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Esophageal ca
- 2. Contents • Introduction • Etiology • Classification • Clinical features • Investigations • Diagnosis and Staging • Treatment • Prognosis • Conclusion
- 3. Introduction • Carcinoma esophagus is common in China, South Africa and Asian countries. In India, it is common in Karnataka and Orissa. • It is less common in America and European countries. • 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.
- 5. 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.
- 6. Epidemiology • Approximately 17,000 cases of esophageal cancer occur annually in the United States and about 480,000 cases occur worldwide. • Worldwide, squamous cell carcinoma (SCC) is the most common, but in the United States, adenocarcinoma is more frequent. • During the last 20 years, the incidence of adenocarcinoma has risen dramatically in Western countries with decline in the incidence of SCC.
- 7. Epidemiology • The incidence rises steadily with age, peak in 6th to 7th decade of life. • Male : Female = 3.5 : 1 • African-American males :White males = 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.
- 8. 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
- 9. Risk factors for SCC • Pt with history of caustic ingestion • Nitrosamines • Vit A and C def • Mycotoxins. • Genetic abnormalities: p53 mutation, loss of 3p and 9q alleli, Cyclin D1 & EGFR mutations.
- 10. Risk factors for Adenocarcinoma • Barretts’s esophagus • GERD • Hiatal hernia • Zoolliger-Ellison sydrome • Obesity • Smoking • Males gander • More common among americans than african americans.
- 12. Spread of Ca Esophagus • Direct • Lymphatic • Haematogenous
- 13. 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.
- 14. 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.
- 15. 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 2nd in liver. • Bronchopneumonia • Melaena.
- 16. 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).
- 17. Investigations • Barium swallow: Shouldering sign and irregular filling defect.
- 18. Investigations • Esophagoscopy - to see the lesion, extent and type.
- 19. 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.
- 20. Investigations • Esophageal ultrasonography - To look for the depth of the tumor, involvement of 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.
- 21. T2 esophageal tumor shown on endoscopic ultrasonogram CT image shows lymph nodes (arrowheads)
- 22. 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).
- 23. 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.
- 24. 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.
- 25. Investigations • Chemoendoscopy, magnification endocsopies- • They are newer methods. • Local topical application of different strains will improve the tumour localization, features and diagnosis. • Biopsy is done in this areas.
- 26. Newer Modalities Of Evaluation • Flow cytometry • P53 immunohistochemistry • Optical coherence tomography • Spectroscopy
- 27. 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.
- 31. Staging of SCC
- 33. 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.
- 34. 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.
- 35. 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.
- 36. Indications for Curative Treatment • Early growth when patient is fit. • When there is no involvement of adjacent perioesophageal structures, bronchus, liver or distant organs.
- 37. 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.
- 38. 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.
- 39. 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.
- 40. 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.
- 41. 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.
- 42. 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.
- 43. 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
- 44. Indications of Palliative therapy • To Relieve pain • To Relieve dysphagia • To Prevent bleeding • To Prevent aspiration
- 45. 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.
- 46. Palliative Procedures • External and intraluminal RT (Brachytherapy) • Chemotherapy • Intubation tube • Endoscopic theraphy – Self expanding metal stents – Endoscopic laser – Endoscopic bipolar diathermy – Endoscopic photodynamic theraphy • Surgery
- 47. 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.
- 48. Chemotherapy • Cisplatin • Methotrexate • 5 FU • Palcitaxel • Etoposide • Bleomycin • Platinum based chemotherapy is beneficial especially in advanced adenocarcinoma of esophagus.
- 49. 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%.
- 50. 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%.
- 51. 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.
- 52. 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.
- 53. 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.
- 54. 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
- 55. 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%.
- 56. 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.
- 57. THANQ