WELCOME
TO
WEEKLY CLINICAL MEETING
ON
80 YEARS MALE WITH DYSPHAGIA, WEIGHT LOSS
AND COUGH
A DIAGNOSTIC DILEMMA.
Chairperson
Dr. Md. Safiul Alam
Associate Prof. & Head
Dept. of Radiotherapy
Presented by
Dr. Muhammad Masudul Hassan Arup
Department of Radiotherapy
Mymensingh Medical College and Hospital
PARTICULARS OF THE PATIENT
Name
Age
Gender
Occupation
Religion
Marital status
Address
: Md. Salim Uddin.
: 80 years.
:
:
:
:
:
Male.
X-Businessman.
Islam.
Married.
Vill: Chota Moheshpur
Upazilla-Muktagacha
Dist.– Mymensingh.
Date of Examination :18.05.11.
PRESENTING COMPLAINTS
1.
2.
3.
Difficulties in swallowing for 8 months.
Occasional cough for 6 months.
Gradual weight loss for 6 months.
HISTORY OF PRESENT ILLNESS

According to the statement of the patient all
his sufferings started 8 months back as he
noticed
progressive
difficulties
in
swallowing. Initially he had problem with
solid food only but for last 2 months, it
increased in severity and developed
swallowing difficulties with liquid also. More
over it was associated with regurgitation and
retro sternal burning sensation. But he did
not give any history of vomiting.
HISTORY OF PRESENT ILLNESS
cont.

In addition to this he had occasional cough
for last 6 months. It was non productive, non
periodic and not accompanied by chest pain
or did not have any relation with posture. The
cough did not aggravate during taking food
either solid or liquid. He never coughed up
blood or blood stained sputum.
 He also complaints of marked weight loss
and generalized weakness for same duration.
HISTORY OF PAST ILLNESS





H/O pulmonary tuberculosis in the year 1988.
H/O peptic ulcer disease with occasional regurgitation
and heartburn for 10 yrs.
No H/O of Diabetes, Hypertension or Bronchial
Asthma.
Never suffered from any major disease other than PTB.
Never underwent any major surgery.
TREATMENT HISTORY

He took anti tubercular drugs for 9 months but no
document is available.
FAMILY HISTORY

No one of his family member ever suffered from this
type of illness.
SOCIOECONOMIC HISTORY

Socioeconomically he belongs to a middle class
family.
PERSONAL HISTORY
 Smoking:
H/O smoking over last 60 years.
Used to smoke 10 sticks per day.
Started smoking with Biri.
For last 10-15 years he is taking
cigarettes.

Betel leaf chewing:
He has also habit of betel leaf
chewing
with betel nut and jarda.
PERSONAL HISTORY
cont.

Diet: Use to take conventional Bangladeshi diet.

Sleep: Normal.
GENERAL EXAMINATION

Appearance: Ill looking.
 Body built: Average.
 Decubitus: On choice.
 Nutritional status: Poor.
 Anemia: Mildly Anemic.
 Jaundice: Absent.
 Cyanosis: Absent.
 Clubbing: Absent.
 Koilonychia: Absent.
 Leukonychia: Absent.
GERNERAL EXAMINATION
cont.

Dehydration: Some sign of dehydration.
 Oedema: Absent.
 Pulse: 78 beats/ min.
 BP : 100/80 mm of Hg.
 Temp: Normal.
 Neck vein: Not engorged.
 Thyroid gland: Normal.
 LN : Not enlarged.
 Skin condition: Normal.
 Hair distribution: Normal.
SYSTEMIC EXAMINATION

Examination of oral cavity, oropharynx:
Normal findings.
SYSTEMIC EXAMINATION
cont.
 Abdominal
examination:
Inspection
Shape- Shunken.
Movement with respiration- Normal.
Position of umbilicus- centrally placed.
Flank- Not full.
Visible swelling- Absent.
SYSTEMIC EXAMINATION
cont.

Hernial orifice- intact.
 Visible peristalsis- Absent.

Scar mark- Absent.

External genitalia- Normal findings.
SYSTEMIC EXAMINATION
cont.
Palpation
Normal temperature.
No muscle guard or rigidity.
No mass.
No organomegaly.
Abdomen is nontender.
Hernial orifice is intact.
External genitalia is normal.
SYSTEMIC EXAMINATION
cont.
 PERCUSSION
Shifting dullness is negative.
Note is tympanatic.

AUSCULTATION
Bowel sound present.
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
No Abnormality Detected
CARDIOVASCULAR SYSTEM
No Abnormality Detected
NERVOUS SYSTEM
No Abnormality Detected
SALIENT FEATURE

Md. Salim Uddin, an 80 years old
X-Businessman,
hailing
from
Chota
Moheshpur of Muktagacha Upazilla of
Mymensingh district was presented with the
complaints of progressive dysphagia for 8
months, occasional cough for 6 months and
gradual weight loss for same duration.
Initially he had swallowing difficulties with
solid food only but later on found difficulties
with liquid also. He had occasional
regurgitation though there was no history of
vomiting.
SALIENT FEATURE

In addition to this he has been suffering from
occasional cough for last 6 months. It was
non productive, non periodic and not
associated with chest pain. The cough was
not aggravated by adopting any particular
posture or during ingestion of food or
drinking of water. He never coughed up
blood or blood stained sputum. He never felt
breathing difficulties during his course of
illness.
 He also complaints of marked weight loss.
SALIENT FEATURE
cont.

In his past illness he gave history of PTB in the
year 1988 for which he took anti tubercular
drugs. He had also peptic ulcer disease with
occasional regurgitation and heartburn for 10
yrs.
 He was a smoker for last 60 years. Also
habituated to betel leaf chewing.
 On general examination he is found, ill looking,
cachexic, dehydrated and mildly anaemic.
Otherwise he is non icteric, acyanosed and
non-oedematous. There is no clubbing,
koilonychia, leuconychia or palpable lymph
nodes. His temperature is normal, pulse rate is
78 beats / min and BP 100/80 mm of Hg.
SALIENT FEATURE
cont.
His systemic examination of abdomen,
respiratory system, cardiovascular system
and nervous system revealed normal
findings.
CLINICAL DIAGNOSIS
?
CLINICAL DIAGNOSIS
NEOPLASM OF OESOPHAGUS WITH LUNG METASTASIS
DIFFERENTIAL DIAGNOSIS
?
DIFFERENTIAL DIAGNOSIS
Malignant
Neoplasm
of
Oesophageal involvement.
Mediastinal Neoplasm with
Tracheo/Bronchial involvement.
Lung
with
Oesophago-
Neoplasm of oesophagus with pulmonary TB.
Benign Oesophageal condition with primary
infection or reactivation of pulmonary TB.
INVESTIGATIONS
Routine Hematological Tests
TC – 11,500 / cu mm.
DC Neutrophils – 70%.
Lymphocytes – 25%.
Monocytes – 04%.
Eosinophils – 01%.
Basophils – 00%.
Hb% 70% .
ESR 40 mm in 1st Hour
Total Platelet Count – 2,30,000/ cu mm.
INVESTIGATIONS
cont.
 Biochemical
Tests:
S. Creatinine – 0.8 mg/dl.
Blood Urea – 30 mg/dl.
S. Bilirubin – 0.4 mg/dl.
S. ALT – 32 U/L.
S. AST – 44 U/L.
S. Alkaline Phosphatase - 160 U/L.
RBS – 6.5 mmol/L.
INVESTIGATIONS
cont.
Barium Swallow X-ray of oesophagus (11.5.11)
 Barium has passed down the oesophagus
without obstruction.
 Margin is regular.
 No
Filling defect, abnormal dilatation or
shouldering effect Seen.
 Mucosal pattern is normal.
Barium Swallow X ray of
oesophagus
INVESTIGATIONS
cont.
ENDOSCOPY OF UPPER GIT (15.5.11)
OESOPHAGUS: An Ulcero-Proliferative growth at the
lower end of oesophagus which is continuous with the
growth below in the stomach.
STOMACH: Whole of the cardia is occupied by an
Ulcero-Proliferative growth.
DEODENUM: Normal
BIOPSY: Taken from the growth
COMMENTS: Ca. Gastro-Oesophageal Junction
ENDOSCOPY OF UPPER GIT
ENDOSCOPIC PHOTOGRAPH OF LOWER END OF OESOPHAGUS AND CARDIA OF STOMACH
SHOWING AGGRESSIVE LOOKING ULCERO-PROLIFERATIVE LESION
INVESTIGATIONS
cont.
CYTOPATHOLOGY OF SPUTUM (10.5.11)
Negative for Malignant Cells
AFB: Not Found
MT (10.5.11) : Negative
INVESTIGATIONS
cont.
USG OF WHOLE ABDOMEN (12.5.11)
Normal Study
INVESTIGATIONS
CXR P/A View
CXR showing an
irregular oval opacity
occupying rt. lower
lung field.
BIOPSY
Endoscopic Biopsy was done on 17.5.11
Histopathology Report Revealed:
Adenocarcinoma of gastric origin.
Grade: III (poorly differentiated)
CT Guided FNAC of Lung Lesion
23.05.2011
CYTOLOGY Revealed:
Sq. Cell Carcinoma
Grade: II
Slide of CT guided FNAC
OTHER INVESTIGATIONS
CT Scan of Chest and upper abdomen
Bronchoscopy
Endoscopic USG
S. Electrolytes
PET
CONFIRM DIAGNOSIS
Double Malignancy:
1. Adenocarcinoma of GastroOesophageal Junction
2. Squamous cell ca. of Right Lung
(Lower lobe)
Staging: Could not be done.
TREATMENT PLAN
IMPROVEMENT OF GENERAL CONDITION
CHEMOTHERAPY
RADIOTHERAPY
IMPROVEMENT OF GENERAL CONDITION
Endoscopic NG Tube Intubation was done
for feeding purpose on 25.05.2011.
Correction of Dehydration and Electrolytes
Imbalance by iv infusion.
CHEMOTHERAPY
Systemic Chemotherapy with following schedule
Inj. 5FU (500 mg) – D1-D4
Inj. Etoposide (100 mg) – D1-D4
Inj. Cisplatin (25 mg) – D1-D4.
[ 4 Weekly cycle ]
CHEMOTHERAPY
Details of Chemotherapy:
CYCLE
DURATION
1ST
28.05.11-01.06.11
2ND
25.06.11-28.06.11
3RD
23.07.11-26.07.11
4TH
20.08.11-23.08.11
TOXICITY
Nausea G II
Diarrhoea G I
Nausea G I
Anaemia G II
Nausea G I
Vomiting G II
Nausea G I
CHEMOTHERAPY RESPONSE
R
Before Treatment
After 3 Cycles of CT
NEXT TREATMENT PLAN
After completion of chemotherapy our next
plan of treatment is External Beam
Radiotherapy to the Gastro-oesophageal
Junction Neoplasm as well as the site of
lung lesion sequentially.
MESSAGE TO HOUSE
Solitary metastatic lesion must be
evaluated with caution and care for
detection of synchronous primary
lesion.