This document discusses a case of esophageal cancer in a 65-year-old male who presented with dysphagia, weight loss, and chest pain. Examination found weight loss and endoscopy revealed an ulcerated mass in the mid-esophagus. The document provides information on the anatomy and types of esophageal cancers. It discusses risk factors, symptoms, investigations including endoscopy, biopsy and imaging. Staging, treatment options including surgery, chemotherapy and radiation are outlined. Prognosis is generally poor but research on neoadjuvant immunotherapy and chemotherapy is showing promise in improving outcomes.

1. Upper GI
Tumors

2. Parts of the
upper GI
tract

4. Case Presentation
A 65yr old male presented in OPD with chief
complains of progressive dysphagia, weight loss and
occasional chest pain.
Patient is a known case of GERD since 2 years,
along with a 40-pack year smoking hx and heavy
alcohol consumption. He is a retired construction
worker, exposed to carcinogens, and has a
sedentary/unhealthy lifestyle.
On examination, patient is pale appearing and has
lost over 10kgs over the last few months.
Upper GI endoscopy reveals a circumferential
ulcerated mass in mid-esophagus & CT scan reveals
esophageal wall thickening

5. Normal
anatomy of the
esophagus

6. Histological
layers of
esophagus

7. Esophageal Leiomyoma

8. Treatment

9. Esophageal Carcinomas
It is the 6th most common cancer in the world
Mostly presents in mid to late adulthood
Has a poor prognosis, only 5-10% of those diagnosed will survive beyond
5 years

10. n

11. Predisposing
factors

12. Sign & Symptoms

13. ENDOSCOPY – 1st line
BIOPSY – for histology & cytology is crucial for accurate diagnosis
BARIUM SWALLOW
CT/MRI
BRONCHOSCOPY
LAPROSCOPY
ENDOSCOPIC US and/or PET SCAN
Investigations

14. • Esophageal CA is almost always diagnosed by endoscopic biopsy
• Endoscopy should be performed in every patient with dysphagia, even if the
barium study is suggestive of a motility disorder
• Contrast-enhanced CT scan of the chest and abdomen, and PET scan should be
done to assess for distant metastasis
• If there is no evidence of distant metastatic disease, endoscopic US should be
performed to assess T-stage and regional lymph nodes involvement

15. Newer modalities of
evaluation
• Flow cytometry
• P53 immunohistochemistry
• Optical coherence tomography
• Spectroscopy

16. Mid-esophageal
proliferative
SCC
Adenocarcinom
a of the lower
esophagus
Mid-esophageal
SCC
Adenocarcinom
a of the cardia

17. NICE Guidelines for oesophagogastric
cancer - NG83
• Offer PET-CT for esophageal and gastro-esophageal junctional tumors that are suitable for radical
treatment
• Do not use endoscopic ultrasound only to distinguish between T2 and T3 tumors
• Only offer endoscopic ultrasound when it will help guide ongoing management
• Only consider staging laparoscopy when it will help guide ongoing management
• Offer HER2 testing in metastatic esophagogastric adenocarcinoma
• Offer endoscopic resection for staging in people with suspected stage 1 esophageal
adenocarcinoma

18. TNM Staging
Tis High grade dysplasia
T1 Tumor invading lamina propria or submucosa
T2 Tumor invading muscularis propria
T3 Tumor invading beyond muscularis propria
T4 Tumor invading adjacent structures
Tx Primary tumor cannot be assessed
N0 No regional lymph node metastases
N1 Regional lymph node metastases
Nx Lymph nodes cannot be assessed
M0 No distant metastases
M1(a) Celiac node involved (distal tumors)
Supraclavicular node involved (proximal tumors)
M1(b) Celiac or supraclavicular node involved if not remote from tumor site (i.e. not 1a)
All distant metastases
Mx Distant metastases cannot be assessed.

20. Treatment

21. Treatment
• Stage 1: Esophagectomy with gastric pull-up
• Stage IIa: Esophagectomy with gastric pull-up
• Stage IIb: Neoadjuvant chemoradiation, restaging, and esophagectomy
with gastric pull-up
• Stage III: Neoadjuvant chemoradiation, restaging, and esophagectomy
with gastric pull-up
• Stage IV: Chemoradiation and esophageal stent or palliative therapy

22. Surgical approaches

23. Ivor Lewis Procedure

24. Trans-hiatal esophagectomy

25. Palliative
Care

26. Palliative
Procedures
1. External or intraluminal radiotherapy (brachytherapy)
2. Chemotherapy
3. Intubation tube
4. Endoscopic therapy
• Self-expanding metal stents
• Endoscopic laser
• Endoscopic photodynamic therapy
5. Paliative surgeries

27. • Fan et al., conducted a meta-analysis of 27 phase-II/III clinical trials, incorporating a total of 815 patients, with
resectable stage I-IV esophageal CA.
• The main objective of this meta-analysis was to systematically assess and provide the most updated and
comprehensive evidence regarding the safety & efficacy of neoadjuvant immunotherapy combined with
chemotherapy, in patients with resectable esophageal CA.
• The primary outcomes were the pathological complete response (pCR) rate and the major pathological response
(MPR) rate. Secondary outcomes were treatment-related severe adverse events.
• pCR: 31.4% (95% CI: 27.6-35.3) & MPR: 48.9% (95% CI: 42.0-55.9).
• Severe adverse events: 26.9% (95% CI: 16.7-38.3)
• The study demonstrated promising clinical & safety outcomes with neoadjuvant therapy combined with chemo in
patients with resectable esophageal CA. Supports the prospective wide application of this treatment option.

28. Gastroesophageal
Junction (GEJ) Cancer

29. Types of gastro oesophageal junction
cancer
• Type 1
Type 1 GOJ cancer spreads down into the gastro oesophageal junction from above. So, the cancer cells are in the lower
part of the oesophagus and the gastro oesophageal junction. The cancer’s centre is between 1 and 5 cm above the
junction.
• Type 2
Type 2 GOJ cancers develop at the actual gastro oesophageal junction. The cancer's centre is between 1 cm above and 2
cm below the junction.
• Type 3
Type 3 GOJ cancer spreads up into the gastro oesophageal junction from below. So there are cancer cells in the top of the
stomach and the gastro oesophageal junction. The cancer’s centre is between 2 and 5 cm below the junction.

31. Risk Factors

32. Risk Factors
There are different risks factors for each type of GOJ cancer.
• Type 1
Type 1 GOJ cancers are similar to oesophageal cancers. Barrett's oesophagus increases your risk of type 1 GOJ cancer. This is a condition
where the cells lining your oesophagus have become abnormal. This can happen due to long term acid indigestion (acid reflux).
• Type 2
We don't have such a good understanding of what causes type 2 cancers. Type 2 characteristics are somewhere between stomach and
oesophageal cancer cells.
• Type 3
Type 3 GOJ cancers are similar to stomach cancers. They are linked to infection with Helicobacter pylori (H.pylori). H. pylori is a bacteria
that lives in the mucous of the lining of the stomach.

33. Signs and Symptoms

34. GEJ Cancer Types

35. Lymphatic spread

36. Diagnosis

37. Endoscopic picture
A view through the
endoscope (Fig A) shows an
ulcerated mass in the distal
esophagus at the
gastroesophageal (GE)
junction, which appears
malignant.
It is arising from abnormal,
pink mucosa (Barrett’s
mucosa)

38. Radiographic imaging
Fig A: Radiographs from a double-contrast upper
gastrointestinal series show an eccentric filling defect
in the anterolateral portion of the distal esophagus
Fig B: There is irregularity of the distal esophageal
wall, a finding consistent with severe erosive changes,
probably from reflux.
Fig C: Axial CT of the upper abdomen (without the
administration of intravenous contrast material shows
thickening of the right anterolateral wall of the distal
esophagus (arrow), corresponding in location to the
mass seen on the upper gastrointestinal study.
Fig D: There is an enlarged (1.0 cm)
lymph node in the gastrohepatic ligament

39. Fig: Adenocarcinoma at the
gastroesophageal junction with
central depression shown by
asterisk.

40. Treatment

41. Surgery

42. Esophagectomy

43. Gastrectomy

44. Chemotherapy

45. Radiotherapy

46. Targeted therapy

47. Prognosis

48. Research