1. Esophageal Tumors
Carcinoma (from the Greek karkinos, or
"crab", and -oma, "growth")
Carcinoma of Esophagus
Carcinoma is a malignant neoplasm of epithelial cell origin.
Carcinoma- Malignant epithelial
tumor
Lecture 5

2. Esophageal tumors
• Most (> 99%)esophageal tumors are MALIGNANT,
fewer than 1% are benign.
• Benign tumors: Squamous cell papilloma,
Adenoma, leiomyoma, lipoma, fibroma,
neurofibroma, rhabdomyoma, lymphangioma &
hemangioma.
• Malignant tumors: are carcinomas because
sarcomas are extremely rare.

3. Carcinoma of esophagus
Two morphologic variants :
I . Adenocarcinoma
<10%
II. Squamous cell
carcinoma

4. • Worldwide, squamous cell
carcinoma is more common, but in
the United States and other Western
countries adenocarcinoma is on the
rise.
• A general rule of thumb
is that a cancer in the upper twothirds is a squamous cell carcinoma
and one in the lower one-third is an
adenocarcinoma.

5. ADENOCARCINOMA
Adenocarcinoma denotes a lesion in which the
neoplastic epithelial cells grow in glandular
patterns.
Adenocarcinoma of the esophagus typically arises in
a background of Barrett esophagus and
long-standing GERD.
Strong association with Barrett Esophagus

6. Risk of adenocarcinoma
Cruciferous
Vegetables
Barrett esophagus
Fruit
Age- over 60 (6th -7th decades)
Sex- more common in MEN (7times)
documented dysplasia
tobacco use,
obesity,
prior radiation therapy.
Obesity
Risk is reduced
Whites
H Pylori
NSAID(Aspirin)
Coffee
Pizza
by------?

7. Barrett esophagus is the only recognized precursor of esophageal adenocarcinoma.
The degree of DYSPLASIA is the strongest predictor of the progression to cancer.

8. Dysplasia---Carcinoma in situ--Invasive Carcinoma

9. Morphology
Esophageal adenocarcinoma usually occurs in the
distal third of the esophagus and may invade
the adjacent gastric cardia. Initially appearing as
flat or raised patches in otherwise intact
mucosa, large nodular masses of 5 cm or more
in diameter may develop. Alternatively, tumors
may infiltrate diffusely or ulcerate and invade
deeply.
Nodular,
elevated mass in the lower esophagus

10. Microscopy
of Esophageal Adenocarcinoma
• Barrett esophagus is
frequently present adjacent
to the tumor.
• Tumors most commonly produce
mucin and form glands, often with
intestinal-type morphology.

11. • less frequently tumors are
composed of diffusely
infiltrative signetring cells or,
• in rare cases, small
poorly
differentiated

12. Clinical Features.
Dysphagia,
Odynophagia ( severe pain on swallowing)
Obstruction
progressive weight loss,
Anorexia,
Fatigue,
Weakness,
hematemesis,
chest pain,
Cough
vomiting.

13. Diagnosis
•
•
•
•
•
Barium swallow
CT
PET
Endoscopic ultrasound
Endoscopy
•Biopsy

14. Prognosis-Poor-dismal
• By the time symptoms appear, the tumor has
usually spread to submucosal lymphatic vessels.
As a result of the advanced stage at diagnosis,
overall 5-year survival is less than 25%(15%) with
most patients dying within the first year of
diagnosis.
• In contrast, 5-year survival approximates 80% in
the few patients with adenocarcinoma limited to
the mucosa or submucosa.

15. SquamouS Cell CarCinoma
SQUAMOUS
CELL
CARCINOMA
ESOPHAGEAL

16. Squamous (Epidermoid) cell
carcinoma
a cancer in which the tumor cells
resemble stratified squamous
epithelium.
90%
of esophageal cancer.

17. Risk factors of SCC of Esophagus
•Esophageal disorders
•Life style or Bad habits
•Dietary factors
•Genetic predisposition
Age, Sex, Poverty, Radiation, Race, HPV, Celiac disease.
I. Esophageal disorders:
• Long standing esophagitis
• Achalasia
• Plummer-Vinson Syndrome

18. II. Life style:
• Alcohol
• Tobacco
• An important contributing variable is retarded
passage of food through the esophagus,
prolonging mucosal exposure to potential carcinogens such
as those contained in tobacco and alcohol beverages.
• There is a well-defined predisposing role for chronic
esophagitis, which is often the consequences of
alcohol and tobacco use.

19. III. Dietary Factors
• Def. of vit.
• Def. of trace metals
• Fungal contamination of food stuffs
• High content of nitrites/nitrosamines
• Frequent consumption of very hot beverages.

20. IV. Genetic predisposition:
Nonepidermolytic palmoplantar keratoderma.
•Tylosis
Howel-Evans syndrome
A genetic disorder characterized by
thickening (hyperkeratosis) of the palms
and soles, white patches in the mouth
(oral leukoplakia), and a very high risk
of esophageal cancer.
Autosomal dominant
• Abnormalities affecting the p16/INK4
tumor suppressor gene and the
epidermal growth factor receptors are
frequently present in SCC of the
esophagus. Mutation in
of these tumors.
p53
in 50%

22. V. Age. Over 45
VI. Sex. Males
females.
4
times more frequently than
VII. Poverty
VII. Race- more common in BLACKS (6 times)
IX. Previous radiation therapy to the
mediastinum.
X. HPV
XI. Coeliac disease

23. • Esophageal squamous cell carcinoma incidence
varies up to 180-fold between and within
rural and
underdeveloped areas.
countries, being more common in
• The regions with highest incidences are
•Iran,
central
China, Hong Kong,
Brazil, and South Africa.

24. Pathogenesis
The majority of esophageal squamous cell
carcinomas in Europe and the United States
are at least partially attributable to the use of
ALCOHOL AND TOBACCO ,
which synergize to increase risk.

25. Pathogenesis of sCC
• However, esophageal squamous cell carcinoma is
also common in some regions where alcohol and
tobacco use is uncommon. Thus,
• nutritional deficiencies, as well as
• polycyclic hydrocarbons, nitrosamines, and
• other mutagenic compounds, such as those found
in fungus-contaminated foods, must be
considered.

26. Pathogenesis of sCC
• Human papillomavirus (HPV)
infection has also been implicated in
esophageal squamous cell carcinoma
in high-risk areas but not in lowrisk regions.

27. Pathogenesis of sCC
• The molecular pathogenesis of esophageal
squamous cell carcinoma remains
loss of
several tumor suppressor
genes, including p53 and
p16/INK4a, is involved.
incompletely defined, but

28. Clinical Features
• Dysphagia
• Odynophagia
• Obstruction
• Weight loss
• Hemorrhage
• Sepsis

29. Morphology
• Squamous cell carcinoma begins as an in situ lesion termed
squamous dysplasia.
• Epithelial dysplasia
• Carcinoma in situ
• Invasive cancer

30. MorPhology
• Early overt lesions appears as:
small, gray-white,
plaquelike thickenings or
elevation of the mucosa..

31. In months to years these lesions become
tumorous, taking one of three forms:
1. Polypoid fungating type (60%): The most common
type. Cauliflower-like friable mass protruding into the
lumen.
• 2. Ulcerating type (25%): A necrotic ulcer with
everted edges that extend deeply and sometimes
erode into the respiratory tree (Pneumonia), aorta
or
elsewhere.
(exsanguination)(
• 3. Diffuse infiltrative type (15%): appears as
annular, stenosing narrowing of the lumen due to
infiltration into the wall of esophagus.

33. • SCC arise about (locations):
• 20% in the cervical& upper thoracic esophagus
50% in the middle third
• 30% in the lower third

35. Morphology
• Most squamous cell carcinomas are moderately to
well-differentiated.
Intercellular bridges,
Keratinization &Epithelial pearls
are commonly seen.
Epithelial nest,
Epithelial pearl,
Squamous pearl
Karatin pearl l

36. Regardless of histology,
symptomatic tumors are generally
very large
at diagnosis and have already invaded the
esophageal wall.

37. • Less common histologic variants include
• verrucous squamous cell carcinoma,
• spindle cell carcinoma, and
• basaloid squamous cell carcinoma

38. Prognosis- dismal
• 5-year survival rates are 75% in individuals with
superficial esophageal carcinoma but much lower
in patients with more advanced tumors.
• Lymph node metastases, which are common, are
associated with poor prognosis.
• The overall 5-year survival
remains a dismal 9%.

41. Esophageal cancer. A, Adenocarcinoma usually occurs distally and, as in this
case, often involves the gastric cardia. B, Squamous cell carcinoma is most
frequently found in the mid-esophagus, where it commonly causes strictures.

45. Normal Esophagus (Squamous epithelium)

46. in Barrett's esophagus , the squamous epithelia are
replaced by intestinalized metaplastic columnar
epithelia

47. Barrett's adenocarcinoma with moderate to poor differentiation. Atypic tumor cells
form quite irregular tubules and some form solid cord

53. Esophageal adenocarcinoma
organized into back-to-back glands

54. Squamous cell carcinoma composed of nests of malignant
cells that partially recapitulate the organization of squamous
epithelium