Esophageal Cancer

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A case presentation of patient with CA esophagus we managed and literature review at the end

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  • This is a colorful dinner.we can see there are fish, egg, beef, a lot of vegetalble, fruits,such as water melon. and so on. How delicious they are!. But if a people cannot swallow the food, it must be terrible. And he may have this disease, esophageal cancer.
  • First of all, let’s have a look at the normal esophagus. It is a hollow muscular tube , about 10-inch long, extent from the throat to the stomach. When people eat, the esophagus will contract and push the food down into the stomach. This picture shows the detail structure. Esophagus has four layers: the inner layer is mucosa, then submucosa, muscle, and the outer t layer, fibrous membrane. In the chest, the esophagus locates in the posterior mediastinum. We can see in front of the esophagus,they are the trachea, brochus and heart, please notice here.. Behind the esophagus is the spine. This slide shows the detail structure. Esophagus has four layers: the inner most layer is mucosa, then submucosa, muscle, and the outer most layer, fibrous membrane.
  • The esophagus is commonly divided into three portions. cervical, thoracic and abdominal. The thoracic portion is divided into three sections. Upper third, middle third and lower third. Carcinomas of the thoracic esophagus are most commonly located in the middle third of the organ; most of the remainder is in the lower third; and only 10% are located in the upper third.
  • What’s the main pathologic type of esophageal cancer? Two major types of esophageal cancer include squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma of the esophagus is the predominant histology in the cervical esophagus and upper and middle thirds of the thoracic esophagus, whereas adenocarcinoma in the distal esophagus. Squamous cell carcinoma starts in squamous cells that line the esophagus and usually develops in the upper and middle part of the esophagus; Adenocarcinoma begins in the glandular tissue in the lower part of the esophagus at the junction between the esophagus and the stomach; Treatment is similar for both types, Rare tumors of the esophagus occur in less than 1% of cases and include small cell neuroendocrine cancer, lymphoma, and sarcoma
  • We have just reviewed the anatomy of esophagus.now we are talking about the epidemiology and etiologo of esophageal cancer.
  • As we know, lung cancer is the leading cause of cancer death.how about esophageal cancer? Esophageal cancer is the seventh leading cause of death from cancer among American men 。 but We can see, the mortality of esophageal cancer is low in american women .
  • The cause of esophageal cancer is unknown. It is suspected that nutritional and environmental factors may play an important role.Age 65 or older : Age is the main risk factor for esophageal cancer. In the United States, most people are 65 years of age or older when they are diagnosed with esophageal cancer. Being male : In the United States, men are more than three times as likely as women to develop esophageal cancer. Smoking : People who smoke are more likely than people who don't smoke to develop esophageal cancer. Heavy drinking : People who have more than 3 alcoholic drinks each day are more likely than people who don't drink to develop squamous cell carcinoma of the esophagus. Heavy drinkers who smoke are at a much higher risk than heavy drinkers who don't smoke. In other words, these two factors act together to increase the risk even more.
  • Diet: Studies suggest that having a diet that's low in fruits and vegetables may increase the risk of esophageal cancer. Obesity: Being obese increases the risk of adenocarcinoma of the esophagus. Acid reflux Acid reflux is the stomach acid abnormal backward flow into the esophagus. A symptom of reflux is heartburn, but some people don't have symptoms. The stomach acid can damage the tissue of the esophagus. After many years of reflux, this tissue damage may lead to adenocarcinoma of the esophagus in some people.
  • If the disease has spread elsewhere, this may lead to symptoms related to this: Supraclavicular lymph node metastasis, liver metastasis could cause liver mass, jaundice and ascites, lung metastasis could cause shortness of breath, pleural effusions, etc.
  • There are many examination mothods to help the docotor for the esophageal cancer diagnosis. Including….., how to choose them?
  • When the patient comes to us, what examination should be given? To differentiate from other diseases, we often give barium swallow first, because it is quick, comfortable and cheap.
  • Barium swallow : After you drink a barium solution , you have x-rays taken of your esophagus and stomach. The barium solution makes your esophagus show up more clearly on the x-rays. Now we see the normal esophagus, it is flexible, smooth, you can see the mucosa is intact and continuous.
  • Then here comes the cancer. We can see the esophagus is narrow and stiff. These picture show us obvious barium defect with irregular shape and the mucosa is discontinued. We consider the patient has esophageal cancer. But it is not enough, because the tumor diagnosis includes two parts: pathology diagnosis and staging diagnosis. SLIDE12 Pathology diagnosis depends on endoscopy. It is a flexible telescope, it can pass through the mouth and go into the esophagus. Using endoscopy, we made the tissue biopsy. Then we get the pathologic result.
  • for these patients whose diagnosis are highly suspected and uncertained, Upper endoscopy (esophagoscopy) and biopsy should be taken.
  • Pathology diagnosis depends on endoscopy. It is a flexible telescope, it can pass through the mouth and go into the esophagus. Using endoscopy, we made the tissue biopsy. Then we get the pathologic result.
  • From this picture we can see, the tumor of the esophagus is about 3 centimeter, the esophagus has a little obstruction
  • As to staging diagnosis, I should mention a new and effective endoscopic ultrasonography, in short EUS.
  • It looks similar to endoscopy, but on the head, there is an ultrasound equitment, in the esophagus, it can scan the wall of esophagus and the lymph nodes nearby.
  • Under EUS, all the layer of esophagus is clearly shown. In this picture, we see the invasion of tumor and the metastatic lymph node. The accuracy is over 85% percent and it benefit the stage diagnosis greatly.
  • From the CT, we can find the border of the tumor,and if the organs nearby the the esophagus have been invade
  • We can also use MRI, sometimes PET, bronchoscopy and Laparoscopy , when we have all the results, we can make the staging diagnosis.
  • Staging is a way of describing a cancer, such as the size of a tumor and if or where it has spread Staging is the most important tool for doctors to predict the patient’s survival. Here, I emphasize, correct diagnosis is very important.
  • So what is the TNM system of EC? Staging is described by the TNM system: the size and location of the T umor, whether cancer has spread to nearby lymph N odes, and whether the cancer has M etastasized (spread to other areas of the body) Let me explain one by one.
  • SLIDE14 T stage describes the invasion of the tumor. This picture can help you understand. When the tumor is limited in the epithelia layer, and the basement membrane is still intact, it is called cancer in situ, this is a definition you should keep in mind. and it is defined as Tis. If the tumor gets over the basement membrane, but doesn’t reach the muscle layer, it is T1. As long as the muscle layer is involved, it is T2. When the whole wall of esophagus is infiltrated, it is T3. Once the tumor continues to invade the organ nearby, like thoracic duct, it is T4.
  • N stage is used to evaluate the regional lymph node metastasis, and it is easy to remember. If region lymph node metastasis happens, it is N1. On the contrary, it is N0.
  • M stage means distal metastasis. It is separated into 2 groups, a little complicated. You just need to know when the tumor spread to other organ of the body, like brain, lung, liver, it is M1b.
  • This slide shows the whole stage system. Just have impression, you are not required to remember it. But you should know why the stage diagnosis is so important.
  • In summary,we can see
  • We design the treatment plan usually according to the stage of esophageal cancer, the location of the esophageal cancer and the general health of the patient Staging is the most important tool for doctors to predict the patient’s survival. From this picture, it is obvious that earlier diagnosis means better pronosis. Here, I emphasize, correct diagnosis is very important.
  • The staging is very important, because the treatment depends on the staging. You can see for different stage, we should perform different therapy. For example, for stage IIA, we shall give surgery directly. But to stage IV, we should not perform operation, but give chemoradiotherapy.
  • There are many treatment methods for esophageal cancer patients. Including ….We will talk them one by one
  • surgical resection: The objectives of surgical treatment are to achieve a complete and potentially curative resection when possible, to restore and maintain satisfactory swallowing for the remainder of the patient’s life. Just only 25 to 30% of patients in whom complete resection is possble
  • Surgery may also be used to create a new pathway to the stomach, insert a feeding tube, or other methods to help a person if unable to eat
  • Chemotherapy depends on the tumor type, but tends to be cisplatin-based (or carboplatin or oxaliplatin) every three weeks with fluorouracil (5-FU). In more recent studies, addition of epirubicin (ECF) was better than other comparable regimens in advanced nonresectable
  • For patients who are found to have cancer spread to other organs or who, for some other reason, can't have surgery, combined chemotherapy and radiotherapy is the most common treatment.
  • If the patient can’t accept surgery . Chemotherapy+radiotherapy is the most common treatment stratege. Since swallowing difficulties are not always immediately relieved by this combined therapy, other means to improve swallowing are available. These include….
  • The average life expectancy of patients with esophageal cancer is only a few months.with about 25% dying with 6 months and 75%dying within 1 year
  • In summary, I hope you can remember the following key points. Don’t forget
  • The patient with esophageal cancer can chew any food he likes, but it is the luxury of swallowing that satifies the sence of enjoying this food. This surgery was undertaken to restore the luxury of swallowing.
  • That is all for today. Thank you for your attention. Wish you a happy weekend!
  • Esophageal Cancer

    1. 1. Esophageal Cancer By Dr. Monsif Iqbal PGT Surgical II 1
    2. 2. Case Presentation 2
    3. 3. PATIENT’s PROFILE• Name: XYZ• Age: 68 yrs.• Sex: Male• Address : Wah Cantt.• D.O.A: 25-05-2012• M.O.A: OPD 3
    4. 4. PRESENTING COMPLAINTS• Dysphagia 4 months• Weight loss 4
    5. 5. PAST HISTORY• Seen by ENT specialist 4 months back but no diagnosis made• Then Upper GI endoscopy at MH Rawalpindi---- report was normal• Upper GI endoscoscopy at POF on 16-05-2012----- revealed small nodules in lower 5 cm of esophagus and a large 10*10 cm nodule around the opening of esophagus.• HCV positive 5
    6. 6. Drug HISTORY• Not significant 6
    7. 7. PERSONAL HISTORY• Smoker----- 40 years (smoking 12 /day) 7
    8. 8. PHYSICAL EXAMINATION:1. GPE: An old aged emaciated gentleman, lying comfortably in bed His vitals are; – Pulse: 80/min – B.P: 130/80 mm of Hg – Oxygen Sat: 96% – Temp: Afebrile Rest of GPE unremarkable. 8
    9. 9. Systemic Examination• On abdominal examination – Scaphoid abdomen – No mass palpable – Bowel sounds +ve• Rest of the systemic examination unremarkable 9
    10. 10. Management plan• Barium swallow• CT scan chest+abdomen 10
    11. 11. 11
    12. 12. 12
    13. 13. 13
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    15. 15. 15
    16. 16. 16
    17. 17. • We prepared the patient for surgery• Routine investigations, Hb 9.8 g/dl and ALT of 73…..• 03 units of blood arranged• Esophagogastrectomy--06/06/2012 17
    18. 18. • The operative findings were – Huge mass covering proximal 3/5th of the stomach and lower one third of the esophagous. The stomach was adherent to the underlying structures• It was decided per-operatively to go for esophagogastrectomy with colonic interposition using ascending colon 18
    19. 19. 19
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    37. 37. • Post operatively the recovery is uneventful so far…… 37
    38. 38. Esophageal Cancer 38
    39. 39. 39
    40. 40. Anatomy: Normal Esophagus 40
    41. 41. 41
    42. 42. Types of Esophageal Cancer 42
    43. 43. Epidemiology and Etiology 43
    44. 44. Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths, by Sex, US, 2010 44
    45. 45. Epidemiology and Etiology(1)• An estimated 16,470 new cases in the United States in 2008• Nearly four times more common among men than women 45
    46. 46. Epidemiology and Etiology(2)• Incidence of esophageal cancer has increased six-fold in the past three decades• Incidence rates of adenocarcinoma have increased recently, especially in the Western hemisphere 46
    47. 47. Risk Factor(1)• Age 65 or older• Being male• Smoking• Heavy drinking 47
    48. 48. Risk Factor(2)• Diet:• Obesity: increase the risk of adenocarcinoma• Acid reflux 48
    49. 49. Clinical presentation• Dysphagia• Vomiting• Weight loss• Coughing• Back pain• Hoarseness 49
    50. 50. Spread of CA esophagous• Local Spread• Lymphyatic spread• Blood spread 50
    51. 51. Diagnosis 51
    52. 52. How is Esophageal Cancer Diagnosed?• Barium swallow (esophagram)• Upper endoscopy (Esophagoscopy) and biopsy (Diagnosis is confirmed with a biopsy)• Endoscopic ultrasound• Bronchoscopy• Computed tomography (CT) scan• Magnetic resonance imaging (MRI)• Positron emission tomography (PET) scan 52
    53. 53. Diagnosis (1)Barium swallow (Esophagram) 53
    54. 54. 54
    55. 55. 55
    56. 56. 56
    57. 57. 57
    58. 58. Diagnosis (2)Upper GI Endoscopy (Esophagoscopy) and Biopsy 58
    59. 59. Pathology diagnosis - Upper GI endoscopy 59
    60. 60. 60
    61. 61. Endscopic ultrasonography (EUS) 61
    62. 62. Endscopic ultrasonography (EUS) 62
    63. 63. Endoscopic ultrasonography (EUS) 63
    64. 64. CT 64
    65. 65. 65
    66. 66. Diagnosis and staging• MRI• PET-CT• Bronchoscopy• Laparoscopy 66
    67. 67. Staging 67
    68. 68. TNM stage Other regular tests 68
    69. 69. T stage (Tumor)Mucosa Tis T1 T2 T3 T4 69
    70. 70. N stage (lymph node) N0 N1 70
    71. 71. M stage (metastasis)M1a M1b 71
    72. 72. Classification of Stage Groupings for Esophageal Cancer 72
    73. 73. Stage I (T1N0M0) Esophageal Cancer • Cancer is in the mucosa and submucosa (the two inside layers of the esophagus) • Cancer cells are in the lining of the esophagus 73
    74. 74. Stage IIA (T2N0M0 or T3N0M0) Esophageal Cancer • Cancer is in either of the two outer layers of the esophagus 74
    75. 75. Stage IIB (T1N1M0 orT2N1M0 ) Esophageal Cancer • Cancer is in the submucosa or muscular layer of the esophagus • Cancer has spread to some lymph nodes near the tumor 75
    76. 76. Stage III (T3N1M0 or T4anyNM0) Esophageal Cancer • Cancer is in the outside layer of the esophagus or in the tissue near the esophagus • Cancer has spread to lymph nodes near the tumor 76
    77. 77. Stage IVA (anyTanyNM1a) Esophageal Cancer • Cancer has spread to the lymph nodes in the abdomen or neck 77
    78. 78. Stage IVB (anyTanyNM1b) Esophageal Cancer • Cancer has spread to other parts of the body besides the lymph nodes 78
    79. 79. Treatment 79
    80. 80. How to design the treatment plan• Staging whether the cancer has invaded nearby structures whether the cancer has spread to lymph nodes or other organs• where the cancer is located within the esophagus• The general health of patient 80
    81. 81. Treatment of Esophageal CancerEMR or Surgery Chemoradiotherapy Surgery Surgery+adjuvant therapy 81
    82. 82. Regimen• Endoscopic Mucosal Resection(EMR)• Surgery• Chemotherapy• Radiotherapy• Combined-modality therapy• Palliative Therapy 82
    83. 83. Endoscopic Mucosal Resection(EMR)• Indication of EMR Tis or T1a (defined as tumor involving the mucusa but not involving submucosa) 83
    84. 84. Surgery• The mainstay of treatment• 5-year survival rates of 15% to 30% are reported• Esophagectomy: removal of part of the esophagus; remaining portion is connected to the stomach• Lymph nodes around the esophagus may also be removed 84
    85. 85. • Esophagectomy Techniques – Transhiatal (Orringer) – Ivor lewis – Three field (McKeown’s) 85
    86. 86. 86
    87. 87. Indication of operation1 early stage ( stage 0, 1)2 middle stage (stage 2, 3)3 tumor recurrence after radiotherapy(no distal metastasis).4 palliative treatment 87
    88. 88. 88
    89. 89. Radiotherapy• Squmous cell carcinoma of the esophagus are radiosensitive and potentially radiocurable 89
    90. 90. Chemotherapy• Chemotherapy alone is seldom an effect palliative modality in patient. Commonly in combination with radiotherapy• Methotrexate,bleomycin,cisplatin,5-fluorouracil have been used in squmous cell carcinoma• Cancer Chemotherapy may be given after surgery (adjuvant), before surgery (neoadjuvant) or if surgery is not possible; in this case, cisplatin and 5-FU are used. 90
    91. 91. Combined-modality therapy:• Is the best treatment for advanced esophageal cancer. Combined-modality therapy can improve the 3- and 5- year survival rates.• Including: Surgery+chemotherapy Surgery+radiotherapy Chemotherapy+radiotherapy Radiochemotherapy+surgery 91
    92. 92. Palliative Therapy• Photodynamic Therapy• Laser therapy• Esophageal stenting• Feeding gastrostomy• Colonic interposition• External-beam irradiation 92
    93. 93. What Is the Prognosis for Esophageal Cancer? 93
    94. 94. Prognosis Time (month) 94
    95. 95. In summary• What’s the sympotom and signs of esophageal cancer?• What’s the main pathologic type of esophageal cancer?• How can we design the treatment according the staging of esophageal cancer? 95
    96. 96. 96
    97. 97. SWALLOWING……. 97
    98. 98. THANKS 98

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