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Esophageal cancer


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surgical procedures for esophageal cancer

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Esophageal cancer

  1. 1. By: OLAJUYIGBE GBOLAHAN Saratov State Medical University
  2. 2.  Hollow muscular tube 25 cm in length which spans from the cricopharyngeus at the cricoid cartilage to gastroesophageal junction (Extends from C7-T10).  Has 4 constrictions-  At starting(cricophyrangeal junction)  crossed by aortic arch(9’inch)  crossed by left bronchus(11’inch)  Pierces the diaphragm(15’inch)  Histologically 4 layers: mucosa, submucosa, muscular & fibrous layer.
  3. 3. Four regions of the esophagus:  Cervical = cricoid cartilage to thoracic inlet (15–18 cm from the incisor).  Upper thoracic = thoracic inlet to tracheal bifurcation (18–24 cm).  Midthoracic = tracheal bifurcation to just above the GE junction (24–32 cm).  Lower thoracic = GE junction (32–40 cm).
  4. 4.  Rich mucosal and submucosal lymphatic system.  The submucosal lymphatics may extend long distances.  The submucosal plexus drains into the regional lymph nodes in the cervical, mediastinal, paraesophageal, left gastric, and celiac axis regions
  5. 5. • Esophageal intraepithelial neoplasia • Glandular epithelial dysplasia/adenocarcinoma in situ in Barrett's mucosa Preinvasive Neoplasia • Squamous cell carcinoma • Adenocarcinoma, • Adenoid cystic carcinoma • Mucoepidermoid carcinoma • Adenosquamous carcinoma • Small cell carcinoma • Carcinoid tumor • Malignant melanoma • Sarcomas Invasive Malignant Neoplasia 95%
  6. 6.  Esophageal cancer is the 7th leading cause of cancer deaths.  accounts for 1% of all malignancy & 6% of all GI malignancy.  Most common in China, Iran, South Africa, India and the former Soviet Union.  The incidence rises steadily with age, reaching a peak in the 6th to 7th decade of life.  Male : Female = 3.5 : 1  African-American males : White males = 5:1
  7. 7.  Worldwide SCC responsible for most of the cases.  Adenocarcinoma now accounts for over 50% of esophageal cancer in the USA, due to association with GERD , Barretts’s esophagus & obesity.  SCC usually occurs in the middle 3rd of the esophagus (the ratio of upper : middle : lower is 15 : 50 : 35).  Adenocarcinoma is most common in the lower 3rd of the esophagus, accounting for over 65% of cases.
  8. 8.  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 as tea)  Underlying esophageal disease (such as achalasia and caustic strictures, Tylosis)  Genetic abnormalities:  p53 mutation, loss of 3p and 9q alleli
  9. 9.  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 as Zollinger-Ellison syndrome. Barrett’s esophagus is a metaplasia of the esophageal epithelial lining. The squamous epithelium is replaced by columnar epithelium,with 0.5% annual rate of neoplastic transformation.
  10. 10. A- Annular type: more common in lower 1/3. B- Ulcerative type: raised everted edge- necrotic floor- indurated base C- Cauliflower type (60%): fungating mass. A B C
  11. 11.  No serosal covering, direct invasion of contiguous structures occurs early.  Commonly spread by lymphatics (70%)  ** Cervical esophagus → lower deep cervical L.N.  ** Thoracic esophagus → para-oesophageal & tracheo-bronchial lymph nodes  ** Abdominal esophagus → lymph nodes along the lesser curvature of the stomach → coeliac axis L.N.  Lymph node involvement increases with T stage.  T1 – 14 to 21%  T2 – 38 to 60%  25% - 30% hematogenous metastases at time of presentation.  Most common site of metastases are  lung, liver, pleura, bone, kidney & adrenal gland  Median survival with distant metastases – 6 to 12 months
  12. 12. PRIMARY TUMOR  Tx → Primary tumor cannot be assessed  TO→ No evidence of primary tumor  Tis→ Carcinoma in situ  T1 → Tumor invades mucosa or submucosa  T2→ Tumor invades musculosa  T3→ Tumor invades adventitia.  T4→ Tumor invades adjacent structures. REGIONAL LYMPH NODES  Nx→ Regional nodes cannot be assessed  NO→ No regional node metastasis  N1 → Regional node metastasis DISTANT METASTASES  Mx→ Presence of distant metastasis cannot be assessed  MO→ No distant metastases  M1 → Distant metastasis
  13. 13.  DYSPHAGIA: Cardinal symptom, characterized by;  Onset: Late onset  Course: Continuous and progressive course  Duration: Short duration (few months).  First to: solid but not to fluids, later to both fluids & solids  Associated with: very bad general condition • REGURGITATION: Regurgitation is effortless while vomiting is forcible. • PAIN: Usually a late manifestation. • Wt. loss – more than 5 % of total body wt. in 40 – 70% pt. associated with worst prognosis.
  14. 14.  Cachexia, Malnutrition, dehydration, anemia,.  Aspiration pneumonia.  Distant metastasis.  Invasion of near by structures: e.g.  Recurrent laryngeal nerve → Hoarseness of voice  Trachea → Stridor & trachea/esophageal fistula→ cough, choking & cyanosis  Perforation into the pleural cavity → Empyema  back pain in celiac axis node involvement
  15. 15.  Detailed history & Physical examination: Dysphagia, odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines, history of GERD. Examine for cervical or supraclavicular adenopathy.  Barium Swallow a.Fungating and ulcerative mass: narrowed irregular filling defect. b.Annular mass:  - If middle stricture: Apple core appearance with evident shouldering  - If lower stricture: Rat tail appearance.
  16. 16. Rat tail appearance Apple core appearance
  17. 17. Cancer lower 1/3 Filling defect (ulcerative type)
  18. 18.  Confirmation of diagnosis:  Esophagoscopy: allow direct visualization and biopsy, measure proximal & distal distance of tumor from incisor, presence of Barrett’s esophagus. Early, superficial cancer Circumferential ulceration esophageal cancer Malignant stricture of esophagus
  19. 19. Lung: chest x-ray & C.T Liver: US Bone: Bone scan & Bone survey Brain: C.T.
  20. 20.  Endoluminal endoscopic ultrasound: to detect wall penetration and regional LN status.  CT and MRI Scan T4 esophageal cancer
  21. 21.  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 staging Figure 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 in diameter. Based on size criteria, these lymph nodes may be considered benign on CT scan
  22. 22.  Site of disease  Extent of disease involvement  Co-morbid conditions  Patient preference. Prerequisite for surgery disease should be 5 cm beyond cricophyrangeus. Surgery indications Lower 1/3rd esophageal ds involving GE junction. Tumor size <5 cm .
  23. 23. Operable Inoperable Radical surgery followed by chemoradiotherapy Palliative procedure
  24. 24. Unfit patient Presence of distant metastases Unresectable tumor Infiltration of important structure as trachea, aorta CRITERIA OF INOPERABILITY
  25. 25.  Transhiatal esophagectomy is performed in 4 phases.  Initially, the abdomen is opened and assessed for metastasis and resectability. The stomach is mobilized in preparation for resection.  In the second phase, the esophageal hiatus is widened and mediastinal esophagus is mobilized.  In the third phase, through a cervical incision, the cervical esophagus is mobilized and upper mediastinal dissection is performed.  Finally, the esophagus is resected and a stomach tube created. The stomach tube is brought up in the neck and esophagogastric anastomosis is done. Mobilization of Stomach Cervical Incision
  26. 26. Creation of Stomach tube Mobilization of Cervicothoracic esophagus Exposure of Cervical esophagus
  27. 27.  The Ivor Lewis esophagectomy is appropriate for tumors of the distal esophagus and gastroesophageal junction  A two-stage procedure. The first stage consisted of a laparotomy and mobilization of the stomach, and the second stage was a right thoracotomy, resection of the esophagus, and esophagastric anastomosis.  The advantages of the Ivor Lewis esophagectomy include excellent visualization of all parts of the operation, ability to perform two-field lymphadenectomy, lower leak rate, and lower chance of injury to the recurrent laryngeal nerves.
  28. 28. The esophagus is encircled with a large penrose drain. The lower esophagus can be mobilized under direct vision transhiatally to confirm resectability of the tumor. The hiatus is enlarged to fit four fingers
  29. 29. With care to preserve proper orientation, the stomach is delivered through the hiatus into the chest.
  30. 30.  Esophageal resection through a left thoracotomy is less commonly used than the Ivor Lewis procedure or transhiatal esophagectomy.  When esophagectomy is performed through a left thoracotomy, either posterolateral thoracotomy or a thoracoabdominal incision may be used.  After mobilization and resection of the lower half of the thoracic esophagus, reconstruction is performed in the mediastinum or, preferably, in the neck between the remaining portion of the esophagus and the gastric fundus.  A left thoracotomy provides free access to the esophagus from the level of the aortic arch to the hiatus. This procedure is usually performed for distal esophageal and gastroesophageal lesions. Although less popular than either the Ivor Lewis approach or transhiatal esophagectomy, it continues to be useful in the treatment of esophageal or gastric tumors near the gastroesophageal junction.
  31. 31. Drawings illustrate transthoracic esophagectomy through a left thoracotomy. Drawing a shows how the thorax is usually entered through the left sixth intercostal space. To further expose the esophagus, the incision may be extended posteriorly (as in posterolateral thoracotomy). The incision may be extended anteriorly across midline or inferiorly as a midline incision. Drawings b and c show how resection of the lower esophagus and cardia is performed with end-to-side esophagogastrostomy.
  32. 32. 1 2 3 1. stomach, 2. right or left colon, 3. jejunum. Other options include; revascularized grafts and gastric tube
  33. 33.  1. LASER tunneling with endoluminal stenting  2. Photodynamic therapy  3. Intubation  4. Gastrostomy for feeding
  34. 34. Patients may be intubated with expandable metallic stents, which can be deployed by endoscopy under fluoroscopic guidance and can keep the esophageal lumen patent. Stents are particularly useful for patients with a tracheoesophageal fistula.
  35. 35. Very bad (5 year survival rate 5%) due to: 1- Old age 2- Bad general condition before operation 3- Early local spread 4- High morbidity after operation e.g. empyema, leakage from anastomosis