The document discusses esophageal cancer and adenocarcinoma of the esophagogastric junction. It provides details on: 1) The anatomy of the esophagus and locations of narrowing points. 2) Risk factors, clinical manifestations, staging, and diagnostic evaluations for esophageal cancer. 3) Treatment options including surgery, chemotherapy, radiation therapy, and palliative care. 4) Principles of endoscopic staging, therapy and surgery are outlined.

1. Esophageal Cancer
and
Adenocarcinoma of
Esophagogastric Junction:
Practical Points
Facebook: Happy Friday Knight

2. ANATOMY OF ESOPHAGUS

3. • A muscular tube
• From pharynx to cardia of stomach
• 3 narrowing points: tend to hold up objects and
injured when ingesting corrosive agent
– Uppermost: entrance of esophagus caused by
cricopharyngeal muscle (1.5 cm)
– Middle: caused by crossing of Lt main stem bronchus
and aortic arch (1.6 cm)
– Lowermost: hiatus caused by sphincter (1.6-1.9 cm)

4. Brunicardi FC et al. Schwartz’s Principles of
Surgery. 10th ed. McGraw-Hill Education, 2015

5. Brunicardi FC et al.
Schwartz’s Principles of
Surgery. 10th ed. McGraw-
Hill Education, 2015

6. • Cervical portion: 5 cm
– From lower border of cricoid cartilage to sternal
notch
• Thoracic portion: 20 cm
– Upper: from sternal notch to azygos vein arch
– Middle: azygos vein to inferior pulmonary vein
– Lower: inferior pulmonary vein to EGJ
• Abdominal portion: 2 cm

7. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.

8. • Musculature:
– Outer longitudinal and inner circular layer
– 2 – 6 cm uppermost contains only striated muscle,
then smooth muscle gradually becomes more
abundant
• Primary function of esophagus is to transport
materials from pharynx to stomach
• Swallowing – three phases: oral, pharyngeal,
esophageal

9. Esophagogastric Junction (Z-line)
http://www.nature.com/gimo/contents/pt1/fig_tab/gimo14_F1.html

10. Esophagogastric Junction (Z-line)
https://www.e-ce.org/journal/view.php?number=6788

11. Esophagogastric Junction (Z-line)
http://www.anatomybox.com/gastro-esophageal-junction/

12. AEG: Siewert’s Classification
https://openi.nlm.nih.gov/detailedresult.php?img=PMC3496368_cmar-4-367f1&req=4
Type I, II: treat as
esophageal cancer
Type III: treat as gastric
cancer

13. Esophageal Cancer

14. General Consideration
• Most common types of primary esophageal cancer:
– Squamous cell carcinoma: more common in proximal to middle
esophagus
– Adenocarcinoma: more common in lower esophagus
• Overall 5-year survival rate: 42%
• With complete surgical removal of the tumor, the 5-year
survival rate is around
– 90% for pTis
– 75% for pT1
– 45% for pT2
– 30% for pT3
– 10% to 15% for pT4 disease

15. General Consideration
• SCCs
• Acs
• Leiomyosarcoma
• Melanoma
• Metastatic lesion

16. General Consideration
• Risk Factors
– Male
– Age 55 – 60 years
– Obesity
– Smoking
– Alcohol (SCCA >> ACA)
– Low intake of vitamin C and E
– High intake of carbohydrates
– COX-2
– Decreased risk: fruits and vegetable intake, NSAIDS
and aspirin use

17. General Consideration
• Risk factors specific to adenocarcinoma
– Barrette esophagus
– GERD
– Lower sphincter-relaxing medications:
nitroglycerin, anticholinergics, β-adrenergic
agonists, aminophyllines, and benzodiazepines
– Helicobacter pylori infection: negative association

18. Clinical Manifestation
• Early symptom: absent
• Dysphagia (74%)
• Weight loss (57%)
• Odynophagia (pain when swelling: 17%)
• Cough, dyspnea, hoarseness
• Pain: back, retrosternal, abdominal

19. Staging
• TNM

23. Yeo CJ et al.
Shackelford’s surgery
of alimentary tract.
7th ed. Philadelphia:
Elsevier Saunders,
2013.

24. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed.
Philadelphia: Elsevier Saunders, 2013.

25. Diagnostic Evaluation
NCCN. Esophageal and esophagogastric
junction cancers. Version 4.2017

26. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

27. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

28. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

29. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

30. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

31. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

32. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

33. Non-surgical candidates
NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

34. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

35. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

36. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

37. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

38. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

39. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

40. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

41. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

42. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

43. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

44. Principles of Systemic Therapy
• Depends on performance status,
comorbidities, and toxic profile
• Trastuzumab: add in Her-2 overexpressing
metastatic adenocarcinoma
• 2-drug cytotoxic agents are preferred over 3
drug ones because of lower toxicity.
• Preop CRT is preferred for localized
adenocarcinoma of the thoracic esophagus or
EGJ

45. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

46. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

47. Radiation Therapy
• Dose: 1.8 – 2.0 Gy/day
– Preop: 41.4 – 50.4 Gy
– Postop: 45 – 50.4 Gy
– Definitive: 50 – 50.4 Gy

48. Palliative Care
• Prevent and relieve suffering
• Best possible quality of life
• Dysphagia:
– Most common cause: obstruction but may be due
to tumor-related dysmotility
– Treatment: esophageal stent (do not use in
patients who are candidates for curative surgery)

49. Palliative Care
• Dysphagia
– Grading scale:
• Gr 0: able to swallow solid food without special
attention to bite size or swallow
• Gr 1: able to swallow solid food cut into pieces less than
18 mm in diameter and thoroughly chewed
• Gr 2: able to swallow semisolid food (consistency of
baby food)
• Gr 3: able to swallow liquid only
• Gr 4: unable to swallow liquid or saliva

50. Palliative Care
• Obstruction
– Endoscopic lumen restoration (antegrade and
retrograde endoscopy with serial dilatation)
– Enteral access: jejunal or gastrostomy tube
– External beam radiation therapy
– Brachytherapy
– Chemotherapy
– Surgery in selected cased
– Wire-guided or balloon dilation
– Endoscopy or fluoroscopy-guided expandable metal
stent placement

51. Palliative Care
• Nausea/vomiting: may be from obstruction
• Bleeding
– From tumor surface: endoscopic
electrocoagulatioin
– May be from aorto-esophageal fistualization
• Pain
– Severe uncontrolled pain from stent placement,
stent should be removed

52. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

53. NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017

54. Principles of
Endoscopic Staging and Therapy
• Diagnosis
• Staging
• Primary treatment
• Treatment of the symptoms
• Post-treatment surveilance

55. • Diagnosis
– EGD
• Location of tumor relate to teeth and EGJ
• Length
• Circumferential involvement
• Degree of obstruction
– Multiple biopsies (6-8 pieces)
Principles of
Endoscopic Staging and Therapy

56. • Staging
– EUS
• T: tumor invasion
• N: LN involvement
• M: surrounding organs
Principles of
Endoscopic Staging and Therapy

57. https://www.gastrohep.com/images/image.asp?id=407

58. • Primary Treatment
– Endoscopic Mucosal Resection (EMR)
– Endoscopic Submucosal Dissection (ESD)
– Indications:
• pTis,
• pT1a,
• ≤ 2𝑐𝑚,
• Well or moderate differentiated carcinoma
• pT1b in non-fit patients
Principles of
Endoscopic Staging and Therapy

59. http://ghrnet.org/index.php/JT/article/view/775/889

60. http://ghrnet.org/index.php/JT/article/view/775/889

61. http://ghrnet.org/index.php/JT/article/view/775/889

62. http://endotoday.com/endotoday/ESD.html

63. Principles of
Endoscopic Staging and Therapy
http://www.iiharaiin.com/summary_cancer7.html

64. • Techniques
– 3 standard methods
• Strip biopsy
• Cap-fitted panendoscope (EMRC)
• EMR with ligation (EMRL)
– Preparation:
• Chromoendoscopy to detect mucosal margin
• Marking lesion margin: 5 mm from lesion
• Submucosal injection:
– NSS
– Non lifting sign: contraindication for EMR
Endoscopic Mucosal Resection (EMR)

65. https://www.gastrohep.com/images/image.asp?id=920

66. http://www.cancernetwork.com/esophageal-cancer/management-barretts-esophagus/page/0/1

67. • Techniques
– Marking
– Glycerol or sodium hyaluronate injection
– Partial mucosal incision
– Submucosal dissection
Endoscopic Submucosal Dissection (ESD)

69. https://www.slideshare.net/ESOSLIDES/endoscopy-in-gastrointestinal-oncology-slide-4-i-oda-esophageal-esd

70. Principles of Surgery
• Prior to surgery, clinical staging should be performed
using
– CT chest/abdomen
– PET/CT
– EUS
• Laparoscopy may be useful for detecting occult
metastatic disease, especially Siewert II, III
• Clinical T3, N+ should be considered laparoscopic
staging with peritoneal washing
• Positive cytology: M1
• CA esophagus < 5 cm from cricopharyngeus should be
treated with definitive chemoradiation

71. • Unresectable:
– cT4b:
• involvement of heart, great vessels, trachea
• Adjacent organs: liver, lung, pancreas, spleen
– Multi-station bulky lymphadenopathy
– Supraclavicular LN
– Distant metastasis including non-regional lymph
nodes
Principles of Surgery

72. Principles of Surgery
• Esophageal dilation or jejunostomy tube in
patients unable to swallow
• Jejunostomy are preferred to gastrostomy
which may compromise integrity of gastric
conduit for reconstruction

73. Principles of Surgery: Margin?
• Maingot:
– an in-situ margin of 10 cm (fresh contracted
specimen of approximately 5 cm) should be the
goal, to allow a <5% chance of anastomotic
recurrence
– Intraoperative frozen section is one method to
ensure a negative margin.
• Cameron: R0 = microscopic margin clear >
1cm

74. Principles of Surgery: Margin?
Proximal margin: 12 cm
Distal margin: 5 cm

75. Principles of Surgery
• Acceptable operative approaches:
– Ivor Lewis esophagogastrectomy (laparotomy +
right thoracotomy)
– McKeown esophagogastrectomy (laparotomy +
right thoracotomy + cervical anastomosis)
– Transhiatal esophagogastrectomy (laparotomy +
cervical anastomosis)
– Left transthoracic or thoracoabdominal
approaches with anastomosis in chest or neck

76. Principles of Surgery
• Acceptable conduits
– Stomach (preferred in most surgeons)
– Colon (preserved for previous gastric surgery)
– Jejunum (used in esophagectomy with total
gastrectomy)
• At least 15 lymph nodes
• Recurrent resectable cancer after definitive
chemoradiation can be considered for
esophagectomy

77. Evaluation
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015

78. Extent of Resection: Lymphadenectomy
• Standard two-field lymphadenectomy:
removing the nodes and peri-esophageal
tissue below the level of the carina, and the
lymph node stations around the celiac
trifurcation
• Extended two-field lymphadenectomy: two-
field + superior mediastinal LN
• Three-field lymphadenectomy: additional
bilateral cervical LN

79. Esophagogectomy and
Esophagogastrectomy
• Upper: McKweon
• Middle: McKweon or Ivor-Lewis
• Lower: either approaches or transhiatal or Lt
thoracoabdominal (anastomosis at or below
inferior pulmonary vein)

80. Tri-Incisional Esophagectomy
(McKeown Technique)

81. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

82. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

83. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

84. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

85. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

86. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

87. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

88. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

89. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

90. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

91. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

92. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

93. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

94. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

95. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

96. Zinner MJ, Ashley SW. Maingot’s Abdominal
Operation. 11th ed. McGraw-Hill’s Access
surgery.

97. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

98. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

99. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

100. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

101. Ivor-Lewis Technique

102. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

103. Transhiatal Technique

104. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

105. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

106. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

107. Left Thoracoabdominal Approach

108. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

109. Alternative Methods for
Reconstruction: Colon
• Used in prior gastric surgery
• Left preferred to Right side:
– Diameter closed to esophagus
– Less variation of vascular supply
– Greater length
– Cons: atherosclerosis of IMA, diverticular disease
• Preop BE or colonoscope to exclude intrinsic
disease
• Complete bowel preparation

110. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

111. Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

112. • Third choice
• REY replacement
• Free graft transfer
• Pedicle graft transfer
Alternative Methods for
Reconstruction: Jejunum

113. Roux-en-Y
replacement
Zinner MJ, Ashley SW. Maingot’s Abdominal
Operation. 11th ed. McGraw-Hill’s Access
surgery.

114. Pedicle Graft
Zinner MJ, Ashley SW. Maingot’s Abdominal
Operation. 11th ed. McGraw-Hill’s Access
surgery.

115. Free Graft
Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.

116. References
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015
Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.
Cameron JL, Cameron AM. Current Surgical Therapy. 11th ed. Philadelphia: Elsevier, 2014.
Zinner MJ, Ashley SW. Maingot’s Abdominal Operation. 11th ed. McGraw-Hill’s Access surgery.
NCCN. Esophageal and esophagogastric junction cancers. Version 4.2017
Fordick F et al. Oesophageal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-
up. Annals of Oncology 27 (Supplement 5): v50 doi:10.1093/annonc/mdw329 –v57, 2016.
Kuwano H et al. Guidelines for Diagnosis and Treatment of Carcinoma of the Esophagus April 2012 edited by
the Japan Esophageal Society. Esophagus (2015) 12:1–30
Eleftheriadis N et al. Definition and Staging of Early Esophageal, Gastric and Colorectal Cancer. J of tumor. 2014;2(7).
Casson AG et al. What Is the Optimal Distal Resection Margin for Esophageal Carcinoma?. Ann Thorac Surg. 2000;69:205–9
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