This document provides an overview of carcinoma of the esophagus, including epidemiology, etiology, classification, diagnosis, staging, and management. It discusses the different types of esophageal cancer, risk factors, pre-malignant conditions, patterns of spread, diagnostic tools such as endoscopy and imaging, and the AJCC staging system. Treatment options are covered for early stage disease including endoscopic resection and ablation methods, as well as surgical approaches for localized and advanced disease, including transhiatal esophagectomy, Ivor-Lewis esophagectomy, and McKeown esophagectomy. Post-operative complications are also reviewed.

1. CARCINOMA ESOPHAGUS
Dr. S.SIVA SANKAR
1

2. overview
• EPIDEMIOLOGY
• ETIOLOGY
• CLASSIFICATION
& TYPES
MANAGEMENT
• Early stage
• Locally advanced
• Metastatic
• DIAGNOSIS &
STAGING
2

3. ESOPHAGUS
Four regions of the esophagus:
Cervical = cricoid cartilage to
thoracic inlet (15–20 cm from the incisor).
Upper thoracic = thoracic inlet to azygos vein
(20–25cm)
Midthoracic =azygos vein to Inf.pulmonary vein (25–30
cm).
Lower thoracic = Inf.pulmonary vein to GE junction
(30–40 cm).

5. LYMPHATIC DRAINAGE
• Rich mucosal and submucosal
lymphatic system
• Longitudinal arrangement of lymphatics
• The submucosal plexus drains into the
regional lymph nodes in the cervical,
mediastinal, paraesophageal, left
gastric, and celiac axis regions.

6. Lymphatic drainage

7. Epidemiology
• Eighth most common malignancy worldwide.
• Squamous cell carcinoma –most common
histological type ,worldwide.
• Adenocarcinoma incidence is more in western
countries over the past 20 yrs.
• Middle east ,central asia and china have
highest rates of SCC.

8. Etiology & predisposing factors
● Smoking
● nitrates
● Lye ingestion
● Chronic achlasia
● Alcohol
● HIV
● Radiation strictures
● Plummer Vinson syndrome
● Tylosis palmaris et plantaris
● Deficiency of
molybdenum,zinc and vitamin
● Barrett’s esopaghus
● Chronic GERD
● Smoking
Squamous cell carcinoma Adenocarcinoma

9. Premalignant conditions
• Achlasia cardia
• Esophageal web
• Strictures and diverticula
• Plummer Vinson
syndrome

10. Hereditary syndromes associated with ca
esophagus
• Tylosis
• Familial Barrett’s Esophagus
• Bloom syndrome
• Fanconi Anemia

11. ● Upper two third
● Smoking & alcohol
● Less aggressive
● Achlasia cardia is a
predisposing factor
● Lower one third
● Smoking
● Obesity
● Barrett’s
esophagus/GERD
● More aggressive
● Achlasia cardia is not a
predisposing factor
Squamous cell
carcinoma
Adenocarcinoma

12. • H.pylori infection and ca esophagus
• Inversely associted with the risk of
adenocarcinoma.
• Presence of gastric atrophy and H.pylori
increase the risk of SCC.

13. Incidence

14. Pattern of spread
• No serosal covering, direct invasion of contiguous
structures occurs early.
• Commonly spread by lymphatics (70%)
• Lymph node involvement increases with T stage.
T1 – 14 to 21%
T2 – 38 to 60%
• 25% - 30% hematogenous metastases at time of
presentation.
• Most common site of metastases are
lung, liver, pleura, bone, kidney & adrenal gland

15. Barrett esophagus
• Normal squamous
epithelium is replaced by
metaplastic,columnar or
landular epithelium .
• Predispose to
adencarcinoma
• 11 fold more risk than non
barrett esophagus.

16. Barrett esophagus
Dysplasia arising in barrett esophagus
characterised by cytologic malignant changes
• Atypical nuclei
• Increased mitoses
• lack of surface maturation
High grade dysplasia shows more prominent
cytologic or architectural derangements.

17. • Incidence of invasive adenocarcinoma is more
with high grade dysplasia .
• Seattle biopsy protocol
for mapping of barrett esophagus with
high grade dysplasia
Four quadrant biopsies at 1cm intervals along
the entire length of Barrett esophagus in
addition to targeted biopsies of all visible
lesions

18. Clinical features
• Dysphagia- most common symptom (74%)
Progressive in nature
Difficulty to swallow solids>liquids
• Weight loss –seen in 90% of squamous cell
carcinoma .
• GERD/ Reflux symptoms
• Fatiguability
• Dull retrosternal pain

19. Clinical features
• In advanced stage /metastasis
RLN --Hoarseness of voice
Tracheo esophageal fistula –pneumonia
Aortic invasion –exsanguinating
hemorrhage
• Cervical /supracalvicular lymph node
enlargement .

20. Contd..
• Esophageal cancers usually manifests at an
advanced stage (80%)
• Early stage tumour –asymptomatic
diagnosed during endoscopy for barrett
esophagus

21. DIAGNOSIS
• Endoscopic Biopsy
endoscopy should be done in any patient
with dysphagia.
Endoscopic features of malignancy
➢ early stage –ulcerations/small nodules
➢ advanced stage – friable masses,
stricture,
ulcerations.

22. Features to be looked for in endoscopy:
• Location of tumour relative to incisors &
GEJ
• Length of the tumour –proximal and distal
extent
• Degree of obstruction

23. Endoscopy

24. Newer endoscopic imaging
To increase the sensitivity of detection of
dysplasia
• High resolution endoscopy
• Chromoendoscopy
• Narrow band imaging –uses light filters to
allow more narrow wavelengths of the light ,
-better reveals irregular mucosal pattern

25. Narrow band imaging

26. Chromoendoscopy
• Topical application of stains or pigments
• Tissue localisation,characterisation and diagnosis
during endoscopy
• Stains used
• Lugols solution
• Methylene blue
• Indigo carmine
• Congo red
• Phenol red

27. Investigations for staging :
• Endoscopic ultrasound .
to assess T and N stage
Accuracy
T staging 85%
N staging 75%.
Superior to CT /PET for assessment of T and N staging

28. Endoscopic ultrasound
• High frequency transducer (5-30MHz ) is used
• To determine the depth of spread through the
esophageal wall
• Involvement of adjacent organs
• Metastasis to lymph node
• Also detects contiguous spread downward into
cardia
• Can detect metastasis in the liver
• Can also detect small lymph nodes which are
<5mm

29. • Superficial lesions may be resected by EMR
without additional staging
• EMR provides adequate staging for T & N .
To assess distant metastasis
• CECT chest and abdomen
• FDG PET

30. FDG PET
• FDG PET is widely applied both for staging and
and to assess response to preoperative
treatment.
• FDG PET is superior to CT in detection of distant
metastasis .
• Sensitivity 80% specificity 90%
• PET CT fusion. / hybrid FDG-PET/CT improves
specificity and accuracy of noninvasive staging .

31. FDG PET

32. Barium esophagram(barium swallow)
shows irregular narrowing,
rat tail appearance
apple core appearance
shoudering effect
Bronchoscopy for tumour above carina
to assess for direct tracheal invasion .

33. Barrium swallow

34. Barium swallow

35. work up -SUMMARY
• History &physical examination
• Upper GI scopy and biopsy
• Chest /abdominal CT with oral and iv contrast
• FDG-PET/CT if no clinical evidence of
metastasis
• Endoscopic ultrasound ,if no evidence of
unresectable disease
• Endoscopic resection for early stage.

36. Type I carcinoma barret’s esophagus /
true esophageal adeno carcinoma
(epicentre located between 1-5cm
above the anatomic OGJ ) extending to
GE junction
Type II adenocarcinoma of the real
cardia (epicenter located within 1cm
above and 2cm below the OGJ)
Type III adenocarcioma of the
subcardial stomach (epicenter
located 2- 5cm below OGJ)
Gastro esophageal junction tumours
SIEWERT CLASSIFICATION

37. • AJCC 8th edition
• Siewart types 1 & 2 (tumor epicenter located
within 2cm of the proximal stomach )
-staged as Esophageal adenocarcinoma
• Siewart type 3 (epicenters located >2cm into
the stomach ) staged as Gastric cancer .

38. AJCC STAGING SYSTEM 8th edition

39. AJCC STAGING SYSTEM 8th edition

40. Lymph nodes
• Squamous cell carcinoma (proximal&mid
esophageal tumour)
Regional lymph nodes:
periesophageal ,cervical LN
• Adenocarcinoma (distal esophagus &GEJ
tumours)
Regional lymph nodes:
celiac axis upto paratracheal region

42. AJCC STAGING SYSTEM 8th edition

43. AJCC STAGING SYSTEM 8th edition

45. AJCC 8th ed STAGING
● SQUAMOUS CELL
CARCINOMA
• ADENOCARCINOMA

46. MANAGEMENT
Management of premalignant and T1 disease.
Management of localized disease( T2, any N,M0)
Locally advanced disease (T3,N1 -3)
Metastatic disease

47. Management guidelines

51. Early stage esophageal cancer
• Includes High grade dysplasia and superficial
cancer
• Surgery plays a smaller role
• Endoscopic ablation techniques are treatment
of choice

52. Treatment options
• Ablative methods
• Endoscopic mucosal resection

53. Ablation methods
Disadvantages
• Limited depth of penetration
• Lack of definitive patholoical analysis

54. ENDOSCOPIC THERAPY
• Both therapeutic and staging purpose.
The available options are
• Endoscopic mucosal resection
• Ablation methods, including RFA, PDT, and
cryotherapy

55. ENDOSCOPIC THERAPY
Indications
• limited early stage disease.i.e Tis and T1a,
• <2cm
• Well or moderately differentiated SCC or
adenocarcinoma
• Elderely with multiple comorbidities

56. Endoscopic mucosal resection
Indicated in
• Nodular /raised barrett esophagus
• Superficial esophageal cancer /T1a lesions
EMR provides adequate staging for Tumour and
Nodal status.
EMR not adequate for T1b lesions

57. Risk of nodal invasion is more in T1b lesions
• SM1 30% risk
• SM3 >50% risk
• T1 b with SCC has 45% risk
• T1b with adenocarcinoma has 26% risk

58. Endoscopic mucosal resection

59. Endoscopic mucosal resection

60. Ablative therapies
• Radiofrequency ablation
• Cryoablation
• Photodynamic therapy
• Thermal laser
• Argon plasma coagulation
• Multipolar electro coagulation

61. Surgical Treatment
Choice of surgical approach depends upon many
factors:
● Tumor location, length, submucosal extension, and
adherence to surrounding structures
● The type or extent of lymphadenectomy desired
● The conduit to be used to restore GIT
● The preference of the surgeon

62. Tumors of cervical esophagus
• Cervical esophageal cancer is frequently
unresectable because of early invasion of the
larynx, great vessels, or trachea.
• Radical surgery including esophagolaryngectomy may
occasionally be performed for these lesions.
• High morbidity.
• Stereotactic radiation with concomitant chemotherapy
is the most desirable treatment.

63. Tumors of middle third esophagus
• Squamous carcinomas most commonly and are frequently
associated with LN metastasis (thorax, neck or abdomen)
• Midthoracic ca + abdominal LN metsincurable with surgery.
• Isolated cervical LN metastases can be resected.
• T1 and T2 cancers without LN metastases are treated
with resection only.
• LN involvement or transmural cancer (T3) neoadjuvant
chemoradiation therapy followed by resection.

64. Tumors of the lower esophagus
• Tumors of the lower esophagus and cardia are
usually adenocarcinomas.
• If possible, resection in continuity with a LN
dissection should be performed.
• Local recurrence at the anastomosis can be
prevented by obtaining a 10-cm margin of normal
esophagus above the tumor

65. • Considering that the length of the esophagus
and the length of the lesser curvature of the
stomach, a curative resection requires a
cervical division of the esophagus and a
>50% proximal gastrectomy in most patients
with carcinoma of the distal esophagus or
cardia.

66. • Factors that make surgical cure
unlikely include
• advanced stage of carcinoma,
• Tumor >8 cm in length,
• Abnormal axis of the esophagus on a
barium radiogram,
• >4 enlarged LNs on CT,

67. • Advanced stage of ca esophagus
• recurrent laryngeal nerve paralysis,
• Horner's syndrome,
• persistent spinal pain,
• paralysis of the diaphragm,
• fistula formation, and
• malignant pleural effusion.

68. Preoperative evaluation
• Pulmonary function tests
• Cardiac testing
• Nutritional assessment
• Nasoduodenal /jejunostomy tube for
nutritional support
• Laparoscopic staging in adenocarcinoma/GEJ
tumour

69. ESOPHAGECTOMY
Transthoracic esophagectomy
Ivor lewis esophagectomy
Mckeown esophagectomy
Trans hiatal esophagectomy
Transthoracic or thoracoabdominal
Minimally invasive

70. IVOR-LEWIS TRANSTHORACIC
ESOPHAGECTOMY
• Most common surgical approach
• Two phased procedure
• Right thoracotomy with upper midline
laparotomy
• After laparotomy stomach is mobilised –
through rt. 5th space thoracotomy esophagus
with growth is mobilised –partial
esophagectomy and oesophago gastric
anastomosis done in the thorax.

71. Contd..
• Lymph node dissection
upper abdominal and mediastinal lymph
node dissection done.

72. Advantages
Direct visualization and exposure of the
intrathoracic esophagus
Facilitates wider dissection to achieve adequate
radial margin around the tumour and
adequate lymph node dissection .

73. • Complications
• Abdominal and thoracic incisions compromise
cardiopulmonary function in comorbid
patients.
• Intrathoracic anastomotic leak—mediastinitis
• Esophagitis due to bile reflux .

74. TRANSHIATAL ESOPHAGECTOMY
• Distal esophagus and EGJ cancers.
• Upper midline laparotomy incision and a left
neck incision.
• Blunt dissection of thoracic esophagus.
• Cervical anastomosis with a gastric pull-up.
• Disadvantages: Limited thoracic
lymphadenectomy and blind midthoracic
dissection.

75. TRANSHIATAL ESOPHAGECTOMY
Includes midline incision and mobilization of
stomach ---duodenum mobilized and pyloric
drainage procedure done
Left cervical incision made circumferential
dissection of cervical esophagus upto upper
thoracic esophagus .

76. TRANSHIATAL ESOPHAGECTOMY
• Gastric tube is transposed through the
posterior mediastinum to the cervical wound --
--cervical esophagogastric anastomosis done
• Two field lymphadenectomy done
abdominal and lower mediastinal node
basins .

77. TRANSHIATAL ESOPHAGECTOMY
• Avoidance of thoracotomy incision
• Minimises pain and postop pulmonary
complications
• Elimination of mediastinitis associated with
intrathoracic anastomotic leak

78. MCKEOWN THREE PHASE ESOPHAGECTOMY
• Includes right thoracotomy followed by
laparotomy and cervical anastomosis.
• Applicable for tumours in the upper,middle
and lower thoracic esophagus.
• Eliminates complication of Intrathoracic
esophagogastric anastomosis.

79. Lymph node dissection
• Allows a complete 2-field (mediastinal and
upper abdominal) lymphadenectomy under
direct vision.

80. Transthoracic or thoracoabdominal
esophagectomy
• Involves contiguous abdominal and left thoracic
incision through eighth intercostal space.
• Gastric pull-up and an esophagogastric
anastomosis in the left chest .
• Most useful for tumors involving the distal
esophagus and GEJ.

81. GEJ TUMOUR RESECTION
.
• Surgical management is standard of care includes either
an esophagectomy with partial or extended gastrectomy,
with/out thoracotomy.
Principles:
• R0 resection,
• 4-cm (distal) gastric margin, 5-cm
esophageal margin, and
• Resection of at least 15 nodes in basins
appropriate for the primary tumour

82. THE &TTE
The transhiatal esophagectomy (THE) was
developed in an attempt to mainly minimizing
postoperative morbidity/mortality by avoiding
a formal thoracotomy but limiting the extent
of lymph node dissection achievable.
The transthoracic approach (TTE) with two-field
lymphadenectomy (posterior mediastinum,
upper abdomen) was introduced as to improve
completeness of the resection and to increase
locoregional tumor control.

83. Minimally invasive esophagectomy
• Associated with decreased morbidity and shorter
recovery time
• Used in more advanced lesions
Includes
• Laparoscopic
• Thoracoscopic
• Combined
• Hand assisted
• Robotic assisted

84. CHOICE OF ANASTOMOSIS
Cervical Versus Thoracic Anastomosis
• Equally safe when performed using
standardized techniques.
• At present, the choice of anastomotic location
remains clinician dependent.
• A cervical anastomosis has a higher leak rate
and risk of injury to the RLN.
• However, the anastomosis confines of the neck
and thoracic inlet limit surrounding tissue
contamination and, thus, limit morbidity.

85. Choice of conduit
STOMACH
•The stomach is the preferred organ for esophageal replacement
because of its
1.Blood supply,
2.The resistance of these vessels to atherosclerotic disease,
3.The need for a single anastomosis,
4.The ability of the stomach to reach the neck without diffculty.
•Contraindications
1. Prior gastric surgery,
2. Scarring from peptic ulcer disease
3. Involvement with tumor.

88. Colon
•The left colon is preferred over the right colon for
several reasons.
1. Its diameter more closely resembles that of the
esophagus,
2. Its vascular supply has less variation,
3. Greater length can be obtained.
• Atherosclerotic disease most commonly affects the
inferior mesenteric artery,and the left colon is often
more affected by diverticular disease than the right.

91. JEJUNUM
•Jejunal interposition may be applied as a free graft,
pedicled graft, or Roux-en-Y replacement.
•Jejunum is often the third choice (after stomach and
colon) for esophageal replacement, because it
cannot replace the entire esophagus to the neck,
but can be used to replace a portion of the distal or
proximal esophagus.
•Free jejunal grafts are used in limited
reconstructions of the cervical esophagus.

92. Jejunal conduit

93. LYMPH NODE DISSECTION
• Mediastinal lymph node
dissection
from tracheal bifurcation to
esophageal hiatus
• Upper abdominal L.N dissection
Lymph nodes along the
portal vein , common hepatic
artery , celiac trunk ,
left gastric artery ,
splenic artery

94. Mediastinal lymphadenectomy

95. 3 field lymphadenectomy
• complete mediastinal,
• upper abdominal,
• B/L cervical nodes,
commonly practiced in Asian countries for
upper thoracic esophageal cancers.
After Esophaectomy without induction
chemoradiation atleast 15 lymph nodes
should be removed.

96. Feeding jejunostomy
• A feeding jejunostomy tube is inserted at the time
of the surgical resection for all patients undergoing
an esophagectomy and for selected patients who
require nutritional support during induction
chemotherapy and/or radiation therapy.
• The jejunostomy tube is inserted 40 cm distal to the
ligament of Treitz, using either a laparoscopic
approach if technically feasible or through a small
laparotomy incision.

97. POSTOPERATIVE MANAGEMENT
• Enteral feedings are started on POD 2 and
slowly advanced.
• OGS is performed on POD 7 to evaluate for
leak and emptying of the conduit.
• The NG tube generally remains in place until
OGS is performed and demonstrates no leak.
• Minimal liquid diet for approximately 2 weeks

98. Post operative complications
• Anastomotic leak
• Recurrent laryngeal nerve injury
• Chylothorax
• Conduit ischemia
• Anastomotic stricture
• systemic complications ( pneumonia,
myocardial infarction)

99. SALVAGE ESOPHAGECTOMY
• "Salvage esophagectomy" is the esophagectomy
performed after failure of definitive radiation and
chemotherapy.
• The most frequent scenario is one in which distant
disease (bone, lung, brain, or wide LN
metastases) renders the patient nonoperable at
initial presentation.
• Then, systemic chemotherapy, usually with
radiation of the primary tumor, destroys all foci of
metastasis, as demonstrated by CT and CT-PET,
but the primary remains present and
symptomatic.

100. • Following a period of observation, to make sure no
new disease will "pop up," salvage esophagectomy
is performed, usually with an open two-field
approach.
.
• Because of the dense scarring created by
radiation treatment, this procedure is the most
technically challenging of all esophagectomy
techniques.

101. chemoradiation
• Preoperative chemoradiation
• Postoperative chemoradiation
• Definitive chemoradiation

102. Preoperative CR
Preferred
● Paclitaxel and
carboplatin
(Weekly for 5 weeks)
● Fluorouracil and
oxaliplatin
(Day 1 & day 2 then
Every 14 days for 3
cycles)
Adenocarcinoma of
thoracic esophagus/GEJ
• Fluorouracil and cisplatin
Perioperative
• FLOT regimen
(4+4 cycles)
• Fluoropyrimidine and
oxaliplatin (3+3 cycles)

103. Definitive chemoradiation
Preferred regimens
• Paclitaxel and carboplatin (weekly for 5 weeks)
• Fluorouracil and oxaliplatin (every 14 days for
3cycles with radiation followed by 3 cycles
without radiation )
• Fluorouracil and cisplatin (every 28 days for
2cycles with radiation followed by 2 cycles
without radiation )

104. Postoperative chemoradiation
• Fluoropyrimidine (infusional fluorouracil or
capecitabine) before and after
fluoropyrimidine based chemoradiation.
Postoperative chemotherapy alone
• capecitabine and oxaliplatin
• Fluorouracil and oxaliplatin

105. Radiotherapy
• Radiotherapy dosing
Preoperative RT:
41.4 –50.4 Gy (1.8 –2.0 Gy/day )
Postoperative RT :
45 –50.4 Gy (1.8 –2.0 Gy/day )
Definitive radiotherapy:
50—50.4 Gy (1.8 –2.0 Gy/day )

106. CROSS TRIAL
Chemoradiation followed by surgery (trimodality
therapy ) VS surgery alone
5 weees course of CR followed by surery within
4—6 wweeks
In complete patholoical response ,nodal
positivity,5yr survival rate, RO dissection
Benefits in SCC rather thaan adenocarcinoma

107. MAGIC Trial
• Medical Research committee Adjuvant Gastric
Infusional chemotherapy trial
• Preoperative chemotherapy followed by
surgery Vs Surgery alone

108. Follow up
If patient asymptmatic,
• Follow up every 3—6 months for 1—2 yrs,
• every 6—12 months for 3—5 yrs,
then annually
Locoregional recurrence present---- palliative mx
If esophagectomy not done before (only
definitive CR given )—resectablee ----
esophagectomy ,otherwise palliative mx

109. Palliative therapy
• External or intraluminal RT (brachytherapy)
• Traction tubes –celestin /MB tubes through
open surgery
• Pulsion tubes-self expandable metal stents
through endoscopes
• Endoscopic laser
• Chemotherapy
• Transhiatal osophagectomy -orringer

110. Complications of ca esophagus
&prognosis
• Cancer cachexia
• Sepsis,mediastinitis
• Malignant TE fistula –severe respiratory
infection –death
• Erosion into major vessel –bleeding

111. Prognosis
• Not good because of early spread ,longitudinal
lymphatics ,aggresiveness,difficult approach
and late presentation
• Nodal involvement carries bad prognosis
• 5 yr survival rate is only 10%

112. summary
➢T1aN0, M0 with Favourable factors- Endoscopic
Resection
➢ T1b,T2N0 MO- Upfront Radical Esophgectomy
➢T3,T4 No or Any T N+- Cross Trial.
➢ Transthoracic Mckeowen approach with standard 2
field lymphadenctomy is ideal for mid and distal
esophageal carcinoma
➢ Transthoracic Mckeowen with 3 field
lymphadenctomy in Upper esophagus tumours

113. • In case of tumors invading the stomach more
extensively (more than 5 cm along the lesser
curvature), a total gastrectomy through left
thoracoabdominal approach can be performed

115. Norman barrett