11 esophageal cancer


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  • Hi, Good morning, everyone. Maybe you are fa’miliar with (know well) lung cancer, breast cancer, or liver cancer, but for esophageal cancer,I think you aren’t. so, Today we are going to talk about Esophageal Cancer. I am Dr Li
  • This is a colorful dinner.we can see there are fish, egg, beef, a lot of vegetalble, fruits,such as water melon. and so on. How delicious they are!. But if a people cannot swallow the food, it must be terrible. And he may have this disease, esophageal cancer.
  • First of all, let’s have a look at the normal esophagus. It is a hollow muscular tube , about 10-inch long, extent from the throat to the stomach. When people eat, the esophagus will contract and push the food down into the stomach. This picture shows the detail structure. Esophagus has four layers: the inner layer is mucosa, then submucosa, muscle, and the outer t layer, fibrous membrane. In the chest, the esophagus locates in the mediastinum. We can see in front of the esophagus,they are the trachea, brochus and heart, please notice here.. Behind the esophagus is the spine. This slide shows the detail structure. Esophagus has four layers: the inner most layer is mucosa, then submucosa, muscle, and the outer most layer, fibrous membrane.
  • The esophagus is commonly divided into three portions. cervical, thoracic and abdominal. The thoracic portion is divided into three sections. Upper third, middle third and lower third. Carcinomas of the thoracic esophagus are most commonly located in the middle third of the organ; most of the remainder is in the lower third; and only 10% are located in the upper third.
  • What’s the main pathologic type of esophageal cancer? Two major types of esophageal cancer include squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma of the esophagus is the predominant histology in the cervical esophagus and upper and middle thirds of the thoracic esophagus, whereas adenocarcinoma in the distal esophagus. Squamous cell carcinoma starts in squamous cells that line the esophagus and usually develops in the upper and middle part of the esophagus; Adenocarcinoma begins in the glandular tissue in the lower part of the esophagus at the junction between the esophagus and the stomach; Treatment is similar for both types, Rare tumors of the esophagus occur in less than 1% of cases and include small cell neuroendocrine cancer, lymphoma, and sarcoma
  • We have just reviewed the anatomy of esophagus.now we are talking about the epidemiology and etiologo of esophageal cancer.
  • As we know, lung cancer is the leading cause of cancer death.how about esophageal cancer? Esophageal cancer is the seventh leading cause of death from cancer among American men 。 but We can see, the mortality of esophageal cancer is low in american women .
  • We have just talked about mortality of esophageal cancer. how about the incidence rate in women? from this slide we can see, all over the world, incuding developped country and the less developped country. Esophageal cancer is the nineth incidence rate from cancer among women 。
  • The cause of esophageal cancer is unknown. It is suspected that nutritional and environmental factors may play an important role.Age 65 or older : Age is the main risk factor for esophageal cancer. In the United States, most people are 65 years of age or older when they are diagnosed with esophageal cancer. Being male : In the United States, men are more than three times as likely as women to develop esophageal cancer. Smoking : People who smoke are more likely than people who don't smoke to develop esophageal cancer. Heavy drinking : People who have more than 3 alcoholic drinks each day are more likely than people who don't drink to develop squamous cell carcinoma of the esophagus. Heavy drinkers who smoke are at a much higher risk than heavy drinkers who don't smoke. In other words, these two factors act together to increase the risk even more.
  • Diet: Studies suggest that having a diet that's low in fruits and vegetables may increase the risk of esophageal cancer. Obesity: Being obese increases the risk of adenocarcinoma of the esophagus. Acid reflux Acid reflux is the stomach acid abnormal backward flow into the esophagus. A symptom of reflux is heartburn, but some people don't have symptoms. The stomach acid can damage the tissue of the esophagus. After many years of reflux, this tissue damage may lead to adenocarcinoma of the esophagus in some people.
  • What’s the symptoms and signs of EC, we can see the following:
  • So when the tumor occurs, what will the patient complain? To explain the symptoms, we should review the anatomy together. Just we know,Early esophageal cancer may not cause symptoms. When the tumor grows bigger and bigger, esophagus gets narrower and narrower, swallowing will be more and more difficult. As specialists of medical science, we should call this symptom dysphagia. First, patient can still eat anything, then just soft food, and only liquid, at last nothing can be swallowed down. And he will vomit, usually weight loss. Once tumor invades the trachea, patient keeps coughing. If the surface of spine is involved, back pain occurs. When tumor transfers to the lymph node beside the recurrent laryngeal nerve, and the nerve is compressed, the vocal cord cannot move. The patient’s voice will change. He will speak like this. This symptom is called hoarseness.
  • If the disease has spread elsewhere, this may lead to symptoms related to this: Supraclavicular lymph node metastasis, liver metastasis could cause liver mass, jaundice and ascites , lung metastasis could cause shortness of breath , pleural effusions , etc.
  • There are many examination mothods to help the docotor for the esophageal cancer diagnosis. Including….., how to choose them?
  • When the patient comes to us, what examination should be given? To differentiate from other diseases, we often give barium swallow first, because it is quick, comfortable and cheap.
  • Barium swallow : After you drink a barium solution , you have x-rays taken of your esophagus and stomach. The barium solution makes your esophagus show up more clearly on the x-rays. Now we see the normal esophagus, it is flexible, smooth, you can see the mucosa is intact and continuous.
  • Then here comes the cancer. We can see the esophagus is narrow and stiff. These picture show us obvious barium defect with irregular shape and the mucosa is discontinued. We consider the patient has esophageal cancer. But it is not enough, because the tumor diagnosis includes two parts: pathology diagnosis and staging diagnosis. SLIDE12 Pathology diagnosis depends on endoscopy. It is a flexible telescope, it can pass through the mouth and go into the esophagus. Using endoscopy, we made the tissue biopsy. Then we get the pathologic result.
  • for these patients whose diagnosis are highly suspected and uncertained, Upper endoscopy (esophagoscopy) and biopsy should be taken.
  • Pathology diagnosis depends on endoscopy. It is a flexible telescope, it can pass through the mouth and go into the esophagus. Using endoscopy, we made the tissue biopsy. Then we get the pathologic result.
  • From this picture we can see, the tumor of the esophagus is about 3 centimeter, the esophagus has a little obstruction
  • As to staging diagnosis, I should mention a new and effective endoscopic ultrasonography, in short EUS.
  • It looks similar to endoscopy, but on the head, there is an ultrasound equitment, in the esophagus, it can scan the wall of esophagus and the lymph nodes nearby.
  • Under EUS, all the layer of esophagus is clearly shown. In this picture, we see the invasion of tumor and the metastatic lymph node. The accuracy is over 85% percent and it benefit the stage diagnosis greatly.
  • From the CT, we can find the border of the tumor,and if the organs nearby the the esophagus have been invade
  • From this picture, we can see CT can also help the doctor to predict if the lymph node around the tumor has been metastasis. For this patient,there haven’t lymph node metastasis.
  • We can also use MRI, sometimes PET, bronchoscopy and Laparoscopy , when we have all the results, we can make the staging diagnosis.
  • Staging is a way of describing a cancer, such as the size of a tumor and if or where it has spread Staging is the most important tool for doctors to predict the patient’s survival. Here, I emphasize, correct diagnosis is very important.
  • So what is the TNM system of EC? Staging is described by the TNM system: the size and location of the T umor, whether cancer has spread to nearby lymph N odes, and whether the cancer has M etastasized (spread to other areas of the body) Let me explain one by one.
  • SLIDE14 T stage describes the invasion of the tumor. This picture can help you understand. When the tumor is limited in the epithelia layer, and the basement membrane is still intact, it is called cancer in situ, this is a definition you should keep in mind. and it is defined as Tis. If the tumor gets over the basement membrane, but doesn’t reach the muscle layer, it is T1. As long as the muscle layer is involved, it is T2. When the whole wall of esophagus is infiltrated, it is T3. Once the tumor continues to invade the organ nearby, like thoracic duct, it is T4.
  • If the tumor gets over the submucosa, but doesn’t reach the muscle layer, it is T1.
  • As long as the muscle layer is involved, it is T2.
  • When the whole wall of esophagus is infiltrated, it is T3. Once the tumor continues to invade the organ nearby, like thoracic duct, it is T4.
  • N stage is used to evaluate the regional lymph node metastasis, and it is easy to remember. If region lymph node metastasis happens, it is N1. On the contrary, it is N0.
  • The lymphatics networks of the mucosa,submucosa,and muscular layers of the esophagus gather on the external surface in three groups. the upper trunks end in the cervical and in the supraclavicular lymph nodes. the middle trunks end in the posteromediastinal and in the retrotracheal lymph nodes. the lower trunks go to the lymph nodes of the cardia and to those of the lesser curvature of the stomach.
  • M stage means distal metastasis. It is separated into 2 groups, a little complicated. You just need to know when the tumor spread to other organ of the body, like brain, lung, liver, it is M1b.
  • This slide shows the whole stage system. Just have impression, you are not required to remember it. But you should know why the stage diagnosis is so important.
  • In summary,we can see
  • We design the treatment plan usually according to the stage of esophageal cancer, the location of the esophageal cancer and the general health of the patient Staging is the most important tool for doctors to predict the patient’s survival. From this picture, it is obvious that earlier diagnosis means better pronosis. Here, I emphasize, correct diagnosis is very important.
  • The staging is very important, because the treatment depends on the staging. You can see for different stage, we should perform different therapy. For example, for stage IIA, we shall give surgery directly. But to stage IV, we should not perform operation, but give chemoradiotherapy.
  • There are many treatment methods for esophageal cancer patients. Including ….We will talk them one by one
  • surgical resection: The objectives of surgical treatment are to achieve a complete and potentially curative resection when possible, to restore and maintain satisfactory swallowing for the remainder of the patient’s life. Just only 25 to 30% of patients in whom complete resection is possble
  • Surgery may also be used to create a new pathway to the stomach, insert a feeding tube, or other methods to help a person if unable to eat
  • Chemotherapy depends on the tumor type, but tends to be cisplatin -based (or carboplatin or oxaliplatin ) every three weeks with fluorouracil (5-FU). In more recent studies, addition of epirubicin (ECF) was better than other comparable regimens in advanced nonresectable
  • For patients who are found to have cancer spread to other organs or who, for some other reason, can't have surgery, combined chemotherapy and radiotherapy is the most common treatment.
  • If the patient can’t accept surgery . Chemotherapy+radiotherapy is the most common treatment stratege. Since swallowing difficulties are not always immediately relieved by this combined therapy, other means to improve swallowing are available. These include….
  • The average life expectancy of patients with esophageal cancer is only a few months.with about 25% dying with 6 months and 75%dying within 1 year
  • We can see from this picture that the hawk is waiting, trying to search for its prey
  • When he find the prey, he is flying close to the pray,he is very brave
  • The hawk seize it’s target by his effort . What enlightenment can we get from this picture? Just like the hawk, as a doctor, we should be watchful, prepared and sober to our patients. Firstly, we should be patient and alert to observe the patients’ symptom and signs. Treatment for cancer patients is like a long-term struggle. In this struggle, doctors’ professional suggestion and dedication is very important. Hope this kind of hawk’s spirit spread in our medical profession
  • In summary, I hope you can remember the following key points. Don’t forget
  • That is all for today. Thank you for your attention. Wish you a happy weekend!
  • 11 esophageal cancer

    1. 1. Esophageal Cancer <ul><li>Xiaodong Li </li></ul><ul><li>04-02-2010 Thoracic Oncology Department,Cancer center,Sun Yat-Sen University </li></ul>
    2. 2.
    3. 3. Anatomy: Normal Esophagus
    4. 4.
    5. 5. Types of Esophageal Cancer
    6. 6. Epidemiology and Etiology
    7. 7. Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths, by Sex, US, 2003
    8. 8. Worldwide estimates of cancer incidence Int. J. Cancer 1999, 80:827-841
    9. 9. Epidemiology and Etiology(1) <ul><li>An estimated 16,470 new cases in the United States in 2008 </li></ul><ul><li>Nearly four times more common among men than women </li></ul>
    10. 10. Epidemiology and Etiology(2) <ul><li>Incidence of esophageal cancer has increased six-fold in the past three decades </li></ul><ul><li>Incidence rates of adenocarcinoma have increased recently, especially in the Western hemisphere </li></ul>
    11. 11. Risk Factor(1) <ul><li>Age 65 or older </li></ul><ul><li>Being male </li></ul><ul><li>Smoking </li></ul><ul><li>Heavy drinking </li></ul>
    12. 12. Risk Factor(2) <ul><li>Diet: </li></ul><ul><li>Obesity: increase the risk of adenocarcinoma </li></ul><ul><li>Acid reflux </li></ul>
    13. 13. Symptoms and Signs
    14. 14. Symptoms of Esophageal Cancer <ul><li>Dysphagia </li></ul><ul><li>Vomiting </li></ul><ul><li>Weight loss </li></ul><ul><li>Coughing </li></ul><ul><li>Back pain </li></ul><ul><li>Hoarseness </li></ul>
    15. 15. Signs of Esophageal Cancer <ul><li>Supraclavicular lymph node metastasis </li></ul><ul><li>Liver mass </li></ul><ul><li>Bone metastasis </li></ul><ul><li>Hydrothorax </li></ul>
    16. 16. Diagnosis
    17. 17. How is Esophageal Cancer Diagnosed? <ul><li>Barium swallow (esophagram) </li></ul><ul><li>Upper endoscopy (Esophagoscopy) and biopsy ( Diagnosis is confirmed with a biopsy) </li></ul><ul><li>Endoscopic ultrasound </li></ul><ul><li>Bronchoscopy </li></ul><ul><li>Computed tomography (CT) scan </li></ul><ul><li>Magnetic resonance imaging (MRI) </li></ul><ul><li>Positron emission tomography (PET) scan </li></ul>
    18. 18. Diagnosis (1) Barium swallow (Esophagram)
    19. 19.
    20. 20.
    21. 21. Diagnosis (2) Upper Endoscopy (Esophagoscopy) and Biopsy
    22. 22. Pathology diagnosis - Upper endoscopy
    23. 23.
    24. 24. <ul><li>Diagnosis (3) </li></ul><ul><li>Endscopic ultrasonography (EUS) </li></ul>
    25. 25. Endscopic ultrasonography (EUS)
    26. 26. Endoscopic ultrasonography (EUS)
    27. 27. Diagnosis (4) CT
    28. 28.
    29. 29.
    30. 30. Diagnosis (5) <ul><li>MRI </li></ul><ul><li>PET-CT </li></ul><ul><li>Bronchoscopy </li></ul><ul><li>Laparoscopy </li></ul>
    31. 31. Staging
    32. 32. Other regular tests TNM stage
    33. 33. T stage (Tumor) Tis T1 T2 T3 T4 Mucosa
    34. 34. T1
    35. 35. T2
    36. 36. T3
    37. 37. N stage (lymph node) N0 N1
    38. 38.
    39. 39. M stage (metastasis) M1b M1a
    40. 40. Classification of Stage Groupings for Esophageal Cancer
    41. 41. Stage I Esophageal Cancer <ul><li>Cancer is in the mucosa and submucosa (the two inside layers of the esophagus) </li></ul><ul><li>Cancer cells are in the lining of the esophagus </li></ul>
    42. 42. Stage IIA Esophageal Cancer <ul><li>Cancer is in either of the two outer layers of the esophagus </li></ul>
    43. 43. Stage IIB Esophageal Cancer <ul><li>Cancer is in the inner layers of the esophagus </li></ul><ul><li>Cancer has spread to some lymph nodes near the tumor </li></ul>
    44. 44. Stage III Esophageal Cancer <ul><li>Cancer is in the outside layer of the esophagus or in the tissue near the esophagus </li></ul><ul><li>Cancer has spread to lymph nodes, either near the tumor or somewhere else in the body </li></ul>
    45. 45. Stage IVA Esophageal Cancer <ul><li>Cancer has spread to the lymph nodes in the abdomen or neck </li></ul>
    46. 46. Stage IVB Esophageal Cancer <ul><li>Cancer has spread to other parts of the body besides the lymph nodes </li></ul>
    47. 47. Treatment
    48. 48. How to design the treatment plan <ul><li>Staging whether the cancer has invaded nearby structures whether the cancer has spread to lymph nodes or other organs </li></ul><ul><li>where the cancer is located within the esophagus </li></ul><ul><li>The general health of patient </li></ul>
    49. 49. Treatment of Esophageal Cancer EMR or Surgery Surgery Surgery+adjuvant therapy Chemoradiotherapy
    50. 50. Regimen <ul><li>Endoscopic Mucosal Resection(EMR) </li></ul><ul><li>Surgery </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Radiotherapy </li></ul><ul><li>Combined-modality therapy </li></ul><ul><li>Palliative Therapy </li></ul>
    51. 51. Endoscopic Mucosal Resection(EMR) <ul><li>What’s EMR? </li></ul><ul><li>Indication of EMR </li></ul><ul><li>Tis or T1a (defined as tumor involving the mucusa but not involving submucosa) </li></ul>
    52. 52. Surgery <ul><li>The most common treatment </li></ul><ul><li>5-year survival rates of 15% to 30% are reported </li></ul><ul><li>Esophagectomy: removal of part of the esophagus; remaining portion is connected to the stomach </li></ul><ul><li>Lymph nodes around the esophagus may also be removed </li></ul>
    53. 53.
    54. 54. Indication of operation 1 early stage ( stage 0, 1) 2 middle stage (stage 2, 3) 3 tumor recurrence after radiotherapy (no distal metastasis). 4 palliative treatment
    55. 55. Contraindications of operation 1 the lesion is extensive,or involvement of adjacent structures such as trachea, lung, mediastinum. 2 left supraclavicular lymph nodes metastasis or other distal metastasis. 3 serious functional defection of heart lung and liver. serious cachexia.
    56. 56. Radiotherapy <ul><li>Squmous cell carcinoma of the esophagus are radiosensitive and potentially radiocurable </li></ul><ul><li>Radiotherapy to a dose of 6000 cGy resulted in 1-,2-,3- and 5-year survival rates of 33%,12%,8% and 7% </li></ul>
    57. 57. Chemotherapy <ul><li>Chemotherapy alone is seldom an effect palliative modality in patient. Commonly in combination with radiotherapy </li></ul><ul><li>Methotrexate,bleomycin,cisplatin,5-fluorouracil have been used in squmous cell carcinoma </li></ul><ul><li>cancerChemotherapy may be given after surgery (adjuvant), before surgery (neoadjuvant) or if surgery is not possible; in this case, cisplatin and 5-FU are used. </li></ul>
    58. 58. Combined-modality therapy: <ul><li>Is the best treatment for advanced esophageal cancer. Combined-modality therapy can improve the 3- and 5-year survival rates. </li></ul><ul><li>Including: </li></ul><ul><li>Surgery+chemotherapy </li></ul><ul><li>Surgery+radiotherapy </li></ul><ul><li>Chemotherapy+radiotherapy </li></ul><ul><li>Radiochemotherapy+surgery </li></ul>
    59. 59. Palliative Therapy <ul><li>Photodynamic Therapy </li></ul><ul><li>Laser therapy </li></ul><ul><li>Esophageal stenting </li></ul><ul><li>Feeding gastrostomy </li></ul><ul><li>Colonic interposition </li></ul><ul><li>External-bean irradiation </li></ul>
    60. 60. What Is the Prognosis for Esophageal Cancer?
    61. 61. Prognosis Time (month )
    62. 62.
    63. 63.
    64. 64.
    65. 65. In summary <ul><li>What’s the sympotom and signs of esophageal cancer? </li></ul><ul><li>What’s the main pathologic type of esophageal cancer? </li></ul><ul><li>How can we design the treatment according the staging of esophageal cancer? </li></ul>
    66. 66. Thanks