Lecture notes for medical students

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2. Introduction & History.

3. Introduction & History.
• Esophageal cancer is a devastating disease.
• It is the 6th most common cause of cancer
deaths worldwide.

4. Etiology

5. Etiology
• Idiopathic
• Congenital
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative

6. Etiology:Risk factors

7. Etiology:Risk factors
• Alcohol
• Tobacco use.
• synergistic effect.
• Adenocarcinoma GERD> Barrett
esophagus (BE),squamous epithelium that
normally lines the esophagus is replaced by
a columnar epithelium.
• Obesity adenocarcinoma, specifically in
individuals with central fat distribution.

8. Etiology:Risk factors -diet
• Aflatoxin
• Areca nuts or betel quid (areca nuts
wrapped in betel leaves)
• Red meat consumption
• Low selenium levels
• Zinc deficiency
• Low dietary folate intake

9. Etiology:Premalignant conditions
• Caustic stricture
• Achalasia cardia
• Prior gastrectomy
• Use of oral bisphosphonates [30]
• Drinking scalding-hot liquids
• Poor oral hygiene
• Plummer-Vinson syndrome
• Human papillomavirus (HPV) infection

10. Etiology:Premalignant conditions
Hereditary Cancer Predisposition
Syndromes
• Familial Barrett esophagus (FBE)
• Bloom syndrome
• Fanconi anemia (FA)
• Tylosis

11. Etiology:Protective factors
• Consumption of raw vegetables and of
citrus fruits was inversely associated with
risk for esophageal adenocarcinoma.

12. Pathophysiology

13. Pathophysiology
• Squamous cell carcinoma(SCC)
• Adenocarcinoma
• SCC is the most common histology in
Eastern Europe and Asia,
• adenocarcinoma is most common in North
America and Western European countries.
• Squamous cells -upper half
• Adenocarcinoma typically lower half

14. Clinical Features

15. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

16. Demography

17. Demography
• 3-6 cases per 100,000 population
• Unlike in the United States, squamous cell
carcinoma is responsible for 95% of all
esophageal cancers worldwide.
• northern Iran, some areas of southern
Russia, and northern China (sometimes
called an "esophageal cancer belt"), the
incidence of esophageal carcinoma may be
as high as 800 cases per 100,000
population.

18. Demography
• Male-to-female ratio is 3-4:1.
• More common with advancing age;

19. Symptoms

20. Symptoms
• Dysphagia, the most common presenting
symptom of esophageal cancer, is initially
experienced for solids but eventually
progresses to include liquids
• Weight loss
• Bleeding
• Pain
• Hoarseness
• persistent cough and recurrent pneumonia

21. Signs

22. Signs
• None
• Lymphadenopathy in the laterocervical or
supraclavicular area
• Hepatomegaly often indicates unresectable
disease.

23. Prognosis
• Overall 5-year survival rate for esophageal
cancer is 18.8%.
• HER-2 positivity and gene amplification are
independently associated with poor
survival.

24. Investigations

25. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology

26. Diagnostic Studies

27. Diagnostic Studies
Imaging Studies
• X-Ray -Barium swallow
• USG
• CT
• Angiography
• MRI
• Endoscopy with biopsy
• EUS
• Nuclear scan PET scan

28. Endoscopy

29. Differential Diagnosis

30. Differential Diagnosis
• Achalasia cardia
• Esophageal Leiomyoma
• Esophageal Stricture
• Gastric Cancer

31. Staging:TNM classification

32. Staging:TNM classification
• Tis - High-grade dysplasia
• T1 - Tumor invades lamina propria or
submucosa
• T2 - Tumor invades muscularis
• T3 - Tumor inades adventitia
• T4 - Tumor invades adjacent structures

33. Staging:TNM classification
• No regional lymph node metastasis
• N1 - 1-2 regional lymph nodes (N1 is site
dependent)
• N2 - 3-6 regional lymph nodes
• N3 - More than 6 regional lymph nodes
• M0 - No distant metastasis
• M1 - Distant metastasis

34. Staging:TNM classification
• Stage I T1,N0,M0
• Stage II T1T2T3 N0/N1M0
• Stage III T1-T4 N1-3 M0
• Stage IV Any T Any N M1

35. Management

36. Management
• Surgery
• Chemoradiation
• Monoclonal antibody

37. Operative Therapy

38. Operative Therapy
• Surgery remains the cornerstone of TT.
• Endoscopic mucosal resection
• Transhiatal esophagectomy [THE
• Ivor Lewis esophagectomy (right
thoracotomy and laprotomy)
• McKeown esophagectomy (right
thoracotomy followed by laprotomy and
cervical anastomosis)

39. Minimally invasive Therapy

40. Minimally invasive Therapy
• Endoscopic mucosal resection
• Minimally invasive esophagectomy
• Video-assisted thoracoscopy (VATS)

41. Chemoradiation

42. Chemoradiation
• Chemotherapy and radiotherapy for
esophageal cancer are delivered
preoperatively.

43. Investigational

44. Investigational
• photodynamic therapy
• Monoclonal antibody

45. Palliative Care

46. Palliative Care
• Endoscopic lumen restoration or
enhancement
• Temporary self-expanding metal stents
(SEMS)
• External beam radiation therapy (EBRT)
• Brachytherapy
• Chemotherapy
• Laser
• Surgery

47. Prevention of Esophageal
Cancer

48. Prevention of Esophageal
Cancer
• Smoking cessation
• Reduce alcohol abuse
• More fruits, vegetables, and vitamins
• Control of gastroesophageal reflux
• Surveillance upper endoscopy with biopsy
should be considered for patients who have
one of the following hereditary cancer
predisposition syndromes.

49. Hereditary Cancer Predisposition
Syndromes
• Familial Barrett esophagus (FBE)
• Bloom syndrome
• Fanconi anemia (FA)
• Tylosis

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