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Diagnosis





Category: MALIGNANT DISEASE OF THE ESOPHAGUS
Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery

It has been estimated that 70 per cent of stenoses of
the esophagus in adults are malignant in nature. This should stimulate
the early and careful investigation of every case of dysphagia. When
all cases of persistent dysphagia, however slight, are endoscopically
studied, precancerous lesions may be discovered and treated, and the
limited malignancy of the early stages may be afforded surgical
treatment while yet there is hope of complete removal. Luetic and
tuberculous ulceration of the esophagus are to be eliminated by
suitable tests, supplemented in rare instances by biopsy. Aneurysm of
the aorta must in all cases of dysphagia be excluded, for the dilated
aorta may be the sole cause of the condition, and its presence
contraindicates esophagoscopy because of the liability of rupture.
Foreign body is to be excluded by history and roentgenographic study.
Spasmodic stenosis of the esophagus may or may not have a malignant
origin. Esophagoscopy and removal of a specimen for biopsy renders the
diagnosis certain. It is to be especially remembered, however, that it
is very unwise to bite through normal mucosa for the purpose of taking
a specimen from a periesophageal growth. Fungations and polypoid
protuberances afford safe opportunities for the removal of specimens
of tissue.

The esophagoscopic appearances of malignant disease, varying with
the stage and site of origin of the growth, may present as follows:--
1. Submucosal infiltration covered by perfectly normal membrane,
usually associated with more or less bulging of the esophageal wall,
and very often with hardness and infiltration.
2. Leucoplakia.
3. Ulceration projecting but little above the surface at the edges.
4. Rounded nodular masses grouped in mulberry-like form, either dark
or light red in color.
5. Polypoid masses.
6. Cauliflower fungations.

In considering the esophagoscopic appearances of cancer, it is
necessary to remember that after ulceration has set in, the cancerous
process may have engrafted upon it, and upon its neighborhood, the
results of inflammation due to the mixed infections. Cancer invading
the wall from without may for a long time be covered with perfectly
normal mucous membrane. The significant signs at this early stage are:
1. Absence of one or more of the normal radial creases between the
folds.
2. Asymmetry of the inspiratory enlargement of lumen.
3. Sensation of hardness of the wall on palpation with the tube.
4. The involved wall will not readily be made to wrinkle when pushed
upon with the tube mouth.

In all the later forms of lesions the two characteristics are (a) the
readiness with which oozing of blood occurs; and (b) the sense of
rigidity, or fixation, of the involved area as palpated with the
esophagoscope, in contrast to the normally supple esophageal wall.
Esophageal dilatation above a malignant lesion is rarely great,
because the stenosis is seldom severely obstructive until late in the
course of the disease.





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