Oesophagus Carcinoma - Pathophysiology, Diagnosis, Clinical Features, Treatment

1. Carcinoma Esophagus
Abraham Mallela
Roll No: 92

2. Introduction
• 6th most common cancer in the world
• Very poor survival rate
• Common in China , South Africa & Asian Countries
• India - Karnataka & Orissa
• Less common - American and European countries

3. Aetiology
• Diet
• Vit C, A, Riboflavin
Deficiency
• Alcohol & Tobacco
• Fungal contamination
• Esophageal Webs
• Achalasia cardia
• Barret’s Oesophagus
• Plummer-Vinson's
Syndrome
• Corrosive strictures
• Nitrosamines

4. • Tylosis
• Autosomal Dominant condition
• Childhood
• Soles and Palms affected
• 60 % - Ca Esophagus before 60 yrs

5. Pathology
• Middle third - 50%
• Lower third - 33%
• Upper third -17%
• Lower 3cm - columnar epithelium - adenocarcinoma
• Barret’s columnar metaplasia - prone for
adenocarcinoma
• India - Squamous cell ca, Western Countries -
Adenocarcinoma

6. Gross Types
• Annular -15%
• Fungating - 60%
• Ulcerative - 20%
• Polypoid
• Varicoid

7. Spread
• Direct
• Lymphatic
• Blood

8. Direct Spread
• More favorable - Lack of serosal layer
• Upper third - Spreads to muscular layer
• Adheres to left main bronchi, trachea , recurrent
laryngeal nerve , aorta
• May perforate and cause mediastinhtis
• May adhere to pleura also

9. Lymphatic Spread
• Spread by lymphatic permeation & lymphatic
embolisation
• Can cause satellite nodules
• Neck - Supra clavicular lymph nodes
• Abdomen - Coeliac Lymph nodes
• Blood Spread - Liver , Lungs, Brain, Bones

10. CLINICAL FEATURES
SRI SOWMYA
ROLL 93

11. • Recent onset of dysphagia
• Regurgitation
• Anorexia, severe loss of weight, cachexia
• Substernal pain, abdominal pain
• Liver secondaries ,ascites
• Bronchopneumonia,melaena

12. • Features of bronchoesophageal fistula in carcinoma of upper 3rd esophagus
• Left supra clavicular lymph nodes may be palpable
• Hoarseness of voice due to involvement of recurrent laryngeal nerve
• Hiccough due to phrenic nerve involvement
• backpain

13. TNM staging & histological grading
• T 0 – NO primary tumour
• T 1a -invasion into lamina propria,muscularis mucosa
• T 1b-submucosa
• T 2-muscularis propria
• T 3-paraesophageal tissues(adventitia)
• T 4a-resectable adjacent structures(pleura,pericardium,diaphragm)

14. • T4b-unresectable adjacent structures(aorta,vertebral body,trachea)
• N STATUS-NODES
• N 0-no regional lymph node metastasis
• N 1- 1 to 2 positive regional lymph nodes
• N 2-3 to 6 positive regional lymph nodes
• N 3-7 or more positive regional lymph nodes

15. M STATUS
• M O-no distant metastases
• M I-distant metastases
• HISTOLOGICAL GRADING
• G1 –well differentiated
• G 2- moderately differentiated
• G3 –poorly differentiated
• G4-undifferentiated

16. INVESTIGATIONS & MANAGEMENT
OF
CARCINOMA OESOPHAGUS
By Sneha Raj.P
Roll No:94

17. INVESTIGATIONS
BARIUM SWALLOW – Irregular filling defect
- Rat tail lesion on
flouroscopy is typical.
OESOPHAGOSCOPY - To see the lesion, extent
and type
BIOPSY – For histological type and confirmation
CHEST X-RAY - To look for aspiration pneumonia

18. • CT – SCAN - To look for local extension
• BRONCHOSCOPY - To see invasion in upper 1/3rd carcinoma of oesophagus
• LARYNGOSCOPY - To identify vocal cord palsy
• OESOPHAGEAL ENDOSONOGRAPHY - To look for involvement of layers of oesophagus, nodes, cardia
and left lobe of liver

19. • ULTRASOUND ABDOMEN – To look for liver and lymph nodes state in abdomen
• ENDOSCOPIC OESOPHAGEAL STAINING – WITH LABELLED IODINE
RESULTS : Normal mucosa – Brown
In carcinoma – Remains pale
(Mucosa in carcinoma doesn’t take up the iodine)

20. • BLOOD TESTS - Haematocrit, ESR, LFT
• LAPROSCOPY - Used to see peritoneal spread
liver and nodal spread
• VIDEO- ASSISTED THORACOSCOPIC APPROACH – To stage the carcinoma of oesophagus and to identify
the operability and nodal status
• ENDOSCOPIC MUCOSAL RESECTION (EMR) – It’s a diagnostic biopsy tool

21. • CHROMOENDOSCOPY MAGNIFICATION ENDOSCOPIES ( NEWER METHODS) – local topical application of
different stains will improve the tumor localisation, features and diagnosis
STAINS USED:-
1) Absorptive – LUGOLS
METHYLENE BLUE
absorbed by specific cell membrane

22. 2) Contrast – INDIGOCARMINE - permeate into mucosal crevices showing irregularity
3) Reactive – CONGO RED
-PHENYL RED
Show color change due to reaction with cell chemicals
• NEWER MODALITIES OF EVALUATION :
*Flow cytometry
*P53 immunohistochemistry
*Optic coherance tomography
*Spectroscopy

23. TREATMENT
20% Oesophagel cancers are early and
curable
THOSE CONFIRMED:
🡪 With absence of Nodal spread -
RADICAL OESOPHAGECTOMY
*Proximal extent: 10cms above
macroscopic tumor

24. * Distal extent : 5cm from macroscopic
tumor
* Proximal stomach is removed:
especially in the lower 1/3rds of the
tumor
�If nodes are involved-
MULTIMODAL APPROACH
*Curative resection
* Radiotherapy
* Chemotherapy

25. �If >5% lymph nodes are involved:-
POOR PROGNOSIS
🡪If 5/<5% lymph nodes are involved:-
CURATIVE RESECTION
❖NEO ADJUVANT THERAPY-
Chemotherapy and radiotherapy prior to
surgery may improve the survival

26. ❖AGGRESSIVE CHEMORADIATION-
Curative therapy
In some patients especially with upper
1/3rd growths and in patients who are
unfit for surgery
In remaining 80% PALLIATION is the main
modality of treatment

27. • Approaches for different level tumors:
1)POST CRICOID TUMOR
* Treated by radiotherapy- radical
radiotherapy with 5000-6000 rads.
�Often pharyngectomy is done along
with gastric and colonic transposition.
�Complications are more in this
procedure.

28. 2) UPPER THIRD GROWTH
Treated by radiotherapy
�If it is early and operable,
Mc Keown 3 phased oesophagectomy and
anastamosis is done in the neck
*initially laparotomy- to mobilise stomach
* then thoracotomy- to mobilise
oesophagus
* anastamosis between pharynx and
stomach is done in the neck

29. �Split sternum approach
oesophagectomy is also practiced
3) MIDDLE THIRD GROWTH
Ivor lewis operation( lewis-tanner-two-
phased-oesopha-gectomy)

30. Laparotomy 🡪 pyloroplasty 🡪 thoracotomy
🡪 growth with tumor is mobilised 🡪
partial oesophagectomy and
oesophagogastric anastamosis in thorax
🡪 Intercostal tube drainage is placed
during closure
• Right gastroepiploic vessels should be
retained
• Azygous vein should be ligated securely
• Mediastinal nodes should be dissected
• Thoracic duct ligated if needed

31. COMPLICATIONS
Complications in this operation are
Pulmonary-broncho pneumonia
-emphyema
Anastomotic leak
Mediastinitis
Oesophagitis
Sepsis
If growth is inoperable-palliative
radiotherapy

32. 4)LOWER THIRD GROWTH:
• Partial oesophago gastrectomy is done
with oesophago gastric anastomosis
Approach-left thoraco abdominal
• Orringer approach:
palliative surgery
i.e,transhiatal blind total oesophagectomy
with anastamosis in the left side of the
neck