6. MANAGEMENT OF CA OESOPHAGUS
CA OESOPHAGUS
- 6th most common cancer in the world
Incidence
Age → 65 - 75 years
Sex → male : female = 2 : 1
Geographic → Eastern > Western
11. Spread
1. Local spread - commonest spread
- Intra esophageal spread - circular & longitudinal
- in depth
– mucosa ,
submucosa , m/s ,
near by structure
12. - Extra esophageal spread - near by structure
(a) upper ⅓ - larynx , trachea , RLN , Thyroid
(b) middle ⅓ - tracheo-bronchial tree , lungs ,
aorta, mediastinum (mediastinitis)
(c) lower ⅓ - post mediastinum , stomach , liver ,
diaphragm
2. Lymphatic spread - L/N along the oesophagus
(a) upper ⅓ - cervical & supraclavicular L/N
(b) middle ⅓ - hilar L/N , mediastinal L/N
(c) lower ⅓ - Lt gastric , coeliac L/N
3. Blood spread - very rare in squamous cell Ca
- Liver , lungs , Bone , Brain
4. Transcoelomic spread
5. Direct implantation - During biopsy , operation
13. Clinical Features
Tumor itself
- Dysphagia – Painless , Persistent progressive
dysphagia ( Solid→ Semisolid → Liquid
→ Saliva)
- Feeling of sickness of food
- Regurgitation & Haematamesis
- Acute obstruction
- Pain (Late symptom) - Inflammation of oeso;
- Infiltrate to surrounding
structure
15. lower ⅓ - mass in epigastrium d/t coeliac L/N enlarg;
- H & M
- Anorexia & dyspepsia
- Hepatomegaly
16. TNM staging for esophageal cancer
• Tis - Carcinoma in situ/ High grade
dysplasia
• T1 - Tumor invading lamina propria or
submucosa
- T1a - lamina propria or muscularis
mucosa
- T1b - submucosa
• T2 - Tumor invading muscularis propria
• T3 - Tumor invading beyond muscularis propria
• T4 - Tumor invading adjacent structures
- T4a - pleura, pericardium, diaphragm, or
adjacent peritoneum
- T4b – other adjacent structures ( e.g; aorta,
vertebral body, trachea
• Tx - Primary tumor cannot be assessed.
17. • N0 - No regional L/N metastasis
• N1 - 1 to 2 regional L/N
• N2 - 3 to 6
• N3 - >6
( N1 was site dependent)
• M0 - No distant metastasis
• M1(a) - Coeliac node involved (for distal
esophageal tumors)
- Supraclavicular node involved (for
proximal tumors)
• M1(b) - Coeliac or Supraclavicular node
involved if not remote from tumor
site. All other distant metastasis.
• Mx - Distant metastasis cannot be assessed.
18. Stage IA T1 N0 M0
Stage IB T2 N0 M0
Stage IIA T3 N0 M0
Stage IIB T1,T2 N1 M0
Stage IIIA T4a N0 M0
T3 N1 M0
T1,T2 N2 M0
Stage IIIB T3 N2 M0
Stage IIIC T4a N1,N2 M0
T4b Any N M0
Any T N3 M0
Stage IV Any T Any N M1
Anatomical Stage Group
(Adeno & Squamous)
19. Oesophageal Squamous Cell Carcinoma
Prognostic Grouping
T N M Grade Location
Stage IA 1 0 0 1,X Any
Stage IB 1 0 0 2,3 Any
2,3 0 0 1,X Lower
Stage IIA 2,3 0 0 1,X Upper, middle
2,3 0 0 2,3 Lower
Stage IIB 2,3 0 0 2,3 Upper, middle
1,2 1 0 Any Any
Stage IIIA 1,2 2 o Any
3 1 0 Any Any
4a Any Any
Low Stages: AJCC not all = UICC Stages IIIA,B,C & IV : AJCC = UICC
20. Oesophageal Adenocarcinoma
Prognostic Grouping
T N M Grade
Stage IA 1 0 0 1,2,X
Stage IB 1 0 0 3
2 0 0 1,2,X
Stage IIA 2 0 0 3
Stage IIB 3(IIA) 0 0 Any
1,2 1 0 Any
Stage IIIA 1,2 2 0 Any
3 1 0 Any
4a 0 0 Any
Stage IIIB,IIIC, & IV
Low Stage : AJCC not all = UICC
Stage IIIB,IIIC, & IV : AJCC = UICC
21. INVESTIGATION
• Confirm the diagnosis
1. OGD scopy & biopsy
- 1st –line investigation for most patients
- Site & type of malignant lesion
- extent of circumferential involvement of the
esophagus by tumor
- Cytology / Histology specimens taken
22. 2. Ba swallow ( If scopy does not available or can’t
pass by the lesion – to known lower extent & asso;
underlying premalignant condition)
- Persistent irregular filling defect
(Rat’s tail appearance )
- Degree of narrowing of esophageal
lumen
3. Exfoliated cytology (If scopy does not available)
23. For Staging
1. CXR (PA) - Mediastinal L/N
- 2° to lungs
- Aspiration pneumonia
2. CT / MRI - Site , size , circumferential invol;
- reginal L/N , Lungs & pleural 2°,pleural effusion
3. USG (abd) - 2° to liver, coeliac L/N
4. Endoscopic ultrasound - can determine the death of tumor
penetration through the esophageal wall (T1-3), the
invasion of adjacent organs (T4) , & metastasis to L/N (N0 or
N1)
5. Bronchoscopy & Laryngoscopy for vocal cord condition &
TE fistula
6. Positron emission tomography/ Computerized
tomography scan
24. Pre-operative investigation
- Blood for CP
- Urea &electrolyte
- Urine RE & Sugar
- CXR & ECG
- Special investigation
- Nutritional assess; - T & DP
- Pulmonary assess; - Sputum for C & S
- PEFR, Pul; function
test
(FEV 1 / FVC = >75% )
25. Pre-operative preparation
1. Correct U & E
2. Correct anaemia
3. Optimize nutrition
- Withdraw solid food
- Start high-protein liquid diet
- Enteral feed via an NG tube ( if necessary)
4. Optimize respiratory function
- Encourage patient to give up smoking
- Intensive physiotherapy
- Treat any chest infection
26. ECG, PFT,
Anaesthetic assess;
Dx – endoscopy/biopsy
Is patient fit for surgery ?
(and also wants surgery)
No Yes
Contrast-enhanced
CT scan
Palliation
Unresectable
Endoscopic USG (+/-
laparoscopy if gastric
component)
Resectable
>T2N0 Consisder Pre-op
Chemotherapy <T2N0
Resection
M1
M0
27. Treatment of Ca oesophagus
Aim of treatment
To maintain normal function by restoration
of continuity of GIT.
Treatment plan → Operable or Inoperable
- depend on stage of tumor , size of tumor
as well as patient’s general condition
28. Inoperation / unfit for operation
(1) Patient’s factors
- >75 years
- AMI last 6 months
- FEV 1 / FVC = < 60%
(2) Tumor factors
- > T2N0
- Extensive local invasions
- Haematogenous metastasis
- L/N metastasis
- Peritoneal spread
29. Patient fit for operation
1. Early Ca – Radical surgery
2. Advance Ca - Resectable – palliative symptomatic
resection
- Unresectable – palliative intubation
/ by pass
30. (a) Lower & Middle ⅓
1. Lewis Tanner operation ( Ivor Lewis) ( 2 stages )
- initial laparotomy( upper mid lines incision )
- Mobilized the stomach
- divided the Lt gastric, short gastric, & Lt gastroepiploric
arteries
- The stomach is divided to remove the cardia & the upper part
of the lesser curve, including the whole of the Lt gastric
artery & its associated L/N
- Rt thoracotomy (5th Rt ICS incision)
- The azygos vein is divided
- mobilized the esophagus along the thoracic duct
- divided the esophagus (Esophagectomy) just below the
thoracic inlet (proximal clearance of at least 5 cm )
- Esophagogastric anastomosis (Esophago gastrotomy) was
done (by hand or stapler)
31. 2. Mckeown’s operation (3 stages )
- abd incision ( upper mid lines )
- Mobilized the stomach
- 5th Rt ICS incision mobilized the oesophagus
- Neck incision along ant; border of
sternomastoid m/s pull up the oesophagus
& stomach into neck & Esophagectomy &
Esophago gastrotomy done outside the neck
32. 3. Orringer’s operation (Transhiatal oesophagectomy)
- suitable for cancer involving the distal oesophagus
Abd; - upper mid lines abd; incision
- Mobilized the stomach
- The diaphragm is opened
- The posterior mediastinum is entered
- Lower oesophagus & tumor are mobilized
- Upper oesophagus is mobilized by blunt
dissection
Neck - Neck incision along ant; border of
sternomastoid m/s pull up the
oesophagus & stomach into neck &
Esophagectomy & Esophago gastrotomy done
outside the body
33. (b) Upper ⅓ Ca
- Mckeown’s operation
- Radio therapy – commonly use
( All type of CA – Surgical treatment follow by Radio therapy &
Chemotherapy )
2° Advance unresectable Ca
To maintain swallowing fun by intubation or by pass
operation
- Intubation – celestine intubation following by R/T &
Chemo; Rx
- By pass operation – colonic / jejunal interpositioning
- Feeding Gastrostomy / Jejunostomy
Lasar photocoagulation to maintain the lumen of oesophagus
34. Post operative treatment of Ca esophagus
• Minimize pain preferably using a thoracic epidural
• Minimize respiratory failure by;
- Careful patient selection
- Pre-operative physiotherapy
- Post-operative intensive care
- Good pain control
• Minimize post-operative nutritional deficiency
(eg; site a feeding jejunostomy during the
operation)
35. Post operative complication following
oesophagectomy
(1) Pulmonary complication
- the commonest cause of morbidity &
death after oesophagectomy
- 20 – 30 % of patients
- Atelectasis , Pleural effusion , Acute
respiration distress syndrome (ARDS)
- Prevention & treatment
- Routine postoperative bronchoscopy
& bronchial aspiration
36. - ARDS - prone ventilation & prone
position for 6 Hrs every day for 4 days
- Chest drainage is performed routinely after
thoracotomy ; the type of chest drainage or
use of negative pressure suction drainage does
not seem to influence outcome.
(2) Cardiovascular complication
- Arrhythmias occur most commonly on
postoperative days 2-4 .
37. (3) Anastomotic leaks
- 20% of leaks occur before the 7th
postoperative day
- Leak rate ↑ -Period of intra operative
hypotension
- For both hand-sutured & stapled
anastomosis , surgical technique & experience
seem to be the main determinants of a leak.
- Dx by - Clinically
- Water-soluble contrast radiology
- CT scan
38. (4) Bleeding
- From the wound itself
- From intercostal or tracheobronchial vessels
- From the anastomosis staple or suture lines.
(5) Chylotheorax
(6) RLN injuries
(7) Tracheal injury & Tracheo-oesophageaL fistula
(8) Gastric outlet obstruction
(9) Benign anastomotic stricture
39. Inoperation / unfit for operation
• Aim of the palliative treatment
To overcome debilitating or distressing
symptoms while maintaining the best quality
of life possible for the patient & the principle
aim of palliation is to restore adequate
swallowing.
40. Palliative management of advance
esophageal cancer
1. External beam radiotherapy – is better for SCC. It may
produce strictures or fistulation subsequently.
2. Chemotherapy – is good for adenocarcinomas but
patient need to be fairly fit to tolerate it.
3. Intubation - the method of choice is intubation using
a self-expanding metal stent via fibreoptic endoscopy
with or without radiological control. Although
intubation can keep the esophagus patient, a special
diet need to be followed otherwise the stent can
become blocked. Problems include migration of the
stent or tumor growing over or through it.
41. 4. Endoscopic Laser – is good for short, intricsic
tumors to restore swallowing. It may need
repeating. There is a danger of perforation.
5. Ethanol injection - Absolute alcohol can be
injected under endoscopic control via a
variceal injection needle into the obstructing
tumor tissue to induce necrosis.
6. Electrocoagulation – BICAP probe
7. Brachytherapy - involves the placement of a
radioisotope within the lumen of the tumor.
8. Surgical bypass
