy with Single Layer Closure for Treatment of Oesophageal Sarcomas in 6 Dogs''', ''Vet Surg'' 33:428-434</ref>.
+Rarely reported.
 ===Radiotherpy===
-There is little opportunity to use this technique for oesophageal neoplasia as the surrounding organs (the heart and lungs) have a poor tolerance to radiation.  [[Oesophagitis]] and [[Oesophageal Stricture|oesopageal strictures]] have also been reported after thoracic radiotherapy.
+Limited in the thoracic oesophagus due to poor tolerance of the heart, lungs and other surrounding tissues.
 ==Prognosis==
-This is often poor as the disease is usually in its advanced stages at the time of diagnosis, leaving few options for surgical management.  In addition, the metastatic rate of oesophageal tumours is high with local invasion and spread to draining lymph nodes (cervical and prescapular nodes from the cervical oesophagus and mediastinal nodes from the thoracic oesophagus) and to distant organs.
+Often poor as usually in advanced stages on time of diagnosis therefore limiting resection options. In addition, metastatic rate is high: malignant tumours are locally invasive and metastasis occurs via draining lymph nodes (Cervical and Prescapular lymph nodes in the cervical oesophagus and Mediastinal in the thoracic oesophagus) and haematogenous spread to distant areas.
-{{Learning
-|Vetstream = [https://www.vetstream.com/canis/Content/Disease/dis00643.asp, Oesophageal neoplasia]
-|literature search = [http://www.cabdirect.org/search.html?q=%28title%3A%28oesophag*%29+OR+title%3A%28esophag*%29%29+AND+de%3A%28neopla*%29 Oesophageal Neoplasia publications]
-}}
 ==References==
-<references/>
+* Farese J.P, Bacon N.J et al, (2008), Oesophageal leiomyosarcoma in dogs: surgical management and clinical outcome of four cases, Vet Comp Oncol, Mar;6(1):31-8
-* Morris J, Dobson J (2001) '''Gastrointestinal Tract, in Small Animal Oncology,'''' Blackwell Science,'' pp 125-127
+* Morris J, Dobson J (2001) Gastrointestinal Tract, in Small Animal Oncology, Blackwell Science, pp 125-127
-* Liptak J. M, Withrow S.J, (2007),''' Cancer of the Gastrointestinal Tract, in Withrow and MacEwen's Small Animal Clinical Oncology,''' fourth edition, Eds Withrow S.J, Vail D.M, Missouri, ''Saunders Elsevier'', pp 477-478
+* Ranen E, Sharmier M. H, Shahar R. et al, (2004), Partial Esophagectomy with Single Layer Closure for Treatment of Oesophageal Sarcomas in 6 Dogs, Vet Surg 33:428-434
+* Liptak J. M, Withrow S.J, (2007), Cancer of the Gastrointestinal Tract, in Withrow and MacEwen's Small Animal Clinical Oncology, fourth edition, Eds Withrow S.J, Vail D.M, Missouri, Saunders Elsevier, pp 477-478
+[[Category:Oesophagus_-_Pathology]][[Category:To_Do_-_Clinical]]
-{{review}}
-{{OpenPages}}
-[[Category:Oesophagus_-_Pathology]]
-[[Category:Neoplasia]]
-[[Category:Oesophageal Diseases - Dog]][[Category:Oesophageal Diseases - Cat]]
-[[Category:Expert_Review - Small Animal]]