Screening and evaluation of CA esophagus four quadrant biopsy

1. Carcinoma Esophagus
Screening and Evaluation

2. Esophageal cancer
• 8th most common cancer worldwide
• The 6th most common cause of death from
cancer
• Common in countries of the so-called
“Asian esophageal cancer belt”

4. • The age- standardized incidence rate of
esophageal cancer per 100,000
– 27.4 in China
– 10.0 in Japan
– 7.9 in northern Europe
– 7.6 in western Europe
– 5.8 in North America
– 5.5 in Australia/New Zealand

5. • India has an age standardized incidence rate
– 6.5 per 100,000 population for males
– 4.2 per 100,000 population for females
• Striking change in epidemiological pattern in
the past three decades
• Shift from Squamous cell cancers to
Adenocarcinomas of the lower esophagus and
cardia in Western countries

6. • The reason for the shift from SCC to Adeno is
widely attributed to
– Obesity
– Gastroesophageal reflux disease and
– Barrett’s esophagus

7. Screening and Prevention for Early
Cancer
• Screening :
– The search for unrecognized disease or defect by
means of rapidly applied tests, examinations or
other procedures
• Diagnosing at its asymptomatic or early stage
is crucial in improving prognosis

8. Non Endoscopic screening
• In high-incidence areas such as in China
– Abrasive cytology has been used for population
screening
• Two principal types of samplers have been
used
– an inflatable balloon developed in China
– an encapsulated sponge sampler developed in
Japan

9. • When early-stage cancers are diagnosed by
above method
– excellent long-term results with
– 5-year survival rate approaching 90%
– 25-year survival rate of 50%

10. • Balloon technique
– Deflated balloon covered by a cloth net
– Swallowed into the stomach, inflated, and
withdrawn
– Collects exfoliated cells by scraping the mucosal
surface of the esophagus

11. • Sponge technique
– Polyurethane mesh is compressed inside a gelatin
capsule and attached to a string or a thin plastic
stylet
– The capsule is swallowed into the stomach
– The gelatin dissolves, and the mesh expands.
– The mesh is pulled up the esophagus by the
string, collecting exfoliated and scraped mucosal
cells

14. Endoscopic screening
• Primary endoscopic screening
– High resolution/ magnification endoscopy
combined with Lugol’s Iodine staining
– 1% to 3% lugol iodine is mixture of { iodine +
potassium iodide }
– Iodine has affinity to glycogen stains normal
epithelium dark brown
– Sensitivity of 96%
– Specificity of 64%

16. BARRETT’S ESOPHAGUS
• Screening and surveillance for early cancers due
to Barrett’s esophagus have been controversial
• Approximately 20% of adults have heartburn at
least once per week, 5% of whom have Barrett’s
esophagus
• Substantial number of patients will require
screening

17. • Even in patients with severe reflux symptoms
Absolute risk of developing adenocarcinoma is
low
• 40% or more of patients with esophageal
adenocarcinoma have no prior reflux symptoms
and would not be detected through screening
programs
• Presence of Barrett’s esophagus does not change
life expectancy or overall survival.

18. • There is no confirmed evidence proving that
screening or surveillance will lead to improved
survival in patients with Barrett’s esophagus
• Despite the lack of clear evidence, individuals
identified having Barrett’s esophagus should
enter surveillance programs

20. • Systemic four-quadrant, 2-cm biopsy protocol
using large biopsy forceps is recommended
• Dysplasia is the only reliable indicator of risk
development of invasive cancer

23. Evaluation of Ca esophagus

24. • American Joint Committee on Cancer (AJCC)
staging TNM system
• Recently modifications in TNM system

25. 1. Previously used M1a and M1b categories are
deleted
2. The regional nodes encompass areas from
the neck, through the mediastinum to the
upper abdomen, including the celiac nodes
3. The separation of N1 to N3 depends on the
number of nodes involved
4. Squamous cell cancers and adenocarcinoma
are stage-grouped differently

26. 5. Location of tumor and grade of
differentiation are also taken into
consideration
6. Tumors which are located in the
– Lower thoracic esophagus
– Gastroesophageal junction (GEJ)
– within the proximal 5 cm of the stomach (cardia)
that extend into the GEJ or esophagus are stage-
grouped similar to Adenocarcinoma of the
Esophagus and not that of the stomach

27. 7. Cancers with their epicenter in the stomach
– >5 cm distal to the GEJ
– <5 cm from GEJ but not extending into the GEJ or
esophagus
– are stage-grouped using the Gastric cancer
staging system.

28. Definitions of TNM

30. HISTOLOGIC GRADING

31. Staging of Esophageal cancer -
Adenocarcinoma

32. Staging of Esophageal cancer –
Squamous cell carcinoma

33. SIEWERTS CLASSIFICATION
• Classification of tumors located 5 cm proximal
and distal to the GEJ
• Types I to III
– I - Esophageal
– II - Cardiac
– III - Subcardiac

34. • The three types of cancers are different in
– Patient demographics
– Possible etiology
– Histopathologic features and
– Prognosis
• This classification is useful clinically but is not
considered in the new staging system

36. DIVISIONS OF T1 TUMORS ACCORDING
TO THE JAPAN ESOPHAGEAL SOCIETY

39. METHODS OF STAGING
• Specific methods in clinical staging include
– Barium contrast studies
– Bronchoscopy
– Computed tomography (CT) scan
– Percutaneous ultrasound of cervical lymph nodes ±
fine-needle aspiration (FNA) cytology
– Endoscopic ultrasound (EUS) ± FNA
– [18F] fluoro-2-deoxy-d-glocose (FDG) positron
emission tomography (PET) scan
– laparoscopy and/or thoracoscopy

40. Barium Contrast Studies
• Features on a contrast barium study include
– Narrowing of the lumen
– Proximal dilation of the esophagus
– Mucosal irregularity and shouldering
– Tortuosity
– Axis deviation from the midline
– Sinus formation
– fistulization to the bronchial tree

42. Bronchoscopy
• Flexible bronchoscopy is performed to assess
tumor involvement of the tracheobronchial tree
• Especially for tumors in the middle and upper
esophagus.
• Signs of involvement include a
– Widened carina
– External compression
– Tumor infiltration {NR}
– Fistulization {NR}

43. Computed Tomography Scan
• CT scan in staging of esophageal cancer is
useful to detect distant disease
• Metastais occurs to organs like
– Lungs
– Liver
– Bone
– Kidneys

44. • Metastasis to the liver
– >2 cm sensitivity is 70–80%
– <1 cm sensitivity decreses to 50%
• Solitary lung metastases are rare
• It helps in Diagnosis of T4 disease
• the accuracy of CT is inferior to that of EUS

46. Endoscopic Ultrasound
• Used in cervical node involvement in SCC of
CA oesophagus
• Examination of nodes begin with visualization
of common carotid artery and internal jugular
vein at the base of the neck
• Axial scan transverse to vessel performed in
cephalad direction
• Nodes IV, III, II and V are viewed in relation to
carotid and internal jugular

47. • EUS is the only imaging modality to distinguish
the various layers of the esophageal wall
• Appears as Five layers with alternating hyper-
and hypoechoic layers
• Sensitivity 74.5% and Specificity 94.1%
• Information gained by combining preoperative
cervical ultrasound and EUS can be highly
prognostic

48. • Three types of echoendoscopes are used
1. A radial scanning endoscope (5-20MHz)
• provides 360 degree view of esophageal wall
2. EUS miniprobes (12, 20 and 30 MHz)
• Provides excellent resolution but penetration is less
• Used for superficial cancers
3. Curved linear-array transducer scopes (7.5 MHz)
• Used for US guided FNAC

49. T stage on EUS
• Invasion to 2nd hypoechoic layer – T1a
• Invasion to 3rd hyperechoic layer – T1b
• Invasion to 4th hypoechoic layer – T2
• Beyond the fourth layer – T3
• Adjacent structures – T4

51. FDG-PET Scans
• The tracer used is Flurodeoxyglucose
• Principle : Differential glucose metabolism of
cancer
• In Detection of the primary tumor
– Its sensitivity is 78 to 95%
• FDG –nonavidity
– Adeno CA of the GEJ and proximal stomach
sometimes show limited or absent FDG accumulation
– Related to diffusely growing subtype and poorly
differentiated tumors

52. • No Value in T stage
– does not define the layers of the esophageal wall
• For locoregional nodal metastases its spatial
resolution is insufficient as it cannot separate
tumor from juxta tumoral lymphnode

53. • The accuracy of PET in locoregional nodes is
only moderate.
• EUS-FNA is superior in this regard.
• PET is more useful for picking up distant
metastases.

55. Thoracoscopy and Laparoscopy
• Thoracoscopic staging usually involves
– right-sided approach
– opening of the mediastinal pleura from below the
subclavian vessels to the inferior pulmonary vein
with lymph node sampling
• Thoracoscopy and laparoscopy can identify
nodes or metastatic disease missed by CT

56. VIDEO ASSISTED THORACOSCOPIC
SURGERY {VATS}
• Minimally invasive thoracic surgery without
the need for thoracotomy
• VATS provides adequate visualization despite
limited access to the thorax
• Advantage is it can be performed on patients
– who have marginal pulmonary reserve
– severe debilitating patients who cant be taken up
for thoracotomy

57. • Use : VATS is principally employed in the
management of
– Pulmonary
– Mediastinal and
– Pleural pathology

59. Technique of VATS
• Patient in left lateral decubitus position
• Right thoracoscopy was performed using one-
lung ventilation.
• The telescope was introduced into the sixth
intercostal space at the posterior axillary line
• Two additional trocars were inserted under direct
vision with the use of carbon dioxide insuflation
• A fourth trocar if needed is inserted in the third
intercostal space at the anterior axillary line

60. • Three anterior trocars and one posterior trocar in
a so-called "baseball diamond" configuration
• The mediastinal pleura overlying the upper part
of the esophagus incised and the incision
continued from the level of the azygos vein to the
inferior pulmonary vein.
• The tracheoesophageal groove was dissected,
and biopsy specimens of the lymph nodes
obtained with blunt dissection

61. References
• Maingot’s Abdominal Operations 12th Ed
• Shackelford’s Surgery of the Alimentary Tract
7th Ed

62. THANK YOU