* Carcinoma of oesophagus *

 Incidence : More in males above 50 years .

 Predisposing factors :

1. Obesity & reflux oesophagitis : leading to Barrett’s

oesophagus .
2. Barrett’s oesophagus ( lined by columnar mucosa) is now the
most important predisposing factor .
3. Benign tumors e.g. papilloma
4.Chronic irritation by certain food or spices ( more in china , japan
& India ) , smoking , spirits or sepsis.

5.Dysplasia & Leucoplakia

6. Achalasia of oesophagus.
7. Corrosive oesophagitis.
8. Plummer Vinson’s syndrome.
 Pathology :
I- Site :
♦ Lower 1/3: 50%. ♦ Middle 1/3: 30%. ♦ Upper 1/3 : 20 %
II- Gross picture :

a. Annular stricture type: The commonest type

b.Ulcerative type: rare

♦ The ulcer show features of malignancy, (describe it).
 c.Proliferative type: very rare .
♦ It form a bulky fungating cauliflower mass with ulceration,
necrosis, hge & infection .

III-Microscopic picture:

A- Squamous cell carcinoma :

⧫The commont type , usually in the upper 2/3 of esophagus

B- Adenocarcinoma :

♦ In the lower 1/3 of the oesophagus. It may be spread from

carcinoma of stomach or from Barrett’s oesphagus . It is one of
the followings :

a. Columnar cell adenocarcinoma: malignant cells are arranged

in complete or incomplete irrigular acini.
b. Spheroidal cell carcinoma: groups of spheroidal cells are
separated by variable amount of fibrous tissue.
c. Colloid or mucoid carcinoma: it is an adenocarcinoma with
excess mucin in the cells, acini and tissue spaces.
IV . Staging : TNM system

• T : Primary tumour .

▪ T is : Tumor localized to the mucosa above the basement

membrane .

▪ T1 : Tumor invades the lamina propria, muscularis mucosae, or

submucosa .
▪ T2 : Tumor invades the muscularis propria
▪ T3 : Tumor invades the adventitia

▪ T4 : Tumor invades adjacent structures .

• N : regional lymph node metastasis

▪ N0 : No regional lymph node metastasis
▪ N1 : 1-2 regional lymph node metastasis
▪ N2 : 3-6 regional lymph node metastasis
▪ N3 : 7 or more regional lymph node metastasis
• M : distal metastases .
▪ M0 : No distal metastases .
▪ M1 : presence of distal metastases .
 Complications :
I. Spread :
A) Direct spread :
⧫ Intra-mural : Circumferential & longitudinal microscopic spread
beyond palpable edge of the tumor.
⧫ Extra-mural :To the surrounding structures (thyroid, trachea,
R.L.N. , lung, pleura , aorta, pericardium , diaphragm , liver ..
etc.).
B) Lymphatic spread : By permeation and embolization to.

⧫ Cervical part : to deep cervical L.Ns.

⧫ Thoracic part : posterior mediastinal , tracheal , trachea-bronchial &
posterior diaphragmatic L.Ns
⧫ Abdominal part : para-oesophageal , left gastric then celiac L.Ns .

C) Blood Spread : ( 2L + 2B or LBLB )

⧫ Cervical & Thoracic parts : mainly to the to lungs, bones ( ribs &

thoracic vertebrae ) , brain via systemic circulation.

⧫ Abdominal part : mainly to the liver via portal circulation.
D) Trans-peritoneal Spread :

⧫ Rare , only in the abdominal part of the oesophagus .

II. Bleeding : haematemesis and melena.

III. Obstruction: Very common → dysphagia →malnutrition

IV. Perforation: May occur → mediastinitis → mediastinal abscess.

V. Pulmonary complications , infections , anaemia , cachexia and

death.

 Clinical picture :
1- Dysphagia :
⧫ It is the commonest presenting symptoms but it is a late feature .

⧫ Dysphagia is recent , rapidly , progressive , continuous first to solid

only , then to soft diet and lastly in advanced cases to fluids.

⧫ In advanced cases ,the patient can not swallow his own saliva

leading to continuous drooping of saliva and aspiration pneumonia .

♦ At the time of presentation about 2/3 of the circumference of the
oesophagus are involved.

2- In more advanced late cases:

⧫ Regurgitation of food and saliva

⧫ Pulmonary complications.
⧫ Progressive loss of weight.
 ⧫ Haematemesis and melena

⧫ Chest pain , dysphonia (R.L.N.), diaphragmatic paralysis (phrenic n.)

, Horner’s syndrome.
⧫ Enlarged cervical L.Ns., compression of S.V.C., maligant pleural

effusion, ascites or bony pain.

⧫ Manifestations of distal metastases :

1. Abdominal masses (enlarged L.Ns & peritoneal nodules).

2. Liver metastases : jaundice with enlarged, hard, nodular &
tender liver.
3. Lung metastases : chest pain , dyspnea , cough & haemoptasis
, malignant pleural effusion .
4. Bone metastases : bony pain , bony swelling & pathological
fractures .
5. Brain metastases : headache , repeated projectile vomiting &
blurring of vision .
6. Malignant ascites : Marked ,tense & hemorrhagic ascites .
7. P-R and P-V examination: may show pelvic deposits
 DD : Other causes of dysphagia .
 Investigations :
I) Laboratory investigations:
1. Occult blood in stool : usually positive .
2. Blood picture : usually show anaemia.
3. Tumor markers : CEA , CA19-9 & CA125 evaluate response to
treatment and follow up of the patient .

II) Radiological investigations :

1. Ba. swallow: may show
⧫ Irregular narrowing with mild proximal dilatation.

⧫ Shouldering,

⧫ Rat tail appearance

⧫ Irregular filling defect.

• Shouldering Irregular filling defect

• Barium swallow before and after chemotherapy

2. U/S & endoscopic U/S is very important to detect local extent

of the tumor , mediastinal invasion and lymph nodes enlargement .
3. C.T. scan : chest and upper abdomen.
4. PET scan (positron emission tomography scan) : show local tumor ,
nodal & distal metastases for accurate staging.
➢ PET : A procedure to find malignant tumor cells in the body. A small amount
of radioactive glucose is injected IV. The PET scanner rotates around the body
and makes a picture of where glucose is being used in the body. Malignant
tumor cells show up brighter in the picture because they are more active and
take up more glucose than normal cells do.
 5. A PET scan and CT scan may be done at the same time. This is called
a PET-CT.
III) Oesophagoscopy and biopsy are the most important
investigaions.
IV) Laryngoscopy and bronchoscopy to detect spread to the RLN &
tracheo-bronchial tree.
V) Investigations to detect metastasis. (Mention in any malignancy)
1. Plain x-ray : chest & bone to detect lung & bone metastases .
2. U/S of chest & abdomen .
3. CT & MRI for brain , bone , chest & abdomen .
4. Radioactive isotopic scan of lung , liver , bone & brain .
5.PET scan & PET-CT.

6.Aspiration of pleural effusion or ascites show hemorrhagic fluid

containing malignant cells .

7.Thoracoscopic and laparoscopic exploration with biopsy .
 Treatment :
I) Operable case : ( potentially curable )( 10% of cases )
⧫ Features:-

1. Clinically & investigations: localized mobile tumour, no

peritoneal nodules, no malignant ascites, no distal metastasis and
the patient is fit for surgery.
2. At laparotomy: the first step in the operation is to assessthe
operability. The tumour is operable if it is localized to the organ
with no invasion of important surrounding structures, no ascites or
or peritoneal nodules and no liver metastasis.
⧫ Aim : resection of the tumor with 10 cm safety margin on either
sides with lymphadenectomy of the draining lymph nodes and
restoration of the continuity of the GIT by gastric pull up .
⧫ Method :

1. Neoadjuvant chemotherapy and radiotherapy before operation

improve survival rate in a proportion of patients .
2. Radical surgery :
a) Carcinoma lower 1/3 of oesophagus :Oesophago-gastrectomy
▪ Through left thoraco-abdominal incision excision of the
oesophgus and upper part of stomach with gastric pull up to
perform oesophago-gastric anastomosis in the thorax .

b) Carcinoma middle 1/3 of oesophagus : Ivor Lewis

▪ Through upper middle line abdominal incision , the stomach
is mobilized to the thorax .
▪ Through incision in the right 5th. intercostals space the
oesophagus is excised down to the cardia with oesophago-
gastric anastomosis in the thorax (gastric pull up).
c) The most popular is total oesophagectomy through
abdominal transhiatal approach ( without thoracotomy ) , with
restoration of continuity by gastric pull up , by anastomosis of
the stomach with the remaining part of oesophagus in the neck
, through cervical incision .

Transhiatal approach
d) Most recent minimal invasive oesophagectomy through
laparoscopic and thoracoscopic technique with oesophago-
gastric anastomosis in the neck or the thorax .
3.Adjuvant post-operative radiotherapy & chemotherapy: if +
ve nodes or + ve margins.

 laparoscopic and thoracoscopic oesophagoectomy

II) Inoperable cases:
⧫ Features:- ( The reverse of operable cases )

⧫ Aim : Palliative measures to relieve dysphagia to allow the

patient to swallow .
⧫ Methods :

1. Intubation: Through an oesophagoscope a rigid tube is

inserted into the tumor to keep the lumen patent to relieve
dysphagia is the best.
2. Colon by pass or gastric pull up to by pass the
obstruction . (major operation with high mortality).
3. Radiotherapy and chemotherapy.
4. Endoscopic laser photocoagulation cause coagulative
necrosis of the tumor .

5. Gastrostomy is rarely used nowadays (inhalation lung

complications).
 Prognosis :
▪ Depends on degree of differentiation , depth of infiltration ,
presence of lymph node metastases , infiltration of surrounding
structures or distal metastases .
▪ At the time of diagnosis 2/3 of patients with esophageal cancer are
incurable .
▪ 5 year survival is 5-10 %