Carcinoma Esophagus

Dr. E. Okon, MD
 Contents
• Introduction
• Etiology
• Classification
• Clinical features
• Investigations
• Diagnosis and Staging
• Treatment
• Prognosis
• Conclusion
 Introduction
• Carcinoma esophagus is common in China, South Africa and
Asian countries. In India, it is common in Karnataka and Orissa.
●
Asian esophageal cancer belt (Eastern Turkey, Iran Northern
Afghanistan, Northern India, Northern China)

• Incidence rate in Nigeria ranges between 0.4-0.6%.

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

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

malignancies.

• Dysphagia is most common symptom at presentation. By this

time of presentation, it becomes advanced and inoperable and
only palliative is treatment of choice.
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)
• Non-keratinized stratified squamous epithelium
• Segmental blood supply.
• Only part of GIT which shows very thinly scattered
Meissner’s plexus.
• Longitudinal arrangement of veins and lymphatics.
 Epidemiology

• Worldwide, squamous cell carcinoma (SCC) is the most

common, adenocarcinoma is more frequent in US, UK
• Ibadan, Nigeria - The middle third of the oesophagus was
the most common location of the neoplasm and the vast
majority (94.5%) were squamous cell carcinomas (H.U
Pindinga et al, 1997)

• During the last 20 years, the incidence of adenocarcinoma

has risen dramatically in Western countries with decline in
the incidence of SCC.
 Epidemiology

• The incidence rises steadily with age, peak in 6th to 7th

decade of life.

• Male : Female = 3.5 : 1

• SCC usually occurs in the middle 3rd of the esophagus. The

ratio of upper : middle : lower is 15 : 50 : 35.

• Adenocarcinoma is most common in the lower 3rd of the

esophagus, accounting for 65% of cases.
 Risk factors for SCC

• Alcohol and tobacco

• Males gender– 4 times more common
• HPV 16, 18
• Plummer-vinson syndrome
• Achalasia cardia
• Tylosis – RHBDF2 gene
• Fanconi anemia – FANCD1 and BRCA2 gene
 Risk factors for SCC

• Patient with history of caustic ingestion

• Nitrosamines

• Vit A and C def

• Mycotoxins.

• Genetic abnormalities:
p53 mutation, loss of 3p and 9q allele, Cyclin D1 & EGFR mutations.
 Risk factors for Adenocarcinoma
• Barretts’s esophagus
• GERD
• Hiatal hernia
• Zolinger-Ellison sydrome
• Obesity
• Smoking
• Males gender
• More common among Americans than
Africans
 Pathologic classification
• Pre-invasive neoplasm
●
Esophageal intraepithelial neoplasia
●
Glandular epithelial dysplasia/adenocarcinoma in situ
●
Barret's esophagus

• Invasive Malignant Neoplasia

●
SQCC
●
Adenocarcinoma
●
Adenoid cystic carcinoma
●
Mucoepidermoid Ca
●
AdenoSQ Ca
●
Small cell Ca
●
Carcinoid tumor
●
Malignant melanoma
●
Sarcomas
 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.
●
Narrowing of lumen from 24mm to 12mm
• Regurgitation.
• Anorexia and loss of weight (severe), cachexia.
Substernal or abdomen pain.
• Ascites due to metastasis to liver.
• Bronchopneumonia
• Melena.
 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.
• Hiccoughs, due to phrenic nerve involvement.
• Back pain—due to nodal spread
(paraoesophageal/coeliac nodes).
 Investigations
• Barium swallow: Shouldering sign and irregular filling
defect.
●
Intraluminal vs Intramural lesions
●
Intrinsic vs extrinsic
 Investigations
• Esophagoscopy - to see the lesion, extent and type.
 Investigations
• Endoscopy
1. Location of the lesion (with respect to distance from the incisors)
2. Nature of the lesion (friable, firm, polypoid)
3. Proximal and distal extent of the lesion
4. Relationship of the lesion to the cricopharyngeus muscle, the
GEJ, and the gastric cardia
5. Distensibility of the stomach
 Investigations

• Biopsy - for histological type and confirmation.

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

• Bronchoscopy - to see invasion in upper third growth.

• Laryngoscopy - To identify vocal cord palsy.

 Investigations

• Esophageal ultrasonography -
To look for the depth of the tumor, involvement of
nodes, cardia and left lobe of the liver. Overstages T
status buut understages N status.

• 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.
CT scan is helpful but its accuracy is only 57% for T
staging, 74% for N staging, and 83% for M staging
T2 esophageal tumor CT image shows lymph nodes
shown on endoscopic (arrowheads)
ultrasonogram
 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 lymph node
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.
• CT 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.
AJCC TNM Classification
Staging of Adenocarcinoma
Staging of SCC
 Treatment

• Factors to consider in treatment of Esophageal

CA
1. Histology, location, and local extent (depth of invasion) of the primary tumor
2. Status of the local and regional lymph nodes
3. Presence of distant lymph nodes or systemic disease
4. Overall condition of the patient (including nutritional status and ability to swallow)
5. Intended goal of treatment—curative or palliative
• 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 and 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. Outcome of surgery depends on location of
tumour; number, location and size of nodes; tumour
grading.

– 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 chemoradiotherapy.

• 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 near total esophagectomy/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.

 Indications of Palliative therapy

• 80% of pts have advanced tumor at the time of

presentation and so they are amenable for only palliative
treatment.
• Nodes greater than 5 involvement
• Invasive, poorly differentiated grade.
• Length of involvement >8cm.
• Abnormal esophageal axis in barium study.
• Horner’s syndrome
• Loss of wt >20%
• Metastatic disease
 Indications of Palliative therapy

• 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 RT (Brachytherapy)

• Chemotherapy

• Intubation tube

• Endoscopic therapy
– 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.
• It carries 90% success rate.
• Problems are 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
• It is used to core a channel through the tumor to improve
dysphagia. It causes thermal destruction of tumor. Nd
YAG laser and Diode laser are used.

• Success rate of palliation is 85%.

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

and fistula formation.
Endoscopic photodynamic therapy (PDT)

– It is used to destruct tumor and to relieve dysphagia.

It is often used as a therapy in early cancer.
Photosensitive haematoporphyrin agent is injected
intravenously 48 hours before endoscopy. It is
activated over tumour using laser. Sunburn, fever,
perforation, pleural effusions are complications. It is
effective only to superficial cancers.
 Pallative Surgeries
• Transhiatal Orringer’s blind oesophagectomy is a
palliative surgical procedure.

• Kirschner palliative gastric bypass done in advanced

carcinoma esophagus wherein mobilised stomach is
brought to neck via retrosternal or subcutaneous route
and anastomosed to divided cervical oesophagus.Lower
cut end of oesophagus is anastomosed to a jejunal loop.
Here oesophagus is left alone.
 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%.

 Summary
• Esophagus has no serosal covering, so direct invasion
of adjacent structures occurs early.

• Commonly spread by lymphatics (70%).

• Most common symptom at presentation is dysphagia.

• Often diagnosed late, so most therapeutic approaches are

palliative.

• During the last 20 years, the incidence of adenocarcinoma

has risen dramatically in Western countries.
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