1. WELCOME TO WEEKLY CLINICAL MEETING ON 80 YEARS MALE WITH DYSPHAGIA, WEIGHT LOSS AND COUGH 80 YEARS MALE WITH DYSPHAGIA, WEIGHT LOSS AND COUGH A DIAGNOSTIC DILEMMA.

2. 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

3. PARTICULARS OF THE PATIENT Name : Md. Salim Uddin. Age : 80 years. Gender : Male. Occupation : X-Businessman. Religion : Islam. Marital status : Married. Address : Vill: Chota Moheshpur Upazilla-Muktagacha Upazilla-Muktagacha Dist.– Mymensingh. Dist.– Mymensingh. Date of Examination :18.05.11.

4. PRESENTING COMPLAINTS 1. Difficulties in swallowing for 8 months. 2. Occasional cough for 6 months. 3. Gradual weight loss for 6 months.

5. 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.

6. 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.

7. 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.

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

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

10. SOCIOECONOMIC HISTORY  Socioeconomically he belongs to a middle class family.

11. PERSONAL HISTORY  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: 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.

12. PERSONAL HISTORY cont.  Diet: Use to take conventional Bangladeshi diet.  Sleep: Normal.

13. 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.

14. 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.

15. SYSTEMIC EXAMINATION  Examination of oral cavity, oropharynx: Normal findings.

16. SYSTEMIC EXAMINATION cont.  Abdominal examination: Inspection Inspection Shape- Shunken. Shape- Shunken. Movement with respiration- Normal. Movement with respiration- Normal. Position of umbilicus- centrally placed. Position of umbilicus- centrally placed. Flank- Not full. Flank- Not full. Visible swelling- Absent. Visible swelling- Absent.

17. SYSTEMIC EXAMINATION cont.  Hernial orifice- intact.  Visible peristalsis- Absent.  Scar mark- Absent.  External genitalia- Normal findings.

18. SYSTEMIC EXAMINATION cont. 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.

19. SYSTEMIC EXAMINATION cont.  PERCUSSION Shifting dullness is negative. Shifting dullness is negative. Note is tympanatic. Note is tympanatic.  AUSCULTATION Bowel sound present. Bowel sound present.

20. SYSTEMIC EXAMINATION RESPIRATORY SYSTEM No Abnormality Detected CARDIOVASCULAR SYSTEM No Abnormality Detected NERVOUS SYSTEM No Abnormality Detected

21. 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.

22. 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.

23. 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.

24. SALIENT FEATURE cont. His systemic examination of abdomen, respiratory system, cardiovascular system and nervous system revealed normal findings. His systemic examination of abdomen, respiratory system, cardiovascular system and nervous system revealed normal findings.

25. CLINICAL DIAGNOSIS ?

26. NEOPLASM OF OESOPHAGUS WITH LUNG METASTASIS

27. DIFFERENTIAL DIAGNOSIS ?

28. Malignant Neoplasm of Lung with Oesophageal involvement. Mediastinal Neoplasm with Oesophago- Tracheo/Bronchial involvement. Neoplasm of oesophagus with pulmonary TB. Benign Oesophageal condition with primary infection or reactivation of pulmonary TB.

29. INVESTIGATIONS Routine Hematological Tests TC – 11,500 / cu mm. TC – 11,500 / cu mm. DC - Neutrophils – 70%. DC - Neutrophils – 70%. Lymphocytes – 25%. Lymphocytes – 25%. Monocytes – 04%. Monocytes – 04%. Eosinophils – 01%. Eosinophils – 01%. Basophils – 00%. Basophils – 00%. Hb% - 70%. Hb% - 70%. ESR - 40 mm in 1 st Hour ESR - 40 mm in 1 st Hour Total Platelet Count – 2,30,000/ cu mm. Total Platelet Count – 2,30,000/ cu mm.

30. INVESTIGATIONS cont.  Biochemical Tests: S. Creatinine – 0.8 mg/dl. S. Creatinine – 0.8 mg/dl. Blood Urea – 30 mg/dl. Blood Urea – 30 mg/dl. S. Bilirubin – 0.4 mg/dl. S. Bilirubin – 0.4 mg/dl. S. ALT – 32 U/L. S. ALT – 32 U/L. S. AST – 44 U/L. S. AST – 44 U/L. S. Alkaline Phosphatase - 160 U/L. S. Alkaline Phosphatase - 160 U/L. RBS – 6.5 mmol/L. RBS – 6.5 mmol/L.

31. 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.

32. Barium Swallow X ray of oesophagus

33. 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

34. ENDOSCOPY OF UPPER GIT ENDOSCOPIC PHOTOGRAPH OF LOWER END OF OESOPHAGUS AND CARDIA OF STOMACH SHOWING AGGRESSIVE LOOKING ULCERO-PROLIFERATIVE LESION

35. INVESTIGATIONS cont. CYTOPATHOLOGY OF SPUTUM (10.5.11) Negative for Malignant Cells AFB: Not Found MT (10.5.11) : Negative

36. INVESTIGATIONS cont. USG OF WHOLE ABDOMEN (12.5.11) Normal Study

37. INVESTIGATIONS CXR P/A View CXR showing an irregular oval opacity occupying rt. lower lung field. CXR showing an irregular oval opacity occupying rt. lower lung field.

38. BIOPSY 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)

39. CT Guided FNAC of Lung Lesion 23.05.2011 CYTOLOGY Revealed: Sq. Cell Carcinoma Grade: II Slide of CT guided FNAC

40. 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 PET PET

41. CONFIRM DIAGNOSIS Double Malignancy: Double Malignancy: 1. Adenocarcinoma of Gastro- Oesophageal Junction 1. Adenocarcinoma of Gastro- Oesophageal Junction 2. Squamous cell ca. of Right Lung (Lower lobe) 2. Squamous cell ca. of Right Lung (Lower lobe) Staging: Could not be done. Staging: Could not be done.

42. TREATMENT PLAN IMPROVEMENT OF GENERAL CONDITION CHEMOTHERAPY RADIOTHERAPY

43. Endoscopic NG Tube Intubation was done for feeding purpose on 25.05.2011. Endoscopic NG Tube Intubation was done for feeding purpose on 25.05.2011. Correction of Dehydration and Electrolytes Imbalance by iv infusion. Correction of Dehydration and Electrolytes Imbalance by iv infusion.

44. CHEMOTHERAPY Systemic Chemotherapy with following schedule Inj. 5FU (500 mg) – D 1 -D 4 Inj. 5FU (500 mg) – D 1 -D 4 Inj. Etoposide (100 mg) – D 1 -D 4 Inj. Etoposide (100 mg) – D 1 -D 4 Inj. Cisplatin (25 mg) – D 1 -D 4. Inj. Cisplatin (25 mg) – D 1 -D 4. [ 4 Weekly cycle ] [ 4 Weekly cycle ]

45. CHEMOTHERAPY Details of Chemotherapy: CYCLEDURATION TOXICITY 1 ST 28.05.11-01.06.11 28.05.11-01.06.11 Nausea G II Diarrhoea G I 2 ND 25.06.11-28.06.11 25.06.11-28.06.11 Nausea G I Anaemia G II 3 RD 23.07.11-26.07.11 23.07.11-26.07.11 Nausea G I Vomiting G II 4 TH 20.08.11-23.08.11 20.08.11-23.08.11 Nausea G I

46. CHEMOTHERAPY RESPONSE After 3 Cycles of CTBefore Treatment R

47. 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. 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.

48. MESSAGE TO HOUSE Solitary metastatic lesion must be evaluated with caution and care for detection of synchronous primary lesion. Solitary metastatic lesion must be evaluated with caution and care for detection of synchronous primary lesion.