ONCOSURGERY

1. NEOPLASMS OF ESOPHAGUS
PRESENTER - DR. Dharmdev Yadav (assistant
professor IIMSR) ex senior resident kgmu lucknow

2. BENIGN TUMORS
• Mc – Leiomyoma (70%)
• 2nd Mc – Esophageal cysts (20%)

4. LEIOMYOMA
• Account for 2/3rd of all benign tumors of esophagus.
• Dysphagia occurs when tumor is more than 5 cm in diameter
• Diagnosis – esophagoscopy and barium swallow
• Biopsy is contraindicated – can cause perforation.

5. TREATMENT
• Enucleation
• Limited esophageal resection if tumor lies in lower esophagus and cannot be
enucleated.

6. ESOPHAGEAL CYSTS
• 2nd most common – 20% of benign esophageal tumors
• Congenital foregut cyst
• Acquired epithelial cyst

8. • Papilloma - associated with HPV and GERD, endoscopic excision
• Fibrovascular polyp – diagnosed with barium swallow, endoscopy, excision.
• Lipoma – usually asymptomatic and can be observed
• Fibroma – if symptomatic – enucleation.
• Hemangioma – it looks like esophageal varices – dysphagia, bleeding
Tx – observation, excision, radiotherapy.

9. CARCINOMA ESOPHAGUS
• Introduction
• Etiology
• Classification
• Spread
• Clinical features
• Investigations
• Diagnosis and Staging
• Treatment
• Prognosis

10. INTRODUCTION
• It is the 8TH most common cancer worldwide and is 6TH most common cause of cancer
related death.
• It most commonly presents in 6TH and 7TH decades of life.
• SCC and Adenocarcinoma are the most common cell types while other malignancies
such as melanoma and small cell carcinomas are rare.
• SCC is the predominant histological type.
• SCC remains steady, however in western countries, there has been an epidemiological
shift since the 1990s from SCC to adenocarcinoma such that incidence of
adenocarcinoma has surpassed that of SCC.

11. ANATOMICAL SPECIALTIES
• Lacks serosa
• Proximal 1/3 striated muscle and distal 2/3 smooth muscle.
• Segmental blood supply.
• Longitudinal arrangement of veins and lymphatics
• SCC most commonly occurs in middle 3rd of esophagus.
• Adenocarcinoma most commonly occurs in lower 3rd of esophagus

13. ETIOLOGY
• RISK FACTORS FOR SCC
 Alcohol
 Smoking
 Vit c deficiency
 Hot beverages
 Smoked fish and nitrosamine compounds
 Zinc, selenium, molybdenum deficiency
 HPV 16, 18
 Achalasia cardia
 Plummer vinson syndrome
 Tylosis
 Alkali injury
 Genetic predisposition
 Fanconi syndrome

14. RISK FACTORS OF ADENOCARCINOMA
Barrett’s esophagus
Obesity
Smoking
Scleroderma
Hiatus hernia
GERD
Scleroderma
Zollinger Ellison syndrome

16. SPREAD
• DIRECT SPREAD
Lack of serosa favors local extension.
It can spread through muscular layer and get adherent to left main bronchus, trachea,
recurrent laryngeal nerve( causes hoarseness), aorta or its branches(causes fatal hemorrhage).
Can perforate and cause mediastinitis.
broncho-esophageal, trachea-esophageal, esophageal-aortic fistulas can occur in advanced
cases.

17. • LYMPHATIC SPREAD
In the neck it spreads to the supraclavicular lymph nodes
Thorax – it spreads to para esophageal, tracheoesophageal and subdiaphragmatic
lymph nodes.
Abdomen – to the coeliac lymph nodes
• BLOOD spread to the liver, lungs, brain and bones

18. CLINICAL FEATURES
• Progressive dysphagia is the most common
symptom. Solids > liquids. More than 70
percent of lumen should be blocked to cause
significant dysphagia.
• Regurgitation
• Anemia
• Weight loss
• Halitosis
• Substernal or abdominal pain
• Hoarseness of voice when RLN is involved
• Aspiration and choking when tumor
obstruction is present or airway-esophageal
fistula
• Choking and cough on drinking water are
typical of fistula and associated hemoptysis is
common.
• Ascites due to liver secondaries
• Bronchopneumonia

19. INVESTIGATIONS
• 1ST / IOC – Endoscopy with biopsy
• IOC for Staging – PET-CT > CECT
• IOC for metastasis – 18 FDG PET

20. BARIUM SWALLOW
• Irregular filling defect • Shouldering sign

23. • Biopsy – for confirming diagnosis and histological type
• Chest x ray – to look for aspiration pneumonia
• Bronchoscopy / laryngoscopy – to see invasion in cases of upper 1/3rd growths

24. ENDOSCOPIC ULTRASONOGRAPHY
• To look for the depth of the tumor, involvement of nodes, cardia and left lobe of
liver. Nodes smaller than 5mm can be very well visualized by EUS which may be
missed in CT scan.
• It is the only imaging modality able to distinguish the various layers of esophagus
wall, usually seen as five alternating hyper and hypoechoic layers using 12-MHz
ultrasound.
• The drawback is that many advanced cancers do not permit passage of a
conventional echoendoscope.

28. CT SCAN
• To look for local extension, nodal status, peri esophageal, diaphragmatic,
pericardial vascular infiltration, obliteration of mediastinal fat and status of
tracheobronchial tree in case of upper third growth

29. FDG-PET
• SCC are FDG avid.
• Adenocarcinomas of OGJ sometimes show limited or absent FDG accumulation
regardless of tumor volume.
• It is mostly used for detecting regional and non regional nodes, as well as distant
metastasis.
• Change in uptake after neoadjuvant treatment is similarly useful in predicting
histological response and outcome

31. OTHER INVESTIGATIONS
• USG abdomen – to look for liver secondaries , lymph node status in abdomen.
• Chromoendoscopy using lugol’s iodine – normal mucosa is stained brown, while
dysplastic and early cancer are unstained.
• Laparoscopy – to see peritoneal spread, liver spread and nodal spread. Biopsy can
be taken from different places.
• Video assisted thoracoscopic approach – to stage esophageal carcinoma

33. STAGING
• Careful disease staging is essential to guide therapy.
• Current staging classification is according to American Joint Committee on
Cancer(AJCC)

35. TREATMENT
• CURATIVE
• PALLIATIVE

36. ENDOSCOPIC MUCOSAL RESECTION
• It is basically a diagnostic biopsy tool, but can be therapeutic in early and pre
malignant lesion.
• T1a tumors are resected by EMR as risk of lymph node metastasis is very low.
• It involves injection of saline (or other solutions such as glycerol or hyaluronic
acid) into the submucosal plane to raise the mucosal lesion.
• It is then sucked into a cap fitted onto tip of endoscope, looped by a snare wire
and cut by electrocautery.
• For larger lesions, piecemeal resection is needed.

38. ENDOSCOPIC SUBMUCOSAL DISSECTION
• It involves marking of margins of lesion, then submucosal injection, cutting the
mucosal edges along line of marking, submucosal dissection of tumor from its
bed and lastly hemostasis.
• It is more demanding than EMR.
• There is increased risk of post resection stricture formation if too much the
circumference of mucosa is removed.
• For early barrett’s , EMR and ESD can be done with additional ablation of whole
length of barrett’s using RFA.

40. PRINCIPLES
• Only 20 percent of esophageal cancers present early. In such early growths
confirmed with the absence of nodal spread, curative surgery is the main
approach– radical esophagectomy.
• Proximal extent of resection should be minimum of 10cm and distal extent
minimum 5 cm from the macroscopic tumor.
• Proximal stomach has to be removed in lower 1/3 tumors.
• If nodes are present, the multimodal treatment should be used – curative
treatment , chemo/radiotherapy.

41. • Outcome of surgery depends on location of tumor, number , location, size of
nodes, tumor grading.
• Neoadjuvant therapy prior to surgery may improve the survival.
• Aggressive chemoradiation may be used as curative therapy in some patients of
upper 1/3rd growths who are unfit for surgery.
• Palliative therapy is done for patients unfit for surgery, having metastasis. It is to
relieve pain and dysphagia, and also to prevent aspiration and bleeding.

42. UPPER 1/3RD GROWTH(SCC)
• Treated mainly by stereotactic radiotherapy with concomitant chemotherapy.
• Usually unresectable due to invasion of trachea, larynx and great vessels.
• Surgery is mostly reserved for salvage, when there is incomplete response or for
recurrent disease.
• In early and operable cases McKeown three phased esophagectomy and
anastomosis can be done.

43. MCKEOWN THREE PHASED ESOPHAGECTOMY
• It consist of
• Cervical component
• Thoracic component
• Abdominal component

45. MIDDLE 1/3RD GROWTH
• Ivor lewis operation( lewis – tanner two staged esophagectomy) – abdominal and
right thoracotomy.
• Partial esophagectomy and esophagogastric anastomosis is done in thorax.
• If growth is inoperable, palliative radiotherapy is given.

46. LOWER 1/3RD GROWTH (SCC AND
ADENOCARCINOMA)
• Left thoraco-abdominal approach ,partial esophagectomy is done with
esophagogastric anastomosis. Often jejunal roux-en-y anastomosis is done.
• Orringer approach i.e transhiatal blind total esophagectomy with anastomosis in
left side of neck

49. MINIMALLY INVASIVE PROCEDURES
• Traditional open procedures are increasingly replaced by minimally invasive
methods, by a combination of video – assisted thoracoscopy(VATS) and
laparoscopy or robotic techniques.
• Both thoracic and abdominal phases can be performed via minimally invasive
technique or one phase can be done by open surgery (HYBRID surgery).

50. ESOPHAGEAL CONDUITS
• Best – stomach
• Colon
• Jejunal roux loop
Routes
• Posterior mediastinal
• Retrosternal
• Subcutaneous

52. LYMPHADENECTOMY
• Two field dissection – mediastinal nodes and upper abdominal nodes around
coeliac trunk.
Mediastinal field –
• Standard – below tracheal bifurcation
• Extended – standard plus right paratracheal including those around right RLN.
• Total – extended plus nodes around left RLN.
 Three field lymphadenectomy – Two field plus bilateral cervical nodes including
supraclavicular nodes.

54. COMPLICATIONS
• Hemorrhage
• Atelectasis
• Pneumonia
• Atrial fibrillation
• Arrythmias
• Anastomotic leak
• Ischemia of conduit
• RLN injury
• Mediastinitis
• Chylothorax
• Stricture

55. CHEMOTHERAPY
CROSS REGIME
• Cisplatin
• 5-Flourouracil
MAGIC TRIAL
• Cisplatin , 5-FU , epirubicin
COMPLICATIONS
• Nephrotoxic, neurotoxic, ototoxic,
highly emetogenic
• Methotrexate
• Paclitaxel
• Etoposide
• Bleomycin

56. PALLIATIVE THERAPY
• 80% of patients have advanced tumor at time of presentation and they are only
amenable to palliative care.
• To relieve pain
• To relieve dysphagia
• To prevent bleeding
• To prevent aspiration
• Is done when patient is not fit for surgery, metastasis.

57. • Stenting – SEMS – self expanding metallic stents
• Radiotherapy
• Photodynamic therapy
• Cryotherapy
• Endoscopic laser
• Intubation

58. PROGNOSIS
Not good because of –
• Early spread
• Longitudinal lymphatics
• Difficult approach
• Late presentation
• 5 year survival rate in india is 15 - 20 %

59. THANK YOU