esophageal carcinoma is one of the common gastrointestinal malignancy. Its usually present at advanced stage. Its management requires diagnosis as early as possible and staging followed by proper planning of treatment. Its treatment include endoscopic, surgical, adjuvant chemotherapy and palliative management.

1. Esophageal Carcinoma
Dr. Md. Ashiqur Rahman.
Phase-B Resident,
Dept. of Gastroenterology, BSMMU.

2. Anatomy
• Conduit to transport food from oral cavity to stomach
• During swalloing it distends 2cm A/P and 3cm laterally
• Length : 18-26cm
• 2 sphincter
UES, contracted at rest, prevents air entering into esophagus.
LES, Contracted at rest prevents entry of gastric contents

4. Histology
• Mucosa
• Submucosa
• Muscularis propria
• Adventitia
• No serosa

6. Lymphatic drainage
• Upper esophagus drain to the deep cervical nodes.
• Midesophagus to the mediastinal nodes.
• Distal esophagus to the celiac and gastric nodes.
• Lymphatic systems are interconnected by numerous channels

7. Esophageal cancer
• 8th most common cancer worldwide with an estimated 456,000 cases
• Sixth leading cause of cancer mortality accounting for approx. 400,000 deaths.
• In 2018 there were 17,290 new cases and 15,850 deaths due to esophageal
cancer in the USA.
• Esophageal cancer usually presents at an advanced stage, and thus curative
treatment is limited and the prognosis is poor,
• 5-year survival rates, improved in patients with early and locally advanced
cancers.
• Overall 5-year survival less than 20%.

8. • Esophageal cancer has 2 main subtypes
Esophageal squamous cell carcinoma (ESCC)
Esophageal adenocarcinoma (EAC)

9. 445 known cases of esophageal cancer diagnosed and/or treated at this center, AC
comprised 23 % and SCC, 71 %.
The majority of AC was in the lower third of the esophagus (56 %), followed by the GE
junction (31 %), middle third in 11 % and upper third in 1 %.
The middle third of the esophagus was the most common site for SCC (43 %), followed by
the lower third (30 %), upper third in 21 % and GE junction in 6 %.

10. Esophageal squamous cell carcinoma(ESCC)
 ESCC is the most common form of esophageal cancer worldwide
 It represents 90% of all cancers in most Asian, African,and Eastern
European countries.
 The incidence was higher in patients older than age 60.
 Male > female
 Location- Middle > Upper

11. Risk factors
• Environmental
Tobaco – smooking increase 3-7 times, other form betel nuts.
Alcohol – 3-5 times, risk increase with alcohol intake above 140 g/week
Nutritional deficiencies- Vitamin A, C, and E folic acid, zinc, and
selenium
• After a 10-year follow-up, a study showed that selenium
supplements along with β-carotene and vitamin E reduced risk of
esophageal cancer death by 17% among ≤ 55years

12. • Dietary –long history of consuming very hot drinks, hot herbal tea, N-nitroso
compounds (animal carcinogens)
• Infection –HPV serotypes 16 and 18.
• Low SES
• Esophageal disorders-
1. Achalasia
 Approximately 5%,
 Between 1 to 16 years after diagnosis,
 Risk is increased 16 fold, esp. in men

13. 2. Esophageal strictures- alkali ingestion increased risk of ESCC decades after the
initial ingestion.
3. Plummer-Vinson syndrome (iron deficiency anemia, dysphagia, and post-cricoid
webs)
• Tylosis- autosomal dominant disorder characterized by hyperkeratosis of the
palms/soles and leukoplakia
• Protective Factors
 Obesity
 Aspirin, NSAIDS
 Fruits and vegetables

14. Esophageal Adenocarcinoma(EAC)
 EAC is the predominant type of esophageal cancer in the West
 M > F(8 times)
 Location- distal third
 Risk factors-
High dietary calories intake
Obesity
GERD
Smoking

15. (1903 – 1979)

16. Barrett’s Esophagus
• Replacement of normal squamous epithelium of the distal esophagus with
specialized intestinal epithelium.
Barett’s esophagus(BE) two types
 Long segment ( metaplastic epth. > 3cm)
 Short segment ( metaplastic epth. < 3cm)
• Prague classification
 C (circumferential extent of metaplastic epth.)
 M ( maximal extent of metaplastic epth.)

19. Genetic factor
• Somatic-cell genetic abnormalities during the metaplasia-dysplasia-carcinoma in
the esophageal epithelium
• Hypermethylation of tumor suppressor genes in both EAC and ESSC

20. Clinical features
• Asymptomatic
• Dysphagia
initially with solid foods
then to liquids in the later stages of the disease
Solid food dysphagia occurs when luminal diameter of 13 mm or less.
• Weight loss
• Severity of dysphagia and weight loss is proportional to the degree of
luminal obstruction.
• Odynophagia less common, usually indicates an ulcerated lesion.

21. Continue ..
• Anemia
• Cervical lymphadenopathy
• Chest pain
 Often radiating to the back
 Involvement of para-esophageal structure
• Esophageal-respiratory fistula
 Recurrent pneumonia
 Pleural effusion
• Esophageal-aortic fistula
 GI haemorrhage
• Recurrent laryngeal nerve injury
 Hoarseness of voice
• Metastatic lesions in L.N, lungs, liver, brain, and bone.

22. Investigations
• Laboratory tests- Non-specific
Anaemia
Hypoalbuminaemia
Hypercalcaemia
• Imaging
CXR
CT
FDG-PET/CT
EUS

23. • CXR
1. Aspiration pneumonia
2. Dilated esophagus e air-fluid level
3. Metastasis in lungs
4. Pleural effusion
5. Signs of fistula

24. Barium contrast esophagography
• Early cancer- Plaque, nodularity,ulceration,focal irregularity
• Advanced tumor- overt mass, stricture e shouldering, luminal narrowing
• It is useful prior to endoscopy in suspected T-E fistula

26. CT of chest
 Thickening/irregularity, focal stricture e prox. dilation, intraluminal mass.
 Signs of aspiration pneumonia, mets, lymphadenopathy, T-E fistula
 CT is the modality of choice for staging distant metastasis
 T stage on the basis of wall thickness and contour
 Sensitivity/specificity- 52%/91%
Stage Wall thickness
T0 <5mm
T1, T2 5 to 15mm
T3 >15mm
T4 Mass effect or invasion

28. Endoscopy with biopsy
 High-resolution endoscopy
 Chromoendoscopy
 Narrow band imaging,
 Autofluorescence imaging,
 Confocal laser endomicroscopy

30. Continue..
• High-resolution endoscopy (>1 million pixels) increase the yield for
detection of dysplasia and early cancer
• Findings
Normal appearing mucosa, ulcers, nodules, and overt masses.
• Certain techniques increase the yield
taking multiple biopsy(6-8)
brush cytology
EUS
• Submucosal infiltrative pattern
bite-on-bite biopsy, EUS guided tissue sampling

31. Chromoendoscopy
• Conventional involves the use of special stains to highlight subtle architectural
changes which help to direct biopsies and predict histology
• Lugol’s iodine, methylene blue, acetic acid, crystal violet, indigo carmine
• Lugol’s Iodine stains glycogen containing cells of the normal epithelium and is not
taken up by dysplastic cells that are glycogen depleted.
• Lugol’s is most commonly used for a suspicion of ESCC.
• Others useful for EAC
• Limitation
 can not differentiate dysplasia and inflammation
 time consuming.

32. Electronic chromoendoscopy
• To detect signs of dysplasia and cancer by using selective light filters to highlight
subtle architectural and vascular changes in the mucosa
• NBI is most common
• Sensitivity- 92%

34. Confocal laser endomicroscopy
• Real time in vivo microscopic imaging of esophageal mucosa.
• It involve adminstration of I/V or tropical contrast agent, taken by normal mucosal
cell not in dysplastic cells, they appear dark.
• This method create an approx. 1000 magnification.
• 2 method
 endoscope based
 probe based
• Benefit
 Reduce the number of biopsy/pt.

35. Screening & surveillance
• ESSC
Chromoendoscopy with Lugol’s iodine
Sensitivity and specificity- over 90%
1-time screening at age 50 for reasource limited
3-time screening at age 40 for better reasource country.
The current screening guidelines include:
 One-time Lugol’s chromoendoscopy for high-risk Asian and African
populations beginning at the age of 40.
Endoscopy with Lugol’s or NBI every 6 months to 1 year after completion of
therapy for head and neck squamous cell cancer for 10 years.
Screening could also be considered for patients at high risk (tylosis,
achalasia, and caustic injury)

36. • Other endoscopy techniques such as NBI and AFI as
screening tools.
• NBI has been shown to detect early esophageal lesions based
on superficial vasculature and surface structure changes.
• AFI is not sufficiently sensitive for lesions smaller than 10
mm,

37. EAC

39. AJCC TNM classification for E and EGJ tumor

43. • Staging done by
Clinically
Endoscopy with mucosal biopsies,
Multidetector CT (MDCT)
18F-FDG-PET
EUS with FNA for cytology
EMR and ESD
Laparoscopy in distal esophagus involvement and peritoneal metastasis suspected
Brochoscopy, if upper esophagus involve

44. Continue..
 Early cancer- Tis,T1a,T1b without L.N involvement
Tis and T1a lesions have a predicted lymph node metastasis rate <10%
T1b lesions lymph node metastasis rate 56%
The best predictors of lymph node invasion are SM3 invasion
 Late cancer- T2 to T4b, with or without L.N involvement
 Locoregional disease- stage 1-3
 Metastatic disease- stage 4

46. FDG-PET
 Helps in detecting distant metastasis
 Sensitivity/specificity-71%/93%
 Restaging after neoadjuvant therapy better

47. EUS
• To assess depth of tumor invasion
• Helps to choose candidates for endoscopic or surgical treatments.
• Best staging modality for T stage and locoregional lymph node (N) by most experts
• The accuracy for T stages 85% to 90%, lymph node (N) staging accuracy 70% to
90%

48. • Endosonographic features of malignant lymph nodes include lesions
are
 hypoechoic,
 rounded,
 smooth surface,
 >10 mm, and
 located in close proximity to tumor.
• The accuracy for detecting malignant L.N is close to 80%, increases to
92% to 98% with FNA for cytology

50. Treatment
• A multidisciplinary approach to the treatment of esophageal cancer is essential
and requires input from experts in surgical oncology, radiation oncology, medical
oncology, gastroenterology, radiology, pathology, and often palliative care.
• Factors consider – Tumor location, staging, histologic type, comorbidity, patient
preferrance
• Surgery is the standard treatment for a medically optimized surgical candidate
with a localized, non-superficial tumor.
• For a patient with a localized tumor who is not a surgical candidate, definitive
chemoradiation with curative intent may be considered.
• For all others (metastatic disease), palliation is recommended.

51. • The primary objective is to identify those patients who may benefit from
neoadjuvant therapy and those with widespread metastatic disease who are
better candidates for palliation
• Patients with cervical or cervicothoracic esophageal tumors (<5 cm from the
cricopharyngeus) are usually poor candidates for surgery because of limitations in
surgical techniques.
• These patients are typically treated with definitive chemoradiation.

52. Treatment options
Surgery
Endoscopic
Chemotherapy(neadjuvent and adjuvent)
Radiotherapy
Targated therapy
Immunotherapy
Palliative/best supportive therapy

53. Surgery
• Surgery alone is considered the standard of care and treatment of
choice for T1b and T2 cancers without nodal involvement or distant
metastasis.
• Surgery in conjunction with a multimodal approach is indicated for T1
to T4a tumors with lymph node metastases.

54. Resectable Esophageal cancer
• Depends on
 L.N involvement,
 Distant metastasis,
 Age,
 Comorbidities,
 Performance status
1. T1a,T1b,T2 without L.N involvement and distant metastasis
2. T1-T3 with regional L.N involvement can be done,if age, performance
status support
3. T4a tumors with involvement of pericardium, pleura, or diaphragm are
resectable

55. Unresectable Esophageal cancer
1. T4b tumors with involvement of the heart, great vessels, trachea, or
adjacent organs including liver, pancreas, lung, and spleen are
unresectable.
2. Most patients with multi-station, bulky lymphadenopathy should be
considered unresectable,.
3. Patients with EGJ and supraclavicular lymph node involvement
should be considered unresectable.
4. Stage IV are unresectable.

56. Surgical techniques
Ivor Lewis esophagogastrectomy (laparotomy + right thoracotomy)
 McKeown esophagogastrectomy (right thoracotomy + laparotomy +
cervical anastomosis)
Transhiatal esophagogastrectomy (laparotomy + cervical anastomosis)
minimally invasive esophagogastrectomy
• Acceptable conduits
Gastric (preferred)
 Colon
 Jejunum
• Acceptable lymph node dissections:
 Standard
 Extended (en-bloc)

57. Outcome
• Similar outcomes between surgery and chemoradiation for stage I disease,
but the risk of local recurrence was significantly higher in the
chemoradiation group.
• Most recurrences in the chemoradiation group were intramucosal
carcinoma and were cured after salvage therapy (mainly endoscopic),
• Perioperative morbidity- 40-50%
• Most common
 Pneumonia
 anastomotic leak
• Overall 5-year survival rate after esophagectomy for stage I esophageal
cancer is 53% to 77 %

58. Endoscopic treatment
• EET has revolutionized the management of BE-related dysplasia, early
EAC and esophageal squamous dysplasia, early ESCC.
• The role of endoscopic treatment of esophageal cancer can be either
for curative or palliative.
• Basic principles of EET in dysplasia and early EAC are
resection of all visible lesions
eradication of the remaining BE to reduce the risk of metachronous neoplasia
management of immediate adverse events such as bleeding, perforation, and
long-term adverse events such as strictures and recurrence
enrollment in surveillance programs after achieving complete eradication

59. EMR
Advantages:
En-bloc resection of lesions with a
diameter up to 2 cm
More effective when scar tissue
present
Moderate sedation
Disadvantages:
Requires a submucosal
injection(cap-assisted)
Adjusting the snare in the cap
notch can be tedious
Perforation rates might be higher
based on small series
Failure of the lesion to “lift” with
submucosal injection suggests
infiltration,or submucosal
invasion, and EMR is not advised
ESD
Advantages
Allows en-bloc resection of large
lesions( 3-5cm away from target
lesion)
Better curative resection rates
when compared with EMR
Lower incidence of local
recurrence
Disadvantages
Technically difficult
Time-consuming and costly
Requires experience
Increased risk of perforation
(compared with EMR)
Higher rate of esophageal
stenosis with ESD
Over night stay

60. The European Society of Gastrointestinal Endoscopy recommends that
ESD is the preferred method of endoscopic resection

64. Ablation
• PDT, RFA, or cryotherapy can be used alone or, in conjunction with resection
techniques
• RFA is being increasingly used in patients with Barrett’s, HGD and in Tis
• PDT is rarely used in clinical practice currently due to high risk of adverse reactions
(strictures and photosensitivity) and the availability of other ablative techniques.
• Major limitations
not provide tissue for pathologic evaluation
staging and
recurrences

65. Endoscopic Surveillance
• Once eradication of all neoplasia/high-risk preneoplasia has been
achieved, endoscopic surveillance is recommended.
• Upper GI endoscopy should be performed
3 monthly for the 1st year
6 monthly for the 2nd year, then annually

66. Palliative intent
• Stenting is the modality of choice for relieving dysphagia in malignent esophaseal
obstruction.
• Stenting is preferred over dilation because it is short-lived and results more
complications, like perforation
• SEMS has fewer complications than plastic stents
• Uncovered SEMS have a higher risk of tumor overgrowth and fistula formation.
• Covered SEMS can successfully seal a tracheo-esophageal fistula in up to 86% of
patients with esophageal cancer.
• The ASGE recommends, placement of esophageal stents for fistulas because it
provide durable and immediate relief

71. Chemotherapy
• Recommended for advanced esophageal and EGJ adenocarcinoma.
• Regimens should be chosen in the context of performance status (PS), co-
morbidities, and toxicity profile.
• Trastuzumaba should be added to first-line chemotherapy for HER2
overexpressing metastatic adenocarcinoma.
• 2-drug cytotoxic regimens are preferred for patients with advanced disease
• 3-drug cytotoxic regimens for medically fit pt
• Preoperative chemoradiation is the preferred for localized adenocarcinoma of the
thoracic esophagus or EGJ.
• Perioperative chemotherapy is an option for distal esophagus and EGJ.

72. Common regime
• Paclitaxel + carboplatin
• Flurouracil + oxaliplatin
• Fluropyramidine + Oxaliplatin
• Flurouracil + Leucovorin + Oxaliplatin + Docetaxel ( FLOT) only
for EAC
• Trastuzumab for HER overexpression in metastatic
adenocarcinoma

73. Radiotherapy
• In contrast to neoadjuvant chemotherapy and chemoradiotherapy not shown any
benefit for preoperative radiation alone
• Radiotherapy alone should be used only for palliative purposes or for patients
who are not candidates for chemotherapy
• Newer radiation therapy techniques are aimed at increasing dose delivery to the
target tissue to reduce toxicity to the surrounding organs (heart, lungs, skin).
• Both EAC and ESCC benefited from neoadjuvant chemoradiation therapy.

74. What’s New
• Recently FDA-approved therapy is pembrolizumab, an antibody to
programmed death ligand-1 (PD-L1).
• Pembrolizumab is approved for refractory adenocarcinomas with PD-
L1 positive/microsatellite instability/ DNA mismatch repair gene
defect
• Trastuzumab for HER2 overexpressing metastatic adenocarcinoma

75. Palliative care

76. Dysphagia grading scale
 Grade 0: Able to eat solid food without special attention
 Grade 1: Able to swallow solid food cut into pieces less than 18 mm
in diameter
 Grade 2: Able to swallow semisolid food (consistency of baby food)
 Grade 3: Able to swallow liquids only
 Grade 4: Unable to swallow liquids or saliva

77. Complete esophageal obstruction( unable to swallow liquid)
 Endoscopic lumen restoration, generally performed via simultaneous retrograde
and antegrade endoscopy
 Enteral access for purposes of hydration and nutrition - placement of J-tube or
gastrostomy tube
 External beam radiation therapy (EBRT)
 Brachytherapy may be considered in place of EBRT if a lumen allows the use of
applicators.
 PDT,
 Chemotherapy
 Surgery may useful in carefully selected patients

78. • Severe esophageal obstruction (able to swallow liquids only)
 Endoscopic dilation
 Placement of partially or fully covered SEMS.
 Distal end of the stent should remain above the EGJ to reduce symptoms of reflux and risk of
aspiration.
 EBRTand brachytherapy both effectively treat malignant dysphagia.
 The onset of symptom relief is slower than endoscopic palliation

79. • Bleeding
Acute-(A-E fistula) endoscopic electrocoagulation, argon plasma coagulation
Chronic bleeding- EBRT
• Pain according to WHO analgesic ladder
• Nausea and vomiting- antiemetic, but may be due to luminal obstruction.

80. ESSC
Stage I – III Loco
regional Disease
Multidisciplinary
Evaluation
Surgical
Candidate
Non- Surgical
Candidate
Endoscopic
ChemoR
Palliative Mx
Tis, T1a, No T1b, T4a, No-Nt,
T4b
ER/Ablation
or,
Esophagectomy
T1b,T2,N0
(low risk )
T2,N0 (High risk) T4b
T4,any N
Preoperative
ChemoR or,
Definitive
ChemoR
Definitive
ChemoR
Esophagectomy

81. EAC
Stage I – III Loco
regional Disease
Multidisciplinary
Evaluation
Surgical
Candidate
Non- Surgical
Candidate
Endoscopic
ChemoR
Palliative Mx
Tis, T1a,
No,T1b sup.
T1b, T4a, No-Nt,
T4b
ER/Ablation
or,
Esophagectomy
T1b,T2,N0
(low risk )
T2,N0 (High risk) T4b
T4,any N
Preoperative,
periperative
ChemoR or,
Definitive
ChemoR
Definitive
ChemoR
Esophagectomy

86. Prognosis
• Best predictor of esophageal cancer survival is depth of invasion and lymph node
involvement.
• N stage of esophageal cancer is an independent factor affecting overall and
disease-free survival
• 5-year survival for local nodal disease (41%) regional nodal disease (23%), distant
nodal disease (5%) at presentation.
• 5-year survival for Tis or T1a cancer is 95% to 100%

87. THANK YOU

88. REFERRENCES
 National Comprehensive Cancer Network (NCCN)
guideline on management of Esophageal Carcinoma
version 3.2020
 Sleisenger and Fordtran’s Gastrointestinal and Liver
Disease(PATHOPHYSIOLOGY • DIAGNOSIS •
MANAGEMENT )
 Textbook of Gastrointestinal Radiology – 4th edition
 CURRENT Diagnosis & Treatment (Gastroenterology,
Hepatology, & endoscopy)
 Internet