Carcinoma of esophagus n


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Carcinoma of esophagus n

  1. 1. Esophageal Tumors Carcinoma (from the Greek karkinos, or "crab", and -oma, "growth") Carcinoma of Esophagus Carcinoma is a malignant neoplasm of epithelial cell origin. Carcinoma- Malignant epithelial tumor Lecture 5
  2. 2. Esophageal tumors • Most (> 99%)esophageal tumors are MALIGNANT, fewer than 1% are benign. • Benign tumors: Squamous cell papilloma, Adenoma, leiomyoma, lipoma, fibroma, neurofibroma, rhabdomyoma, lymphangioma & hemangioma. • Malignant tumors: are carcinomas because sarcomas are extremely rare.
  3. 3. Carcinoma of esophagus Two morphologic variants : I . Adenocarcinoma <10% II. Squamous cell carcinoma
  4. 4. • Worldwide, squamous cell carcinoma is more common, but in the United States and other Western countries adenocarcinoma is on the rise. • A general rule of thumb is that a cancer in the upper twothirds is a squamous cell carcinoma and one in the lower one-third is an adenocarcinoma.
  5. 5. ADENOCARCINOMA Adenocarcinoma denotes a lesion in which the neoplastic epithelial cells grow in glandular patterns. Adenocarcinoma of the esophagus typically arises in a background of Barrett esophagus and long-standing GERD. Strong association with Barrett Esophagus
  6. 6. Risk of adenocarcinoma Cruciferous Vegetables Barrett esophagus Fruit Age- over 60 (6th -7th decades) Sex- more common in MEN (7times) documented dysplasia tobacco use, obesity, prior radiation therapy. Obesity Risk is reduced Whites H Pylori NSAID(Aspirin) Coffee Pizza by------?
  7. 7. Barrett esophagus is the only recognized precursor of esophageal adenocarcinoma. The degree of DYSPLASIA is the strongest predictor of the progression to cancer.
  8. 8. Dysplasia---Carcinoma in situ--Invasive Carcinoma
  9. 9. Morphology Esophageal adenocarcinoma usually occurs in the distal third of the esophagus and may invade the adjacent gastric cardia. Initially appearing as flat or raised patches in otherwise intact mucosa, large nodular masses of 5 cm or more in diameter may develop. Alternatively, tumors may infiltrate diffusely or ulcerate and invade deeply. Nodular, elevated mass in the lower esophagus
  10. 10. Microscopy of Esophageal Adenocarcinoma • Barrett esophagus is frequently present adjacent to the tumor. • Tumors most commonly produce mucin and form glands, often with intestinal-type morphology.
  11. 11. • less frequently tumors are composed of diffusely infiltrative signetring cells or, • in rare cases, small poorly differentiated
  12. 12. Clinical Features. Dysphagia, Odynophagia ( severe pain on swallowing) Obstruction progressive weight loss, Anorexia, Fatigue, Weakness, hematemesis, chest pain, Cough vomiting.
  13. 13. Diagnosis • • • • • Barium swallow CT PET Endoscopic ultrasound Endoscopy •Biopsy
  14. 14. Prognosis-Poor-dismal • By the time symptoms appear, the tumor has usually spread to submucosal lymphatic vessels. As a result of the advanced stage at diagnosis, overall 5-year survival is less than 25%(15%) with most patients dying within the first year of diagnosis. • In contrast, 5-year survival approximates 80% in the few patients with adenocarcinoma limited to the mucosa or submucosa.
  16. 16. Squamous (Epidermoid) cell carcinoma a cancer in which the tumor cells resemble stratified squamous epithelium. 90% of esophageal cancer.
  17. 17. Risk factors of SCC of Esophagus •Esophageal disorders •Life style or Bad habits •Dietary factors •Genetic predisposition Age, Sex, Poverty, Radiation, Race, HPV, Celiac disease. I. Esophageal disorders: • Long standing esophagitis • Achalasia • Plummer-Vinson Syndrome
  18. 18. II. Life style: • Alcohol • Tobacco • An important contributing variable is retarded passage of food through the esophagus, prolonging mucosal exposure to potential carcinogens such as those contained in tobacco and alcohol beverages. • There is a well-defined predisposing role for chronic esophagitis, which is often the consequences of alcohol and tobacco use.
  19. 19. III. Dietary Factors • Def. of vit. • Def. of trace metals • Fungal contamination of food stuffs • High content of nitrites/nitrosamines • Frequent consumption of very hot beverages.
  20. 20. IV. Genetic predisposition: Nonepidermolytic palmoplantar keratoderma. •Tylosis Howel-Evans syndrome A genetic disorder characterized by thickening (hyperkeratosis) of the palms and soles, white patches in the mouth (oral leukoplakia), and a very high risk of esophageal cancer. Autosomal dominant • Abnormalities affecting the p16/INK4 tumor suppressor gene and the epidermal growth factor receptors are frequently present in SCC of the esophagus. Mutation in of these tumors. p53 in 50%
  21. 21. V. Age. Over 45 VI. Sex. Males females. 4 times more frequently than VII. Poverty VII. Race- more common in BLACKS (6 times) IX. Previous radiation therapy to the mediastinum. X. HPV XI. Coeliac disease
  22. 22. • Esophageal squamous cell carcinoma incidence varies up to 180-fold between and within rural and underdeveloped areas. countries, being more common in • The regions with highest incidences are •Iran, central China, Hong Kong, Brazil, and South Africa.
  23. 23. Pathogenesis The majority of esophageal squamous cell carcinomas in Europe and the United States are at least partially attributable to the use of ALCOHOL AND TOBACCO , which synergize to increase risk.
  24. 24. Pathogenesis of sCC • However, esophageal squamous cell carcinoma is also common in some regions where alcohol and tobacco use is uncommon. Thus, • nutritional deficiencies, as well as • polycyclic hydrocarbons, nitrosamines, and • other mutagenic compounds, such as those found in fungus-contaminated foods, must be considered.
  25. 25. Pathogenesis of sCC • Human papillomavirus (HPV) infection has also been implicated in esophageal squamous cell carcinoma in high-risk areas but not in lowrisk regions.
  26. 26. Pathogenesis of sCC • The molecular pathogenesis of esophageal squamous cell carcinoma remains loss of several tumor suppressor genes, including p53 and p16/INK4a, is involved. incompletely defined, but
  27. 27. Clinical Features • Dysphagia • Odynophagia • Obstruction • Weight loss • Hemorrhage • Sepsis
  28. 28. Morphology • Squamous cell carcinoma begins as an in situ lesion termed squamous dysplasia. • Epithelial dysplasia • Carcinoma in situ • Invasive cancer
  29. 29. MorPhology • Early overt lesions appears as: small, gray-white, plaquelike thickenings or elevation of the mucosa..
  30. 30. In months to years these lesions become tumorous, taking one of three forms: 1. Polypoid fungating type (60%): The most common type. Cauliflower-like friable mass protruding into the lumen. • 2. Ulcerating type (25%): A necrotic ulcer with everted edges that extend deeply and sometimes erode into the respiratory tree (Pneumonia), aorta or elsewhere. (exsanguination)( • 3. Diffuse infiltrative type (15%): appears as annular, stenosing narrowing of the lumen due to infiltration into the wall of esophagus.
  31. 31. • SCC arise about (locations): • 20% in the cervical& upper thoracic esophagus 50% in the middle third • 30% in the lower third
  32. 32. Morphology • Most squamous cell carcinomas are moderately to well-differentiated. Intercellular bridges, Keratinization &Epithelial pearls are commonly seen. Epithelial nest, Epithelial pearl, Squamous pearl Karatin pearl l
  33. 33. Regardless of histology, symptomatic tumors are generally very large at diagnosis and have already invaded the esophageal wall.
  34. 34. • Less common histologic variants include • verrucous squamous cell carcinoma, • spindle cell carcinoma, and • basaloid squamous cell carcinoma
  35. 35. Prognosis- dismal • 5-year survival rates are 75% in individuals with superficial esophageal carcinoma but much lower in patients with more advanced tumors. • Lymph node metastases, which are common, are associated with poor prognosis. • The overall 5-year survival remains a dismal 9%.
  36. 36. Esophageal cancer. A, Adenocarcinoma usually occurs distally and, as in this case, often involves the gastric cardia. B, Squamous cell carcinoma is most frequently found in the mid-esophagus, where it commonly causes strictures.
  37. 37. Normal Esophagus (Squamous epithelium)
  38. 38. in Barrett's esophagus , the squamous epithelia are replaced by intestinalized metaplastic columnar epithelia
  39. 39. Barrett's adenocarcinoma with moderate to poor differentiation. Atypic tumor cells form quite irregular tubules and some form solid cord
  40. 40. Esophageal adenocarcinoma organized into back-to-back glands
  41. 41. Squamous cell carcinoma composed of nests of malignant cells that partially recapitulate the organization of squamous epithelium