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 1-stage transthoracic esophagectomies With continent reconstruction

Esophageal Cancer Pathophysiology Esophageal carcinoma arises in the mucosa

►Subsequently, it tends to invade the: * submucosa and * muscular layers

► and, eventually, contiguous structures such as the: * tracheobronchial tree * aorta or * 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 3-6 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

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History ►

Esophageal Cancer Clinical Presentation History (1) Dysphagia Is the most common presenting symptom

Esophageal Cancer Clinical Presentation History (1) 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 (2) Weight loss

** Is the second most common symptom and occurs in more than 50% of people with esophageal carcinoma

Esophageal Cancer Clinical Presentation History ►(3) 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 (4) Hoarseness Caused by invasion of the recurrent laryngeal nerve is a sign of unresectability

Esophageal Cancer

Clinical Presentation History (5) Respiratory symptoms Can be caused: 1) by aspiration of undigested food or 2) 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: 1) dysplasia ► 2) to carcinoma in situ►3)to carcinoma

Esophageal Cancer Causes Potential contributing factors for squamous cell carcinoma include the following: 1) Chronic ingestion of: hot liquids or foods is a contributing factor 2)

Vitamin or nutritional deficiencies have been recognized as contributing factors

3) Poor oral hygiene may lead to esophageal cancer

Esophageal Cancer Causes (Potential contributing factors) 3) Exposure to: nitrosamines in the environment or food has been linked to esophageal cancer 4) 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) 5) Certain medical conditions e.g.: * Plummer-Vinson syndrome and * caustic injury to the esophagus are associated with an increased incidence of esophageal cancer 6) 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 1) Achalasia 2) Esophageal Stricture Fig: Barium swallow demonstrating stricture due to

cancer

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 demonstrate hypercalcemia

carcinomas

may

Esophageal Cancer Workup Lab examinations PT and aPTT study findings may demonstrate: hepatic insufficiency or nutritional deficiencies And are part of preoperative screening

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:

*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: 1) esophageal carcinoma and 2) 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 * Intubations with expandable: metallic or plastic 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 1) Pull up with esophagogastric anastomosis 2) Colon interposition

Esophageal Cancer Treatment Surgical Care Complications occur in approximately 40% of patients 1) Respiratory complications (15-20%) include: * atelectasis * pleural effusion and * pneumonia

Esophageal Cancer Treatment Surgical Care 2) Cardiac complications (15-20%) include: * cardiac arrhythmias and * myocardial infarction

3) 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: a) the functional status of the patient and b) the experience of the surgeon and c) the team taking care of the patient

Esophageal Cancer Prognosis Survival depends on the: 1) stage of the disease 2) lymph node metastases or 3) solid organ metastases

Tumor Stage

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