CARCINOMA

ESCOPHAGUS
PRESENTOR- DR YASHWANTH B
MODERATOR- DR PRAVEEN
EPIDEMOLOGY
• Esophageal cancer is the 8th most common cancer worldwide and the
6th most common cause of death from cancer

• The disease is common in countries of the so-called “Asian esophgeal

cancer belt”. Its incidence is 50- 100 fold higher than the rest of the
world.

• Esophageal cancer most commonly presents in the 6 th and 7th decades

of life.
• It is male- predominant disease.

• Over the past 3 decades, there has been an epidemiological shift from
scc to adenocarcinoma of the lower esophagus and cardia in white
populations in western countries.

• In eastern countries, however, scc remains the predominant type and is

mostly located in mid esophagus.
Alcohol
• ALDH2- two main variants are noted, they are due to replacement of
glutamate with lysine at position 487.
• Glu/glu- normal catalytic activity
• Lys/lys- no detectable activity, cannot tolerate alcohol due to unpleast
side effects of acetaldehyde.
• Glu/lys- reduced activity
GERD
• GERD has been implicated as one of the strongest risk factors for the
development of adenocarcinoma of the esophagus.
• Chronic reflux is associated with Barrett’s esophagus, the
premalignant precursor of esophageal adenocarcinoma.
• Population-based case-control studies that examined the relationship
between symptomatic reflux and risk of adenocarcinoma of the
esophagus have demonstrated that increased frequency, severity, and
chronicity of reflux symptoms are associated with a 2- to 16-fold
increased risk of adenocarcinoma of the esophagus, regardless of the
presence of Barrett’s esophagus
Barrett esophagus
• Barrett esophagus (BE) is a change in the mucosa of the esophagus
from squamous epithelium to metaplasia columnar epithelium as a
result of GERD.

• The clinical significance of BE is its role as a risk factor in the

development of esophageal adenocarcinoma (EA).

• Patients with BE are up to 40 times more likely to develop esophageal

adenocarcinoma than the general population.
Pathogenesis
• Barrett metaplasia occurs as a result of exposure of esophageal
epithelium to gastric and duodenal fluids.

• When native squamous esophageal mucosa is exposed to gastric acid

and duodenal bile, it undergoes an adaptive metaplasia to become
mucus-secreting columnar cells with interspersed goblet cells.

• Following metaplasia, these cells can then undergo morphologic

changes called dysplasia.
Treatment
• The management of patients with BE is based upon the degree of
dysplasia.

• The initial treatment strategy for all patients with BE should be geared
at the treatment of reflux.

• PPI therapy is mainstay in the management of BE.

Treatment options
• Radiofrequency ablation

• Cryotherapy

• Endoscopic mucosal resection

Helicobacter pylori infection
• Infection with Helicobacter pylori, and particularly with cagA+
strains, is inversely associated with the risk of adenocarcinoma of the
esophagus.
• The mechanism of action is unclear, although an H. pylori infection
can result in chronic atrophic gastritis, leading to decreased acid
production and potentially reducing the development of Barrett’s
esophagus.
• Atrophic gastritis may promote bacterial overgrowth, leading to
intragastric nitrosation, with the production of nitrosamines increasing
the risk of esophageal squamous cell carcinoma.
Tylosis
Hyperkeratosis of
• Palms
• Soles
• Esophageal papillomas
Plummer Vinson syndrome
• Iron deficiency anemia
• Glossitis, cheilitis
• Brittle finger nails
• Splenomegaly
• Esophageal webs
Clinical features
• Dysphagia- more to solid; progressive (most common)
• Other symptoms- regurgitation, vomiting, odynophagia and weight
loss
• Symptoms of advanced disease-
1. Chronic cough- may indicate development of malignant TEF
2. Hoarseness of voice- involvement of RLN
3. Horner’s syndrome
4. Diaphragmatic paralysis
Diagnosis
• Investigation of choice to confirm the diagnosis
Endoscopic biopsy

• Investigation of choice for staging

PET CT

• Investigation of choice for depth and nodal staging

EUS
EUS
Barium swallow
• Esophageal cancer is characteristically described as
Staging
• The T stage advances as tumor invades from mucosa deep to muscle,
adventitia, and beyond the esophagus.
• Regional nodes encompass areas from the neck and through the
mediastinum to the upper abdomen, including the celiac nodes. The
segregation of N1 to N3 is by the number of involved lymph nodes.
• Location is defined by the position of the epicenter of the tumor in the
esophagus and classified as X: location unknown; Upper: cervical
esophagus to lower border of azygos vein; Middle: lower border of
azygos vein to lower border of inferior pulmonary vein; and Lower:
lower border of inferior pulmonary vein to stomach, including
gastroesophageal junction.
Clinical stage grouping for SCC
Clinical stage grouping for Adeno CA
• Controversy exists regarding whether adenocarcinoma of the
gastroesophageal junction (GEJ) should be staged as esophageal or
gastric cancer.
• Adenocarcinoma of the cardia was staged as esophageal cancer
according to the seventh edition of the AJCC staging system.
However, assigning tumors at this location as esophageal or gastric is
somewhat arbitrary.
• The definition of esophagogastric junction is thus revised in the 8th
edition of AJCC system such that cancer involving it with epicenters
no more than 2 cm into the gastric cardia are staged as
adenocarcinoma of the esophagus and those with more than 2cm
involvement of the gastric cardia are staged as stomach cancer, even if
the edges of the tumors invades the esophagogastric junction.
Siewert classification
Treatment
Stage directed therapy
• Treatment options for esophageal cancer were limited in the past.
• Surgical resection, radiotherapy, and plastic stenting for palliation
were the only 3 choices.
• With the advancement of technology, there has been a proliferation of
therapeutic options.
• Staging has becoming increasing more important in stratifying patients
for different treatment methods, either alone or in combination with
others.
Early squamous cell cancers
• The risk of nodal metastases is the
most important factor to consider in
choosing the therapeutic option.
• The reported rates of nodal
involvement in T1a-EP, T1a-LMP,
and T1a MM tumors are 0%, 3.3%,
and 12.2%, respectively.
• For T1b-SM1, SM2, and SM3
lesions, the respective rates of
lymph node involvement are 26.5%,
35.8%, and 45.9%, respectively.
• Tumors with minimal risk of nodal metastases, such as T1a-EP and
LMP, are amenable to endoscopic mucosal resection (EMR).
Circumferential mucosal resection may result in cicatricial stenosis.
• Therefore, EMR is indicated for lesions not exceeding two-thirds of
the circumference of the esophagus. EMR can also be a feasible
treatment for tumors of moderate risk of nodal metastases such as T1a-
MM or T1b-SM1.
• SM2 and SM3 lesions are associated with significant risk of nodal
metastases and should be treated with the same approach as in
advanced cancers.
EMR
• EMR is performed by injection of saline into the submucosal plane to
raise the mucosal lesion.
• The lesion is then sucked into a cap fitted onto the tip of endoscope,
looped by a snare wire, and cut by blend-current electrocautery.
• The limitation of this technique is that the size of the lesion should be
less than the size of the cap, and the generally recommended size of
the lesion should be less than 2 cm.
• For larger lesions, if resected by EMR, complete resection can only be
achieved with piecemeal resection, which is associated with increased
recurrence rate when compared to ESD.
Endoscopic submucosal dissection
ESD is more complex. There are several steps in ESD, as follows:
• (1) marking: the border of the lesion is marked by electrocautery
• (2) submucosal injection: injection of solution into the submucosal
tissue plane
• (3) precut: cutting the mucosal edges along the line of marking
• (4) submucosal dissection: dissecting the lesion from the submucosal
bed
• (5) hemostasis.
Advanced esophageal cancer
• Surgical resection remains the mainstay of treatment for Localized
esophageal cancer.

• Surgery in combination with multimodality treatment is also a

standard of care.

• Palliative methods have also improved when cure is not possible.

Important aspects to enhance better outcome after esophagectomy are

1. Selecting appropriate patients for resection,

2. Choice of surgical techniques and their execution,

3. perioperative care.
Cervical esophageal cancer
• The incidence of cervical esophageal cancer accounts for 2% to 10% of all
esophageal carcinomas.
• Pharyngolaryngoesophagectomy (PLE), with or without adjuvant
radiotherapy, has been the gold standard of treatment since first reported by
Ong and Lee in 1960.
• The procedure involves cervical and abdominal incisions and a thoracotomy.
• Tumors located at the hypopharyngeal and cervical esophageal regions were
resected together with the whole length of the esophagus, and the gastric
tube was pulled up to the neck via the posterior mediastinum for
pharyngogastric anastomosis. A permanent end tracheostomy was created.
Intrathoracic esophageal cancers
Surgery McKeown Ivor Lewis Oringers

Location Upper third Middle third Lower third

Middle third(above (below aortic arch)
the aortic arch)
No.s incisions 3 2 2

Anastomotic site Neck Thorax(at the apex) Neck

Transthoracic vs Transhiatal route
• The largest randomized controlled trial to date compared 106 patients who
underwent THE and 114 patients who underwent TTE for mid-lower third/cardia
adenocarcinoma.
• Pulmonary complication rates were 27% for THE and 57% for TTE. The THE
group had longer ventilation time, intensive care unit stay, and hospital stay.
• In-hospital mortality and overall 5-year survival rates were similar in both groups.
• Patients who underwent TTE had more lymph nodes harvested (31 vs 16). In those
with 1 to 8 positive lymph nodes, TTE had a survival advantage (64% vs 23% at 5
years).
• However, survival rates were similar in patients without nodal metastases or with
more than 8 nodal metastases.
• In choosing TTE or THE, there are several factors to consider,
including the location and stage of the tumor, neoadjuvant treatment,
and the intended extent of the lymphadenectomy.
• For upper or middle third tumors or advanced tumors closely related
to the tracheobronchial tree, in patients who have had prior
chemoradiation where tissue planes may have been obliterated, the
THE approach may not be safe.
• However, THE can be more safely performed for distally located
tumors where dissection can be performed under visual control.
• Oncologically, if extended nodal dissection is planned for the middle
and superior mediastinum, THE would not be suitable, and this is only
possible with TTE.
Resection margins of primary tumor
• Esophageal cancer has a tendency to spread longitudinally.
• The deeper the invasion of the primary tumor, the more likely this
spread will happen.
• The chance of finding tumor histologically at the resection margin and
also subsequent recurrence at the anastomosis is reduced with
increasing length of the transected esophagus away from the primary
tumor.
• Proximal extent- 10cm
• Distal extent- 5cm
Choice of esophageal substitute
Gastric conduit
• The most commonly used conduit is the gastric tube, and of the many
configurations, an isoperistaltic tube based on the greater curvature
with preservation of the right gastric and right gastroepiploic vessels
is most reliable.

• The simplicity of preparation, adequate length, and robust blood

supply make it the first choice as the esophageal substitute.
• Disadvantages of the gastric conduit include the fact that patients who
have an intrathoracic stomach often experience postprandial
discomfort and early satiety related to loss of normal gastric functions
such as receptive relaxation.
• Patients can also suffer from acid reflux, possible gastric ulceration,
and dysfunctional propulsion.
• The level of the esophagogastric anastomosis has a bearing on the
severity of reflux.
• Patients who have a low intrathoracic anastomosis tend to have more
severe reflux and esophagitis compared with the high intrathoracic or
cervical anastomosis.
• Preserving a longer length of esophagus, on the other hand,
theoretically may enhance swallowing function.
Colonic conduit
• A colonic conduit provides good long-term swallowing function; it
seems to have active peristalsis, and this is cited as an explanation for
its superior function as an esophageal substitute when compared with
a passive gastric conduit.
• Although peristalsis can be demonstrated immediately following
surgery, long-term emptying likely relies on gravity.
• When the distal stomach is retained in the abdomen after a colon
interposition with a cologastric anastomosis, the latter provides
additional reservoir function.
Jejunal conduit
• The jejunum is used most frequently after distal esophagectomy and
total gastrectomy for cancer of the lower esophagus and gastric cardia.
• A Roux-en-Y configuration seems best, as it prevents bile reflux to the
esophagus.
• A jejunal loop used in a modified Merendino procedure to interpose
between the esophagus and proximal stomach after limited resection
of the distal esophagus and GEJ has also been advocated.