Introduction except the treatment part. Its only for Medical Doctors

1. Cancer of the Esophagus
CHAIRMAN – DR. A S GODHI
CO - CHAIRMAN – DR. R. S. KOUJALAGI
PRESENTER – DR. S S K KANTH KAVIPURAPU

2. Introduction
 Ca esophagus is the 8th
most common cancer in the
world.
 6th
most common cause of death from cancer.
 The disease is most common in countries of the so
called “Asian Esophageal cancer belt” which
stretches from eastern Turkey and east of the
Caspian sea through northern Iran, northern
Afghanistan, and the southern areas of former Soviet
Union such as Turkmenistan, Uzbekistan and Tajikistan
to northern China and India.

3. Introduction
 Esophageal cancer most commonly presents in
the sixth to seventh decades of life.
 It is a male predominant disease with
 M:F ratio of 3:1 for Sq. ca and 15:1 for Adeno Ca.

4. Introduction
 Types of Ca Esophagus:
 Squamous cell carcinoma
 Adenocarcinoma
 Less common types:
 Mucoepidermoid cancer
 Adenosquamous cancer
 Small cell cancer
 Basaloid squamous cancer
 Sarcomatoid cancer
 Lymphoma, melanoma, and various subtypes of
Stromal tumors

5. Etiology
 Squamous Carcinoma
 Smoking
 Alcohol consumption
 Hot beverages
 N- nitroso compounds –
Pickled / smoked food
 Caustic ingestion
 Acalasia
 Bulimia tylosis
 Plummer Vinson Syndrome
 External beam radiation
 Adenocarcinoma
 Smoking
 Alcohol consumption
 Esophageal diverticula
 GERD
 Acid suppression
medication
 Barretts esophagus
 Malignancy of
aerodigestive tract.

6. Squmaous Cell carcinoma
 Squamous cell carcinomas arise from the squamous mucosa that is
native to the esophagus.
 Found in the upper and middle thirds of the esophagus 70% of the time.
 Male to female ratio is 3:1.
 It occurs in the 5th
decade of life. Infrequent before 30 years of age.
 It has highest mortality in 60-70 years of age in men.
 The 5-year survival rate varies but can be as high as 70% with polypoid
lesions and as low as 15% with advanced tumors

7. Adenocarcinoma
 Adenocarcinoma now accounts for almost 70% of all esophageal
carcinomas diagnosed in the United States and Western countries.
 There are a number of factors responsible for this shift in cell type:
 Increasing incidence of GERD
 Western diet
 Increased use of acid-suppression medications
 As an adaptive measure, the squamous-lined distal esophagus
changes to become lined with metaplastic columnar epithelium
(Barrett’s esophagus). Progressive changes from metaplastic
(Barrett’s esophagus) to dysplastic cells may lead to the
development of esophageal adenocarcinoma.

8. Adenocarcinoma
 Histologically, esophageal adenocarcinoma
arises from one of three sites:
 Submucosal glands of the esophagus
 Heterotopic islands of columnar epithelium
 Malignant degeneration of metaplastic columnar
epithelium (Barrett’s esophagus)
 Male to female ratio – 15:1
 Infrequent before the age of 40 years.

9. Symptoms
 Asymptomatic
 Mimic symptoms fo GERD
 Heartburn,
 regurgitation,
 Indigestion
 Dysphagia
 Weight loss
Advanced Disease
Choking
Coughing
Aspiration
Suggests tracheoesophageal fistula
Hoarseness
Vocal cord paralysis
Suggests invation of Recurrent Layngeal
nerve.
Jaundice – Liver metastasis
Chronic pain - Bone metastasis
Respiratory symptoms – lung metastasis

10. Diagnosis
 Esophagram: A barium esophagram is
recommended for any patient
presenting with dysphagia.
 The esophagram provides an overview
of anatomy and function.
 It can differentiate intraluminal from
intramural lesions and discriminate
between intrinsic (from a mass
protruding into the lumen) and extrinsic
(from compression of a structures
outside the esophagus) compression.
 The classic finding of an apple core
lesion in patients with esophageal
cancer is recognized easily.

11. Diagnosis
 Endoscopy:
 The diagnosis of esophageal cancer is best made from an
endoscopic biopsy. During endoscopy, it is critical to
document the following:
 Location of the lesion (with respect to distance from the
incisors)
 Nature of the lesion (e.g., friable, firm, polypoid)
 Proximal and distal extent of the lesion
 Relationship of the lesion to the cricopharyngeus muscle, GEJ,
and gastric cardia
 Distensibility of the stomach.
Early, superficial
cancer
Circumferential
ulceration esophageal
cancer
Malignant
stricture of
esophagus

12. Diagnosis
 A CT scan of the chest and abdomen is important to
assess the
 length of the tumor,
 thickness of the esophagus and stomach,
 regional lymph node status (including cervical, mediastinal,
and celiac lymph nodes),
 distant disease to the liver and lungs.
 It is also helpful for determining T4 lesions, in which the
lesion is invading surrounding structures. It may identify a
fistula or other anatomic variations, such as a deviated
trachea. Although a CT scan is helpful, its accuracy is only
57% for T staging, 74% for N staging, and 83% for M staging.

13. Diagnosis
Figure Esophageal cancer with tracheal invasion. CT
scan shows circumferential wall thickening of the
proximal esophagus (arrowheads), which shows
irregular interface with the posterior wall of the trachea
(arrows), indicating direct extension into the lumen
Figure Esophageal cancer with aortic invasion. An
arc (bent arrow) of the contact between the
esophageal cancer (arrows) and the aorta
(arrowheads) is more than 90 degrees, indicating
aortic invasion.

14. Diagnosis
 PET:
 An 18
F-fluorodeoxyglucose (FDG)–
positron emission tomography
(PET) scan evaluates the primary
mass, regional lymph nodes, and
distant disease.
 The sensitivity and specificity of PET
for evaluating metastatic disease
are 88% and 93%, respectively. For
evaluation of lymph node disease,
has a sensitivity (72%), specificity
(86%), and accuracy (76%).
 MRI
 MRI is helpful. It can accurately
detect T4 lesions and metastatic
lesions in the liver but overstages T
and N status, with only a 74%
accuracy.

15. Diagnosis
 Endoscopic ultrasound:
 EUS is the most critical component of esophageal
cancer staging
 The information obtained from EUS will help guide
medical and surgical therapy.
 The experienced endoscopic ultrasonographer can
identify
 the depth and length of the tumor,
 degree of luminal compromise,
 status of regional lymph nodes,
 and involvement of adjacent structures.
 In addition, biopsy samples can be obtained of the
mass and lymph nodes in the paratracheal, subcarinal,
paraesophageal, celiac, lesser curvature, and
gastrohepatic regions.

16. Diagnosis
 EUS tends to overstage T status and understage N status.
 The accuracy of EUS for T staging correlates directly with
increasing T stage.
 T1 lesions, EUS is 84% accurate,
 95% accuracy in estimating T4 lesions.
 Size and location of the lymph node influence the
accuracy, so that lymph nodes smaller than 1 cm tend to
be evaluated less accurately.
 The overall sensitivity (78%) and specificity (60%) of EUS for
evaluating lymph nodes are poor but improve dramatically
for evaluating celiac lymph nodes, for which the sensitivity
and specificity are 72% and 97%, respectively.

17. Diagnosis
 Bronchoscopy, mediastinoscopy, thoracoscopy, and
laparoscopy are all useful staging tools

18. Staging
Primary Tumor (T)*
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis High-grade dysplasia†
T1
Tumor invades lamina propria, muscularis mucosae,
or submucosa
T1a
Tumor invades lamina propria or muscularis
mucosae
T1b Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades adventitia
T4 Tumor invades adjacent structures
T4a
Resectable tumor invading pleura, pericardium, or
diaphgragm
T4b
Unresectable tumor invading other adjacent
structures, such as aorta, vertebral body, trachea,
etc.
Regional Lymph Nodes (N)‡
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1-2 regional lymph nodes
N2 Metastasis in 3-6 regional lymph nodes
N3 Metastasis in seven or more regional lymph nodes
Distant Metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
Tumor-Node-Metastasis (TNM) Staging of Esophageal Carcinoma
From Edge S, Byrd D, Compton C, et al (eds):
AJCC cancer staging manual, ed 7, New York, 2010, Springer.

20. Stage grouping
Stage Grouping
STAGE T N M GRADE
TUMOR
LOCATION¶
Squamous Cell Carcinoma§
0 Tis (HGD) N0 M0 1, X Any
IA T1 N0 M0 1, X Any
IB T1 N0 M0 2-3 Any
T2-3 N0 M0 1, X Lower, X
IIA T2-3 N0 M0 1, X Upper, middle
T2-3 N0 M0 2-3 Lower, X
IIB T2-3 N0 M0 2-3 Upper, middle
T1-2 N1 M0 Any Any
IIIA T1-2 N2 M0 Any Any
T3 N1 M0 Any Any
T4a N0 M0 Any Any
IIIB T3 N2 M0 Any Any
IIIC T4a N1-2 M0 Any Any
T4b Any M0 Any Any
Any N3 M0 Any Any
IV Any Any M1 Any Any

21. Stage grouping
Adenocarcinoma
0 Tis (HGD) N0 M0 1, X
IA T1 N0 M0 1-2, X
IB T1 N0 M0 3
T2 N0 M0 1-2, X
IIA T2 N0 M0 3
IIB T3 N0 M0 Any
T1-2 N1 M0 Any
IIIA T1-2 N2 M0 Any
T3 N1 M0 Any
T4a N0 M0 Any
IIIB T3 N2 M0 Any
IIIC T4a N1-2 M0 Any
T4b Any M0 Any
Any N3 M0 Any
IV Any Any M1 Any

22. Thank you.