Esophageal Carcinoma

Esophagus - Anatomy

Surgical anatomy • Muscular tube 25 cm long • Extent – cricopharyngeal sphincter to cardia of the stomach • 2 cm esophagus lies below the diaphragm

• Three constrictions – Cricopharyngeal -15cm from incisor – Aorta – 25 cm from incisor – Left bronchus – 25 cm from incisor – Diphragmatic and sphinctric constriction – 40cm from the incisor

Esophagoscopy • Two types – Fibre-optic • Commonly used • Used under light sedation • Reduced chances of perforation

– Rigid (done after barium swallow) • Not used commonly • Needs anaesthesia • Used for removing foreign bodies

Esophageal Carcinoma

Introduction • the seventh leading cause of cancer death worldwide. • Common in areas of northern Iran, some areas of southern Russia, and northern China. • Squamous cell carcinoma is common but recently the cases of adenocarcinoma are increasing • Male more than female. • sixth and seventh decades of life. (probably no other carcinoma causes greater misery to the patient due to development of inability to swallow even fluids)

pathology •

Macroscopically three types 1 An annular stenosing lesion usually found at the cardia 2. An epitheliomatous ulcer with raised everted edges 3. A fungating cauliflower like friable mass

Spread of the cancer • Direct .the main method of spread and most important to the surgeon. it is both longitudal and transverse in direction and erodes the muscular wall • Lymphatic . • Bloodstream metastasis to liver are fairly common and bone secondaries can also occur

Etiology • Squamous – cigarette smoking and chronic alcohol exposure are the most common etiological factors for squamous cell carcinoma. – Chronic ingestion of hot liquids or foods – Vitamin or nutritional deficiencies – Poor oral hygiene – Exposure to nitrosamines in the environment or food – Certain medical conditions (e.g., Plummer-Vinson syndrome) and caustic injury to the esophagus – Human papilloma virus infection

• Adenocarcinoma – GERD is the most common predisposing factor for adenocarcinoma of the esophagus – Barrett's esophagus

Clinical features • • • • • • • • •

Progressive dysphagia initially experienced for solids, but eventually it progresses to include liquids Only 40 % patient report in within 3 months feeling that food is sticking on its way down to the stomach Weight loss is the second most common symptom Pain or discomfort can be felt in the epigastric or retrosternal area. Hoarseness caused by invasion of the recurrent laryngeal nerve Respiratory symptoms can be caused by aspiration of undigested food or by direct invasion of the tracheobronchial tree by the tumor. the regurgitated material is alkaline mixed with saliva and possibly streaked with blood Pain if it occur is usually a late manifestation (but is not a contraindication to an exploratory operation)

Diagnosis • Endoscopic ultrasound - the depth of penetration of the tumor (T staging) and the presence of enlarged periesophageal lymph nodes • Abdominal and chest CTscans - 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 • Exfoliative cytology .in China lavage of the esophagus and examination of the fluid for malignant cell have lead to discovery of early carcinoma when radiology and oesphagoscopy have been negative • Dysphagia requires dilation again after a month the diagnosis is usually carcinoma

• Many of these patient have a long standing nutritional deficiency and therefore hemoglobin,plasma protein and blood chemistry must all be checked and corrected ,if necessary before surgical treatment

• Principal a gastrostomy should never be carried out for esophageal carcinoma . • It is no longer required as preoperative measure to improvise a patient nutrition because this can be carried out asby 2-3 mm tube from the nose to the stomach or by modern regimens for iv feeding • It should never be carried out only to prongle the life of the patient who cannot swallow the food because the subsequent state of the patient when inevitable inhalation lung complication occur due to inability to swallow saliva is most distressing

• Curative treatment should be either resection of the tumor or a radical course of radiotherapy but only 25 % of all the patient are suitable.the remainder require some palliative radiotherapy or palliation bypass • • •

A curative resection implies that no visible macroscopic tumor has been left behind. A pallitative resection means that recognisable tumor has acutally been left in situ Histological confermation of the curative rescection by examining the lateral margin spread and longitudinal extent must alwas be done.unfortunatly 25% of the patient present in late stage where no treatment can be done only short term measures to reduce the suffering

Curative treatment by surgery • Operative aim is to remove the tumor and to restore continuity by the interposition of the stomach, jejunum or colon • Curative treatment should me attempted providing • 1. the patient is fit enough on general appearance to withstand a very major surgical procedure • 2.there is no evidence of spread to the supraclavicular glands , tracheobronchial tree or liver

Postcricoid carcinoma • To optain a good chance of cure the tumor must have not spread too far laterally but it is also important for the surgeon to excise at least 10 cm margin longitudinally to minimize the chance of recurrence at the anastomosis . This implies that it is difficult to optain such a margin in tumors of the postcricoid region and the upper one third of the oesophagus . • So postcricoid carcinoma of the esophagus should be treated by radiotherapy • Alternative surgical treatment pharyngolaryngectomy with gastric transposition, colon transposition and tracheostomy is major undertaking with major complication

• Esophagoscopy: direct visualization and biopsies of the tumor

• Barium swallowhelping detect strictures and intraluminal masses

• Chest CT scan showing invasion of the trachea by esophageal cancer.

• Esophageal cancer: Staging T3N1

• Bronchoscopy is indicated for cancers of the middle and upper third of the thoracic esophagus to help exclude invasion of the trachea or bronchi. • 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. • A new modality for staging is positron emission tomography scanning, which can help elucidate hypermetabolic foci of disease activity

• the left adrenal gland (thick pink arrow), 2 foci in the anterolateral right chest wall (thin orange arrows), 2 paraspinal foci in the right mid-lumbar region (thin purple arrows), the left upper lumbar paraspinal region (curved blue arrow), the right supraclavicular region (red arrow head), and the mid-to-lower esophagus (thick yellow arrow).

Differential diagnosis • • • •

Benign tumor- leiomyoma Achalasia cardia Esophageal Stricture Peptic strictures due to reflux

Management • Medical • Surgery • Radiotherapy

Surgery • Esophagectomy is the treatment of choice for esophageal cancer. – Transhiatal esophagectomy – Transthoracic esophagectomy – Ivor-Lewis 2 stage and 3 stage surgery

• Contraindications – metastatic disease, – tumor invasion of nearby structures – severe cardiovascular or pulmonary disease.

complication • fistula of esophageal anastomosis

Radiation Therapy • • • •

Palliative neoadjuvant therapy adjuvant therapy Each treatment lasts a few minutes and treatment is usually given 5 days per week, for 6 weeks. • Side effects include the following: – – – – – – –

Dental cavities Difficulty swallowing Dry, sore mouth and throat Fatigue Loss of appetite Reddening of the skin Swelling of the mouth and gums

Chemotherapy • Chemotherapy is not used as a primary treatment for esophageal cancer. • Commonly cisplatin, 5-FU and paclitaxel based combination is used • Common side effects include the following: – – – – – – –

Diarrhea Fatigue Hair loss Loss of appetite Mouth and lip sores Nausea and vomiting Skin rash and itching

Stage wise Therapy • Stage 0: Surgery is the best therapy • Stage I: surgery. • Stage II and III: – surgery – chemoradiation followed by surgery.

• Stage IV: Palliative therapies – radiation therapy, – chemotherapy, – Bypass- stenting, laser therapy, surgical.

Prognosis • Advanced disease and metastatic esophageal cancer have a poor prognosis. • The overall 5-year survival rate for esophageal cancer is 20-25%