Good contents for UG level. By Yogesh Yadav, SGT Medical College, Gurgaon, Haryana

1. Yogesh Yadav
SGT Medical College,
Gurgaon

2. Worldwide, esophageal cancer
is the most common
malignancy
most common cause of
cancer-related death.

3. 2. Dietary2. Dietary::
a.a. Ing e stio n o f e xo g e no us carcino g e nsIng e stio n o f e xo g e no us carcino g e ns
( To bacco , HPVe tc. ) & pro m o ting( To bacco , HPVe tc. ) & pro m o ting
facto rs asfacto rs as ::
- Polyhydrophenols
- Nitrates and nitrosamines
- Aflatoxine.
b. Abse nce o f pro te ctive substance sb. Abse nce o f pro te ctive substance s
in fruits and g re e n ve g e table s:in fruits and g re e n ve g e table s:
As vitamin A, B2, C, E, and iron, zinc
1. Chronic irritation:1. Chronic irritation:
SSepsis, SSyphilis, SSpirits,
SSpices, SSmoking. (5 S)(5 S)
3- Precancerous conditions:3- Precancerous conditions:
•1.Reflux disease and Barrett’s esophagus (most
important(
2.Achalasia cardia, Plummer- Vinson syndrome.
•3.Ectopic gastric epithelium
•4.Previous irradiation; Corrosive strictures.

4. Site:
a. Upper third: 17%
b. Middle third: 50%
c. Lower third: 33%

5. N/E:
A.A.Annular type:Annular type: more common in lower 1/3.
B.B.Ulcerative type:Ulcerative type: raised everted edge-
necrotic floor- indurated base
C.C.Cauliflower type (60%):Cauliflower type (60%): fungating mass.
A B C

6. M/E:
A.A.Squamous cell carcinomaSquamous cell carcinoma (60%)(60%)
B.B.Adenocarcinoma (40 %)Adenocarcinoma (40 %) in the lower end of the
oesophagus from:
• Barrett’s esophagus (commonest)
• Heterotropic gastric mucosa
• Adenocarcinoma of the stomach spreading
upwards.
• Adenocarcinoma arising from esophageal
submucosal glands.
A.A.Rare types:Rare types: adenoid cystic, and mucoepidermoid
carcinoma, melanoma, carcinoid, small cell carcinoma

7. Spread:
1.1. Direct:Direct:(main route):(main route): to the surroundingto the surrounding
2.2. Lymphatic:Lymphatic: mainly in a downward direction.mainly in a downward direction.
1.1. Cervical esophagusCervical esophagus →→ lower deep cervical L.N.lower deep cervical L.N.
2.2. Thoracic esophagusThoracic esophagus →→ para-oesophageal &para-oesophageal &
tracheo-bronchial lymph nodestracheo-bronchial lymph nodes
3.3. Abdominal esophagusAbdominal esophagus →→ lymph nodes along thelymph nodes along the
lesser curvature of the stomachlesser curvature of the stomach →→ coeliac axiscoeliac axis
L.N.L.N.
3.3. Blood (rare):Blood (rare):
1. Liver, lung, bone, brain

8. TNMstaging
Primary tumor (T)Primary tumor (T)
TO→ No primary tumor
Tis→ Carcinoma in situ- high grade dysplasia.
T1 → Tumor invades lamina propria or submucosa
T2→ Tumor invades muscularis propria
T3→ Tumor invades beyond muscularis propria.
T4a→ Tumor invades adjacent structures- pleura,
pericardium, diaphragm.
T4b→ Tumor invades adjacent structures- trachea, bone,
aorta.

10. TNMstaging contd.
Regional lymph nodes (N)Regional lymph nodes (N)
NO→ No regional node metastasis
N1 → Lymph node metastases in 1-2 nodes
N2 → Lymph node metastases in 3-6 nodes
N3 → Lymph node metastases in 7 or more nodes
Distant metastasis (M)Distant metastasis (M)
MO→ No distant metastases
M1 → Distant metastasis

12. More
common in
Old maleOld male
than female
(> 45 years)(> 45 years)

13. (1)(1) Dysphagia (the cardinalDysphagia (the cardinal
symptom)symptom)::
(difficult in swallowing)
characterized bycharacterized by
a- OnsetOnset: Late onset
b- CourseCourse: Continuous and progressive
course
c- DurationDuration: Short duration (few
months).
d- First toFirst to: solid but not to fluids, later to
both fluids & solids
e- AssociatedwithAssociatedwith: very bad general
condition

14. (2) Regurgitation(2) Regurgitation
(Re g urg itatio n is e ffo rtle ss while vo m iting is
fo rcible )
(3) Pain:(3) Pain: usually a late manifestation.
(characterizedbypointingpain)(characterizedbypointingpain)
(4) Complications.(4) Complications.
(1) Cachexia, Malnutrition, dehydration, anaemia.
(2) Aspiration pneumonia.
(3) Distant metastasis.
(4) Invasion of near by structures: e.g.
1. Recurrent laryngeal nerve → Hoarseness of voice
2. Trachea → Stridor → cough, choking & cyanosis
3. Perforation into the pleural cavity → Empyema

15. A- For diagnosis:
(1 ) Barium swallo w:(1 ) Barium swallo w:
a.a. Fungating and ulcerative massFungating and ulcerative mass: narrowed irregular
filling defect.
b.b. Annular massAnnular mass:
- If middle stricture: Apple core appearanceApple core appearance with
evident shouldering
- If lower stricture: Rat tail appearanceRat tail appearance.
Cancer lower 1/3Cancer lower 1/3
Filling defect (ulcerativeFilling defect (ulcerative
type)type)
Rat tail appearance

16. (2) Eso phag o sco py + Bio psy and(2) Eso phag o sco py + Bio psy and
cyto lo g ycyto lo g y
(the m o st im po rtant)(the m o st im po rtant)
A- For diagnosis:

17. B- For evaluation of
resectability:
(1 ) Endo lum inale ndo sco pic US:(1 ) Endo lum inale ndo sco pic US:
to detect wall penetration and regional LN status.
T4 esophageal cancer
(2) CT and MRI.(2) CT and MRI.(3) Tho raco sco py o r laparo sco py:(3) Tho raco sco py o r laparo sco py:
to detect Intrathoracic and intrabdominal disease.

18. LungLung: chest x-ray & C.T
LiverLiver: US
BoneBone: Bone scan & Bone survey
BrainBrain: C.T.
C- For
staging:

19. 1-1- Complete blood picture:Complete blood picture:
iron deficiency anemia.
2-2- Occult blood in stoolOccult blood in stool
3-3- Tumor markers:Tumor markers: CEA - CA15-3
D-
Laboratory:

20. - Non invasive method of detecting primary, nodal, distant
metastases & locally recurrent tumor
- The technique estimates area of high glucose metabolism
(the tumor) by measurement of the uptake of
radiotracer (Flurodeoxyglucose FDG).
E- Positron emission tomography
(PET):

21. Treatment of cancer esophagusTreatment of cancer esophagus
Operable Inoperable
Radical surgery followed
by chemoradiotherapy
Palliative procedure

22. Criteria
of
inoperability
Unfit patient
Presence of distant metastases
Unresectable tumor
Infiltration of important structure
as trachea, aorta

23. Operable cancer esophagusOperable cancer esophagus
Upper 1/3 Lower 1/3
Total
esophagectomy
Subtotal esophago-
gastrectomy
Middle 1/3
Partial esophago-
gastrectomy
+ appropriate LN dissection

24. Tumors of thoracic esophagus (middle 1/3)Tumors of thoracic esophagus (middle 1/3)
Ivor-Lewis
operation
McKeown’s 3 stage en
block esophagectomy
•Abdomen is opened,
stomach is mobilised &
wound is closed.
•Rt thoracotomy is done
through 6 ICS in Lt lateral
position.
•Growth is removed &
Eso+Gast anastomosis is
done.
•Removal of all LN
(abd+thor)
•3 incisions: Abdominal, Rt
posterolateral thoractomy
through 5 ICS, Lt cervical
incision.
•GI continuity obtained by
gastric tube anastomosis
to cervical esophagus.

25. After esophagectomy
The esophagus is replaced by
After esophagectomy
The esophagus is replaced by
1. Gastric pull up in the neck:1. Gastric pull up in the neck:
the best
2. Colon interposition:2. Colon interposition:
3. Free jejunal replacement:3. Free jejunal replacement:
Gastric pull upColon interposition

26. Inoperable cancer esophagusInoperable cancer esophagus
Non-obstructed Obstructed
Palliative chemo-
radiotherapy
1. LASER tunneling with endoluminal
stenting
2. Photodynamic therapy
3. Intubation
4. Jejunostomy or Gastrostomy for feeding

27. Very bad (5 year survivalVery bad (5 year survival
rate 10%) due to:rate 10%) due to:
1- Old age1- Old age
2- Bad general condition before operation2- Bad general condition before operation
3- Early local spread3- Early local spread
4- High morbidity after operation e.g.4- High morbidity after operation e.g.
empyema, leakage from anastomosisempyema, leakage from anastomosis

28. •Majority of Esophageal Ca advanced atMajority of Esophageal Ca advanced at
diagnosis.diagnosis.
•Best results obtained after surgery-Best results obtained after surgery-
radical esophagectomy.radical esophagectomy.
•Curative resections are major surgeries &Curative resections are major surgeries &
should be undertaken by experiencedshould be undertaken by experienced
surgeon.surgeon.
•The entire treatment of Ca Esophagus isThe entire treatment of Ca Esophagus is
aimed at Cure in minority of cases &aimed at Cure in minority of cases & reliefrelief
of dysphagia in almost all casesof dysphagia in almost all cases..