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Esophageal cancer

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Esophageal cancer

  1. 1. Malignant DisordersMalignant Disorders of the Esophagusof the Esophagus
  2. 2. Esophageal CancerEsophageal Cancer  88thth commonest cancercommonest cancer  Nepal : 3.79/ 100 000 -Nepal : 3.79/ 100 000 -  Most esophageal tumors are malignant, fewerMost esophageal tumors are malignant, fewer than 1% are benignthan 1% are benign  High prevalence areas are Asia, Africa andHigh prevalence areas are Asia, Africa and northern Francenorthern France  13,000 new patients in the United States13,000 new patients in the United States
  3. 3. Esophageal CancerEsophageal Cancer  Most patients still present with locally advancedMost patients still present with locally advanced (stage T 3 and/or N 1 ) disease(stage T 3 and/or N 1 ) disease  Two types of histologyTwo types of histology Squamous cellSquamous cell Adeno CaAdeno Ca
  4. 4. Esophageal CancerEsophageal Cancer  Adeno Ca now becoming predominantAdeno Ca now becoming predominant  Squamous cell still persists in patients with theSquamous cell still persists in patients with the usual risk factors for other aerodigestive tractusual risk factors for other aerodigestive tract carcinomas.carcinomas.
  5. 5. Risk FactorsRisk Factors  CONSUMPTION OF:CONSUMPTION OF: Tobacco, Alcohol (5 times each)Tobacco, Alcohol (5 times each)  UNDER-CONSUMPTION OF:UNDER-CONSUMPTION OF: Fruits, Fresh meat, Riboflavin. Beta-carotene,Fruits, Fresh meat, Riboflavin. Beta-carotene, Vitamin C, Magnesium, Vegetables, Fresh fish,Vitamin C, Magnesium, Vegetables, Fresh fish, Niacin, Vitamin A, Vitamin B complex, ZincNiacin, Vitamin A, Vitamin B complex, Zinc
  6. 6. Risk FactorsRisk Factors  PREDISPOSING CONDITIONS:PREDISPOSING CONDITIONS: Caustic injury, Esophageal webs, Achalasia, Barrett'sCaustic injury, Esophageal webs, Achalasia, Barrett's esophagus, Esophageal diverticulaesophagus, Esophageal diverticula  OTHER EXPOSURE:OTHER EXPOSURE: Asbestos, Ionizing radiation, Exceptionally hotAsbestos, Ionizing radiation, Exceptionally hot beverages (tea), Location: Middle East, South Africa,beverages (tea), Location: Middle East, South Africa, northern China, southern Russia, Indianorthern China, southern Russia, India
  7. 7. Anatomy of EsophagusAnatomy of Esophagus
  8. 8. Squamous Cell CarcinomaSquamous Cell Carcinoma  95% of esophageal cancer worldwide95% of esophageal cancer worldwide  Commonly 7Commonly 7thth decade of life, 1.5-3 times moredecade of life, 1.5-3 times more common in mencommon in men  Thought to occur from prolonged exposure ofThought to occur from prolonged exposure of esophageal mucosa to noxious stimuli in personsesophageal mucosa to noxious stimuli in persons with a genetic predisposition to the disease.with a genetic predisposition to the disease.
  9. 9. Squamous Cell CarcinomaSquamous Cell Carcinoma  Histologically, characterized by invasive sheetsHistologically, characterized by invasive sheets of cells that run together and are polygonal, oval,of cells that run together and are polygonal, oval, or spindle-shaped with a distinct or raggedor spindle-shaped with a distinct or ragged stromal-epithelial interface.stromal-epithelial interface.  Located mainly in the thoracic esophagus,Located mainly in the thoracic esophagus, approximately 60% of these tumors are found inapproximately 60% of these tumors are found in the middle third and about 30% in the distalthe middle third and about 30% in the distal third.third.
  10. 10. Squamous Cell CarcinomaSquamous Cell Carcinoma  Four major gross pathologic presentations:Four major gross pathologic presentations: (1) fungating: predominantly intraluminal growth(1) fungating: predominantly intraluminal growth with surface ulceration and extreme friabilitywith surface ulceration and extreme friability that frequently invades mediastinal structures;that frequently invades mediastinal structures; (2) ulcerating: flat-based ulcer with slightly raised(2) ulcerating: flat-based ulcer with slightly raised edges; hemorrhagic, friable with surroundingedges; hemorrhagic, friable with surrounding indurationinduration
  11. 11. Squamous Cell CarcinomaSquamous Cell Carcinoma (3) infiltrating: a dense, firm, longitudinal and(3) infiltrating: a dense, firm, longitudinal and circumferential intramural growth patterncircumferential intramural growth pattern (4) polypoid: intraluminal polypoid growth with a(4) polypoid: intraluminal polypoid growth with a smooth surface on a narrow stalk (fewer thansmooth surface on a narrow stalk (fewer than 5% of cases)5% of cases)  A 5-year survival of 70% is associated with theA 5-year survival of 70% is associated with the polypoid tumor compared with a less than 15%polypoid tumor compared with a less than 15% 5-year survival for all other types5-year survival for all other types
  12. 12. AdenocarcinomaAdenocarcinoma  Most common cell type of esophageal cancer inMost common cell type of esophageal cancer in the United States and Europe.the United States and Europe.  Adenocarcinoma arises from the superficial andAdenocarcinoma arises from the superficial and deep glands of the esophagus, mainly in thedeep glands of the esophagus, mainly in the lower third of the esophagus, especially near thelower third of the esophagus, especially near the gastroesophageal junction.gastroesophageal junction.
  13. 13. AdenocarcinomaAdenocarcinoma  Whites are at four times greater risk than blacksWhites are at four times greater risk than blacks  Men have an eightfold higher risk than women.Men have an eightfold higher risk than women.  In the US and Europe, frequency of this tumorIn the US and Europe, frequency of this tumor is increasing faster than any other cancer.is increasing faster than any other cancer.
  14. 14. AdenocarcinomaAdenocarcinoma  Esophageal adenocarcinoma may have one ofEsophageal adenocarcinoma may have one of three origins:three origins: • malignant degeneration of metaplastic columnarmalignant degeneration of metaplastic columnar epithelium (Barrett's mucosa)epithelium (Barrett's mucosa) • heterotopic islands of columnar epitheliumheterotopic islands of columnar epithelium • the esophageal submucosal glands.the esophageal submucosal glands.
  15. 15. AdenocarcinomaAdenocarcinoma  Gastric adenocarcinoma may also involve the esophagusGastric adenocarcinoma may also involve the esophagus secondarily.secondarily.  Gastroesophageal junction tumors arise initially as flat or raisedGastroesophageal junction tumors arise initially as flat or raised patches of mucosa. They may subsequently ulcerate and becomepatches of mucosa. They may subsequently ulcerate and become large (up to 5 cm) nodular masses.large (up to 5 cm) nodular masses.  Tumor size is related to prognosis. For tumors smaller than 5Tumor size is related to prognosis. For tumors smaller than 5 cm, 40% are localized, 25% have spread beyond the esophagus,cm, 40% are localized, 25% have spread beyond the esophagus, and 35% have metastasized or are unresectable. For tumors thatand 35% have metastasized or are unresectable. For tumors that are more than 5 cm in length, 10% are localized, 15% haveare more than 5 cm in length, 10% are localized, 15% have invaded mediastinal structures, and 75% have metastasized.invaded mediastinal structures, and 75% have metastasized.
  16. 16. Rare esophageal cancersRare esophageal cancers  Anaplastic small cell (oat cell) carcinoma arise inAnaplastic small cell (oat cell) carcinoma arise in the esophagus from same argyrophilic cellsthe esophagus from same argyrophilic cells found in the lung.found in the lung.  Adenoid cystic esophageal carcinomaAdenoid cystic esophageal carcinoma  Primary malignant melanoma of esophagusPrimary malignant melanoma of esophagus  Carcinosarcoma, features of SSC and malignantCarcinosarcoma, features of SSC and malignant spindle cell sarcoma.spindle cell sarcoma.
  17. 17. Clinical FindingsClinical Findings  Dysphagia in more than 90% of patients withDysphagia in more than 90% of patients with esophageal canceresophageal cancer  Nonspecific retrosternal discomfortNonspecific retrosternal discomfort  IndigestionIndigestion  Weight lossWeight loss  PainPain  Regurgitation, resp symptoms, hoarsenessRegurgitation, resp symptoms, hoarseness
  18. 18. Clinical FindingsClinical Findings SymptomSymptom PercentPercent  DysphagiaDysphagia 87-9587-95  Weight lossWeight loss 42-7142-71  Vomiting or regurgitationVomiting or regurgitation 29-4529-45  PainPain 20-4620-46  Cough or hoarsenessCough or hoarseness 7-267-26  DyspneaDyspnea 55
  19. 19. Clinical FindingsClinical Findings  Careful examination of cervical andCareful examination of cervical and supraclavicular lymph nodessupraclavicular lymph nodes  FNA or excisional biopsy for diagnosisFNA or excisional biopsy for diagnosis  Evaluate for abdominal masses and liverEvaluate for abdominal masses and liver nodularitynodularity  Labwork, imaging studiesLabwork, imaging studies
  20. 20. Barium swallowBarium swallow Barium swallowBarium swallow evaluationevaluation MucosalMucosal irregularityirregularity Tumor shelfTumor shelf
  21. 21. EndoscopyEndoscopy Endoscopic evaluationEndoscopic evaluation Esophageal biopsyEsophageal biopsy and brushings forand brushings for cytologycytology EstablishesEstablishes diagnosis in 95% ofdiagnosis in 95% of patients withpatients with malignant stricturesmalignant strictures
  22. 22. Imaging StudiesImaging Studies  Computed tomography (CT) of the chest andComputed tomography (CT) of the chest and upper abdomen is the standard radiographicupper abdomen is the standard radiographic technique for staging esophageal cancer.technique for staging esophageal cancer.  Normal esophageal wall thickness 5mmNormal esophageal wall thickness 5mm  Regional adenopathyRegional adenopathy  Metastasis to lung, liver, adrenal, or distantMetastasis to lung, liver, adrenal, or distant nodesnodes  FNA biopsy for tissue diagnosisFNA biopsy for tissue diagnosis
  23. 23. Imaging StudiesImaging Studies  Positron emission tomography (PET)Positron emission tomography (PET)  Does not rely on anatomic or structuralDoes not rely on anatomic or structural distortion for detecting malignancydistortion for detecting malignancy  PET is 88% sensitive, 93% specific, and 71 toPET is 88% sensitive, 93% specific, and 71 to 91% accurate for identifying distant metastasis91% accurate for identifying distant metastasis
  24. 24. Imaging StudiesImaging Studies  Cellular FDG uptake is not specific for tumorsCellular FDG uptake is not specific for tumors and that areas of inflammation often predisposeand that areas of inflammation often predispose to false-positive resultsto false-positive results  MRI has a 56 to 74% accuracy in detectingMRI has a 56 to 74% accuracy in detecting lymph node metastaseslymph node metastases
  25. 25. Endoscopic UltrasoundEndoscopic Ultrasound  Method of choice to determine depth of tumorMethod of choice to determine depth of tumor invasion and regional nodal disease andinvasion and regional nodal disease and involvement of adjacent structures, with aninvolvement of adjacent structures, with an overall accuracy to 92%overall accuracy to 92%  A significant error associated with endoscopicA significant error associated with endoscopic ultrasound T staging is to overstage 7 to 11% ofultrasound T staging is to overstage 7 to 11% of early diseaseearly disease
  26. 26. Endoscopic UltrasoundEndoscopic Ultrasound
  27. 27. TNM StagingTNM Staging  T: PRIMARY TUMORT: PRIMARY TUMOR • T 0 No evidence of a primary tumorT 0 No evidence of a primary tumor • T is Carcinoma in situ (high-grade dysplasia)T is Carcinoma in situ (high-grade dysplasia) • T 1 Tumor invading the lamina propria, muscularis mucosae,T 1 Tumor invading the lamina propria, muscularis mucosae, or submucosa but not breaching the boundary betweenor submucosa but not breaching the boundary between submucosa and muscularis propriasubmucosa and muscularis propria • T 2 Tumor invading muscularis propria but not breaching theT 2 Tumor invading muscularis propria but not breaching the boundary between muscularis propria and periesophagealboundary between muscularis propria and periesophageal tissuetissue • T 3 Tumor invading periesophageal tissue but not adjacentT 3 Tumor invading periesophageal tissue but not adjacent structuresstructures • T 4 Tumor invading adjacent structuresT 4 Tumor invading adjacent structures
  28. 28. TNM StagingTNM Staging  N: REGIONAL LYMPH NODESN: REGIONAL LYMPH NODES  N 0 No regional lymph node metastasisN 0 No regional lymph node metastasis  N 1 Regional lymph node metastasisN 1 Regional lymph node metastasis  M: DISTANT METASTASISM: DISTANT METASTASIS  M 0 No distant metastasisM 0 No distant metastasis  M 1 Distant metastasisM 1 Distant metastasis
  29. 29. Stage GroupingStage Grouping  Stage 0Stage 0 T 0 N 0T 0 N 0 T is N 0 M0T is N 0 M0  Stage IStage I T 1 N 0 M0T 1 N 0 M0  Stage IIStage II IIAIIA T 2 N0 M 0T 2 N0 M 0      T 3 N 0 M0T 3 N 0 M0 IIBIIB T 1 N 1 M0T 1 N 1 M0      T 2 N 1 M0T 2 N 1 M0
  30. 30. Stage GroupingStage Grouping  Stage IIIStage III T 3 N 1 M0T 3 N 1 M0 T 4 any N M 0T 4 any N M 0  Stage IVStage IV any T any N M 1any T any N M 1
  31. 31. 5 Year Survival5 Year Survival  Stage IStage I 50-55%50-55%  Stage IIAStage IIA 15-35%15-35%  Stage IIBStage IIB 15-27%15-27%  Stage IIIStage III 4-15%4-15%  Stage IVStage IV 0-2%0-2%
  32. 32. AlgorithmAlgorithm
  33. 33. Treatment OptionsTreatment Options  Palliative Treatment for unresectable lesionsPalliative Treatment for unresectable lesions include:include:  DilatationDilatation  StentingStenting  Photodynamic therapyPhotodynamic therapy  Radiation therapyRadiation therapy  Laser therapyLaser therapy  Surgical palliationSurgical palliation
  34. 34. Treatment OptionsTreatment Options  Curative resection?Curative resection? Ivor – LewisIvor – Lewis Mc KwoenMc Kwoen TranshiatalTranshiatal Minimally invasive esophagectomyMinimally invasive esophagectomy  Mid esophagus approached from rightMid esophagus approached from right  Distal esophagus from leftDistal esophagus from left
  35. 35. Mid-Esophageal TumorMid-Esophageal Tumor
  36. 36. Upper Esophageal TumorUpper Esophageal Tumor
  37. 37. Stomach MobilizationStomach Mobilization
  38. 38. Esophageal SubstitutionEsophageal Substitution
  39. 39. Esophageal SubstitutionEsophageal Substitution
  40. 40. Adjuvant treatmentAdjuvant treatment  Neo-adjuvant treatmentNeo-adjuvant treatment  Definitive chemo-radiotherapyDefinitive chemo-radiotherapy  Palliative radiotherapyPalliative radiotherapy  Palliative Treatment for unresectable lesionsPalliative Treatment for unresectable lesions include:include:  DilatationDilatation  StentingStenting  Photodynamic therapyPhotodynamic therapy  Radiation therapyRadiation therapy 

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