Benign tumors of the esophagus include leiomyomas, cysts, and polyps. Leiomyomas are the most common benign tumor, usually occurring in the lower two-thirds of the esophagus in males. Esophageal cysts often present in childhood and are located along the right side. Malignant esophageal tumors are usually advanced at diagnosis and involve the muscular wall. Squamous cell carcinoma is most common and risk factors include smoking and alcohol. Diagnosis involves endoscopy with biopsy and imaging such as CT scan. Treatment options include surgery, chemotherapy, and radiation, but long-term survival remains low given late-stage presentation.

1. Tharindu Gunasiri
group 1
TUMORS OF THE
ESOPHAGUS

2. Benign Esophageal Tumors and
Cysts
• Benign tumors are rare (< 1 %)
• Classified in two groups
– Mucosal
– Extramucosal (intramural)
• More useful classification:
– 60% of benign neoplasms are leiomyomas
– 20% are cysts
– 5% are polyps
– Others (< 2 percent)

3. Leiomyomas
• Most common benign tumor of the esophagus
• Intramural in the circular muscle layer
• Average age at presentation is 38; twice as common in
males
• 90% occur in lower 2/3 of esophagus
• Obstruction and regurgitation may occur in large
lesions
• Dx:
– barium swallow is the most useful method
– CXR
– endoscopy
• Tx: majority can be removed by simple enucleation;
large tumors or those involving the GEJ may require
esophageal resection

4. Esophageal Cysts
• Arise as diverticula of the embryonic foregut of this
cyst present in childhood
• Over 60% are located along the right side of the
esophagus
• Enteric and bronchogenic cysts are the most
common
• 60% present in the first year of life with either
respiratory or esophageal symptoms
• Cyst found in the upper third of the esophagus
present in infancy while lower third lesions present
later in childhood
• Surgical excision by enucleation is the preferred
treatment

5. Pedunculated Intraluminal
Tumors (Polyps)
• Benign polyps are rare
• Usually occur in older men and may cause
intermittent dysphagia
• Are sometimes easily missed with barium
swallow and esophagoscopy

6. Malignant Tumors of the
Esophagus
• Usually are in advanced stages at the time of
diagnosis (involving the muscular wall and extending
into adjacent tissues)
• Alcohol consumption and cigarette smoking seem
to be the most consistent risk factors
• Esophageal squamous cell carcinoma (95% of all
esophageal cancers) is a disease of men (5: 1)
• Squamous cell esophageal cancer occurs least
frequently in the cervical esophagus and
• Squamous cell esophageal cancer occurs most
often in the upper and midthoracic segments

7. Malignant Tumors of the
Esophagus
• Adenocarcinoma constitute approximate 8%
of primary esophageal cancers
• Most often occur in the distal third of the
esophagus in the 6th decade of life, but now
occurs not only more frequently but in younger
patients and is often detected at an earlier
stage
• Male to female ratio is 3:1
• Patients with Barretts metaplasia are 40 times
more likely to develop adenocarcinoma
• These tumors are aggressive as well

8. Clinical Presentation
• Dysphagia is the presenting complaint in 80-
90% of patients with esophageal carcinoma
• Early symptoms are sometimes nonspecific
retrosternal discomfort or indigestion
• As the tumor enlarges, dysphagia becomes
more progressive.
• Later symptoms include weight loss,
odynophagia, chest pain and hematemesis

9. Diagnosis
• Barium swallow has 92% accuracy
– Identify abn peristalsis, mucosal irregularity and annular
constructions
• Fiberoptic endoscopy with biopsy and washings is confirmatory
in 95% of cases
• Bronchoscopy with biopsyto r/o involvement of bronchus in
upper 2/3 tumors and synchronous lung primary
• Nasopharyngoscopy and direct laryngoscopy to r/o
synchronous head and neck lesions and vocal cord involvement
• CT scan of chest with extension to liver and adrenals to assess
tumor spread

10. Staging of Tumors
• Endoscopic ultrasound-to define the depth of
invasion and presence of paraesophageal
lymph nodes
• Chest x-ray ± abnormal findings
• CT scan (most widely used and now
standard radiographic means of a staging)
• Bronchoscopy for tumors which are proximal
to the trachea

11. The TNM classification
• (a) “T” (depth of invasion of the primary
tumor).
• (b) “N” (regional lymph involvement).
• (c) “M” (presence or absence of distant
metastases).

12. Primary Tumors (T)
• Tx Primary tumor cannot be assessed (cytologically
positive tumor not evident endoscopically or
radiographically)
• T0 No evidence of primary tumor (e.g., after treatment
with radiation and chemotherapy)
• Tis Carcinoma in situ
• T1 Tumor invades lamina propria or submucosa, but
not beyond it
• T2 Tumor invades muscularis propria
• T3 Tumor invades adventitia
• T4 Tumor invades adjacent structures (e.g., aorta,
tracheobronchial tree, vertebral bodies, pericardium)

13. Regional Lymph Nodes (N)
A. Nx Regional nodes cannot be assessed
B. N0 No regional node metastasis
C. N1 Regional node metastasis

14. Distant Metastasis (M)
1. M0 No metastasis
2. M1 Distal metastasis

15. Stage Grouping
STAGE T N M
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage IIA T2
T3
N0
N0
M0
M0
Stage IIB T1
T2
N1
N1
M0
M0
Stage III T3
T4
N1
N1
M0
M0
Stage IV Any T Any N M1

16. Treatment
• Local tumor invasion or distant metastatic disease precludes
cure.
• Esophageal Ca is a systemic disease when it is diagnosed;
local therapy (radiation or operation) is simply unable to
eradicate this malignancy.
• The 5-year survival rate in Western countries from esophageal
Ca treated by either radiation or surgery is generally < 10%
• More than 80% of the patients die within 1 year of diagnosis.
Consequently, until very recently, the primary aim of therapy for
esophageal carcinoma has been palliation (restoring the
patient's ability to swallow).
• Esophageal Ca is notorious for its ability to spread in the
submucosal lymphatics well beyond the gross extent of the
tumor
• Resection to clear margins are therefore desirable to minimize
the possibility of recurrent tumor at the anastomotic suture line.

17. Surgery
• Resection provides the best palliation
for most patients with localized
carcinoma.
• Esophageal resection and reconstruction
remain formidable operations in patients
whose nutritional and pulmonary status
have been compromised by impaired
swallowing.

18. Surgery
Left thoracoabdominal incision
– Is the approach to distal esophageal Ca.
– Distal esophagus, proximal stomach, and adjacent LN-bearing
tissues are resected, and intrathoracic esophagogastric anastomosis
is performed.
IVOR-LEWIS ESOPHAGECTOMY
– high intrathoracic esophagogastric anastomosis is performed. In
either case, a gastric drainage procedure (pyloromyotomy or
pyloroplasty) is recommended to prevent subsequent postvagotomy
gastric outlet obstruction due to pylorospasm.
– approach for higher thoracic esophageal tumors
Transhiatal esophagectomy without thoracotomy (limited exposure of the
intrathoracic esophagus and its blood supply and the risk of
hemorrhage and the inability to carry out a complete mediastinal
lymph node dissection ).
Laryngopharyngocesophagectomy. For treatment of Ca involving the
cervicothoracic esophagus (and frequently the larynx).

19. Transhiatal esophagectomy
without thoracotomy
• Cervical (arrowhead) and upper
abdominal midline (arrow)
incisions are made.
• Mobilization of the stomach for
esophageal replacement is performed
through a laparotomy with pyloroplasty.
• The esophagus is mobilized from
the back wall of the trachea
through the cervical incision.
• From below, the surgeon’s hand
passes through the widened hiatus.
Any remaining attachments of the
muscular esophageal tube are
avulsed from the esophageal wall.

20. Transhiatal esophagectomy
without thoracotomy
Disadvantages:
• limited exposure of the intrathoracic
esophagus & its blood supply
• the risk of hemorrhage
• the inability to carry out a complete
mediastinal lymph node dissection

21. Transhiatal esophagectomy without
thoracotomy (Orringer Technique)
• The cervical esophagus is clamped,
leaving adequate length for
reconstruction
• The esophagus is then extracted from
the mediastinum.
• The stomach is divided at the proximal
region with a stapler or clamp
Pyloromyotomy is performed at the
distal portion
• Remaining portion of the stomach is
advanced to the neck for
esophagogastric anastomosis.

22. Left thoracoabdominal
esophagectomy
• the approach to
distal esophageal Ca
• Distal esophagus,
proximal stomach,
and adjacent LN-bearing
tissues are
resected
• intrathoracic
esophagogastric
anastomosis is
performed.

23. IVOR-LEWIS ESOPHAGECTOMY
• approach for higher
thoracic esophageal
tumors
• high intrathoracic
esophagogastric
anastomosis is
performed
• In either case, a
gastric drainage
procedure
(pyloromyotomy or
pyloroplasty) is
recommended to
prevent subsequent
postvagotomy gastric
outlet obstruction due
to pylorospasm.

24. Chemotherapy
• No data proved that chemotherapy alone provides improved
survival or palliation.
• Single-agent chemotherapy used to treat many patients with
esophageal Ca who present with distant disease, with cisplatin,
mitomycin, and 5-fluorouracil achieving reported response rates of
35%.
• Combination chemotherapy regimens such as: cisplatin, bleomycin,
and vindesine or methotrexate; cisplatin, mitoguazone, and
vindesine or vinblastine; and cisplatin and 5-fu used for metastatic
or unresectable esophageal Ca, with reported response rates of 11-
55% for 3-9 months.
• Combination chemotherapy has been used preoperatively in a
combined modality approach to esophageal Ca in hopes of
controlling occult metastatic disease and improving the resectability
rate.

25. Multimodality therapy
• Because most patients have systemic or locally invasive
disease that precludes cure, there is efforts to improve
survival with multimodality therapy.
• Experience with combined preoperative radiation
therapy and chemotherapy, as well as preoperative
chemotherapy and postoperative adjuvant radiation,
are encouraging.
• This therapy provide better local-regional control of
the tumor than can be achieved by radical resection of
the esophagus alone.

26. Transoral intubation
• Uses a variety of tubes (Souttar, Mackler, Mousseau, Fell,
and Celestin) and the Wilson-Cook and self-expanding
stents, have been used to provide palliation.
• Esophageal intubation carries an overall reported mortality
that ranges from 3-15% and a complication rate of 20%.
Complications:
• 1. perforation of the esophagus
• 2. migration of the tubes
• 3. obstruction of the tubes by food
• or tumor overgrowth.

27. • Endoscopic laser therapy improves dysphagia,
but multiple treatments are required and long-
term benefit is seldom achieved.
• Palliative internal bypass. Bypass of unresectable
Ca with colonic interposition, gastric tubes or
retrosternal gastric bypass as a method of
palliation.
• These procedures are of considerable magnitude
and carry a high mortality rate and survival in
these patients’ averages < 6 months.

28. Thank you !!!