CT scan and EUS are important investigations for esophageal cancer to accurately stage the tumor and assess involvement of nearby structures and lymph nodes. EUS in particular provides very detailed images and is better than CT for assessing depth of tumor invasion and detecting small lymph nodes that may be missed on CT. Accurate staging is important for determining resectability and treatment planning.

1. CA Esophagus-Presentation
and its Diagnosis
PRESENTER: DR SAMRAT SHRESTHA
MODERATOR: ASSOC PROF DR GHANSHYAM THAPA

2. Contents
• Introduction
• Etiology
• Classification
• Clinical features
• Investigations
• Diagnosis and Staging
• Prognosis
• Conclusion

3. Anatomy Of
Esophagus
Source- Sabiston text book of
surgery 21st edition pg 1043

4. Source- Sabiston text book of surgery 21st edition pg 1015

5. Anatomical Specialties
• Lacks serosa (other structure without serosa is rectum).
• Contains 2 different types of muscles (striated and
smooth at proximal 1/3 and distal 2/3 respectively)
• Segmental blood supply.
• Only part of GIT which shows very thinly scattered
Meissner’s plexus.
• Longitudinal arrangement of veins and lymphatics.

6. Epidemiology
• 8th most common cancer worldwide
• 6th most common cause of cancer death.
• 572,000 case worldwide annually.(Source- Sabiston text book of surgery
21st edition pg 1015)
• Highest-risk area, stretching from Northern Iran through central
Asian republics to North-Central China
“Esophageal cancer belt“(Thrift AP. Cancer Epidemiol. 2016)

7. • Typically present at advance stage
• 5 year survival rate approximately 19%
• MC histological type:
Adenocarcinoma in western countries
Squamous Cell Carcinoma: Worldwide

8. • SCC may arise in any part of esophagus
• Majority of cases arise in proximal and middle esophagus.
• Adenocarcinomas arise in distal esophagus or GEJ.
• Under current AJCC AND NCCN Guidelines:
GEJ AdenoCa are staged and classified as Esophageal Ca 
Exception of Siewert III tumors (tumors with an epicenter 2–5 cm
below the GEJ)  Gastric cancers

10. Epidemiology
• Incidence rises steadily with age, peak in 6th to 7th
decade of life(65-74)
• Median age of diagnosis 67.1
• Male : Female = 7 : 1
• African-American males :White males = 5:1
• SCC usually occurs in the middle 3rd of the esophagus. The
ratio of upper : middle : lower is 15 : 50 : 35.
• Adenocarcinoma is most common in the lower 3rd of the
esophagus, accounting for 65% of cases.

11. Source: Bailey and love 28th
edition pg 1136
AETIOLOGICAL FACTOR FOR
ESOPHAGEAL CANCER

12. • Smoking
• 2.08 times greater in smokers
• Obesity and metabolic syndrome
Esophageal or gastric cardia AC:
BMI 25 and 30 kg/m2: 1.71 (95% CI 1.5-1.96)
BMI ≥30 kg/m2 : 2.34 (95% CI 1.95-2.81)
Obesity doesn’t increase risk of SCC
No association between alcohol drinking and esophageal
AC
Napier KJ . World J Gastrointest Oncol. 2014

13. Dietary factors
• N-nitroso compounds
Mutagenic potential via inducing alkyl adducts in DNA
• Chewing of areca nuts or betel quid
Release of copper: collagen synthesis by fibroblasts
• High-temperature beverages and foods
• Hot tea (60 to 64°C)
• Drinking tea within two minutes of pouring (versus after >6
minutes)
• Drinking ≥700 mL per day of tea at ≥60°C
Jemal A. CA Cancer J Clin. 2011

14. Underlying esophageal disease
Achalasia
• SCC increased 16-fold during the first 1 to 24 years of
diagnosis
• Average of 14 years after the diagnosis of achalasia
Caustic esophageal injury
• Average time to diagnosis of SCC was 41 years (range 13 to 71
years) following the ingestion
Sandler RS. JAMA. 1995

15. Prior gastrectomy
• Patients with SCC: 10 % history of partial gastrectomy
• Common risk factors predisposing to SCC and partial
gastrectomy
Atrophic gastritis
• Twofold increased risk of SCC (but not AC)
Islami F. Ann Oncol. 2011

16. Human papillomavirus (HPV)
• Significant association between HPV infection and SCC
• Odds ratio 3.32, 95% CI 2.26-4.87
• Serotypes 16 and 18
• Tylosis
• Hyperkeratosis of palms of the hands
and soles
• Increased incidence of esophageal SCC
• Mutation in the RHBDF2 gene
• Howel-Evans syndrome
Iwaya T. Gastroenterology. 1998

17. Bisphosphonates
• US Food and Drug Administration (FDA) recommendation:
bisphosphonates not be used in patients with BE
• Associated with its adverse GI effects, including an increased
risk of esophagitis, esophageal erosions, and esophageal
ulcers
Upper aerodigestive tract cancer
• Synchronous or metachronous esophageal cancer: 3 to 14%
Wysowski DK. N Engl J Med. 2009

18. • Findings: Risk factors for cancer in Barrett esophagus include chronic GERD, hiatal hernia, advanced age,
male sex, white race, cigarette smoking, and obesity with an intra-abdominal body fat distribution. The
annual risk of esophageal cancer is approximately 0.25% for patients without dysplasia and 6% for patients
with high-grade dysplasia. High-quality studies have found no significant differences in cancer incidence
for patients with Barrett esophagus whose GERD is treated medically or surgically. Endoscopic eradication
therapy with radiofrequency ablation significantly reduces the frequency of progression to cancer for
patients with high-grade dysplasia.
• Conclusions and relevance: Endoscopic screening is recommended for patients with multiple risk factors
for cancer in Barrett esophagus. For patients with Barrett esophagus without dysplasia, endoscopic
surveillance at intervals of 3 to 5 years is recommended, and GERD is treated much as it is for patients
without Barrett esophagus. Endoscopic eradication therapy is the treatment of choice for high-grade
dysplasia and is an option for low-grade dysplasia. Endoscopic eradication therapy is not recommended for
the general population of patients with nondysplastic Barrett esophagus.

19. • GERD affects up to 44% of the general population in USA
• Approximately 5–8% will develop Barrett’s esophagus
• Estimated annual rate of neoplastic transformation of 0.2–0.5%
per year.
SOURCE- Bailey and love 28th edition pg 1136

20. Clinical Features: Thoracic esophageal tumors
• Progressive dysphagia(74%) is the commonest feature.
• Early symptoms may include a mild hold-up sensation - progress
from dysphagia to a solid, soft and eventually to a liquid diet.
• 2/3rd of lumen should be occluded to cause dysphagia.
• Weight loss (57%)
• Odynophagia (17%)
• Regurgitation
• Asymptomatic: 6 to 10%
SOURCE:Shackelford’s SURGERY of the ALIMENTARY TRACT,8th edition, pg 365

21. Clinical Features
• Anorexia
• Aspiration and choking related to tumor obstruction and
presence of an esophagus–airway fistula.
• Choking and cough on drinking water are typical of
fistulation and associated hemoptysis is common.
• Blood loss is less common for SQCC than
adenocarcinoma.
• Chronic blood loss can lead to IDA.

22. Acute GI bleeding can occur, though it is rarely severe,
except for aorto-esophageal fistula
Substernal or abdomen pain.
 Ascites due secondary in liver.
Bronchopneumonia
Melaena.
Features of broncho-oesophageal fistula in carcinoma
of upper third esophagus .

23. Left supraclavicular lymph nodes may be palpable.
Hoarseness of voice due to involvement of recurrent laryngeal
nerve.
Hiccough, due to phrenic nerve involvement.
Back pain—due to nodal spread (paraoesophageal/coeliac
nodes).

24. Cervical esophageal tumors
• 11 to 24%: hoarseness as a presenting symptom
• Weight loss
• Dysphagia
• Locally advanced disease at the time of diagnosis

25. • Early cancers are usually asymptomatic
• Only picked up on endoscopy performed for other reasons,
except in countries where a screening program exists.
• For squamous cell dysplasia and cancer, chromoendoscopy
using Lugol’s iodine is a useful adjunct.

26. • Results: During the study period, there has been a statistically significant increment of the
rate of esophageal adenocarcinoma (APC 3.70). The rates of elderly and of asymptomatic
patients increased over time (APCs 0.98 and 6.24), whereas the rates of malnutrition,
alcoholic drinking, and gastric ulcer decreased (APCs -1.50, -1.72, and -5.20). Reflux rate
increased until 1997 and decreased thereafter (APCs 6.96 and -4.48), whereas the rate of
Barrett esophagus increased until 1992 (APC 35.84) and then leveled. The rates of patients
with previous neoplasms increased over time (APCs 3.22 and 4.86). There have been
significant changes in systemic comorbidities, with an increase of hypertension and cardiac
disease (APCs 7.56 and 1.86) and a decrease of advanced liver disease and pulmonary
disease (APCs -2.67 and -1.74).
• Conclusion: Current EC patient has more often an esophageal adenocarcinoma and is more
frequently elderly, asymptomatic, a survivor of previous neoplasms, and a patient with
hypertension and cardiac disease than 30 years ago. On the contrary, malnutrition,
alcoholic drinking, gastric ulcer, pulmonary disease, and advanced liver disease decreased.

27. Investigations
• Barium swallow: Shouldering sign and irregular filling
defect.

28. Investigations
• Esophagoscopy - to see the lesion, extent and type.

29. • Care should also be taken to assess rest of oesophagus
• Pharynx and larynx to ensure no synchronous tumours are
present.
• Movement of vocal cords should be assessed.
• For cancers of mid- or upper oesophagus in
proximity to airway-Bronchoscopy- ensure no
airway Involvement
Esophagectomy will be contraindicated
if airway infiltration present

30. Investigations
• Biopsy - Histological type and confirmation.
• Chest X-ray - Look for aspiration pneumonia.
• Bronchoscopy - Invasion in upper third growth
• Laryngoscopy: Identify vocal cord palsy.

31. Esophageal Endoscopic ultrasonography

33. Investigations
• Esophageal Endoscopic ultrasonography
To look for
1) Depth of tumor
2) Involvement of nodes, cardia and left lobe of
liver.
3) Nodes smaller than 5 mm can be very well
visualized by EUS which may be missed in CT
scan.
4) Infiltration to adjacent structures (cT4) is most
accurately assessed.

34. Accuracy of EUS for tumour and nodal staging averages 85%
and 75%, respectively.
EUS-guided FNA can be used to obtain cytological proof
of involved lymph nodes.
EUS is superior to CT and PET for assessment of T and
N status

35. CT image shows lymph nodes
(arrowheads)
Source- Bailey and love 2th edition pg 1139

36. • Meta-analysis of 44 studies demonstrated- EUS had an overall T-stage
accuracy of 79%.
• Pooled sensitivity and specificity for T1a tumors were 84% and 91%,
respectively.
• FOR T1b, pooled sensitivity and specificities were 83% and 89%,
respectively.
• EUS was able to accurately differentiate between T1a and T1b tumors
• EUS, when combined with FNA, has increased accuracy as compared to EUS
or CT alone for regional lymph node staging. EUS, EUS-FNA, CT, and PET
scan all work in conjunction with each other to identify the correct staging
of esophageal cancer.

37. CT scan
• To look for
1) Local extension
2) Nodal status
3) Perioesophageal, diaphragmatic, pericardial vascular
infiltration
4) Obliteration of mediastinal fat
5) Status of tracheobronchial tree in case of upper third
growth.

38. Source- Uptodate

39. • Results: PET was less sensitive (41% in high-sensitivity mode, 35% in low-sensitivity mode) than CT
(63% to 87%) for diagnosing tumor involvement in locoregional lymph nodes, which was identified by
surgical assessment in 72% of patients. Notable, however, was the greater specificity of PET-
determined nodal sites (to approximately 90%) compared with CT (14% to 43%). In detecting
histologically proved distant metastases (n = 10), PET performed considerably better when applied in
the high-sensitivity mode, with a sensitivity rate of approximately 70% and a specificity rate of more
than 90% in the total group and in the subset of patients with correlative CT data. In the low-sensitivity
mode, CT identified only two of seven metastatic sites, whereas the high-sensitivity mode resulted in
an unacceptably high rate of false-positive readings (positive predictive value, 29%). PET correctly
identified one additional site of metastasis that was not detected by CT.
• Conclusions: The relatively low sensitivity of PET for identifying locoregional lesions precludes its
replacement of conventional CT staging. However, the primary advantage of PET imaging is its superior
specificity for tumor detection and improved diagnostic value for distant metastatic sites, features that
may substantially affect patient management decisions. In conclusion, PET imaging is useful in the
initial staging of esophageal cancer and provides additional and complementary information to that
obtained by CT imaging.

40. Locoregional staging should be performed with EUS
PET is complementary or competitive to CT for distant metastasis
remains unanswered
Future lies in staging malignant strictures not amenable to EUS
staging
Sandha et al. Gastrointest endos. 2018

42. Investigations
• U/S abdomen—to look for liver and lymph nodes status
in abdomen.
• Endoscopic esophageal staining with labelled iodine -
Normal mucosa is stained brown and carcinoma
remains pale (as mucosa in carcinoma will not take up
iodine).

43. Investigations
• Laparoscopy –
 Useful to see peritoneal spread, liver spread and nodal spread
 Potentially resectable, clinical T3 or T4
 Only reliable method to detect peritoneal seedlings.
 Biopsy from different places can also be taken.
 Prevent unnecessary laparotomy.

44. FDG-PET SCAN
• SCC are usually FDG avid
• Detection of primary tumour is useful.
• Adenocarcinomas of OGJ sometimes show
limited or absent FDG accumulation regardless of
tumour volume (FDG non-avidity).
• It is mostly used for detecting regional and non-
regional nodes, as well as distant metastases.

45. • Uptake by tumour may have some prognostic value
• Change in uptake after neoadjuvant treatment is
similarly useful in predicting histological response
and outcome.
• PET does not define oesophageal wall no value in
cT staging.
• Spatial resolution is also insuffcient to separate
primary tumour with juxtatumoral nodes because of
interference from primary cancer.

46. PET/CT
• PET/CT scan may demonstrate
distant metastatic disease
• Eliminate need for undergoing
EUS.
• PET/CT scan may also identify a
suspicious lymph node that can
be specifically examined and
sampled during the EUS
procedure
• PET with CT scan is used for
staging and to see response for
therapy.

47. Investigations
• Endoscopic mucosal resection (EMR) –
– It is basically a diagnostic biopsy tool, but can be
therapeutic in early and premalignant lesion.
– T1a tumors are resected by EMR, as the risk of
lymphnode
metastasis is very low.
– Endoscopic submucosal dissection removes the
lesion up to muscularis propria.

48. Investigations
• Chromoendoscopy, magnification endocsopies-
• They are newer methods.
• Local topical application of different strains will
improve the tumour localization, features and
diagnosis.
• Biopsy is done in this areas.

49. Newer Modalities Of Evaluation
• Flow cytometry
• P53 immunohistochemistry
• Optical coherence tomography
• Spectroscopy

50. Diagnosis and Staging
• Esophageal ca is almost always diagnosed by
endoscopic biopsy.
• Endoscopy should be performed in every patient with
dysphagia, even if barium esophagus is suggestive of
a motility disorder.
• CECT and PET scan to evaluate for distant metastatic
disease.
 If there is no evidence of distant metastatic disease,
EUS should be performed to assess T stage and
regional lymph nodes.

51. AJCC TNM Classification

53. Staging of Adenocarcinoma

54. Staging of SCC

55. Prognosis
• Not good because of early spread, longitudinal lymphatics,
aggressiveness, difficult approach, late presentation.
• Nodal involvement carries bad prognosis.
• 5-year survival rate is only 19%.

56. REFERENCES
1. Bailey and love 28th edition
2. Sabiston text book of surgery 21st edition
3. Shackelford’S SURGERY OF THE ALIMENTARY TRACT,8th edition
4. UPTODATE

57. THANK YOU