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1. Malignant DisordersMalignant Disorders
of the Esophagusof the Esophagus

2. Esophageal CancerEsophageal Cancer
 88thth
commonest cancercommonest cancer
 Nepal : 3.79/ 100 000 -Nepal : 3.79/ 100 000 -
 Most esophageal tumors are malignant, fewerMost esophageal tumors are malignant, fewer
than 1% are benignthan 1% are benign
 High prevalence areas are Asia, Africa andHigh prevalence areas are Asia, Africa and
northern Francenorthern France
 13,000 new patients in the United States13,000 new patients in the United States

3. Esophageal CancerEsophageal Cancer
 Most patients still present with locally advancedMost patients still present with locally advanced
(stage T 3 and/or N 1 ) disease(stage T 3 and/or N 1 ) disease
 Two types of histologyTwo types of histology
Squamous cellSquamous cell
Adeno CaAdeno Ca

4. Esophageal CancerEsophageal Cancer
 Adeno Ca now becoming predominantAdeno Ca now becoming predominant
 Squamous cell still persists in patients with theSquamous cell still persists in patients with the
usual risk factors for other aerodigestive tractusual risk factors for other aerodigestive tract
carcinomas.carcinomas.

5. Risk FactorsRisk Factors
 CONSUMPTION OF:CONSUMPTION OF:
Tobacco, Alcohol (5 times each)Tobacco, Alcohol (5 times each)
 UNDER-CONSUMPTION OF:UNDER-CONSUMPTION OF:
Fruits, Fresh meat, Riboflavin. Beta-carotene,Fruits, Fresh meat, Riboflavin. Beta-carotene,
Vitamin C, Magnesium, Vegetables, Fresh fish,Vitamin C, Magnesium, Vegetables, Fresh fish,
Niacin, Vitamin A, Vitamin B complex, ZincNiacin, Vitamin A, Vitamin B complex, Zinc

6. Risk FactorsRisk Factors
 PREDISPOSING CONDITIONS:PREDISPOSING CONDITIONS:
Caustic injury, Esophageal webs, Achalasia, Barrett'sCaustic injury, Esophageal webs, Achalasia, Barrett's
esophagus, Esophageal diverticulaesophagus, Esophageal diverticula
 OTHER EXPOSURE:OTHER EXPOSURE:
Asbestos, Ionizing radiation, Exceptionally hotAsbestos, Ionizing radiation, Exceptionally hot
beverages (tea), Location: Middle East, South Africa,beverages (tea), Location: Middle East, South Africa,
northern China, southern Russia, Indianorthern China, southern Russia, India

7. Anatomy of EsophagusAnatomy of Esophagus

8. Squamous Cell CarcinomaSquamous Cell Carcinoma
 95% of esophageal cancer worldwide95% of esophageal cancer worldwide
 Commonly 7Commonly 7thth
decade of life, 1.5-3 times moredecade of life, 1.5-3 times more
common in mencommon in men
 Thought to occur from prolonged exposure ofThought to occur from prolonged exposure of
esophageal mucosa to noxious stimuli in personsesophageal mucosa to noxious stimuli in persons
with a genetic predisposition to the disease.with a genetic predisposition to the disease.

9. Squamous Cell CarcinomaSquamous Cell Carcinoma
 Histologically, characterized by invasive sheetsHistologically, characterized by invasive sheets
of cells that run together and are polygonal, oval,of cells that run together and are polygonal, oval,
or spindle-shaped with a distinct or raggedor spindle-shaped with a distinct or ragged
stromal-epithelial interface.stromal-epithelial interface.
 Located mainly in the thoracic esophagus,Located mainly in the thoracic esophagus,
approximately 60% of these tumors are found inapproximately 60% of these tumors are found in
the middle third and about 30% in the distalthe middle third and about 30% in the distal
third.third.

10. Squamous Cell CarcinomaSquamous Cell Carcinoma
 Four major gross pathologic presentations:Four major gross pathologic presentations:
(1) fungating: predominantly intraluminal growth(1) fungating: predominantly intraluminal growth
with surface ulceration and extreme friabilitywith surface ulceration and extreme friability
that frequently invades mediastinal structures;that frequently invades mediastinal structures;
(2) ulcerating: flat-based ulcer with slightly raised(2) ulcerating: flat-based ulcer with slightly raised
edges; hemorrhagic, friable with surroundingedges; hemorrhagic, friable with surrounding
indurationinduration

11. Squamous Cell CarcinomaSquamous Cell Carcinoma
(3) infiltrating: a dense, firm, longitudinal and(3) infiltrating: a dense, firm, longitudinal and
circumferential intramural growth patterncircumferential intramural growth pattern
(4) polypoid: intraluminal polypoid growth with a(4) polypoid: intraluminal polypoid growth with a
smooth surface on a narrow stalk (fewer thansmooth surface on a narrow stalk (fewer than
5% of cases)5% of cases)
 A 5-year survival of 70% is associated with theA 5-year survival of 70% is associated with the
polypoid tumor compared with a less than 15%polypoid tumor compared with a less than 15%
5-year survival for all other types5-year survival for all other types

12. AdenocarcinomaAdenocarcinoma
 Most common cell type of esophageal cancer inMost common cell type of esophageal cancer in
the United States and Europe.the United States and Europe.
 Adenocarcinoma arises from the superficial andAdenocarcinoma arises from the superficial and
deep glands of the esophagus, mainly in thedeep glands of the esophagus, mainly in the
lower third of the esophagus, especially near thelower third of the esophagus, especially near the
gastroesophageal junction.gastroesophageal junction.

13. AdenocarcinomaAdenocarcinoma
 Whites are at four times greater risk than blacksWhites are at four times greater risk than blacks
 Men have an eightfold higher risk than women.Men have an eightfold higher risk than women.
 In the US and Europe, frequency of this tumorIn the US and Europe, frequency of this tumor
is increasing faster than any other cancer.is increasing faster than any other cancer.

14. AdenocarcinomaAdenocarcinoma
 Esophageal adenocarcinoma may have one ofEsophageal adenocarcinoma may have one of
three origins:three origins:
• malignant degeneration of metaplastic columnarmalignant degeneration of metaplastic columnar
epithelium (Barrett's mucosa)epithelium (Barrett's mucosa)
• heterotopic islands of columnar epitheliumheterotopic islands of columnar epithelium
• the esophageal submucosal glands.the esophageal submucosal glands.

15. AdenocarcinomaAdenocarcinoma
 Gastric adenocarcinoma may also involve the esophagusGastric adenocarcinoma may also involve the esophagus
secondarily.secondarily.
 Gastroesophageal junction tumors arise initially as flat or raisedGastroesophageal junction tumors arise initially as flat or raised
patches of mucosa. They may subsequently ulcerate and becomepatches of mucosa. They may subsequently ulcerate and become
large (up to 5 cm) nodular masses.large (up to 5 cm) nodular masses.
 Tumor size is related to prognosis. For tumors smaller than 5Tumor size is related to prognosis. For tumors smaller than 5
cm, 40% are localized, 25% have spread beyond the esophagus,cm, 40% are localized, 25% have spread beyond the esophagus,
and 35% have metastasized or are unresectable. For tumors thatand 35% have metastasized or are unresectable. For tumors that
are more than 5 cm in length, 10% are localized, 15% haveare more than 5 cm in length, 10% are localized, 15% have
invaded mediastinal structures, and 75% have metastasized.invaded mediastinal structures, and 75% have metastasized.

16. Rare esophageal cancersRare esophageal cancers
 Anaplastic small cell (oat cell) carcinoma arise inAnaplastic small cell (oat cell) carcinoma arise in
the esophagus from same argyrophilic cellsthe esophagus from same argyrophilic cells
found in the lung.found in the lung.
 Adenoid cystic esophageal carcinomaAdenoid cystic esophageal carcinoma
 Primary malignant melanoma of esophagusPrimary malignant melanoma of esophagus
 Carcinosarcoma, features of SSC and malignantCarcinosarcoma, features of SSC and malignant
spindle cell sarcoma.spindle cell sarcoma.

17. Clinical FindingsClinical Findings
 Dysphagia in more than 90% of patients withDysphagia in more than 90% of patients with
esophageal canceresophageal cancer
 Nonspecific retrosternal discomfortNonspecific retrosternal discomfort
 IndigestionIndigestion
 Weight lossWeight loss
 PainPain
 Regurgitation, resp symptoms, hoarsenessRegurgitation, resp symptoms, hoarseness

18. Clinical FindingsClinical Findings
SymptomSymptom PercentPercent
 DysphagiaDysphagia 87-9587-95
 Weight lossWeight loss 42-7142-71
 Vomiting or regurgitationVomiting or regurgitation 29-4529-45
 PainPain 20-4620-46
 Cough or hoarsenessCough or hoarseness 7-267-26
 DyspneaDyspnea 55

19. Clinical FindingsClinical Findings
 Careful examination of cervical andCareful examination of cervical and
supraclavicular lymph nodessupraclavicular lymph nodes
 FNA or excisional biopsy for diagnosisFNA or excisional biopsy for diagnosis
 Evaluate for abdominal masses and liverEvaluate for abdominal masses and liver
nodularitynodularity
 Labwork, imaging studiesLabwork, imaging studies

20. Barium swallowBarium swallow
Barium swallowBarium swallow
evaluationevaluation
MucosalMucosal
irregularityirregularity
Tumor shelfTumor shelf

21. EndoscopyEndoscopy
Endoscopic evaluationEndoscopic evaluation
Esophageal biopsyEsophageal biopsy
and brushings forand brushings for
cytologycytology
EstablishesEstablishes
diagnosis in 95% ofdiagnosis in 95% of
patients withpatients with
malignant stricturesmalignant strictures

22. Imaging StudiesImaging Studies
 Computed tomography (CT) of the chest andComputed tomography (CT) of the chest and
upper abdomen is the standard radiographicupper abdomen is the standard radiographic
technique for staging esophageal cancer.technique for staging esophageal cancer.
 Normal esophageal wall thickness 5mmNormal esophageal wall thickness 5mm
 Regional adenopathyRegional adenopathy
 Metastasis to lung, liver, adrenal, or distantMetastasis to lung, liver, adrenal, or distant
nodesnodes
 FNA biopsy for tissue diagnosisFNA biopsy for tissue diagnosis

23. Imaging StudiesImaging Studies
 Positron emission tomography (PET)Positron emission tomography (PET)
 Does not rely on anatomic or structuralDoes not rely on anatomic or structural
distortion for detecting malignancydistortion for detecting malignancy
 PET is 88% sensitive, 93% specific, and 71 toPET is 88% sensitive, 93% specific, and 71 to
91% accurate for identifying distant metastasis91% accurate for identifying distant metastasis

24. Imaging StudiesImaging Studies
 Cellular FDG uptake is not specific for tumorsCellular FDG uptake is not specific for tumors
and that areas of inflammation often predisposeand that areas of inflammation often predispose
to false-positive resultsto false-positive results
 MRI has a 56 to 74% accuracy in detectingMRI has a 56 to 74% accuracy in detecting
lymph node metastaseslymph node metastases

25. Endoscopic UltrasoundEndoscopic Ultrasound
 Method of choice to determine depth of tumorMethod of choice to determine depth of tumor
invasion and regional nodal disease andinvasion and regional nodal disease and
involvement of adjacent structures, with aninvolvement of adjacent structures, with an
overall accuracy to 92%overall accuracy to 92%
 A significant error associated with endoscopicA significant error associated with endoscopic
ultrasound T staging is to overstage 7 to 11% ofultrasound T staging is to overstage 7 to 11% of
early diseaseearly disease

26. Endoscopic UltrasoundEndoscopic Ultrasound

27. TNM StagingTNM Staging
 T: PRIMARY TUMORT: PRIMARY TUMOR
• T 0 No evidence of a primary tumorT 0 No evidence of a primary tumor
• T is Carcinoma in situ (high-grade dysplasia)T is Carcinoma in situ (high-grade dysplasia)
• T 1 Tumor invading the lamina propria, muscularis mucosae,T 1 Tumor invading the lamina propria, muscularis mucosae,
or submucosa but not breaching the boundary betweenor submucosa but not breaching the boundary between
submucosa and muscularis propriasubmucosa and muscularis propria
• T 2 Tumor invading muscularis propria but not breaching theT 2 Tumor invading muscularis propria but not breaching the
boundary between muscularis propria and periesophagealboundary between muscularis propria and periesophageal
tissuetissue
• T 3 Tumor invading periesophageal tissue but not adjacentT 3 Tumor invading periesophageal tissue but not adjacent
structuresstructures
• T 4 Tumor invading adjacent structuresT 4 Tumor invading adjacent structures

28. TNM StagingTNM Staging
 N: REGIONAL LYMPH NODESN: REGIONAL LYMPH NODES
 N 0 No regional lymph node metastasisN 0 No regional lymph node metastasis
 N 1 Regional lymph node metastasisN 1 Regional lymph node metastasis
 M: DISTANT METASTASISM: DISTANT METASTASIS
 M 0 No distant metastasisM 0 No distant metastasis
 M 1 Distant metastasisM 1 Distant metastasis

29. Stage GroupingStage Grouping
 Stage 0Stage 0 T 0 N 0T 0 N 0
T is N 0 M0T is N 0 M0
 Stage IStage I T 1 N 0 M0T 1 N 0 M0
 Stage IIStage II IIAIIA T 2 N0 M 0T 2 N0 M 0
T 3 N 0 M0T 3 N 0 M0
IIBIIB T 1 N 1 M0T 1 N 1 M0
T 2 N 1 M0T 2 N 1 M0

30. Stage GroupingStage Grouping
 Stage IIIStage III T 3 N 1 M0T 3 N 1 M0
T 4 any N M 0T 4 any N M 0
 Stage IVStage IV any T any N M 1any T any N M 1

31. 5 Year Survival5 Year Survival
 Stage IStage I 50-55%50-55%
 Stage IIAStage IIA 15-35%15-35%
 Stage IIBStage IIB 15-27%15-27%
 Stage IIIStage III 4-15%4-15%
 Stage IVStage IV 0-2%0-2%

32. AlgorithmAlgorithm

33. Treatment OptionsTreatment Options
 Palliative Treatment for unresectable lesionsPalliative Treatment for unresectable lesions
include:include:
 DilatationDilatation
 StentingStenting
 Photodynamic therapyPhotodynamic therapy
 Radiation therapyRadiation therapy
 Laser therapyLaser therapy
 Surgical palliationSurgical palliation

34. Treatment OptionsTreatment Options
 Curative resection?Curative resection?
Ivor – LewisIvor – Lewis
Mc KwoenMc Kwoen
TranshiatalTranshiatal
Minimally invasive esophagectomyMinimally invasive esophagectomy
 Mid esophagus approached from rightMid esophagus approached from right
 Distal esophagus from leftDistal esophagus from left

35. Mid-Esophageal TumorMid-Esophageal Tumor

36. Upper Esophageal TumorUpper Esophageal Tumor

37. Stomach MobilizationStomach Mobilization

38. Esophageal SubstitutionEsophageal Substitution

39. Esophageal SubstitutionEsophageal Substitution

40. Adjuvant treatmentAdjuvant treatment
 Neo-adjuvant treatmentNeo-adjuvant treatment
 Definitive chemo-radiotherapyDefinitive chemo-radiotherapy
 Palliative radiotherapyPalliative radiotherapy
 Palliative Treatment for unresectable lesionsPalliative Treatment for unresectable lesions
include:include:
 DilatationDilatation
 StentingStenting
 Photodynamic therapyPhotodynamic therapy
 Radiation therapyRadiation therapy
