Neoplasms of esophagus

1. NEOPLASMS OF ESOPHAGUS
PRESENTER - DR. SANGEM SAI NIKHIL (PG)
MODERATOR – DR. SALINI (ASSISTANT PROFESSOR)

2. BENIGN TUMORS
• Mc – Leiomyoma (70%)
• 2nd Mc – Esophageal cysts (20%)

4. LEIOMYOMA
• Account for 2/3rd of all benign tumors of esophagus.
• Dysphagia occurs when tumor is more than 5 cm in diameter
• Diagnosis – esophagoscopy and barium swallow
• Biopsy is contraindicated – can cause perforation.

5. TREATMENT
• Enucleation
• Limited esophageal resection if tumor lies in lower esophagus and cannot be
enucleated.

6. ESOPHAGEAL CYSTS
• 2nd most common – 20% of benign esophageal tumors
• Congenital foregut cyst
• Acquired epithelial cyst

8. • Papilloma - associated with HPV and GERD, endoscopic excision
• Fibrovascular polyp – diagnosed with barium swallow, endoscopy, excision.
• Lipoma – usually asymptomatic and can be observed
• Fibroma – if symptomatic – enucleation.
• Hemangioma – it looks like esophageal varices – dysphagia, bleeding
Tx – observation, excision, radiotherapy.

9. CARCINOMA ESOPHAGUS
• Introduction
• Etiology
• Classification
• Spread
• Clinical features
• Investigations
• Diagnosis and Staging
• Treatment
• Prognosis

10. INTRODUCTION
• It is the 8TH most common cancer worldwide and is 6TH most common cause of cancer
related death.
• It most commonly presents in 6TH and 7TH decades of life.
• SCC and Adenocarcinoma are the most common cell types while other malignancies
such as melanoma and small cell carcinomas are rare.
• SCC is the predominant histological type.
• SCC remains steady, however in western countries, there has been an epidemiological
shift since the 1990s from SCC to adenocarcinoma such that incidence of
adenocarcinoma has surpassed that of SCC.

11. ANATOMICAL SPECIALTIES
• Lacks serosa
• Proximal 1/3 striated muscle and distal 2/3 smooth muscle.
• Segmental blood supply.
• Longitudinal arrangement of veins and lymphatics
• SCC most commonly occurs in middle 3rd of esophagus.
• Adenocarcinoma most commonly occurs in lower 3rd of esophagus

13. ETIOLOGY
• RISK FACTORS FOR SCC
 Alcohol
 Smoking
 Vit c deficiency
 Hot beverages
 Smoked fish and nitrosamine compounds
 Zinc, selenium, molybdenum deficiency
 HPV 16, 18
 Achalasia cardia
 Plummer vinson syndrome
 Tylosis
 Alkali injury
 Genetic predisposition
 Fanconi syndrome

14. RISK FACTORS OF ADENOCARCINOMA
Barrett’s esophagus
Obesity
Smoking
Scleroderma
Hiatus hernia
GERD
Scleroderma
Zollinger Ellison syndrome

16. SPREAD
• DIRECT SPREAD
Lack of serosa favors local extension.
It can spread through muscular layer and get adherent to left main bronchus, trachea,
recurrent laryngeal nerve( causes hoarseness), aorta or its branches(causes fatal hemorrhage).
Can perforate and cause mediastinitis.
broncho-esophageal, trachea-esophageal, esophageal-aortic fistulas can occur in advanced
cases.

17. • LYMPHATIC SPREAD
In the neck it spreads to the supraclavicular lymph nodes
Thorax – it spreads to para esophageal, tracheoesophageal and subdiaphragmatic
lymph nodes.
Abdomen – to the coeliac lymph nodes
• BLOOD spread to the liver, lungs, brain and bones

18. CLINICAL FEATURES
• Progressive dysphagia is the most common
symptom. Solids > liquids. More than 70
percent of lumen should be blocked to cause
significant dysphagia.
• Regurgitation
• Anemia
• Weight loss
• Halitosis
• Substernal or abdominal pain
• Hoarseness of voice when RLN is involved
• Aspiration and choking when tumor
obstruction is present or airway-esophageal
fistula
• Choking and cough on drinking water are
typical of fistula and associated hemoptysis is
common.
• Ascites due to liver secondaries
• Bronchopneumonia

19. INVESTIGATIONS
• 1ST / IOC – Endoscopy with biopsy
• IOC for Staging – PET-CT > CECT
• IOC for metastasis – 18 FDG PET

20. BARIUM SWALLOW
• Irregular filling defect • Shouldering sign

23. • Biopsy – for confirming diagnosis and histological type
• Chest x ray – to look for aspiration pneumonia
• Bronchoscopy / laryngoscopy – to see invasion in cases of upper 1/3rd growths

24. ENDOSCOPIC ULTRASONOGRAPHY
• To look for the depth of the tumor, involvement of nodes, cardia and left lobe of
liver. Nodes smaller than 5mm can be very well visualized by EUS which may be
missed in CT scan.
• It is the only imaging modality able to distinguish the various layers of esophagus
wall, usually seen as five alternating hyper and hypoechoic layers using 12-MHz
ultrasound.
• The drawback is that many advanced cancers do not permit passage of a
conventional echoendoscope.

28. CT SCAN
• To look for local extension, nodal status, peri esophageal, diaphragmatic,
pericardial vascular infiltration, obliteration of mediastinal fat and status of
tracheobronchial tree in case of upper third growth

29. FDG-PET
• SCC are FDG avid.
• Adenocarcinomas of OGJ sometimes show limited or absent FDG accumulation
regardless of tumor volume.
• It is mostly used for detecting regional and non regional nodes, as well as distant
metastasis.
• Change in uptake after neoadjuvant treatment is similarly useful in predicting
histological response and outcome

31. OTHER INVESTIGATIONS
• USG abdomen – to look for liver secondaries , lymph node status in abdomen.
• Chromoendoscopy using lugol’s iodine – normal mucosa is stained brown, while
dysplastic and early cancer are unstained.
• Laparoscopy – to see peritoneal spread, liver spread and nodal spread. Biopsy can
be taken from different places.
• Video assisted thoracoscopic approach – to stage esophageal carcinoma

33. STAGING
• Careful disease staging is essential to guide therapy.
• Current staging classification is according to American Joint Committee on
Cancer(AJCC)

35. TREATMENT
• CURATIVE
• PALLIATIVE

36. ENDOSCOPIC MUCOSAL RESECTION
• It is basically a diagnostic biopsy tool, but can be therapeutic in early and pre
malignant lesion.
• T1a tumors are resected by EMR as risk of lymph node metastasis is very low.
• It involves injection of saline (or other solutions such as glycerol or hyaluronic
acid) into the submucosal plane to raise the mucosal lesion.
• It is then sucked into a cap fitted onto tip of endoscope, looped by a snare wire
and cut by electrocautery.
• For larger lesions, piecemeal resection is needed.

38. ENDOSCOPIC SUBMUCOSAL DISSECTION
• It involves marking of margins of lesion, then submucosal injection, cutting the
mucosal edges along line of marking, submucosal dissection of tumor from its
bed and lastly hemostasis.
• It is more demanding than EMR.
• There is increased risk of post resection stricture formation if too much the
circumference of mucosa is removed.
• For early barrett’s , EMR and ESD can be done with additional ablation of whole
length of barrett’s using RFA.

40. PRINCIPLES
• Only 20 percent of esophageal cancers present early. In such early growths
confirmed with the absence of nodal spread, curative surgery is the main
approach– radical esophagectomy.
• Proximal extent of resection should be minimum of 10cm and distal extent
minimum 5 cm from the macroscopic tumor.
• Proximal stomach has to be removed in lower 1/3 tumors.
• If nodes are present, the multimodal treatment should be used – curative
treatment , chemo/radiotherapy.

41. • Outcome of surgery depends on location of tumor, number , location, size of
nodes, tumor grading.
• Neoadjuvant therapy prior to surgery may improve the survival.
• Aggressive chemoradiation may be used as curative therapy in some patients of
upper 1/3rd growths who are unfit for surgery.
• Palliative therapy is done for patients unfit for surgery, having metastasis. It is to
relieve pain and dysphagia, and also to prevent aspiration and bleeding.

42. APPROACH FOR DIFFERENT LEVEL TUMOURS
 Post cricoid tumour (Squamous cell carcinoma):
• Treated mainly by radiotherapy. Radical radiotherapy— 5000-6000 rads.
• Often pharyngo-laryngo-esophagectomy is done along with gastric or colonic transposition.
But complications are more in this procedure. Free jejunal transfer is the other option.
• Definitive chemoradiotherapy has become the alternative treatment to preserve the larynx.

43. UPPER 1/3RD GROWTH(SCC)
• Treated mainly by stereotactic radiotherapy with concomitant chemotherapy.
• Usually unresectable due to invasion of trachea, larynx and great vessels.
• Surgery is mostly reserved for salvage, when there is incomplete response or for
recurrent disease.
• In early and operable cases McKeown three phased esophagectomy and
anastomosis can be done.

44. MCKEOWN THREE PHASED ESOPHAGECTOMY
• It consist of
• Cervical component
• Thoracic component
• Abdominal component

45. ABDOMINAL COMPONENT
• It is performed first.
• Stomach mobilization
• Duodenum kocherisation
• Pyloroplasty
• Esophagial hiatus mobilized and hiatal opening enlarged.
• Stomach partially delivered into chest cavity.
• Feeding jejunostomy can be placed and abdomen closed.

46. THORACIC COMPONENT
• Right posterolateral thoracotomy in 4th 5th intercostal space.
• Ventilation maintained through one lung anesthesia.
• Inferior pulmonary ligament divided, lung retracted, mediastinal pleura over
esophagus divided, azygos vein ligated.
• Esophagus dissected and para esophageal nodes included in resected specimen.
• Care taken not to damage RLN.
• Ligation of thoracic duct depends on surgeon to reduce the incidence of
chylothorax.
• Stomach is fully delivered into chest. Stomach divided and closed into tubular
conduit.

47. CERVICAL COMPONENT
• Esophagus encircled by a soft drain.
• Cervical esophagus divided and latex drain attached to distal portion, it is then
pulled through thoracotomy opening.
• Latex drain then attached to gastric tube or alternative conduit and delivered into
neck and anastamosed.

49. MIDDLE 1/3RD GROWTH
• Ivor lewis operation( lewis – tanner two staged esophagectomy) – abdominal and
right thoracotomy.
• Partial esophagectomy and esophagogastric anastomosis is done in thorax.
• If growth is inoperable, palliative radiotherapy is given.

50. LOWER 1/3RD GROWTH (SCC AND
ADENOCARCINOMA)
• Left thoraco-abdominal approach ,partial esophagectomy is done with
esophagogastric anastomosis. Often jejunal roux-en-y anastomosis is done.
• Orringer approach i.e transhiatal blind total esophagectomy with anastomosis in
left side of neck

51. THORACO ABDOMINAL ESOPHAGECTOMY
• Suitable approach for tumors involving distal esophagus, OGJ and gastric cardia.
• Right lateral decubitus position.
• Single incision transverse or oblique abdominal incision extending onto left
chest.
• 6th 7th 8th ICS.
• Diaphragm incised in circumferential manner around hiatus to prevent injury to
phrenic nerve or its branches.
• Inferior phrenic artery ligated, lung retracted upwards.
• Stomach mobilized, esophagus freed with longitudinal incision in parietal pleura
between aorta and pericardium.

52. • Vagus identified and divided, distal esophagus encircled with soft drains and
dissected.
• Thoracic duct ligated above diaphragm to prevent chylothorax.
• Stomach is divided and gastric conduit formed.
• Esophago-gastric anastomosis performed beneath aortic arch.
• Gastric tube is sutured to diaphragmatic edge to prevent herniation.
• 2 chest drains placed- apex and base of left lung.
• Thoracic incision makes patient more prone to respiratory complications.

54. TRANSHIATAL ESOPHAGECTOMY
• Involves abdominal and cervical incisions only.
• Stomach, OGJ and distal esophagus mobilized through abdominal incision.
• Intrathoracic component of esophagus frees through hiatus and proximally via
the cervical incision.
• Resected esophagus is reconstructed using gastric remnant or intestinal loop.
• It is passed through chest via posterior mediastinum and anastamosed to cervical
esophagus without tension.

57. MINIMALLY INVASIVE PROCEDURES
• Traditional open procedures are increasingly replaced by minimally invasive
methods, by a combination of video – assisted thoracoscopy(VATS) and
laparoscopy or robotic techniques.
• Both thoracic and abdominal phases can be performed via minimally invasive
technique or one phase can be done by open surgery (HYBRID surgery).

59. ESOPHAGEAL CONDUITS
• Best – stomach
• Colon
• Jejunal roux loop
Routes
• Posterior mediastinal
• Retrosternal
• Subcutaneous

61. LYMPHADENECTOMY
• Two field dissection – mediastinal nodes and upper abdominal nodes around
coeliac trunk.
Mediastinal field –
• Standard – below tracheal bifurcation
• Extended – standard plus right paratracheal including those around right RLN.
• Total – extended plus nodes around left RLN.
 Three field lymphadenectomy – Two field plus bilateral cervical nodes including
supraclavicular nodes.

63. COMPLICATIONS
• Hemorrhage
• Atelectasis
• Pneumonia
• Atrial fibrillation
• Arrythmias
• Anastomotic leak
• Ischemia of conduit
• RLN injury
• Mediastinitis
• Chylothorax
• Stricture

64. CHEMOTHERAPY
CROSS REGIME
• Cisplatin
• 5-Flourouracil
MAGIC TRIAL
• Cisplatin , 5-FU , epirubicin
COMPLICATIONS
• Nephrotoxic, neurotoxic, ototoxic,
highly emetogenic
• Methotrexate
• Paclitaxel
• Etoposide
• Bleomycin

65. PALLIATIVE THERAPY
• 80% of patients have advanced tumor at time of presentation and they are only
amenable to palliative care.
• To relieve pain
• To relieve dysphagia
• To prevent bleeding
• To prevent aspiration
• Is done when patient is not fit for surgery, metastasis.

66. • Stenting – SEMS – self expanding metallic stents
• Radiotherapy
• Photodynamic therapy
• Cryotherapy
• Endoscopic laser
• Intubation

67. PROGNOSIS
Not good because of –
• Early spread
• Longitudinal lymphatics
• Difficult approach
• Late presentation
• 5 year survival rate in india is 15 - 20 %

68. THANK YOU