Esophageal Cancer

note
 Introduction
• Carcinoma of esophagus – 9th most
common cancer in the world (1) & 15th
most common cancer in Malaysia
(2.1%).
• Disease of mid to late adulthood,
with poor survival rate (2) .

• Bailey & Love; SHORT PRACTICE OF SURGERY, 24th Edition

• Report Of The National Cancer Registry - Cancer Incidence In
Malaysia 2003
 Aetiology
Modifiable Non-modifiable
• Tobacco smoking • Age – higher risk in
• Alcohol intake >60 y/o
• Gastroesophageal • Sex – common in male
reflux disease (GERD) • Family history of
and its resultant cancer
Barrett's esophagus
• Others – radiation
therapy, Plummer-
Vinson syndrome,
nitrosamine ingestion.
 Clinical Manifestation
• Dysphagia is the first symptom in
most patients, odynophagia may be
present.
• Substantial weight loss.
Diagnostic test/Investigation
• Barium swallow
• Esophagogastroduodenoscopy (EGD)
• Biopsy taken & examined
histologically
• CT-scan of chest
• Endoscopic ultrasound
• PET-scan
 Clinical Manifestation
• Nausea and
vomiting,
regurgitation of food
may present due to
disruption normal
peristalsis.
• Look signs & symptoms
of spread – lung
(recurrent
pneumonia,
Endoscopy demonstrating intraluminal esophageal
cancer.
Chest CT scan showing invasion of the trachea by
esophageal cancer
Endoscopy and radial endoscopic ultrasound images of submucosal
tumour in mid-esophagus.
This specimen depicts a cancer at the area of the junction between the
esophagus and stomach. It is a large irregular mass. The objective of
endoscopic surveillance in Barrett's esophagus is to detect these processes
early on when there is a high probability for cure.
Normal esophageal epithelium
Squamous cell carcinoma

Adenocarcinoma of esophagus
Staging - TMN
Staging
 Treatment option
• General approaches
– adequate nutrition needs to be assured
• Definitive treatment/Surgery
– Esophageal resection (esophagectomy)
remains a crucial part of the treatment
of esophageal cancer.
 Surgery
– Indication
• Diagnosis of esophageal cancer must be made in a patient who is a
candidate for surgery.
• Surgery is indicated when high-grade dysplasia is present in a patient
with Barrett esophagus. As many as 50-70% of such patients are
found to have cancer when the esophagus is resected.
– Contraindication
o Metastasis to N2 nodes (ie, celiac, cervical, or supraclavicular lymph
nodes) or solid organs (eg, liver, lungs) is a contraindication.
o Invasion of adjacent structures (eg, recurrent laryngeal nerve,
tracheobronchial tree, aorta, pericardium) is a contraindication.
o Severe associated comorbid conditions (eg, cardiovascular disease,
respiratory disease) can decrease a patient's chances of surviving an
esophageal resection.
o Cardiac function and respiratory function are carefully evaluated
preoperatively. A forced expiratory volume in 1 second of less than
1.2 L and a left ventricular ejection fraction of less than 0.4 are
relative contraindications to the operation.

http://emedicine.medscape.com/article/277930-treatment
 Surgery
• 2 types;
• transthoracic esophagectomy [TTE]
• transhiatal esophagectomy [THE]
Historical standard chest and abdominal incisions used in the past to remove tumors of the
esophagus. (A) Either one continuous incision from the chest onto the abdomen or separate chest
and abdominal incisions are used. (B) Portion of esophagus to be removed is shown in the colored
area. (C) Completed esophageal replacement using the stomach connected to the esophagus high
in the chest. The pylorus (muscle at the outlet of the stomach) has been cut to insure that the
stomach empties adequately after the operation. (From Orringer MB. Chapter 20 Tumors, injuries,
and miscellaneous conditions of the esophagus in Greenfield LJ, Mulholland MW, Oldham KT, et al,
eds. Surgery Scientific Principles and Practice, 3rd Edition, Lippincott Williams & Wilkins,
Philadelphia, 2001, pg 706 with permission, modified from Ellis FH Jr. Treatment of carcinoma of
the esophagus and cardia. Mayo Clin Proc 1960;35:653
(A) Transhiatal removal of the esophagus being performed through an abdominal incision and a
neck incision without the need to open the chest. (B) Side view showing the surgeon's hand
proceeding upward into the chest through the abdomen as an instrument with a sponge at the
end of it is used to dissect the esophagus from above. (From Orringer MB. Chapter 20 Tumors,
injuries, and miscellaneous conditions of the esophagus in Greenfield LJ, Mulholland MW,
Oldham KT, et al, Eds, Surgery Scientific Principles and Practice, 3rd Edition, Lippincott Williams
& Wilkins, Philadelphia, 2001, pg 707 with permission, modified from Orringer MB, Sloan H.
Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg 1978;76:643
 Other modalities
• Neoadjuvant & Adjuvant therapy
– Chemotherapy; cisplatin, 5-fluorouracil
(5-FU), paclitaxel, and anthracyclines.
– Radiotherapy; can improve dysphagia
• Stent; to relieve the obstruction or
close the fistula.
• Laser therapy & Photodynamic
therapy (PDT)
http://emedicine.medscape.com/article/277930-treatment
 Prognosis
In general, the prognosis of esophageal cancer is quite poor,
because so many patients present with advanced disease: The
overall five-year survival rate (5YSR) is less than 5%.

http://en.wikipedia.org/wiki/Esophageal_cancer
Thank You