This document discusses dysphagia and esophageal cancer. It presents a case study of a 65-year-old male with dysphagia, weight loss, and odynophagia. Diagnostic workup revealed a mass in the distal esophagus, and biopsy showed esophageal adenocarcinoma. Risk factors for esophageal cancer are discussed, as well as changes in incidence rates over time. Methods for screening, staging, and managing esophageal cancer are described, including endoscopic resection, chemotherapy, radiation, surgery, stents, and palliative care. Prevention strategies focus on moderating risk factors like tobacco, alcohol, diet, and weight management. The outlook emphasizes earlier diagnosis, biomarkers, and

1. Dysphagia in relation to
Esophageal Cancer
Dr Muzaffar Mehdi
MBBS MD Gastroenterology
Senior Registrar Gastroenteology
Shaikh Zayed Postgraduate Medical Institute
Lahore
1

2. Road Map For Today
 Case presentation & interactive discussion
 Literature review for Ca esophagus
–Diagnostic work up
–Screening
–Management of Ca Esophagus
–Prevention
–Future & outlook
2

3. Case History
 A 65 years old male resident of Kabul
Afghanistan
 Dysphagia  4 months
 Weight loss  4 months
 Odynophagia  4 months
3

4. HOPI
 Dysphagia
 Gradual in onset
 Progressive started with solid bolus now to
liquids
 Regurgitation of undigested food plus
water
 Associated with pain during swallowing
and weight loss of more then 10
percentile of body weight in last 4 months.
4

5. Systemic enquiry &Past history
 Except weight loss nothing special on
systemic enquiry
 No comorbids
 Past History of dyspepsia over several
years for which he use hakeem
medications
 Family History : negative for DM,HTN TB,
CKD,Lymphoma ,Ca colon.
 Personal history : smoker , Naswar ,
kahwa drinker daily 6 ,7 cups.
5

6. Examination
 Pallor +
 Jaundice-ve
 Lymph nodes + ve supraclavicular and
anterior cervical chain
 Liver not palpable .Spleen not palpable.
6

7. Differential Diagnosis
 Esophageal carcinoma
 Peptic stricture
 Achalasia cardia
 DES
 EoE
7

8. How will you investigate ?
 CBC PLATELETS
 LFTS
 RFTS
 Na K
 URINE CE
8

9. Radiology and Endoscopy
 Chest X ray
 Barium Swallow
 CT scan chest & upper abdomen
 Endoscopy plus biopsies
 Endoscopic ultrasound
9

10. Diagnosis and Management
 CT scan revealed mass distal esophagus
 Endoscopic biopsy showed OAC
 Patient was referred to Inmol hospital for
neo adjuvant chemoradiotherapy and will
require surgery.
10

11. Literature Review
11

12. Epidemiology
 Sixth most common cause of cancer associated
death globally 5th most common in 3rd world
 In 2012, there were an estimated 456,000 diagnoses
of oesophageal cancer
 Of diagnosed, 398,000 were OSCC and 52,000 were
OACs
 5year survival rate for all patients is less than 20%,
even in developed countries
 Incidence of oesophageal cancer increases with age
12

13. Risk Factors
OSCC
 Tobacco smoking
carcinogen
polycylic hydrocarbons
nitosamines
 Alcohol
actetadehyde 5 folds>
 Low fruit intake
micronutrients deficiencies
vit A,E
 Low socioecnomic status
 Hot beverages
Hot tea kahwa
 HPV
 Tylosis
 Chromosomal abnormalties 10q23
OAC
 Barrett esophagus
 Gerd
acid and bile reflux
 Obesity
High BMI
central visceral
 Metabolic syndrome
 Tobacco smoking
 Male sex (7:1 )
 Red meat intake
 Low fruit and vegetables
 H pylori (inverse relation)
 Genetics
13

14. Key differences between OSCC &OAC
14

15. Changing trends
 Until the 1970s
– Squamous Cell Ca 75%
– Adeno Ca 25%
 Past 20-30yrs
– Incidence of OSCC has decreased both in AA
and Caucasian
– Incidence of AdenoCa increased by 45% in
Caucasian men and 50% in black AA men
– In 1994 60% of all esophageal cancers were
adenocarcinoma.
15

16. Pathogenesis
16

17. Progression of Barrett’s Esophagus
4% per year
1% per year
0.5 % per year 17

18. Clinical Symptoms
 Dysphagia
 Odynophagia
 Weight loss( involuntary and progressive )
 Less often: Dyspnea, cough, hoarseness and
pain in retro-sternal, back or right upper
abdominal
 Metastatic Disease: Lymphadenopathy
(Virchow’s node), hepatomegaly, pleural effusion
 Malena
 Fatigue
18

19. Diagnosis & staging
 Endoscopy
Lugol iodine
Chromoendoscopy
Narrow band endoscopy
(Biopsy Histology)
 Endoscopic Ultrasound
 CT scan Abdomen Chest
 PET scan –FDG PET
 Bronchoscopy Laparoscopy
19

20. Barium swallow & Meal
20

21. Endoscopy
21

22. Endoscopy
22

23. Endocopy ..
23

24. Endoscopic Ultrasound
24

25. 25

26. CT scan
26

27. Staging
27

28. Cancer of the Distal Esophagus with Metastasis to
a Paraesophageal Lymph Node
NEJM 2003; 349:2241-52
28

29. Diagnostic workup
29

30. Esophageal Carcinoma
 Adenocarinoma : 75% in distal esophagus.
 Squamous Cell Ca: evenly distributed in
middle and lower third
 At Diagnosis: More than 50% have
unresectable tumors or radiographically
visible metastasis 30

31. Screening
 Patients who have GERD for >5 yrs
 Patients who have > 2 risk factors including (male
sex, Caucasian race, obesity or history of smoking
and family HX of Ca esophagus )
 No approved screening guidelines
 No biomarkers approved yet may spare endoscopy
 Screening tool Endoscopy is invasive
 Trans nasal endoscopy ,Capsule endoscopy
,Cytosponge (trefoil factor 3 staining ,aberrant p53
31

32. Screening for Barrett's
32

33. TNM staging
33

34. Tumor-node-metastasis categories
34

35. Management
 Endoscopic: EMR ,EMD ,RFA
 Surgical:
Esophagectomy
proximal gastrectomy
total gastrectomy
transhital vs trans thoracic
minimal invasive
salavage and planned
 Chemotherapy :
Adjuvant
neoadjuvant
peri opertivechemotherapy
chemoradiotherpay
Defeinative chemoradiotherapy (OSCC)
 Palliative treatment : Chemo,Trastuzamab ,Ramucirumabs
 Radiotherapy
 Esophageal Stents
35

36. Management of localized cancer
36

37. ESMO Clinical Practice Guidelines
37

38. Endoscopic mucosal Resection
38

39. Endoscopic submucosal Dissection
39

40. Types of esophagectomies
 Transhiatal
 Exposure is provided by an upper
midline laparotomy and a left
neck incision.
 The thoracic esophagus is bluntly
dissected, and a cervical
anastomosis created;
thoracotomy is not required.
 Drawbacks: inability to perform a
full thoracic lymphadenectomy,
and lack of visualization of the
midthoracic dissection.
 Transthoracic
 The Ivor Lewis esophagectomy
combines a laparotomy with
right thoracotomy, and
produces an intrathoracic
anastomosis.
 This technique permits direct
visualization of the thoracic
esophagus, and allows the
surgeon to perform a limited
lymphadenectomy.
 However formal dissection of
lymph nodes is not performed
40

41. Five-Year Survival Rates for
Esophageal Carcinoma
41

42. Predictors of prognosis.
 Staging of disease at diagnosis
 Weight loss of more than 10 percent of body mass
 Dysphagia
 Large tumors
 Advanced age
 Lymphatic micrometastases (identified by
immunohistochemical analysis) .
 Performance status of patient -ECOG
 Comorbidities
 Surgeon skill and surgery done at high volume
centers 42

43. Role of Radiotherapy
 Radiotherapy : OSCC (has high sensitivity to
radiotherapy with durable response Up to 40% )
 In few cases after CR surgery may become
unnecessary
 Poor surgical candidates
Advantage:
-avoidance of perioperative morbidity and
mortality –In pts with very high risks for
surgery as palliative maneuver as dysphagia
Disadvantage :
-Higher probability of local -
complications like esophago tracheal fistula
43

44. Role of Chemotherapy
 Cancers >T2 or N require Chemo or chemo radio
–neadjuvent or perioperative chemo for
improved survival
‫۔‬CR is better than chemo alone
 Perioperative Chemotherapy
 OEO2
-(ECX )-epirubicin +cisplatin+ capecitabine
‫2۔‬ cycles
 FLOT
DOF ‫۔‬docetaxel+ oxaliplatin + 5 Hourouracil
 Cross. Carboplatin+paclitaxel+radiotherapy
44

45. Palliative Chemotherapy
 More than 50% pts treated with curative intent will have
tumor recurrence and requires palliative chemo
 Palliative radio or stenting relieves dysphagia
 Systemic disease requires chemotherapy
 REAL 2 :Oxilaplatin or cisplatin was used with 5 flourauracil
or Capecetabine
 FOLFOX : oxaliplatin +5 flourouracil +lecuvorin
 2nd line : Taxans + irenetican was used for 6 weeks
 Median survival is < 1yr toxicity over efficacy should be
considered
 OAC with HER 2 +ve trastuzumab +cisplatin
+flouropyrmidines
 Anti VEGFR 2 Ramucirumab +Paclitexal -increase survival
45

46. Palliative measures
46

47. Esophageal stent
47

48. Esophageal stent
48

49. Prevention
Primary prevention
 Avoidance of risk factors
 Moderation of alcohol
intake ,tobacco
 Maintain healthy weight
 Increase fruit intake
 Reduce red meat
Secondary prevention
 Pharmacological
– PPI,
NSAIDs,(Aspirin)
 Endoscopic monitoring
 Local ablative therapy (EMR,
EMD,RFA,Phtoablation )
combinations are better in
LGD Barrett
 Antireflux surgery
 Future is molecular status of
tumor
49

50. Outlook
 Molecular characterization of tumor
 Individualized management
 Earlier diagnosis
 Biomarkers for dysplasia
 Organic solvents breath tests
 Anti PD1 in( PDL1+)
pembrolizumab,nivolumab,ipilumab
 Combination immunotherapy is future
50

51. Thank You!
51