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Esophagus cancer
This document summarizes key information about cancer of the esophagus. It notes that in 2014 there were 18,170 new esophagus cancer cases in the US, with a lifetime risk of 0.5% and 5-year survival rate of 17.5%. Risk factors include tobacco, alcohol, Barrett's esophagus, obesity, and gastroesophageal reflux disease. The two main types are squamous cell carcinoma and adenocarcinoma, with adenocarcinoma now more common due to rising obesity rates. Staging involves assessing tumor depth (T), lymph node involvement (N), and metastases (M). Survival rates vary significantly based on cancer type, stage, and treatment received.
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Esophagus cancer
- 1. Cancer of theEsophagus www.aboutcancer.com
- 2. 2014 Data forEsophagus Cancer New Cases Cancer Deaths 18,170 (1.1%) #19 15,450 (2.6% ) Life Time Risk of developing this cancer is 0.5% 5 Year Survival Rate is 17.5%
- 3. Incidence and Mortalityover the Last 30 Years for Esophagus Cancer
- 4. Trends in 5Year Survival Rates for Adenocarcinoma of the Esophagus
- 5. Esophagus Cancer byGender in 2014 16000 14000 12000 10000 8000 6000 4000 2000 0 Gender Male Female 14,660 3,510 81% 19%
- 6. Esophagus Cancer MedianAge at Diagnosis Year of Data Male Female 1998 – 2002 68 73 2000 - 2004 67 73 2002 – 2006 67 73 2005 – 2009 66 72
- 7. Age – AdjustedSEER Incidence Rates for 2000 - 2011 25 20 15 10 5 0 Age 20-49 Age 50 - 64 Age 65-74 Age 75 + Rates per 100,00
- 8. In the USwhere there is no routine screening for esophagus cancer, most patients present with advanced stages Nearly 50% are advanced beyond local-regional Less than 60% with local-regional can undergo a curative resection 70-80%of resected specimens show spread to the lymph nodes
- 9. National Data 2004-2010 Esophagus Cancer from SEER Stage Incidence Survival/5y Local 21% 39.6% Regional 30% 21.1% Distant 37% 3.8%
- 10. Risk Factors •Tobacco use. • Heavy alcohol use. • Barrett esophagus • Older age. • Being male. • Being African-American.
- 11. Two most commonforms of esophageal cancer are named for the type of cells that become malignant Squamous cell carcinoma forms in squamous cells, the thin, flat cells lining the esophagus. This cancer is most often found in the upper and middle part of the esophagus Adenocarcinoma begins in glandular (secretory) cells. Glandular cells in the lining of the esophagus produce and release fluids such as mucus. Adenocarcinomas usually form in the lower part of the esophagus, near the stomach.
- 12. In the 1960’ssquamous cancer accounted for more than 90% of cases but over the last two decades adenocarcinoma has dramatically increased and is now over 60% in the US Tumors at the esophagogastric junction and proximal 5 cm of the stomach that extend into the EGJ or esophagus are classified and staged as esophageal cancers (the so-called Siewert III EGJ tumors). All other tumors with an epicenter in the stomach >5 cm from the EGJ, or those within 5 cm or the EGJ without extension into the esophagus are staged as gastric cancers.
- 13. Squamous Cancer •Now only accounts for less than 30% of cases in the US • Tobacco and Alcohol are the major risk factors
- 14. Adenocarcinoma • nowmost common type in the US, esp in white men • Obesity and a high Body Mass Index (BMI) are high risk factors, very high BMI risk is 7.6 X higher • GERD (gastroesophageal reflux) high risk • Barrett’s esophagus increases the risk to 30 – 60 X higher
- 15. Trends in theUS for Esophagus Cancer Adenocarcinoma white males Squamous white males Adenocarcinoma black males 1980 1985 1990 1995 2000 2005
- 16. Trends for Adenocarcinomain the US White males Black males White females Black females 1980 1985 1990 1995 2000 2005
- 17. Epidemiology of EsophagusCancer in the US Squamous Adenocarcinoma New cases per Year ~ 7,000 ~10,000 Male : Female 3:1 7:1 Black : White 6:1 1:4 Most Common Site Middle Distal Major Risk Factor Smoking, alcohol Barrett’s
- 18. Barrett’s Esophagus –Columnar Cells Extend Above the GE Junction
- 19. Barrett’s Esophagus •Replacement of normal esophageal lining cells (stratified squamous) with cells that predispose to cancer (metaplastic columnar epithelium) • Due to chronic GERD (gastroesophageal reflux) • Median age at diagnosis is 55y • Predisposed to getting adenocarcinoma of the lower esophagus
- 20. Barrett’s and Cancer • Estimates of the annual cancer incidence in patients with Barrett's esophagus have ranged from 0.1 to 2.0 percent. • Although the risk of developing esophageal cancer is increased at least 30-fold above that of the general population, the absolute risk of developing cancer is low.
- 21. Barrett’s and Cancer • Cancer incidence was 6.3 per 1000 person-years. When only studies with well defined criteria for the diagnosis of Barrett's esophagus were included, the rate was 5.0 per 1000 person-years. • For high-grade dysplasia the corresponding pooled estimate for cancer incidence was 10.2 per 1000 person-years. • The incidence of mortality was 3.0 per 1000 person-years due to esophageal adenocarcinoma and 37.1 per 1000 person-years due to other causes.
- 22. Screening for Barrett’sfrom the AGA (American Gastroenterological Association) Age 50 years or older Male sex White race Chronic GERD Hiatal hernia Elevated body mass index Intra-abdominal distribution of body fat
- 23. Screening for Barrett’sfrom the ACP (American College of Physicians) In men older than 50y with GERD symptoms for more than 5 years plus: Nocturnal reflux symptoms Hiatus hernia Elevated body mass index Tobacco use Intra-abdominal distribution of fat
- 24. Signs and Symptomsof Esophagus Cancer • Difficulty and pain with swallowing • Pressure or burning in the chest • Indigestion or heartburn • Vomiting • Frequent choking on food • Unexplained weight loss • Coughing or hoarseness • Pain behind the breastbone or in the throat
- 25. Esophagus Anatomy 23-25 cm from pharynx to the stomach. Often locations are measured form the teeth at the time of endoscopy and the first 15 cm are before the esophagus begins.
- 26. The esophagus is roughly from C6 to T11
- 29. Primary Site Basedon Proximal Edge of Tumor Anatomic Esophageal Distance name location from teeth Cervical Upper 15 to < 20cm Thoracic Upper 20 to < 25cm Middle 25 to < 30cm Lower 30 to < 40cm Abdominal Lower 40 to 45 cm EGJ/Cardia 40 to 45 cm
- 30. Lymph nodes fromthe esophagus
- 31. Lymph Nodes atRisk for GE junction
- 33. Staging and Diagnostic Studies
- 34. Accuracy in IdentifyingLymph Node Spread, Comparing CT with EUS (endoscopic ultrasound) or EUS + FNA (fine needle aspirate biopsy) Test Sensitivity Specificity CT 29% (17 – 44%) 89% (72 – 98%) EUS 71% (56 – 83%) 79% (59 – 92%) EUS + FNA 83% (70- 93%) 93% (77 – 99%)
- 35. Endoscopic Ultrasound and Peri-esophageal Lymph Nodes Benign Malignant
- 36. Sensitivity in DetectingNodes/ Mets Test Site Sensitivity Specificity EUS celiac N 85% 96% other N 80% 70% CT regional N 50% 83% abdom N 42% 93% Mets 52% 91% PET regional N 57% 85% Mets 71% 93%
- 41. Cross Section Anatomy Heart Esophagus Lung Lung
- 42. Cross Section Anatomyof the Esophagus
- 43. Cross Section Anatomyof the Chest
- 44. Reading a CTScan near the Esophagus
- 45. Normal CT ofthe Esophagus
- 46. CT Squamous Cancerin the Upper Esophagus
- 47. CT Adenocarcinoma Lower Esophagus
- 48. CT and PETScan CT Scan PET Scan
- 49. PET Scan: LargeSquamous Cancer of the Upper Esophagus
- 50. PET Scan MidEsophagus Cancer
- 51. PET Scan LowerEsophagus Cancer
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- 56. Staging System: TN M T = depth of the tumor into the wall of the esophagus N = number of lymph nodes spread M = distant metastases (spread to other parts of the body)
- 57. Layers of the Esophagus
- 58. Layers of theEsophagus epithelium Lamina propria Muscularis mucosa Submucosa Muscularis propria Adventitia
- 59. Layers of theEsophagus g. Stratified epithelial lining f. Mucous membrane e. Muscularis mucosa d. submucosa c. Transverse muscle b. Longitudinal muscle a. Fibrous covering
- 60. Layers of theEsophagus Mucosa Submucosa Muscle Epithelial Lamina Propria Muscular mucosa
- 61. Epithelial Basement Membrane Lamina Propria Muscular mucosa Layers of the Mucosa T is = epithelial only T1a = through the basement membrane into lamina propria or muscularis mucosa T1b = into submucosa Submucosa
- 62. Layers of theEsophagus Muscle Mucosa Submucosa
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- 65. N = Nodes, M = Metastases
- 67. Staging System, Tand N for Esophagus Cancer Tis T1 T1 submucosal intramucosal aorta T3 T4 T2 N0 N1 1-2 nodes Mucosa N2 3-6 nodes N3 7+nodes Submucosa Muscularis propria
- 76. Survival by StageNCDB National Data 2003- 2006 Stage Number Survival/5y I 3,786 (12%) 47.6% II 7,324 (24%) 25.1% III 7,444 (24%) 13.8% IV 11,975 (39%) 3.3%
- 77. Squamous Cancer –Survival after Esophagectomy Years Stage 0 Stage I Stage II Stage III
- 78. Squamous Cancer –Survival after Esophagectomy Stage Ia Stage 0 Stage Ib Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IIIC
- 79. Squamous Cancer Survivalafter Esophagectomy Stage 5 Y 10 Y I 62% 51% Ia 71% 58% Ib 60% 50% II 47% 37% IIa 53% 43% IIb 42% 33% III 20% 16% IIIa 25% 20% IIIb 17% 14% IIIc 14% 12%
- 80. Adenocarcinoma – Survivalafter Esophagectomy Years Stage 0 Stage I Stage II Stage III
- 81. Adenocarcinoma – Survivalafter Esophagectomy Years Stage 0 Stage IA Stage IB Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IIIC
- 82. Adenocarcinoma Survival afterEsophagectomy Stage 5y 10Y I 73% 61% Ia 77% 67% Ib 63% 51% II 41% 33% IIa 50% 37% IIb 40% 30% III 20% 17% IIIa 25% 20% IIIb 17% 14% IIIc 13% 12%
- 83. Cancer of theEsophagus www.aboutcancer.com