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![METHODS OF STAGING
• Specific methods in clinical staging include
– Barium contrast studies
– Bronchoscopy
– Computed tomography (CT) scan
– Percutaneous ultrasound of cervical lymph nodes ±
fine-needle aspiration (FNA) cytology
– Endoscopic ultrasound (EUS) ± FNA
– [18F] fluoro-2-deoxy-d-glocose (FDG) positron
emission tomography (PET) scan
– laparoscopy and/or thoracoscopy](https://image.slidesharecdn.com/esophagus-180609173244/75/Esophagus-39-2048.jpg)
Uploaded bySuhas G
Esophagus
Esophageal cancer is the 8th most common cancer worldwide and the 6th most common cause of cancer death. It is particularly prevalent in Asia. The age-standardized incidence rate is highest in China at 27.4 per 100,000 people. Esophageal cancer rates have shifted from being primarily squamous cell carcinomas to now mostly adenocarcinomas in Western countries, attributed to factors like obesity and gastroesophageal reflux disease. Screening methods include non-endoscopic cytology techniques and endoscopy with Lugol's iodine staining. Staging is done using the TNM system and involves evaluating the depth of tumor invasion and determining if there is regional lymph node or distant metastasis through various imaging and end
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Esophagus
- 1. Carcinoma Esophagus Screening andEvaluation
- 2. Esophageal cancer • 8thmost common cancer worldwide • The 6th most common cause of death from cancer • Common in countries of the so-called “Asian esophageal cancer belt”
- 4. • The age-standardized incidence rate of esophageal cancer per 100,000 – 27.4 in China – 10.0 in Japan – 7.9 in northern Europe – 7.6 in western Europe – 5.8 in North America – 5.5 in Australia/New Zealand
- 5. • India hasan age standardized incidence rate – 6.5 per 100,000 population for males – 4.2 per 100,000 population for females • Striking change in epidemiological pattern in the past three decades • Shift from Squamous cell cancers to Adenocarcinomas of the lower esophagus and cardia in Western countries
- 6. • The reasonfor the shift from SCC to Adeno is widely attributed to – Obesity – Gastroesophageal reflux disease and – Barrett’s esophagus
- 7. Screening and Preventionfor Early Cancer • Screening : – The search for unrecognized disease or defect by means of rapidly applied tests, examinations or other procedures • Diagnosing at its asymptomatic or early stage is crucial in improving prognosis
- 8. Non Endoscopic screening •In high-incidence areas such as in China – Abrasive cytology has been used for population screening • Two principal types of samplers have been used – an inflatable balloon developed in China – an encapsulated sponge sampler developed in Japan
- 9. • When early-stagecancers are diagnosed by above method – excellent long-term results with – 5-year survival rate approaching 90% – 25-year survival rate of 50%
- 10. • Balloon technique –Deflated balloon covered by a cloth net – Swallowed into the stomach, inflated, and withdrawn – Collects exfoliated cells by scraping the mucosal surface of the esophagus
- 11. • Sponge technique –Polyurethane mesh is compressed inside a gelatin capsule and attached to a string or a thin plastic stylet – The capsule is swallowed into the stomach – The gelatin dissolves, and the mesh expands. – The mesh is pulled up the esophagus by the string, collecting exfoliated and scraped mucosal cells
- 14. Endoscopic screening • Primaryendoscopic screening – High resolution/ magnification endoscopy combined with Lugol’s Iodine staining – 1% to 3% lugol iodine is mixture of { iodine + potassium iodide } – Iodine has affinity to glycogen stains normal epithelium dark brown – Sensitivity of 96% – Specificity of 64%
- 16. BARRETT’S ESOPHAGUS • Screeningand surveillance for early cancers due to Barrett’s esophagus have been controversial • Approximately 20% of adults have heartburn at least once per week, 5% of whom have Barrett’s esophagus • Substantial number of patients will require screening
- 17. • Even inpatients with severe reflux symptoms Absolute risk of developing adenocarcinoma is low • 40% or more of patients with esophageal adenocarcinoma have no prior reflux symptoms and would not be detected through screening programs • Presence of Barrett’s esophagus does not change life expectancy or overall survival.
- 18. • There isno confirmed evidence proving that screening or surveillance will lead to improved survival in patients with Barrett’s esophagus • Despite the lack of clear evidence, individuals identified having Barrett’s esophagus should enter surveillance programs
- 20. • Systemic four-quadrant,2-cm biopsy protocol using large biopsy forceps is recommended • Dysplasia is the only reliable indicator of risk development of invasive cancer
- 23. Evaluation of Caesophagus
- 24. • American JointCommittee on Cancer (AJCC) staging TNM system • Recently modifications in TNM system
- 25. 1. Previously usedM1a and M1b categories are deleted 2. The regional nodes encompass areas from the neck, through the mediastinum to the upper abdomen, including the celiac nodes 3. The separation of N1 to N3 depends on the number of nodes involved 4. Squamous cell cancers and adenocarcinoma are stage-grouped differently
- 26. 5. Location oftumor and grade of differentiation are also taken into consideration 6. Tumors which are located in the – Lower thoracic esophagus – Gastroesophageal junction (GEJ) – within the proximal 5 cm of the stomach (cardia) that extend into the GEJ or esophagus are stage- grouped similar to Adenocarcinoma of the Esophagus and not that of the stomach
- 27. 7. Cancers withtheir epicenter in the stomach – >5 cm distal to the GEJ – <5 cm from GEJ but not extending into the GEJ or esophagus – are stage-grouped using the Gastric cancer staging system.
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- 31. Staging of Esophagealcancer - Adenocarcinoma
- 32. Staging of Esophagealcancer – Squamous cell carcinoma
- 33. SIEWERTS CLASSIFICATION • Classificationof tumors located 5 cm proximal and distal to the GEJ • Types I to III – I - Esophageal – II - Cardiac – III - Subcardiac
- 34. • The threetypes of cancers are different in – Patient demographics – Possible etiology – Histopathologic features and – Prognosis • This classification is useful clinically but is not considered in the new staging system
- 36. DIVISIONS OF T1TUMORS ACCORDING TO THE JAPAN ESOPHAGEAL SOCIETY
- 39. METHODS OF STAGING •Specific methods in clinical staging include – Barium contrast studies – Bronchoscopy – Computed tomography (CT) scan – Percutaneous ultrasound of cervical lymph nodes ± fine-needle aspiration (FNA) cytology – Endoscopic ultrasound (EUS) ± FNA – [18F] fluoro-2-deoxy-d-glocose (FDG) positron emission tomography (PET) scan – laparoscopy and/or thoracoscopy
- 40. Barium Contrast Studies •Features on a contrast barium study include – Narrowing of the lumen – Proximal dilation of the esophagus – Mucosal irregularity and shouldering – Tortuosity – Axis deviation from the midline – Sinus formation – fistulization to the bronchial tree
- 42. Bronchoscopy • Flexible bronchoscopyis performed to assess tumor involvement of the tracheobronchial tree • Especially for tumors in the middle and upper esophagus. • Signs of involvement include a – Widened carina – External compression – Tumor infiltration {NR} – Fistulization {NR}
- 43. Computed Tomography Scan •CT scan in staging of esophageal cancer is useful to detect distant disease • Metastais occurs to organs like – Lungs – Liver – Bone – Kidneys
- 44. • Metastasis tothe liver – >2 cm sensitivity is 70–80% – <1 cm sensitivity decreses to 50% • Solitary lung metastases are rare • It helps in Diagnosis of T4 disease • the accuracy of CT is inferior to that of EUS
- 46. Endoscopic Ultrasound • Usedin cervical node involvement in SCC of CA oesophagus • Examination of nodes begin with visualization of common carotid artery and internal jugular vein at the base of the neck • Axial scan transverse to vessel performed in cephalad direction • Nodes IV, III, II and V are viewed in relation to carotid and internal jugular
- 47. • EUS isthe only imaging modality to distinguish the various layers of the esophageal wall • Appears as Five layers with alternating hyper- and hypoechoic layers • Sensitivity 74.5% and Specificity 94.1% • Information gained by combining preoperative cervical ultrasound and EUS can be highly prognostic
- 48. • Three typesof echoendoscopes are used 1. A radial scanning endoscope (5-20MHz) • provides 360 degree view of esophageal wall 2. EUS miniprobes (12, 20 and 30 MHz) • Provides excellent resolution but penetration is less • Used for superficial cancers 3. Curved linear-array transducer scopes (7.5 MHz) • Used for US guided FNAC
- 49. T stage onEUS • Invasion to 2nd hypoechoic layer – T1a • Invasion to 3rd hyperechoic layer – T1b • Invasion to 4th hypoechoic layer – T2 • Beyond the fourth layer – T3 • Adjacent structures – T4
- 51. FDG-PET Scans • Thetracer used is Flurodeoxyglucose • Principle : Differential glucose metabolism of cancer • In Detection of the primary tumor – Its sensitivity is 78 to 95% • FDG –nonavidity – Adeno CA of the GEJ and proximal stomach sometimes show limited or absent FDG accumulation – Related to diffusely growing subtype and poorly differentiated tumors
- 52. • No Valuein T stage – does not define the layers of the esophageal wall • For locoregional nodal metastases its spatial resolution is insufficient as it cannot separate tumor from juxta tumoral lymphnode
- 53. • The accuracyof PET in locoregional nodes is only moderate. • EUS-FNA is superior in this regard. • PET is more useful for picking up distant metastases.
- 55. Thoracoscopy and Laparoscopy •Thoracoscopic staging usually involves – right-sided approach – opening of the mediastinal pleura from below the subclavian vessels to the inferior pulmonary vein with lymph node sampling • Thoracoscopy and laparoscopy can identify nodes or metastatic disease missed by CT
- 56. VIDEO ASSISTED THORACOSCOPIC SURGERY{VATS} • Minimally invasive thoracic surgery without the need for thoracotomy • VATS provides adequate visualization despite limited access to the thorax • Advantage is it can be performed on patients – who have marginal pulmonary reserve – severe debilitating patients who cant be taken up for thoracotomy
- 57. • Use :VATS is principally employed in the management of – Pulmonary – Mediastinal and – Pleural pathology
- 59. Technique of VATS •Patient in left lateral decubitus position • Right thoracoscopy was performed using one- lung ventilation. • The telescope was introduced into the sixth intercostal space at the posterior axillary line • Two additional trocars were inserted under direct vision with the use of carbon dioxide insuflation • A fourth trocar if needed is inserted in the third intercostal space at the anterior axillary line
- 60. • Three anteriortrocars and one posterior trocar in a so-called "baseball diamond" configuration • The mediastinal pleura overlying the upper part of the esophagus incised and the incision continued from the level of the azygos vein to the inferior pulmonary vein. • The tracheoesophageal groove was dissected, and biopsy specimens of the lymph nodes obtained with blunt dissection
- 61. References • Maingot’s AbdominalOperations 12th Ed • Shackelford’s Surgery of the Alimentary Tract 7th Ed
- 62.
Editor's Notes
- #6 Most striking change in epidemiological pattern for esophageal cancer in the past three decades has been the shift from squamous cell cancers to adenocarcinomas of the lower esophagus and cardia in the Caucasian populations in Western countries
- #7 BMI >25
- #15 Other stains used : Methylene blue ( gastric cancer ) Toluidine blue
- #16 FIGURE 17-1 A. Endoscopy using Lugol’s iodine stain. The unstained area is abnormal, showing an early squamous cell cancer of the esophagus. B. Narrow band imaging of the same lesion. Light of lower wavelenght like blue 415nm or green 500nm is used Others
- #17 Gastroesophageal reflux is prevalent; approximately 20% of adults have heartburn at least once per week, 5% of whom have Barrett’s esophagus; thus a very substantial number of patients will require screening. However, the absolute risk of adenocarcinoma is low even in subgroups of patients with severe refl ux symptoms. Moreover, 40% or more of patients with esophageal adenocarcinoma have no prior refl ux symptoms and therefore would not be detected through screening programs targeted to those with such refl ux symptoms. 32 Most patients with Barrett’s esophagus also die from unrelated causes, 44 and the presence of Barrett’s esophagus does not change life expectancy or overall survival.
- #18 In Barrett’s esophagus, the stratified squamous epithelium lining the esophagus is replaced by specialized intestinal-type columnar epithelium
- #26 M1a –metastasis to cervical or celiac nodes M1b – distant metastasis
- #31 Highest histologic grade on biopsy or resection specimen is used. If a tumor is mixed histologic type, it shall be recorded as squamous cell cancer. If grade is not available, it should be recorded as GX and stage grouped as a G1 cancer. G4, undiff erentiated cancers, should be recorded as such and staged grouped similar to G3 squamous cell carcinoma.
- #33 Stage 0 to stage 2B – Inferior border of lower pulmonary vein – upper and lower thoracic oesophagus
- #34 Aims at classifying tumors that are located 5 cm proximal and distal to the GEJ Types I to III (esophageal, cardiac, and subcardiac) stomach (Fig. 17-4). The three types of cancers are different in patient demographics, possible etiology, histopathologic features, and prognosis.58 This classification is useful clinically but is not considered in the new staging system
- #37 T1a ep intra epithelial
- #40 Apart from physical examination and simple chest radiograph, specific methods in clinical staging include barium contrast studies, bronchoscopy, computed tomography (CT) scan, percutaneous ultrasound of cervical lymph nodes ± fine-needle aspiration (FNA) cytology, endoscopic ultrasound (EUS) ± FNA, 2-[18F] fluoro-2-deoxy-d-glocose (FDG) positron emission tomography (PET) scan, and laparoscopy and/or thoracoscopy
- #41 Features on a contrast barium study include mucosal irregularity and shouldering narrowing of the lumen and proximal dilation of the esophagus Tortuosity, angulation, axis deviation from the midline, sinus formation, and fistulization to the bronchial tree are signs indicative of advanced tumor that has traversed the adventitia and involved the neighboring fi xed organs. 59 With the availability of other staging modalities, barium studies are becoming less essential.
- #45 T4 disease tumor invades adjacent structures pleura pericardium diaphragm – resectable Aorta vertebrae trachea
- #46 In the diagnosis of T4 disease, obliteration of the fat plane between the esophagus and the aorta, trachea and bronchi, and pericardium is suggestive of invasion, but the paucity of fat in cachectic patients makes this criterion unreliable. When the area of contact between the esophagus and the aorta extends for more than 90 degrees of the circumference, an 80% accuracy of infiltration was reported,64 but this is by no means absolute and the accuracy is inferior to that of EUS. The sensitivity of detecting mediastinal and abdominal nodal involvement is suboptimal with CT scans because only size alone can be used as diagnostic criterion. However, normal-sized lymph nodes may contain metastatic deposits and enlargement of lymph nodes may be due to reactive and inflammatory hyperplasia. Studies using high-resolution helical CT scanning have demonstrated sensitivities of 11–77% as well as specificities of 71–95% for detection of regional nodal disease.65,66 CT scanning is nowadays commonly performed together with PET scanning; a composite picture is created in the same setting to correlate more accurate anatomy with metabolic uptake (Fig. 17-6). Experience with magnetic those of CT.67
- #49 7.5 mhz depth9cm resolution0.2mm 12mhz depth3cm resolution0.1mm
- #51 Invasion to 2nd hypoechoic layer – T1a lamina propria Invasion to 3rd hyperechoic layer – T1b submucosa Invasion to 4th hypoechoic layer – T2 muscularis propria Beyond the fourth layer – T3 adventitia Adjacent structures – T4
- #52 Bismuth germanium oxide, gadoliniumoxyorthosilicate, lutetium oxyorthosilicate PET scan is gaining popularity in esophageal cancer staging (see Fig. 17-6).80,81 For the detection of the primary tumor, the sensitivity of PET ranges from 78 to 95% with most false-negative tests occurring in patients with T1 or small T2 tumors.65,82 Adenocarcinomas of the GEJ and proximal stomach sometimes show limited or absent FDG accumulation regardless of tumor volume (FDG nonavidity). Some investigators observed this phenomenon in as many as 20% of these patients, which seems to be related to the diffusely growing subtype and poorly differentiated tumors.83 PET does not provide definition of the esophageal wall and thus has no value in T stage. For locoregional nodal metastases, its spatial resolution is also insufficient to separate the primary tumor with juxtatumoral lymph nodes because of interference from the primary tumor, and thus most studies demonstrated poor sensitivity.82,84 This is especially true for nodes in the middle and lower mediastinum, where most primary tumors are found. In one study, the sensitivities of PET for detecting cervical, upper thoracic, and abdominal nodes were 78%, 82%, and 60%, respectively, but was only 38 and 0% respectively for the mid- and lower mediastinum.65 Specificity of PET in detecting regional nodes is usually much better, reaching 95–100% in some studies.82,84 The low rate of false-positive findings is important in preoperative staging. A meta-analysis of 12 publications on PET scanning in esophageal cancer showed that the pooled sensitivity and specificity for the detection of locoregional metastases were 0.51 (95% CI, 0.34–0.69) and 0.84 (95% CI, 0.76–0.91), respectively. For distant metastases, the corresponding figures were 0.67 and 0.97. When two studies (out of 11) that had particularly low sensitivities for detection of distant metastases were excluded (probably because they included more early tumors), the pooled sensitivity improved to 0.72 and specificity to 0.95.85 This study highlights again that the accuracy of PET in locoregional nodes is only moderate. EUS-FNA is superior in this regard. PET is more useful for picking up distant metastases.
- #56 Thoracoscopy and laparoscopy have their advocates. Thoracoscopic staging usually involves a right-sided approach, with opening of the mediastinal pleura from below the subclavian vessels to the inferior pulmonary vein with lymph node sampling. Laparoscopic staging can include celiac lymph node biopsy and the use of laparoscopic ultrasound for detecting liver metastases. One multi-institutional study (CALGB 9380) reported results in 113 patients, and the strategy was feasible in 73% of patients. Thoracoscopy and laparoscopy identified nodes or metastatic disease missed by CT scan in 50% of deaths or major complications occurred, it did involve a general anesthesia, one-lung anesthesia, a median operating time of 210 minutes, and a hospital stay of 3 days.87 Laparoscopy could be used in diagnosing metastases (especially peritoneal spread) or identifying unsuspected cirrhosis, which may contraindicate resection, and it could be performed as a preliminary procedure during the time of planned esophagogastrectomy. Its main contribution would be in lower esophageal and cardial adenocarcinoma, while its value is expected to be minimal for more proximally located tumors.88 Given their invasiveness, thoracoscopy and laparoscopy should be reserved for cases in whom positive confirmation of metastatic disease not otherwise obtainable is essential in deciding on treatment.