Oesophageal carcinoma

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Oesophageal carcinoma

  1. 1. bestpowerpointtemplates.comCarcinoma EsophagusPresented By:JITHIN MAMPATTA
  2. 2. Epidemiology• 9thcommon cancer in the world• Disease of mid to late adulthood• Most common in China, Iran, South Africa,India and the former Soviet Union.
  3. 3. • The incidence rises steadily with age,reaching a peak in the 6thto 7thdecade of life.• Commonly in men over 50 years of age• Worldwide SCC responsible for most of thecases.• SCC usually occurs in the upper two thirdof the esophagusContd…
  4. 4. Contd…• The cause of scc in endemic areas is notdefinitely known but is probably due tofungal contamination of food with productionof carcinogenic mycotoxin , together withnutritional deficiencies in the population
  5. 5. Contd…• Supplimentation of the diet with betacarotene , vit E ,and selenium has beenshown to reduce the incidence in endemicareas
  6. 6. Contd…• Adenocarcinoma more common inwesternised countries and is increasing inincidence due to association with GERD ,Barretts’s esophagus & obesity.• Adenocarcinoma is most common in thelower 3rdof the esophagus
  7. 7. Etiology : Squamous Cell Carcinoma• Smoking and alcohol (80% - 90%)• Dietary factors–N-nitroso compounds (animal carcinogens)– Pickled vegetables and other food-products– Toxin-producing fungi– Betel nut chewing– Ingestion of very hot foods and beverages (such astea)
  8. 8. Contd…•Underlying esophageal disease (suchas achalasia and caustic strictures )• Genetic abnormalities:–p53 mutation, loss of 3p and 9q alleli, amp.Cyclin D1 & amp. EGFR
  9. 9. Etiology : Adenocarcinoma• Associated with Barretts’s esophagus, GERD &hiatal hernia.• Obesity (3 to 4 fold risk)• Smoking (2 to 3 fold risk)• Increased esophageal acid exposure such asZollinger-Ellison syndrome.Fig. Barretts’sesophagusBarrett’s esophagus is ametaplasia of the esophageal epithelial lining. Thesquamous epithelium is replaced by columnarepithelium,with 0.5% annual rate of neoplastictransformation.Barrett’s esophagus is ametaplasia of the esophageal epithelial lining. Thesquamous epithelium is replaced by columnarepithelium,with 0.5% annual rate of neoplastictransformation.
  10. 10. Morphology : Squamous CellCarcinoma• Squamous cell carcinomas are usually preceded bya long prodrome of mucosal epithelial dysplasiafollowed by carcinoma in situ and, ultimately, bythe emergence of invasive cancer• Early overt lesions appear as small, gray-white,plaquelike thickenings or elevations of the mucosa• In months to years, these lesions become tumorous,taking one of three forms:
  11. 11. Morphology : Squamous CellCarcinoma• Squamous cell carcinomas are usually preceded bya long prodrome of mucosal epithelial dysplasiafollowed by carcinoma in situ and, ultimately, bythe emergence of invasive cancer• Early overt lesions appear as small, gray-white,plaquelike thickenings or elevations of the mucosa• In months to years, these lesions become tumorous,taking one of three forms:
  12. 12. Contd…• (1) polypoid exophytic masses thatprotrude into the lumen• (2) necrotizing cancerous ulcerations thatextend deeply and sometimes erode into therespiratory tree, aorta, or elsewhere and• (3) diffuse infiltrative neoplasms thatcause thickening and rigidity of the wall andnarrowing of the lumen
  13. 13. Contd…• Whichever the pattern, about 20% arise inthe cervical and upper thoracic esophagus,50% in the middle third, and 30% in thelower third
  14. 14. Morphology : Adenocarcinoma• Adenocarcinomas seem to arise from dysplastic mucosa in the settingof Barrett esophagus. Unlike squamous cellcarcinomas, they are usually in the distal one-third ofthe esophagus and may invade the subjacent gastriccardia.• Initially appearing as flat or raised patches on anotherwise intact mucosa, they may develop intolarge nodular masses or show deeplyulcerative or diffusely infiltrative features.
  15. 15. Pattern of spread• Commonly spread by lymphatics (70%)• 25% - 30% hematogenous metastases• Most common site of metastases are– lung, liver, pleura, bone, kidney & adrenal gland• Median survival with distant metastases – 6 to 12months
  16. 16. Clinical Features• It is commonly associated with thesymptoms of dysphagia, wt. loss,pain, anorexia, and vomiting• Symptoms often start 3 to 4 monthsbefore diagnosis• Dysphagia - in more than 90% pt.Odynophagia - in 50% of pt.
  17. 17. Contd…Complications:• Cachexia, Malnutrition, dehydration,anaemia,.• Aspiration pneumonia.• Distant metastasis.
  18. 18. Contd…• Invasion of near by structures: e.g.–Recurrent laryngeal nerve → Hoarseness ofvoice–Trachea → Stridor & TOF→ cough, choking &cyanosis–Perforation into the pleural cavity → Empyema–back pain in celiac axis node involvement
  19. 19. Diagnostic Workup• Detailed history & Physical examination: Dysphagia,odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines, historyof GERD. Examine for cervical or supraclavicular adenopathy.• Confirmation of diagnosis:– EGD: allow direct visualization and biopsy, measure proximal & distal distance of tumorfrom incisor, presence of Barrett’s esophagus.Early, superficialcancerCircumferential ulcerationesophageal cancerMalignant strictureof esophagus
  20. 20. • Staging:– CT chest and abdomen: Essential for staging because it can identify extensionbeyond the esophageal wall, enlarged lymph nodes and visceral metastases.
  21. 21. PET Scan• most recently, proven to be valuable staging tool• can detect up to 15–20% of metastases not seen on CT and EUS• low accuracy in detecting local nodal disease compared to CT / EUS• Value in evaluating response to Chemo Therapy & Radio Therapy• addition of PET to CT can improve specificity and accuracy of non-invasive stagingFigure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A,Integrated CT PET demonstrates para-aortic lymph node metastases showing increased FDG uptake(arrowheads). B, Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm indiameter. Based on size criteria, these lymph nodes may be considered benign on CT scan
  22. 22. • Barium swallow:– can delineate proximal and distal margins as well as TEF– Helpful for correlation with simulation film.• Bronchoscopy: rule-out fistula in midesophageal lesions.• Routine Investigations: CBC, chemistries, LFTs.Cancer lower 1/3Cancer lower 1/3Filling defect (ulcerative type)Filling defect (ulcerative type)Rat tail appearanceApple core appearance

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