Carcinoma esophagus is a lethal disease and carries poor prognosis.The diagnosis is usually delayed and over all 5yrs survival is less than 15% In this presentation I have discussed carcinoma esophagus - its pathology, clinical features, investigations and treatment in nutshell

1. Carcinoma Oesophagus
Dr R S Dhaliwal
MS,MNAMS (Surgery ) MCh,DNB (CTVS),
FACS, FCCP,FAMS,FICA,FNCCP,FIACS
Prof of Cardiothoracic Surgery, UCMS
Former , Prof & HOD, CTV Surgery, PGIMER ,
Chandigarh

2. Esophagus -Anatomy
• Normal oesophagus
starts in neck
25 cms long Goes
through the post.
mediastinum ends in
abdomen
2cms lies below the
diaphragm,
Having two sphincters at
upper and lower ends

3. Introrduction
• Anatomical narrowings -
Three constrictions
a. At the beginning due to
Cricopharyngeus (14-16
cms from incisor teeth)
b. Crossing of left main
bronchus and aortic arch
( 25-27 cms from incisor
teeth )
c. At cardiac end ( 35-38
cms from incisor teeth)

4. Introduction
• Histopathology - a Mucosa – a.Stratified
squamous epitheliun b. lamina propria
c.mucularis mucosae
b.Submucosa – esophageal glands & papillae
c.Muscularis externa (propria) –
composition varies *Upper third or superior
part – striated muscle
*Middle third – Smooth and striated muscle
*Inferior third – mainly smooth muscle
d Adventia - minimal

6. Geographical Distribution
• Carcinoma
esophagus more
common in China,
Japan , India ,
South Africa
Belgium ,Iran, U.K.
France and
Iceland

7. Ca esophagus -Epidemology
• In USA it is more common in Afro American males
with H/O of heavy smoking and alcohol intake
• Squamous cell carcinoma was more common in
past but now Adenocarcinoma is more common
in non Hispanic white men
• Adenocarcinoma esophagus is associated with
Barret esophagus
• Incidence and mortality though decreased but
continue to be higher for Afro African males than
Causasian white males in which it has increased

8. Ca Esophagus - Incidence

9. Histopathological Classification
Carcinoma Oesophagus
• Squamous Cell carcinoma -
In upper 2/3rd of
esophagus. Associated with
smoking and alcohol
consumption
• Adenocarcinoma
In lower 1/3rd of
esophagus . Associated
with GERD and Barrett’s
esophagus
Photomicrograph

10. Histological Classificatiom
• Fungating Type – present in 11-60% cases.
Frequently invades mediastinum. Friable, mainly
intraluminal with ulceration
• Ulcerating Type- present in 25-63% cases, flat
base ulcer raised edges,friable, erythema,
induration, hemorrahge
• Infilterating Type –seen in 15-26% cases, circu
mferential intraluminal growth
• Polypoid Type- seen in 2-8% pts, intraluminal
polypoid growth, narrow stalk, best prognosis
(70% 5 yrs survival < 15% for other types )

11. Symptoms & Signs
• Asymtomatic for long time
• Dysphagia-Food getting stuck in esophagus
• Pain during swallowing –odynophagia
• Nausea, vomiting, regurgitation of food
• Hematemesis & melena
• Loss of appetite and Weight loss
• Cough or hoarseness of voice
• Heart burn –retrosternal pain or in epigasterium
increasing on swallowing
• Fistula with bronchus or trachea –Liquids swallowing
causes violent cough Repeated Chest infe ction
• Symtoms due to metastasis – Ascites, jaundice (liver)
breathlessness, pleural effusion ( lung )

12. Risk Factors
• Positive family history
• Old age >50 . Sex – More in males
• Smoking . Heavy drinking
• Reflux esophagitis & Barret’s esophagus
• Obesity increases risk of adenocarcinoma four times
• Corrosive strictures
• Plummer Vinson synderome, Tylosis
• Radiation therapy to mediastinum , Coeliac disease
• Achalasia cardia
• Diet – Low in fruits & vegetables ,Nitrosamines
• Use of Aspirin or NSAIDs , green and yellow vegetables
& fruits and moderate use of coffee is beneficial

13. Diagnosis -Investigations
• Barium Swallow -
It will out line the
esophageal wall .
Carcinoma will be
shown as filling
deffect or ulcer
• PET Scan, Bone Scan,
laparoscopy - Used
to find out distal
metstasis

14. Investigations
• Upper G I Endoscopy -
Most important test
Fiberoptic endoscopy can
be done under L.A. as
OPD procedure , tumour
is seen and Biopsy is
taken
• F O Bronchoscopy Is done
in middle & upper third
Ca esophagus to see
invasion of bronchus or
trachea

15. Endoscopic Ultrasound EUS
• CT Scan, MRI ,
PET ,Endoscopic
ultrasound and
Thoracoscopy
and laparoscopy
are used in
staging of Carc.
esophagus

16. Staging of Ca esophagus
• T PRIMARY TUMOUR Tis Carcinoma in situ
T1 Invades lamina propria or submucosa
T2 Invades muscularis propria
T3 Invades periesphageal tissue
T4 Invades adjacent structures
N REGIONAL LYMPH NODES
N0 No regional node involvement
N1 Regional node involvement
N1-4 More distant node involvement
M DISTANT METASTASIS M0 No distant metastasis
M1 Distant metastasis
Table 1. TNM designations
• STAGE TNM DESIGNATION 0 Tis N0 M0 I
T1 N0 M0 IIA T2-3 N0 M0 IIB T1-2 N1 M0 III
T3 N1 M0, T4 any N M0 IV Any T Any N M1
Table 2. Disease Stage with corresponding TNM designation.

17. Staging
• Stage 0 - Carcinoma in situ
• Stage 1 – T1- Tumor has gone to submucosa
• Stage 2 A-T1N1 - Tumour has gone to submucosa
2 B-T2N1- Tumour to muscle layer,lymph nodes +
2C – T3N0- Tumour gone out of serosa
. Stage 3 A-T3N1- Tumour out of serosa, LN + ve
3 B - Tumour invaded regional organs e.g.airways
pericardium, aorta LN +ve
. Stage4 - Tumour with distant metastasis

18. Stage Grouping
• Stage Tumour Node Metastasis
0 Tis N o M o
I T 1 N o M o
II A T 2 N o M o
T 3 N o M o
II B T 1,2 N 1 M o
III T 3 N 1 M o
T 4 Any N M 1
IV A Any T Any N M 1 a
IV B Any T Any N M 1 b

19. Treatment
• It may be Surgery, Radiotherapy, Chemo-therapy or
combined Chemoradiation
• Treatment may be Curative (Radical)
Palliative( symptomatic)
Surgery
• Radical Surgery –
1.Transthoracic esophagectomy
- Ivor Lewis approach
- McKeown approach
2. Extrathoracic esophagectomy T H E
3. V A T S

20. Surgical treatment
• Radical Surgery gives best chances of cure
• A gastrostomy should never be done as
“Palliation” , it does not releive dysphagia and
prolongs misry of patient
Various surgical approaches are -
• Transthoracic esophagectomy-
a. Left thoracic (+-abdominal) approach -Sweet
The original old approach, for infra aortic
arch tumors of esophagus,
Disadvantages - - Heart comes in the field
-More morbidity - Intrathoracic anastomosis
- Painful - Costal cartilage problems

21. Surgical approaches

22. Surgical treatment
Ivor Lewis approach- Rt thoracotomy+ laparotomy
Whole of thoracic esophagus can be approached
first abdomen is opened, to see for liver metastasis,
stomach is mobilised,pyloromyotomy done and
abdomen closed. Pt positioned and Rt PLT done,
esophagus mobilised , tumour with adeqate
esophagus resected, anastomosis done between
stomach and esophagus
- Long procedure and anesthesia time
- Intrthoracic anastomosis - Morbidity

23. Surgical treatment
• McKeown approach- Laparotomy+RT ALT +
Neck Incision - An intrathoracic anastomosis
leakage carries high mortality.In McKeown
approach esophago gastric anastomosis is in
neck. Leakage in neck has low mortality.
- Time consuming - morbidity
• Extra thoracic or Transhiatal esophagectomy
THE – Orringer approach
Advantages- No thoracotomy - Neck
anastomosis -Minimal mortality & morbidity

24. Surgical treatment

25. Palliative Surgery
• To releive dysphagia in unresectable cancer of
esophagus or if there is fistula with respiratory
tract esophagus can be bypassed using –
.Lt colon . Stomach . Jejunum
Disadvantages Risks of G.A. and major
operation Morbidity and mortality
*Simple and effective methods ( Intubation by
tubes or stents or laser therapy ) are
available now

26. Esophageal bypass with Colon

27. Treatment
• Palliative Surgery -
1. Colon bypass of esophagus
2.Stomach bypas-Total or Gastric tube
3.Jejunal bypass –Pedicled or Free segment
.Supportive Therapy
Methods to releive dysphagia -
A. Intubation – 1.-Intra esophageal tubes –Souttar
Celestin , Atkinson , MB tube , Proctor Livingstone
2.-Expanding Stents
B - Laser therapy -Photodynamic therapy -
C.Radiation –Brachytherapy
- D Bipolar Diathermy E.Baloon dilatation
F. Alcohol injection

28. Treatment
• Radiotherapy – a. Radical - Gives as good results
as surgery in squamous cell carcinoma More
morbidity , later on stricture formation. Used if
patient is not fit for or refuses surery b.
Palliative- To releive dysphagia in very sick pt not
fit for palliative surgery
• Chemotherapy – Used as adjuant modality alone
or with radiation followed by surgery. This
combined modality has given good 5yrs survival
than with single method

29. Palliative Therapy
• Intraesophageal tubes
• Push through -
Souttar’s, Celestin
Atkin son tube
• Pull through
M B Tube , Proctor
Livingstone tube

30. Esophageal Stents

31. Supportive Therapy
• Pain relief - Cancer esophagus or its treatment
may cause pain.This needs pain killers –oral syrups or
tablets , injectable drugs mainly non narcotic
medicines, in severe pain narcotics are used
• Nutrition - Pt may not be able to eat due to
obstruction,poor appetite, vomiting or diarrohea ( due
to Chemo or radiotherapy ) Diet is modified
accordingly- liquid diet, through feeding tube or IV
hyperalimen ta tion
• Psychological support- Patient is anxious and
worried and needs lot of moral and mental support
by family, friends , councilors and psychiaterist

32. Prognosis & Survival
• 5 yrs survival is 18-22% and has not changed
much in last 30yrs despite advacnement in
anesthesia and perioperative care
• Mortality has come down to 7% from 40%
• Use of neoadjuvant chemotherapy before
surgery has given better 5yrs survival in few
randomized trials
• Comparison of THE versus TTE has shown lower
mortality,less blood loss, less operative time, less
pulmonary complications and chyle leak but
more vocal cord paralysis, cardiac problems and
anastomotic leak in THE group than TTE

33. Influencing the
life styles even
after 2500
years
Thank you