anatomy, histology, staging, diagmostic workup of cancer esophagus

1. ESOPHAGUS
G K PRAGATHEESWARI

2. SYNOPSIS
• ANATOMY
• CT ANATOMY
• HISTOLOGY
• ETIOLOGY
• CLINICAL FEATURES
• STAGING
• WORKUP
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Dr. G K Pragatheeswari , MMC

3. ANATOMY
• esophagus is a thin walled hollow muscular tube forming
a food passage between the pharynx and stomach
• extend from cricoid cartilage C7 - GE junction T11
• the tube is flattened anteroposteriorly and it dilates only
during during passage of food
• it descent in front of vertebral column through
mediastinum and pierces diaphragm at T10 vertebra
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4. CONSTRICTIONS
1. at beginiging - pharyngo
esophageal junction (
narrowest lumen of
alimentary canal)
2. crossed by aortic arch
3. crossed by left main
bronchus
4. where it pierces
diaphragm
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5. DIVISION
• Esophagus is roughly 25cm in length
• endoscopic measurement - it starts at 15cm from incisor teeth ends
at 40 cm from incisor teeth, corresponds to C7 and T11 and divided
into
1.cervical
2.thoracic
a. upper
b. middle
c. lower
3. abdominal
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6. cervical
15cm to 20 cm
cricoid cartilage to
sternal notch
C7 to upper border
of T3
upper
thoracic
20cm to 25cm sternal notch to
termination of
azygous vein
upper border of T3 to
T4 T5 junction
middle
thoracic
25cm to 30 cm termination of
azygous vein to
inferior bronchial vein
T5 to T7
lower
thoracic
30cm to 40cm inferior bronchial vein
to GE junction
T7 to T11
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10. RELATIONS
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12. ARTERIAL SUPPLY
1.Cervical part - inferior
thyroid arteries
2.thoracic part -
esophageal branches
of aorta
3.abdominal part - left
gastric artery
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13. VENOUS DRAINAGE
1.upper part - brachio
cephalic veins
2.middle part - azygous
vein
3.lower part - left gastric
vein
lower end of
esophagus is one of
the sites of porto
systemic anastamosis
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14. NERVE SUPPLY
• Para sympathetic
• upper half by RLN
• lower half through plexus
formed by right and left vagus
• sensory , motor, secretomotor
• sympathetic
• upper half by fibres from
middle cervical ganglion
• lower half by fibres from first
four thoracic gnglia
• vasomotor
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15. HISTOLOGY
• esophagus is lined by
keratinised stratified
squamous epithelium,
lower thoracic esophagus
may have columnar
epithelium.
• the endoscopically visible
squamo columnar junction
is called the Z LINE.
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16. • esophageal wall is composed of
1. mucosa - epithelium, basement membrane , lamina propria,
muscularis mucosa.
2. submucosa
3. muscularis propria - inner circular , outer longitudinal
4. outer to this is adventitia( peri esophageal connective tissue)
• serosa is absent here favouring extra esophageal spread
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17. • extensive longitudinal interconnectig system of lymphatics
• the longitudinal nature of lymphatics permits lymphatic metastasis
orthogonal to the depth of tumor
• in addition to longitudinal lymphatics , intramural lymphatics may traverse
the muscularis propria, favouring spread to regional lymph nodes
• lymphatic network is primarily located within submucosa
• some channels also present in lamina propria, hence even the superficial
lesions, may have nodal spread
• lymph can travel into entire length of esophagus before draining into
lymphnodes.
• 40% lymphatic channels extend directly from submucosaand drain into
thoracic duct
• in 6 % skip metastsis have occured without regional node
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19. REGIONAL LYMPH NODES
L left, R-right)
1- supraclavicular
2-upper paratracheal
4-lower paratracheal
5-aortopulmonary
6-anterior mediastinal
7-subcarinal
8Lo-lower paraesophageal
8M-middle paraesophageal
9-pulmonary ligament
10-tracheobronchial
15-diaphragmatic
16-paracardial
17-left gastric
18-common hepatic
19-splenic
20-celiac
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20. TNM staging (AJCC 8th edi)
• TX - Tumor cannot be assed
• Tis - high grade dysplasia
• T1a- tumor invades lamina propria, muscularis
mucosa
• T1b- tumor invades submucosa
• T2 - tumor invades the muscularis propria
• T3 - tumor invades adventitoia
• T4a - tumor invades pleura, pericardium,
azygous vein, diaphragm or peritoneum
• T4b- tumor invades other adjacent structues
like aorta, vertebral body,or airway
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21. • NX - regional lymph nodes cannot be assed
• N0 - No regional lymph node metastasis
• N1 - metastsis in 1 or 2 regional lymph nodes
• N2 - 3- 6 nodes
• N3 - 7 or more
• M0 - no distant metastasis
• M1 - distant metastasis
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22. Hematogenous metastasis
• seen in advanced
esophageal cancer
• liver, lungs, bones,
adrenals ,
kidney,and brain
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24. GE JUNCTION
• Endoscopically the point where the first gastric
fold is encountered
• histologically - squamo columnar junction
• siewert classification - according to location of
tumor
TYPE 1 - the tumor is located > 1cm upto 5cm
above the Zline
TYPE 2 - tumor centre located b/w 1 cm above
upto 2cm below the Z line
TYPE 3 - tumor is located > 2cm caudal to Z line
 siewert type 1 &2 staged as esophageal
tumor
 type 3 is considered as gastric cancer
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25. pathological classification
EPITHELIAL
1. Sqaumous cell ca
2. adeno carcinoma
3. adenosquamous ( taken as scc for staging,
AJCC 8th edi)
4. undifferentiated
5. spindle cell
6. pseudo sarcoma
7. carcino sarcoma
8. verrucous carcinoma
9. mucoepidermoid ca
10. carcinoid
11. small cell
NON EPITHELIAL
1. sarcoma - 13 vaiants
2. malignant melanoma
3. myoblastoma
4. chorio carcinoma
5. lymphoma
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26. ETIOLOGY
• account for 6% of all GI malignancies
• male female 4:1
• higher incidence in linxan, china, russia, caspian region o iran, - arid climate, alkaline soil
• ingestion nitrosamines,nitrosamides, N - nitroso compounds and polyaromatic
hydrocarbons pickled vegetables,alcoholic beverages, cured meats,fish
• plummer vinson syndrome - iron deficiency, low riboflavin
• relative risk 155:1 , >30 g /day tobacco along with 121g/day of alcohol
• betal chewing
• thermal irritation from hot , aerated beverages
• achalasia, tylosis (howel evans syndrome )
• adeno ca - barretts esophagus (10% - 15%)
– GERD , tobacco, smokers
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27. • genetic abnormalities of scc
– p53 mutation
– multiple allele loss of 3p and 9q
– amplification of cyclin D1 and EGFR
cell hyperplasia ,low and high grade dysplasia,
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28. • genetic alteration in adeno ca
– over expression of P53
– multiple allele loss of 17p,5q,13q
– amplification of EGFR and HER 2
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29. clinical features
• location of the primary influence the symptoms
• dysphagia > 90 % patients
• odynophagia 50%
• weight loss 40 - 70 %
• vague chest pain, hoarseness, cough
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30. • advanced lesions
• upper esophagus - impinge / invades RLN , cause hoarseness, vc
palsy > dysphonia
• carotid artery - bleeding,exsanguination
• trachea - breathing difficulty
• tracheo or broncho oesophageal fistula - aspiration. empyema,
• lower esophagus - invades aorta - massive haeorrhage
mediastinits, pyothorax
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31. GE junction tumors
• clinical presentation
– dyspepsia, regurgitation
– GOO : gastric outlet obstruction
– primary lymphatic flow is towards abdomen
– 70% will have nodal mets at presentation
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32. HISTORY
• dysphagia initially for solids then for solids
• odynophagia
• acid reflux, regurgitation
• weight loss (recent > 5% of body weight)
• hemoptysis
• horseness
• h/o smoking , alcohol consumption, betal chewing
• food habits
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33. DIAGNOSTIC WORKUP
• history
• physical examination
• OGD scopy
• barium swallow
• endoscopic ultrasound
• CECT chest
• & abdomen
• PET CT
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34. barium swallow
• not used much nowadays
• patient swallows a packet of effervescent agent
and then rapidly gulps a packet of high density
barium
• barium absobs x rays , seen as opaque
• frontal and left posterior oblique views are taken
• then patient turn right lateral poisition for a view of
fundus
• straight leg raising , valsalva manoeuvre can elicit
GERD
• carcinoma - irregular filling defect
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35. ENDOSCOPY
• OGD scopy - location , extent of tumor , location in
relation to GE junction
• the presence of skip lesions recorded and included in the
overall length of tumor, suffix T(m)
• biopsy - cell type , grade
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36. Endoscopic ultrasound
• esophageal staging is best performed
with the use of EUS,cT
• it is performed as the instrument is with
drawn starting at pylorus
• the individual layers of GI wall are
visualized throughout the procedure
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37. • the presence of mass is usually seens as - hypoechoic
or dark staining in one or more layers, or the loss of usual
layer pattern - biopsy should be performed
• presence oft hypoechoic, rounded, sharply demarcated
structures is diagnostic of nodal disease - FNA of node
should be encouraged whenever possible
• parts of liver are readily seen along lesser curvature
• ascites s/o peritoneal spread
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38. 1. first hyperechoic layer
- acoustic interface
b/w ballon and
mucosa
2. second hypo echoic -
lamina propria and
muscularis mucosa
3. third hyperechoic -
submucosa
4. fourth hypoechoic -
muscularis propria
5. fifth layer - interface
b/w adventitia and
surrounding tissues
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39. Bronchoscopy
• tracheal invasion ,
• fistula
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40. CT CHEST
• initial imaging modality used to determine
• the proximity of tumor to other structures
• cN and c M categories
• nodes are suspicious , when round and or >10 mm in
size short axis diameter
• porto caval node , is an exception to this as it is elongated
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41. C7 LEVEL
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42. T4 LEVEL
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44. picu angle of contact
• angle of contact
between esophageal
tumor and aorta is
measured
• if it is less than 90 deg
patient can be taken up
for surgery
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46. PET CT
• PET CT with FDG is used to refine
1. cN category further away from primary tumor
2. more sensitive in sensing cM than CT
3. estemate the gastric extent of tumor for GE junction
tumors, especially in obstructing tumors of esophagus
however CT chest and PET CT has limited role in
determining the primary tumor category cT
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48. MRI
• not used commonly
• may give the extent of
tumor
• mediastinal infilteration
• nodal involvement
• still T staging is better
done with EUS
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49. REFERENCE
• Anatomy - BD chaurasia, netters atlas, perez
• Clinical features - perez
• staging and work up - AJCC, perez
• images - netters atlas, radiopedia
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50. THANK YOU
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