This document discusses esophageal carcinoma. It begins by describing the anatomy of the esophagus and then discusses the introduction, pathology, etiopathogenesis, and clinical features of esophageal carcinoma. It notes that esophageal carcinoma is usually squamous cell carcinoma or adenocarcinoma. Risk factors for squamous cell carcinoma include smoking and alcohol, while risk factors for adenocarcinoma include gastroesophageal reflux disease and Barrett's esophagus. The document outlines methods of diagnosis, staging, surgery (esophagectomy), lymphadenectomy techniques, and treatment options including neoadjuvant therapy, radiotherapy, palliative care, and endoscopic techniques.

1. OESOPHAGEAL
CARCINOMA

2. ANATOMY
• Blood supply
• -Cervical-inferior thyroid artery
• -Thoracic 4-6 aortic esophageal
arteries and branches of left
bronchial artery
• -Abdominal-Left gastric and
inferior phrenic artery
25cm hollow structure
extending from cricopharynx to
gastroesophageal junction(C7-
T10)
4 constriction
-at cricopharyngeal junction
-crossed by aortic arch
-crossed by left bronchus
-pierces the diaphragm

3. INTRODUCTION
• 6th most common cause of cancer in the world
• Majority of oesophageal carcinoma are squamous cell carcinoma, worldwide
• Western countries predominant are adenocarcinoma
-?mainly due to smoking , alcohol and Barrett’s oesophagus
• Poor prognosis?
-more lymph vessel are present in submucosa -spread is faster
-lymph flow in submucosal plexus runs in longitudinal direction-so primary tumour can extend for
considerable length both superiorly and inferiorly
-cervical oesophagus –has direct spread to regional lymph nodes, less lymphatics in submucosa –
prognosis better

4. PATHOLOGY
Squamous cell carcinoma Adenocarcinoma
2/3rd oesophagus Lower 1/3 (majority near gastroesophageal
junction)
common Rising in trend
Less common malignant oesophageal carcinoma :
-small cell carcinoma
-Melanoma
-leiomysarcoma, lymphoma
-oesophageal involvement by other metastatic tumours

5. AETIOPATHOGENESIS
• Precancerous/predisposing conditions
-achalasia cardia
-Barrett’s oesophagus
-corrosive stricture
-plummer vinson syndrome
-familial keratosis plantaris/palmaris(tylosis)
• Carcinogens
-tobacco, smoking, alcohol abuse
-HPV infection
-Dietary carcinogens(elevated nitrates in drinking water,food containing
fungi geotrichum candidum)

6. SQUAMOUS CELL
CARCINOMA
smoking.
• Alcohol: Chronic alcohol use, especially in combination with
smoking
• Gender: In western countries, the risk for men is 3 to 4 times
greater than that for women.
• Age: Risk increases with age. Approximately 75% of people
with esophageal cancer are diagnosed between 55 and 85 years
of age.
• Occupational exposures: solvents or chemical fumes (e.g., dry
cleaning chemicals).
• Human papillomavirus infection (HPV)
• Other medical conditions:
• Achalasia (a rare disorder in which the lower oesophageal
sphincter does not relax properly to allow food to pass
through);
• tylosis (a rare inherited disease linked to a genetic mutation
thought to be responsible for some esophageal cancers),
• esophageal webs (abnormal protrusions of tissue into the
esophagus that interfere with swallowing)

7. ADENOCARCINOMA
• Gastroesophageal reflux disease (GERD)
• Barrett’s esophagus
• Obesity: Obesity may exacerbate GERD and
Barrett’s, perhaps because it creates greater
pressure on the abdomen, which in turn,
may result in a higher frequency of GERD.
• Gender: Gender appears to be a
contributing factor, with incidence rates in
men 6 to 8 times greater than those in
women

8. MODE OF
SPREAD
• Direct invasion to surrounding
structure like
aorta,trachea/bronchus and
longitudinally via submucosal
lymphatic channels
• Lymph node(common )
-?lymphstics in oesophagus located in
submucosa vs rest of Gastrointestinal
tract where they are located beneath
muscularis propria
• Hematogenous spread:
-liver lungs brain bone

9. CLINICAL FEATURES
Local tumour effect -progressive dysphagia(solid to liquid)
-odynophagia
-loss of appetite, loss of weight
-upper GI bleed
-cough regurgitation, vomiting
Invasion of surrounding
structure
-hoarseness of voice (recurrent laryngeal nerve )
-horner’s syndrome (invasion of sympathetic chain in cervical
region causing ptosis, miosis, anhidrosis on the same side of
and enopthalmos )
-trachea-stridor
-perforation into pleural cavity-emphyema
-back pain-celiac axis node involment
Distant metastasis -hypercalcaemia (paraneoplasic syndrome in SCC)

10. DIAGNOSIS
• Medical history & physical examination
• Blood tests: FBC to detect anemia,
liver function tests to detect liver metastasis.
• Imaging tests: A barium swallow
Esophagoscopy (upper endoscopy)
Endoscopic biopsy
If these test results are inconclusive and suspicion of cancer still exists, endoscopic
ultrasound (EUS), with or without fine needle aspiration (FNA) biopsy may be used
Endoscopic ultrasound (EUS): EUS combines endoscopy and ultrasound to obtain
images of the esophagus.
EUS guided FNA: EUS can be used to guide the placement of a biopsy needle through
which tissue samples are extracted.

11. FOR STAGING
• POSITRON EMISSION AND COMPUTED TOMOGRAPHY
-CT is more sensitive than PET for evaluating local-regional lesions
- PET, however, is superior to CT for detecting distant metastatic sites
• EUS-compared to CT more reliable to evaluate extent of tumour into oesophageal
• Bronchoscopy-to rule out fistula in midesophageal lesion

12. Staging

16. SURGERY- ESOPHAGECTOMY
surgically removing all or part of the esophagus, as well as any tissue (including lymph nodes)
that may contain cancer.
To replace the esophagus, the stomach is pulled into the chest and surgically joined to any
remaining part of the esophagus.
Alternative oesophageal replacement:
-colon
-jejenum
Complications:
Early:
-Respiratory complications due to thoracotomy
-anastomotic leakage
-chylothorax
-injury to recurrent laryngeal nerve
Late:
Benign anastomotic stricture
(higher with cervical then with intrathoracic anastamosis)

17. TECHNIQUES OF ESOPHAGECTOMY
• Modified Ivor Lewis
-right thoracotomy and laparotomy->intrathoracic anastomosis
-resected affected esophagus, 5cm margin proximally and distal lesser curvature of
stomach
-nodal dissection include paraesophageal, subcarinal, perigastric , gastric artery region
and celiac nodes
• McKeown(3 field esophagectomy)
-right thoracotomy , upper midline laparotomy and left sided transverse neck incision
• Transhiatal esophagectomy
-upper midline laparotomy and left sided neck but has incomplete lymphadenectomy

18. LYMPHADENECTOMY
• 1 field –clear Lymph nodes in one area either cervical/thoracic/abdominal
• 2-field-(thoracic +abdomen)
• 3 field
For squamous cell carcinoma-usually 3 field lymphadenectomy done (as it is more
common in uppr and middle position of oesophagus)
Adenocarcinoma-usually 2 field lymphadenectomy (more common in lower esophagus)

19. • Neoadjuvant therapy
-with preoperative chemotherapy/chemoradiotherapy-enhance local control
and resectibility
• Radiotherapy
For attempted cure and palliation of SCC oesophageal carcinoma-if not
suitable for resection
• Palliative treatment-to relieve obstruction/mitigate dysphagia
a)Radiotherapy and chemotherapy-adenocarcinoma less responsive
b)Intraluminal prostheses-rigid tube/expanding stents
-Potential complication:
perforation , erosion
migration of the stent/obstruction
c)Endoscopic laser technique

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