CARCINOMA

ESOPHAGUS
• Introduction
• Etiology
• Classification
• Clinical features
• Investigations
• Diagnosis and Staging
• Treatment
• Prognosis
• Conclusion
 INTRODUCTION

• It is 6th most common cancer in the world.

• It constitutes less than 1% of all cancers. Accounts 7% of all GI

malignancies.
ANATOMY OF
ESOPHAGUS
 ANATOMICAL
SPECIALTIES
• Lacks serosa (other structure without serosa is rectum).
• Contains 2 different types of muscles (striated and
smooth at proximal 1/3 and distal 2/3 respectively)
• Contains 2 different types of epithelium.
• Segmental blood supply.
• Only part of GIT which shows very thinly scattered
Meissner’s plexus.
• Longitudinal arrangement of veins and lymphatics.
 AETIOLOGY
Diet, deficiencies (vit. A, C, riboflavin) -5% common
•
• Mycotoxin -Common after 45 years
•
• Alcohol and tobacco- Common in men
•
• Fungal contamination of food -Common in China
• Human papilloma virus (HPV 16,18) - India
•
• Geotrichum candidum fungi
Achalasia cardia 30%
•
• Oesophageal webs 25%
•
• Barrett’s oesophagus
•
• Plummer-Vinson’s syndrome 15%
•
• Corrosive strictures 30%
•
• Tylosis (Hovels-Evans syndrome)
•
• * Tylosis is an inherited disease with thickening of
 PATHOLOGICAL CLASSIFICATION

1. Squamous cell cancer -affect upper upper 2/3 of

oesophagus

2. Adenocarcinoma- affect lower 1/3 of

oesophagus
 SPREAD OF CA
ESOPHAGUS
• Direct

• Lymphatic

• Haematogenous
 DIRECT
SPREAD
• Lack of serosal layer in esophagus favours local extension.

• In upper third it spreads through muscular layer and get adherent to left
main bronchus, trachea, and left recurrent laryngeal nerve (causes
hoarseness), aorta or its branches (causes fatal haemorrhage).

• It may perforate and cause mediastinitis.

• It may get adherent to pleura.

• Broncho-esophageal, tracheo-esophageal, esophageal-aortic

fistulas can occur in advanced cases.
 LYMPHATIC
SPREAD
• It spreads by lymphatic permeation and lymphatic
embolization.
• It can cause satellite nodules in the esophagus, away from the
main tumour.
• Above in the neck, it spreads to supraclavicular
lymphnodes.
• In thorax, it spreads to para-esophageal, tracheobronchial
lymph nodes to sub diaphragmatic lymph nodes.
• In abdomen, it spreads to coeliac lymph nodes.

• .
 Blood spread

Occurs to liver, lungs, brain and bones.

 CLINICAL
FEATURES

• Recent dysphagia is the commonest feature. Two-third of

the lumen should be occluded to cause dysphagia.
• Regurgitation.
• Anorexia and loss of weight (severe), cachexia.
• Substernal or abdomen pain.
• Ascites due liver secondaries
• Bronchopneumonia
• Melaena.
 CLINICAL
FEATURES

• Features of broncho-oesophageal fistula in carcinoma of

upper third esophagus .
• Left supraclavicular lymph nodes may be palpable.
• Hoarseness of voice due to involvement of recurrent
laryngeal nerve.
• Hiccough, due to phrenic nerve involvement.
• Back pain—due to nodal spread
(paraoesophageal/coeliac nodes).
 INVESTIGATIONS

• Barium swallow: Shouldering sign and irregular filling

defect.
 INVESTIGATIONS

• Esophagoscopy - to see the lesion, extent and type.

 INVESTIGATIONS

• Biopsy - for histological type and confirmation.

• Chest X-ray - to look for aspiration pneumonia.

• Bronchoscopy - to see invasion in upper third growth.

 INVESTIGATIONS

• Esophageal ultrasonography -
To look for the depth of the tumor, involvement of
layer ,nodes, cardia and left lobe of the liver. Nodes
smaller than 5 mm can be very well visualized by EUS
which may be missed in CT scan.

• CT scan –
To look for local extension, nodal status,
perioesophageal, diaphragmatic, pericardial vascular
infiltration, obliteration of mediastinal fat and status of
tracheobronchial tree in case of upper third growth.
 INVESTIGATIONS

• U/S abdomen—to look for liver and lymph nodes status in

abdomen.

• Endoscopic esophageal staining with labelled iodine -

Here normal mucosa is stained brown and carcinoma
remains pale (as mucosa in carcinoma will not take up
iodine).
 INVESTIGATIONS

• Laparoscopy –
– It is useful to see peritoneal spread, liver spread and
nodal spread. It is the only reliable method to detect
peritoneal seedlings. Biopsy from different places can also
be taken. It will prevent unnecessary laparotomy.

• PET with CT scan is used for staging and to see

response for therapy.

• Video assisted thoracoscopic approach—to stage

oesophageal carcinoma.
 INVESTIGATIONS

• Endoscopic mucosal resection (EMR) –

– It is basically a diagnostic biopsy tool, but can be therapeutic in

early and premalignant lesion.
– T1a tumors are resected by EMR, as the risk of lymphnode
metastasis is very low.
– Endoscopic submucosal dissection removes the lesion up to
muscularis propria.
 DIAGNOSIS AND STAGING

• Esophageal ca is almost always diagnosed by

endoscopic biopsy.
• Endoscopy should be performed in every patient with
dysphagia, even if the barium esophagus is suggestive of a
motility disorder.
• CECT of chest and abdomen and PET scan to evaluate
for distant metastatic disease. If there is no evidence of
distant metastatic disease, EUS should be performed to
assess T stage and regional lymph nodes.
 TREATMENT

• Curative

• Palliative
 TREATMENT
• Principles
– Only 20% of esophageal cancers present early and becomes curable.
In such early growths confirmed with absence of nodal spread,
curative surgery is the main approach— radical esophagectomy.

– Proximal extent of resection should be 10 cm above the macroscopic

tumour
– Distal extent of resection is 5 cm from macroscopic distal end of
tumour.

– Proximal stomach has to be removed in lower 1/3rd of tumour.

Sufficient removal of contiguous structures may be needed in
curative resection.
 TREATMENT

• Principles

– If nodes are present, then multimodal approach should be used

like—curative resection; radiotherapy and chemotherapy.

– Neoadjuvant therapy by chemotherapy and/or

radiotherapy prior to surgery may improve the survival.
 TREATMENT

• Principles

– Aggressive chemoradiation also may be used as curative

therapy in some patients especially upper 1/3rd growths and in
patients who are unfit for surgery.

– Palliation therapy is done if patient is not fit for major surgery, if

there is blood spread, if there is spread to adjacent organ and if
there is peritoneal/liver spread. It is to relieve pain and dysphagia
and also to prevent aspiration and bleeding.
 INDICATIONS FOR CURATIVE
TREATMENT
• Early growth when patient is fit.

• When there is no involvement of adjacent perioesophageal

structures, bronchus, liver or distant organs.
APPROACHES FOR DIFFERENT LEVEL
TUMOURS
• Post cricoid tumour (Squamous cell carcinoma):

• Treated mainly by radiotherapy.

• Radical radiotherapy— 5000-6000 rads.

• Often pharyngolaryngectomy is done along with gastric or

colonic transposition. But complications are more in this
procedure. Free jejunal transfer is the other option.
APPROACHES FOR DIFFERENT LEVEL
TUMOURS
Upper third growth (Squamous cell carcinoma):

– Treated mainly by radiotherapy.

– Commonly it invades left recurrent laryngeal nerve and

bronchus.

– In early and operable, McKeown three phased esophagectomy

and anastomosis is done in the neck. Initially laparotomy is
done to mobilise the stomach. Then thoracotomy through right
5th space is done and esophagus is mobilised. Through right
side neck, esophagus with growth is removed. Anastomosis
between pharynx and stomach is done in the neck.
 APPROACHES FOR DIFFERENT LEVEL
TUMOURS
Middle third growth (SCC):

– Ivor Lewis operation (Lewis-Tanner two-phased esophagectomy): By

laparotomy stomach is mobilised and Pyloroplasty is done. Through right
5th space thoracotomy is done and growth with tumour is mobilised.
Partial esophagectomy and esophagogastric anastomosis is done in the
thorax.

– If the growth is inoperable, palliative radiotherapy is given.

 APPROACHES FOR DIFFERENT LEVEL
TUMORS
Lower third growth (SCC and Adeno Ca):

– Here through left thoracoabdominal approach, partial

esophagogastrectomy is done with esophagogastric
anastomosis.Often jejunal Roux-en-Y loop anastomosis is done.

– Orringer approach, i.e. transhiatal blind total esophagectomy with

anastomosis in the left side of the neck. Through laparotomy, stomach and
lower part of the esophagus are mobilised. Through left sided neck
approach, upper part of the esophagus is mobilised using finger. Blind
dissection is completed by meeting both fingers above and below in the
thorax. Later esophagus is pulled up out through the neck wound and
removed.
 OTHER APPROACHES

• Thoracoscopic-laparoscopic esophagectomy and

lymphadenectomy is becoming popular, safer and
effective.

• Radical esophagectomy with 3-field clearance of

abdominal/thoracic and cervical nodes is also practiced in
many centres.
 ESOPHAGEAL SUBSTITUTES

• Stomach: It is preferred one . But postprandial symptoms are

more.

• Colon: It is better as there is less postprandial problems.

Complications are leak, fistula formation.

• Jejunum: It is last option.

 PALLIATIVE THERAPY - DONE
FOR

• To Relieve pain
• To Relieve dysphagia
• To Prevent bleeding
• To Prevent aspiration
 PALLIATIVE TREATMENT

• Palliation therapy is done –

– If patient is not fit for major surgery.

– If there is blood spread.
– If there is adjacent organ spread.
– If there is peritoneal/liver spread.
 PALLIATIVE PROCEDURES
• External and intraluminal Radiotherapy (Brachytherapy)

• Chemotherapy

• Intubation tube

• Endoscopic theraphy
– Self expanding metal stents
– Endoscopic laser
– Endoscopic bipolar diathermy
– Endoscopic photodynamic theraphy

• Surgery
 RADIOTHERAPY

Palliative external radiotherapy

– 3000 Rads. Severe mucositis, stricture and fistula formation are the
complications.

Intraluminal RT
– Loading catheter is placed using endoscope and applicator is fixed
to mouth to give 1500 cGy radiation with least systemic effects.
CHEMOTHERAPY

• Cisplatin
• Methotrexate
• 5 FU
• Palcitaxel
• Etoposide
• Bleomycin
• Platinum based chemotherapy is beneficial especially in
advanced adenocarcinoma of esophagus.
 INTUBATION
• Here guidewire is passed across the growth under X-ray
screening or C-arm guidance .

• Flexible introducer and prosthetic tube is pushed across the

tumor along the guidewire.

• Problems - tube intolerance, poor drainage, airway

compression, reflux, aspiration, displacement, food
blockage, tumor overgrowth beyond the prosthesis
causing its failure.
• Perforation chance is 10%.
 ENDOSCOPIC THERAPY

• Self-expanding metal stents (SEMS) are passed through

endoscope under C-arm guidance.
• It is the ideal method of palliation
• .
• Advantage – perforation is minimal.

• Problems of stents are—aspiration, displacement, erosion,

bleeding, tumor growth across or beyond mesh, food bolus
obstruction, retrosternal pain, need for reinsertion (40%).
Mortality is 1-2%.
 ENDOSCOPIC LASER

• To improve dysphagia.
•
• It causes thermal destruction of tumor.

• Nd YAG laser and Diode laser are used.

• Problems are—fever, chest pain, mortality, perforation and

fistula formation.
ENDOSCOPIC PHOTODYNAMIC
THERAPY (PDT)
• It is used to destruct tumor and to relieve dysphagia
•
• Photosensitive haematoporphyrin agent is injected
intravenously 48 hours before endoscopy.
•
• It is activated over tumour using laser.
•
• Complication -Sunburn, fever, perforation, pleural
effusions
•
• It is effective only to superficial cancers.
 PALLATIVE SURGERIES

1. Transhiatal Orringer’s blind oesophagectomy is a

palliative surgical procedure.

2. Kirschner palliative gastric bypass

mobilised stomach is brought to neck via
retrosternal or subcutaneous route and anastomosed
to divided cervical oesophagus.
 COMPLICATIONS OF ESOPHAGECTOMY

• 5-10% mortality
• Haemorrhage
• Respiratory infection
• Chylothorax, injury to thoracic duct
• Anastomotic leak—thoracic leak is most dangerous (5-10%)
• Hoarseness due to recurrent laryngeal nerve palsy
• Stricture formation (40%)
• GERD
• Conduit necrosis due to ischaemia to stomach or colon
• Colonic dysmotility causing partial obstruction in colon
transfer
 PROGNOSIS

• Not good because of early spread, longitudinal lymphatics,

aggressiveness, difficult approach, late presentation.

• Nodal involvement carries bad prognosis.

• 5-year survival rate is only 10%.

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