Esophageal Cancer

Esophageal Cancer Background Esophageal carcinoma was well described at the beginning of the 19th century, and the first successful resection was performed in 1913 by Frank Torek.

In the 1930, Ohsawa in Japan and Marshall in the United States were the first to perform successful 1stage transthoracic esophagectomies With continent reconstruction.

Esophageal Cancer • Pathophysiology • Esophageal carcinoma arises in the mucosa.

• ►Subsequently, it tends to invade the submucosa and the muscular layer.

• ► and, eventually, contiguous structures such as: • • •

the tracheobronchial tree the aorta or the recurrent laryngeal nerve.

Esophageal Cancer • Pathophysiology • The tumor also tends to metastasize to the periesophageal lymph nodes and, eventually, to the liver, lungs, or both.

• Physiopathology: cascades of events to cancer:

Esophageal Cancer • Frequency • The incidence of esophageal carcinoma is approximately 36 cases per 100,000 persons, although certain endemic areas appear to have higher per-capita rates.

Esophageal Cancer • Sex • Esophageal cancer is generally more common in men than in women, with a male-to-female ratio of 7:1. • Age • Esophageal cancer occurs most commonly during the sixth and seventh decades of life. •

History ►

Esophageal Cancer

• Clinical Presentation • History • Dysphagia • Is the most common presenting symptom.

Esophageal Cancer • Clinical Presentation • History • Dysphagia • Is initially experienced for solids, but eventually it progresses to include liquids.

Esophageal Cancer • Clinical Presentation • History • A complaint of dysphagia in an adult should always prompt an ► endoscopy to help rule out the presence of esophageal cancer. • A barium swallow study is also indicated.

Esophageal Cancer

• • • •

Clinical Presentation History Weight loss Is the second most common symptom and occurs in more than 50% of people with esophageal carcinoma.

Esophageal Cancer • Clinical Presentation • History

• ► Pain • Can be felt in the: • epigastric • or retrosternal area.

• ► It can also be felt over bony structures,

representing a sign of metastatic disease.

Esophageal Cancer • Clinical Presentation • History • Hoarseness • Caused by invasion of the recurrent laryngeal nerve is a sign of unresectability.

Esophageal Cancer

• Clinical Presentation • History • Respiratory symptoms • Can be caused by aspiration of undigested food or by direct invasion of the tracheobronchial tree by the tumor. • ► The latter also is a sign of unresectability.

Esophageal Cancer • Clinical Presentation • Physical Examination • The goals of the workup are to establish the diagnosis and to stage the cancer. • The examination findings are often normal.

Esophageal Cancer • Clinical Presentation • Physical Examination • Lymphadenopathy in the ►laterocervical or • ► supraclavicular areas represents ► metastasis and, if confirmed by needle aspiration or biopsy findings, is a contraindication to surgery.

Esophageal Cancer • Causes • The etiology of esophageal carcinoma is thought to be related to exposure of the esophageal mucosa to noxious or toxic stimuli, ► resulting in a sequence of dysplasia ► to carcinoma in situ ► to carcinoma.

Esophageal Cancer

• Causes • Potential contributing factors for squamous cell carcinoma include the following: • Chronic ingestion of hot liquids or foods is a contributing factor. • Vitamin or nutritional deficiencies have been recognized as contributing factors.

• Poor oral hygiene may lead to esophageal cancer.

Esophageal Cancer • Causes • Potential contributing factors for squamous cell carcinoma include the following:

• Exposure to nitrosamines in the environment or food has been linked to esophageal cancer. • In Western cultures, cigarette smoking and chronic alcohol exposure are the most common etiological factors for squamous cell carcinoma.

Esophageal Cancer • Causes • Potential contributing factors for squamous cell carcinoma include the following:

• Certain medical conditions (e.g. Plummer-Vinson syndrome) and caustic injury to the esophagus are associated with an increased incidence of esophageal cancer. • Human papilloma virus infection has been recognized as a contributing factor.

• Causes • GERD is the most common predisposing factor for adenocarcinoma of the esophagus. • As a consequence of the irritation caused by the reflux of acid and bile, 10-15% of patients who undergo endoscopy for evaluation of GERD symptoms are found to have Barrett epithelium. • The risk of adenocarcinoma among patients with Barrett metaplasia has been estimated to be 30-60 times that of the general population. •

Esophageal Cancer • Differential Diagnosis • Achalasia • Esophageal Stricture

Esophageal Cancer • Workup • Lab examinations • Complete blood cell count may demonstrate anemia secondary to iron deficiency or chronic disease. • ►Liver function tests • ► Patients with squamous cell carcinomas may demonstrate hypercalcemia. •

Esophageal Cancer • Workup • Lab examinations • Prothrombin time and activated partial thromboplastin time coagulation study findings may demonstrate hepatic insufficiency or nutritional deficiencies.

Esophageal Cancer • Workup • Imaging Studies • Barium swallow is very sensitive for helping detect strictures and intraluminal masses.

Esophageal Cancer • Workup • Imaging Studies • Performing esophagogastroduodenoscopy allows direct visualization and biopsies of the tumor.

Esophageal Cancer

• Workup • Imaging Studies • Endoscopic ultrasound is the most sensitive test to help determine the depth of penetration of the tumor (T staging) and the presence of enlarged periesophageal lymph nodes (N staging).

•

Esophageal Cancer

• Workup • Imaging Studies • Abdominal and chest CT scans are useful to help exclude the presence of metastases (M staging) to the lungs and liver and may be useful to help determine if adjacent structures have been invaded

Esophageal Cancer

• Workup • Imaging Studies • Bronchoscopy is indicated for cancers of the middle and upper third of the thoracic esophagus to help exclude invasion of the trachea or bronchi. •

Esophageal Cancer • Workup • Imaging Studies • Bone scan is indicated in patients with complaints suggestive of bone metastases.

• Laparoscopy and thoracoscopy have a greater than 92% accuracy in staging regional nodes. •

Esophageal Cancer

• Workup • Imaging Studies • A new modality for staging is positron emission tomography scanning (PETS).

Esophageal Cancer • Treatment • Medical Care • Nonoperative therapy is usually reserved for patients who have esophageal carcinoma and are not candidates for surgery.

Esophageal Cancer • Treatment • Medical Care • The goal of therapy for these patients is palliation of dysphagia, allowing them to eat.

• A single best method of palliation cannot be applied to every situation.

• Treatment • Medical Care • The most appropriate method to control dysphagia should be tailored for each patient individually, depending on:

• ► tumor characteristics • ► patient preference • ► and the specific expertise of the physician.

• Treatment • Medical Care • The following treatment modalities are available to help achieve this goal: • Chemotherapy

Radiation therapy

• Laser therapy

Photodynamic therapy

• Intubations with expandable metallic stents.

Esophageal Cancer • Treatment • Surgical Care • Esophageal resection (esophagectomy) remains a crucial part of the treatment of esophageal cancer. • It is used in patients who are considered candidates for surgery.

Esophageal Cancer • Treatment • Surgical Care • Complications occur in approximately 40% of patients. • Respiratory complications (15-20%) include: • Atelectasis • pleural effusion • and pneumonia.

Esophageal Cancer • Treatment • Surgical Care • Cardiac complications (15-20%) include: • cardiac arrhythmias • and myocardial infarction.

• Septic complications (10%) include: • wound infection • anastomotic leak • and pneumonia.

Esophageal Cancer • Treatment • Surgical Care • ► Anastomotic stricture may require dilatation (20%). • ► The mortality rate depends on the functional status of the patient and the experience of the surgeon and the team taking care of the patient.

Esophageal Cancer • Prognosis • Survival depends on the: • stage of the disease • Lymph node metastases or solid organ metastases.

• Tumor Stage

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