Carcinoma oesophagus

1. EVOLUTION AND
MANAGEMENT OF
ESOPHAGEAL CARCINOMA
DR.PRIYADARSHAN KONAR
POST GRADUATE TRAINEE
DEPARTMENT OF SURGERY
IMS & SUM HOSPITAL, BBSR
15.09.2017

2. Clinical Anatomy
 Hollow muscular tube 25 cm in length
which spans from the
cricopharyngeus at the cricoid
cartilage to gastroesophageal
junction (Extends from C7-T10).
 Has 4 constrictions-
 At starting(cricophyrangeal
junction)
 crossed by aortic arch(9’inch)
 crossed by left bronchus(11’inch)
 Pierces the diaphragm(15’inch)
 Histologically 4 layers:
mucosa, submucosa, muscular &
fibrous layer. FIGURE Anatomy of the esophagus

3. Contd…
Four regions of the esophagus:
 Cervical = cricoid cartilage
to thoracic inlet (15–18 cm
from the incisor).
 Upper thoracic = thoracic
inlet to tracheal bifurcation
(18–24 cm).
 Midthoracic = tracheal
bifurcation to just above the
GE junction (24–32 cm).
 Lower thoracic = GE
junction (32–40 cm).
Figure Anatomy of the esophagus with
landmarks and recorded distance from the
incisors used to divide the esophagus into
topographic compartments. GE,
gastroesophageal.

4. Lymphatic Drainage
 Rich mucosal and submucosal
lymphatic system.
 2 Types of lymphatic vessels.
 The submucosal plexus drains
into the regional lymph nodes
in the cervical, mediastinal,
paraesophageal, left gastric,
and celiac axis regions.
 The 2nd plexus of finer vessels
is situated in the muscular
coat.
Figure Lymphatic drainage of the esophagus
with anatomically defined lymph node basins

5. Epidemiology
 Esophageal cancer is the 7th leading cause of cancer deaths.
 accounts for 1% of all malignancy & 6% of all GI malignancy.
 Most common in China, Iran, South Africa, India and the former
Soviet Union.
 The incidence rises steadily with age, reaching a peak in the 6th to
7th decade of life.
 Male : Female = 3.5 : 1
 African-American males : White males = 5:1

6. Contd…
 Worldwide SCC responsible for most of the cases.
 Adenocarcinoma now accounts for over 50% of esophageal cancer
in the USA, due to association with GERD , Barretts’s esophagus &
obesity.
 SCC usually occurs in the middle 3rd of the esophagus (the ratio of
upper : middle : lower is 15 : 50 : 35).
 Adenocarcinoma is most common in the lower 3rd of the
esophagus, accounting for over 65% of cases.

7. Risk Factors : Squamous Cell Carcinoma
 Smoking and alcohol (80% - 90%)
 Dietary factors
 N-nitroso compounds (animal carcinogens)
 Pickled vegetables and other food-products
 Toxin-producing fungi
 Betel nut chewing
 Ingestion of very hot foods and beverages (such as tea)
 Underlying esophageal disease (such as achalasia and caustic
strictures, Tylosis)
 Genetic abnormalities:
 p53 mutation, loss of 3p and 9q alleli, amp. Cyclin D1 & amp.
EGFR

8. Risk Factors: Adenocarcinoma
z Associated with Barretts’s esophagus, GERD
& hiatal hernia.
z Obesity (3 to 4 fold risk)
z Smoking (2 to 3 fold risk)
z Increased esophageal acid exposure such as
Zollinger-Ellison syndrome.
Fig. Barretts’s esophagus
Barrett’s esophagus is a
metaplasia of the esophageal epithelial lining.
The squamous epithelium is replaced by
columnar epithelium,with 0.5% annual rate of
neoplastic transformation.

9. CAN HUMAN PAPILLOMA VIRUS BE
THE CAUSE ?
 HPV associated with the previously mentioned risk
factors tripled the esophageal cancer risk .
 Vaccine-preventable HPV-16 and HPV-18 are the
most commonly identified HPV types.

10. Pattern of spread
 No serosal covering, direct invasion of contiguous structures occurs early.
 Commonly spread by lymphatics (70%)
 Lymph node involvement increases with T stage.
 T1 – 14 to 21%
 T2 – 38 to 60%
 25% - 30% hematogenous metastases at time of presentation.
 Most common site of metastases are
 lung, liver, pleura, bone, kidney & adrenal gland
 Median survival with distant metastases – 6 to 12 months

11. Clinical Features
• Dysphagia, the most common presenting symptom of
esophageal cancer, is initially experienced for solids but
eventually progresses to include liquids.
• Weight loss - This is the second most common symptom, occurs
in more than 50% of dx cases.
• Bleeding - Patients may experience bleeding from the tumor.
• Pain - Pain may be felt in the epigastric or retrosternal area;
pain over bony structures indicates metastatic disease
• Hoarseness - This is caused by invasion of the recurrent
laryngeal nerve
• Respiratory symptoms - These can be caused by aspiration of
undigested food or by direct invasion of the tracheobronchial
tree by the tumor; the latter is also a sign of unresectability.

12. CONT..
Complications:
 Cachexia, Malnutrition, dehydration, anaemia,.
 Aspiration pneumonia.
 Distant metastasis.
 Invasion of nearby structures: e.g.
 Recurrent laryngeal nerve → Hoarseness of voice
 Trachea → Stridor & TOF→ cough, choking & cyanosis
 Perforation into the pleural cavity → Empyema
 back pain in celiac axis node involvement

14. Diagnostic Workup
 Detailed history & Physical examination: Dysphagia,
odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines,
history of GERD. Examine for cervical or supraclavicular adenopathy.
 Confirmation of diagnosis:
 EGD: allow direct visualization and biopsy, measure proximal & distal distance of
tumor from incisor, presence of Barrett’s esophagus.
Early, superficial
cancer
Circumferential ulceration
esophageal cancer
Malignant stricture
of esophagus

15.  Staging:
 CT chest and abdomen: Essential for staging because it can identify extension
beyond the esophageal wall, enlarged lymph nodes and visceral metastases.
Figure Esophageal cancer with tracheal invasion. CT
scan shows circumferential wall thickening of the
proximal esophagus (arrowheads), which shows
irregular interface with the posterior wall of the trachea
(arrows), indicating direct extension into the lumen
Figure Esophageal cancer with aortic invasion. An
arc (bent arrow) of the contact between the
esophageal cancer (arrows) and the aorta
(arrowheads) is more than 90 degrees, indicating
aortic invasion.

16. Endoscopic Ultrasonography
 EUS:
 assess the depth of penetration and LN involvement. Limited by the degree of
obstruction.
 Compared with EUS, CT is not a reliable tool for evaluation of the extent of
tumor in the esophageal wall.
55-year-old man with T2 esophageal tumor (m) shown on
endoscopic sonogram. Note alternating hyperechoic and
hypoechoic layers (arrowheads) of normal esophageal wall as
seen on sonography. Innermost layer is hyperechoic and
corresponds to superficial mucosa. Second layer is hypoechoic
and corresponds to deep mucosa and muscularis mucosae.
Third layer is again hyperechoic and corresponds to submucosa
and its interface with muscularis propria. Fourth layer is
hypoechoic and corresponds to muscularis propria, and outer
fifth layer is hyperechoic and corresponds to adventitia.

18. PET Scan
 most recently, proven to be valuable staging tool
 can detect up to 15–20% of metastases not seen on CT and EUS
 low accuracy in detecting local nodal disease compared to CT / EUS
 Value in evaluating response to Chemo Therapy & Radio Therapy
 addition of PET to CT can improve specificity and accuracy of non-
invasive staging
Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A, Integrated CT
PET demonstrates para-aortic lymph node metastases showing increased FDG uptake (arrowheads). B,
Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in diameter. Based on size
criteria, these lymph nodes may be considered benign on CT scan

19.  Barium swallow: demonstrates:-
 irregular narrowing/ulceration.
 Apple-core filling defect is seen only if there is symmetrical, circumferential
narrowing.
 Bronchoscopy: rule-out fistula in midesophageal lesions.
 Routine Investigations
Cancer lower 1/3
Filling defect (ulcerative type)Rat tail appearance
Apple core appearance

20. 20
Other regular tests
TNM stage

21. AJCC TNM classification
 a: Includes nodes
previously labeled as
“M1a”
 b : “M1a” designation is
no longer recognized in
the 7th edn. of the AJCC
system

22. GENERAL APPROACH TO ESOPHAGEAL CA
 Depends on wheather the disease is confined to the esophagus, (T1–T2, N0),
locally advanced (T1–3, N1), or disseminated (any T, any N, M1).
 If cancer is confined to the esophagus, removal of the tumor with adjacent
lymph nodes may be curative.
 Very early tumors confined to the mucosa (T in situ, T1a, intramucosal
cancer) may be addressed with endoscopic treatment.
 When the tumor is locally aggressive, modern therapy dictates a
multimodality approach in a surgically fit patient.
 Multimodality therapy is either chemotherapy followed by surgery or radiation
and chemotherapy followed by surgery.

23. Cont…
 For disseminated cancer, treatment is aimed at palliation
of symptoms.
 If the patient has dysphagia,the most rapid form of
palliation is the endoscopic placement of an expandable
esophageal stent.
 For palliation of GEJ cancer, radiation may be the first
choice, as stents placed across the GEJ create a great
deal of gastroesophageal reflux.

24. Algorithm for the evaluation of esophageal cancer patients to select the proper therapy: curative en
bloc resection, palliative transhiatal resection, or nonsurgical palliation

25. Treatment Overview

26. Treatment Regimen
 Endoscopic Mucosal Resection(EMR)
 Surgery
 Chemotherapy
 Radiotherapy
 Combined-modality therapy
 Palliative Therapy

28. Management depends upon:
 Site of disease
 Extent of disease involvement
 Co-morbid conditions
 Patient preference.

29. Surgery
 Prerequisite for surgery
 disease should be 5 cm beyond cricophyrangeus.
 Surgery indications
 Lower 1/3 rd oesophageal ds involving GE junction.
 Tumor size <5 cm .
 palliative surgery
 5-Year OS for surgery alone is 20–25% (no significant difference
between surgical techniques according to results of 2 meta-analyses)
 Local failure rate around 19–57% when used alone
 surgical morbidity/mortality related to experience of the surgeons.

30. Types of Surgery
 Transhiatal esophagectomy: for tumors anywhere in esophagus or gastric cardia.
No thoracotomy. Blunt dissection of the thoracic esophagus. Left with cervical
anastomosis. Limitations are lack of exposure of midesophagus and direct
visualization and dissection of the subcarinal LN cannot be performed.
 Right thoracotomy (Ivor-Lewis procedure): good for exposure of mid to upper
esophageal lesions. Left with thoracic or cervical anastomosis.
 Left thoracotomy: appropriate for lower third of esophagus and gastric cardia.
Left with low-to-midthoracic anastomosis.
 Radical (en block) resection: for tumor anywhere in esophagus or gastric cardia.
Left with cervical or thoracic anastomosis. Benefit is more extensive
lymphadenectomy and potentially better survival, but increased operative risk.

31. Transhiatal esophagectomy
 Transhiatal esophagectomy is most frequently performed
and recommended for early esophageal cancers of the
middle (below the level of carina) and lower third of
esophagus (type I and II tumors of esophagogastric
junction).
 However, transhiatal esophageal resection may be feasible
in upper esophageal carcinomas in some cases.
 Transhiatal esophageal resection is also performed for
advanced esophageal cancers in patients who are not fit
to undergo a thoracotomy.

32. Transhiatal esophagectomy
Incisions and mobilization of
the stomach. Mobilization of Stomach

33. Widening of hiatus Cervical Incision

34. Exposure of Cervical
esophagus.
Mobilization of
Cervicothoracic
esophagus.

35. Esophageal mobilization
on anterior aspect.
Esophageal mobilization
on posterior aspect.

36. Transection of Cervical
Esophagus Creation of Stomach tube.

37. Stomach tube
Stomach tube pushed through
hiatus towards the neck.

38. Esophagogastric Anastomosis
with a Linear Cutting Stapler.
Completion of the
esophagogastric anastomosis.

39. Postoperative Care and Follow-up
 feeding through the feeding jejunostomy begins on postoperative
day1.
 On postoperative day 6, a swallow study is performed to check for
anastomotic leakage. If no leak is present, patients start oral
feedings. If a leak is present, the drainage tubes are left in place and
nutrition is provided entirely through the feeding jejunostomy until
the leak closes spontaneously.
 Patients are seen by the responsible surgeon at 2 weeks and 4 weeks
after discharge from the hospital and subsequently every 6 months by
an oncologist. Most patients return to their regular level of activities
within 2 months.

40. Complications
Respiratory complications
Atelectasis, in 3% of cases, ,may progress to pneumonia in
some cases which may prolong patient’s stay in ICU.
Pleural effusion
Postoperative hemorrhage may be mediastinal or
intraperitoneal. Source of bleeding include a tear in the azygos
vein, large prevertebral collateral veins, or spleen.
Chylothorax (1%) is a rare complication and is managed
conservatively

41. Recurrent laryngeal nerve injury
 The recurrent laryngeal nerve innervates the upper esophageal
sphincter
 Injuries occur in 1%-3% of cases. It causes vocal cord paresis
and dysphagia ,aspiration,
 Placement of a metal retractor alongside the
tracheoesophageal groove during the cervical dissection of
esophagus should also be avoided. The surgeon should handle
the trachea, thyroid, and cervical esophagus with fingers,
when possible
 Hoarseness due to recurrent laryngeal nerve injury may
resolve spontaneously, but cord medialization procedures may
be required for persistent vocal cord paresis.

42. Cervical esophagogastric anastomotic leak
may lead to stricture formation.
Use of a side-to-side stapled cervical esophagogastric anastomosis has reduced
the incidence of anastomotic leak.
ManAgement
by opening the neck wound at the bedside and local wound packing until
healing by secondary intent occurs.
 Patient may be put on jejunal feeds until the anastomotic leak is controlled.
 For fistula due to anastomotic leak, early bedside esophageal anastomotic
dilatation (with 36F, 40F, and 46F dilators) within 1 week is very helpful and
results in early closure of the fistula by allowing preferential flow of swallowed
esophageal contents down the true lumen rather than through the leak.
 Stent placement can also facilitate fistula closure and is perhaps the preferred
avenue when an anastomotic leak is encountered.

43. Palliative care
 In patients who are not candidates for surgery, treatment focuses on
control of dysphagia.
 The most appropriate method is determined for each patient
individually, depending on tumor characteristics, patient preference,
and the specific expertise of the physician.
 The following treatment modalities are available to help achieve this
goal:
 Chemotherapy
 Radiotherapy
 Laser therapy
 Stents

44.  CHEMOTHERPAY
 Studies found that no consistent benefit with any specific
chemotherapy regimen, Cisplatin, 5-fluorouracil (5-FU), paclitaxel, and
anthracyclines had promising response rates and tolerable toxicity.
 Radiotherapy
 Radiation therapy is successful in relieving dysphagia in approximately
50% of patients
 In a study, Folkert et al found that high-dose-rate (HDR) endoluminal
brachytherapy was well tolerated in medically inoperable patients
with superficial primary or recurrent esophageal cancer.

45. Laser therapy
 Laser therapy (Nd:YAG laser) can help to achieve temporary relief of
dysphagia in as many as 70% of patients.
 The photosensitizer porfimer (Photofrin) is FDA approved for palliation
of patients with completely obstructing esophageal cancer or partially
obstructing cancer that cannot be satisfactorily treated with Nd:YAG
laser therapy.

46. Stents
 Patients may be intubated
with expandable metallic
stents, which can be
deployed by endoscopy
under fluoroscopic
guidance and can keep
the esophageal lumen
patent.
 Stents are particularly
useful for patients with a
tracheoesophageal fistula.

47. NCCN guidelines

52. Conclusion

53.  Surgery alone is regarded as standard treatment only
in carefully selected operable patients with localized
SCC (T1-2 N0-3 M0).
 Preoperative or post-operative radiation alone
(without chemotherapy) does not add any survival
benefit to surgery alone, so this treatment is not
recommended for curative intent in localized tumors.
 Evidence for clinical benefit from preoperative
chemotherapy exists for all types of oesophageal
cancer, though it is stronger for adenocarcinoma (AC).

54.  Patients with AC of the lower oesophagus or OGJ should be managed
with pre- and post-operative chemotherapy (or chemoradiation).
A couple of meta-analyses and two recent phase III trials suggested
that preoperative chemoradiation confers a survival benefit and it
appears that patients benefit with increased tumour down-staging
from preoperative chemoradiation.
Data on adjuvant chemo(radio)therapy is limited, except for lower
oesophageal/OGJ AC after limited surgery (lymph node dissection D1
and less). Therefore, adjuvant therapy is not recommended.

55.  Minimally invasive techniques have been introduced to
reduce postoperative complication rates and recovery times.
 Debates continue as to whether these challenging
techniques decrease morbidity and whether the oncological
outcome is compromised.
 Open surgery remains the standard of care.