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you clinical anatomy: Management of esophageal carcinoma Hollow muscular tube 25 cm in length which spans from the cricopharyngeus at the cricoid cartilage to gastroesophageal junction (Extends from C7-T10).
Has 4 constrictions
Histologically 4 layers: contd........ Epidemiology Esophageal cancer is the 7th leading cause of cancer deaths.
accounts for 1% of all malignancy & 6% of all GI malignancy.
Most common in China, Iran, South Africa, India and the former Soviet Union.
The incidence rises steadily with age, reaching a peak in the 6th to 7th decade of life.
Male : Female = 3.5 : 1
Worldwide SCC responsible for most of the cases.
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 over 65% of cases. lymphatic drainage & blood supply Risk factors: squamous cell carcinoma Four regions of the esophagus:
Cervical = cricoid cartilage to thoracic inlet (15–18 cm from the incisor).
Upper thoracic = thoracic inlet to tracheal bifurcation (18–24 cm).
Midthoracic = tracheal bifurcation to just above the GE junction (24–32 cm).
Lower thoracic = GE junction (32–40 cm). Figure Anatomy of the esophagus with landmarks and recorded distance from the incisors used to divide the esophagus into topographic compartments. GE, gastroesophageal. Figure: Lymphatic drainage of the esophagus with anatomically defined lymph node basins Figure:arterial supply Figure: venous drainage old - male - smoking dietary factors obesity achalasia tylosis Genetic abnormalities: p53 mutation Risk Factors: Adenocarcinoma Barrett’s esophagus is ametaplasia of the esophageal epithelial lining. The squamous epithelium is replaced by columnar epithelium,with 0.5% annual rate of neoplastic transformation. Pattern of spread No serosal covering, direct invasion of contiguous structures occurs early.
Commonly spread by lymphatics (70%)
Lymph node involvement increases with T stage.
- T1 – 14 to 21%
- T2 – 38 to 60%
25% - 30% hematogenous metastases at time of presentation.
Most common site of metastases are
- lung, liver, pleura, bone, kidney & adrenal gland
Median survival with distant metastases – 6 to 12 months Site-wise nodal involvement Pathological Classification It is commonly associated with the symptoms of dysphagia, wt. loss, pain, anorexia, and vomiting
Symptoms often start 3 to 4 months before diagnosis
Dysphagia - in more than 90% pt. Odynophagia - in 50% of pt.
Wt. loss – more than 5 % of total body wt. in 40 – 70% pt. associated with worst prognosis. clinical features: Cachexia, Malnutrition, dehydration, anaemia,.
Invasion of near by structures: e.g.
-Recurrent laryngeal nerve Hoarseness of voice
-Trachea Stridor & TOF cough, choking & cyanosis
-Perforation into the pleural cavity Empyema
-back pain in celiac axis node involvement complications contd....... AJCC TNM classification staging of sq.cell carcinoma & adenocarcinoma Diagnostic Workup Detailed history & Physical examination: Dysphagia, odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines, history of GERD. Examine for cervical or supraclavicular adenopathy.
Confirmation of diagnosis:
EGD: allow direct visualization and biopsy, measure proximal & distal distance of tumor from incisor, presence of Barrett’s esophagus. Staging:
CT chest and abdomen: Essential for staging because it can identify extension beyond the esophageal wall, enlarged lymph nodes and visceral metastases. Figure Esophageal cancer with aortic invasion. An arc (bent arrow) of the contact between the esophageal cancer and the aorta is more than 90 degrees, indicating aortic invasion Figure Esophageal cancer with tracheal invasion. CT scan shows circumferential wall thickening of the proximal esophagus , which shows irregular interface with the posterior wall of the trachea, indicating direct extension into the lumen Endoscopic Ultrasonography EUS:
assess the depth of penetration and LN involvement. Limited by the degree of obstruction.
Compared with EUS, CT is not a reliable tool for evaluation of the extent of tumor in the esophageal wall. Fig. —55-year-old man with T2 esophageal tumor (m) shown on endoscopic sonogram. Note alternating hyperechoic and hypoechoic layers (arrowheads) of normal esophageal wall as seen on sonography. Innermost layer is hyperechoic and corresponds to superficial mucosa. Second layer is hypoechoic and corresponds to deep mucosa and muscularis mucosae. Third layer is again hyperechoic and corresponds to submucosa and its interface with muscularis propria. Fourth layer is hypoechoic and corresponds to muscularis propria, and outer fifth layer is hyperechoic and corresponds to adventitia. PET Scan most recently, proven to be valuable staging tool
can detect up to 15–20% of metastases not seen on CT and EUS
low accuracy in detecting local nodal disease compared to CT / EUS
Value in evaluating response to Chemo Therapy & Radio Therapy
addition of PET to CT can improve specificity and accuracy of non-invasive staging Barium swallow: can delineate proximal and distal margins as well as TEF
Helpful for correlation with simulation film. Bronchoscopy: rule-out fistula in midesophageal lesions. Routine Investigations: CBC, chemistries, LFTs. Preinvasive Neoplasia
Esophageal intraepithelial neoplasia
Glandular epithelial dysplasia/adenocarcinoma in situ in Barrett's mucosa
Invasive Malignant Neoplasia
Squamous cell carcinoma
Adenoid cystic carcinoma
Small cell carcinoma
Sarcomas Treatment Management protocol General Recommendations Based on Stage:
Stage I, II, and III esophageal cancers are all potentially resectable. Treatment 1- endoscopy: (ESD) can eradicate early gastro-oesophageal mucosal cancer Patients have special nutritional needs during treatment for esophageal cancer.
Many people with esophageal cancer find it hard to eat because they have trouble swallowing. The esophagus may be narrowed by the tumor or as a side effect of treatment. Some patients may receive nutrients directly into a vein. Others may need a feeding tube (a flexible plastic tube that is passed through the nose or mouth into the stomach) until they are able to eat on their own. 2- curative surgery: The two types of esophagectomy are
Trans-hiatal esophagectomy or THE, which is performed on both the abdomen and the neck.
Trans-thoracic esophagectomy or TTE, which as the name suggests requires the surgeon to open the chest cavity. In the early stages of the cancer, curative surgery is normally the first option.
Surgery to remove the affected lymph nodes and mucosa and tumors is known as an Esophagectomy, which is essentially removal of part or the entire esophagus, depending on the extent of damage. eseophageal resection Gastric resection Distal (antral) tumors should be treated by subtotal gastrectomy and proximal tumors by total gastrectomy (grade B).
Cardia, subcardia and type II oesophago-gastric junctional tumours should be treated by transhiatal extended total gastrectomy or oesophago-gastrectomy (grade B). Esophageal Replacement surgery: stomach is pulled up Chemotherapy and Radiotherapy Oesophageal Squamous Cell Carcinoma There is no evidence to support the use of preoperative radiotherapy in oesophageal squamous cell carcinoma (grade A; Ia).
Chemoradiation is the definitive treatment of choice for localised squamous cell carcinoma of the proximal oesophagus (grade A; Ia). Oesophageal Adenocarcinoma (Including Type I, II and III Oesophago-gastric Junctional Adenocarcinoma) Preoperative chemoradiation improves long-term survival over surgery alone (grade A; Ia).
There is no evidence to support the use of preoperative radiotherapy in oesophageal adenocarcinoma (grade A; Ia).
Preoperative chemotherapy with cisplatin and 5-fluorouracil (5-FU) improves long-term survival over surgery alone (grade A; Ia). Inoperable Tumors ( 60% of the patients)
* Local spread( e.g tracheoesophageal fistula,)
* Distant spread* Bad general condition Palliative treatment Options 1-Endoscopic laser to core a channel through the tumor 2- Intubations: 3-Dilatation transhiatal esophagectomy clinical anatomy
lymphatic drainage & blood supply
pattern of spread & classification
treatment Objectives: plummer-vinson syndrome