Carcinoma Of The Esophagus

Hassan Bharmal
Pathologic Classification
 Typing
●
Squamous Cell Ca
●
Adenocarcinoma
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Uncommon
–
Grading
TNM Classification
Staging
 Epidemiology
th
●
9 most common Ca in th world
th
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5 most common in developing countries
●
Unusual high incidencies in Japan, Kazakhstan,
South Africa
●
In Kenya higher incidencies reported in Western
Kenya
 Epidemiology

Total number of malignancies diagnosed at MTRH from 1st

January 1997 to December 31st 2001
1. Cancer of esophagus - 407
2. Cancer of cervix - 269
3. Leukemia - 187
4. Cancer of the breast - 158
5. Cancer of the liver - 156
6. Cancer of the prostate - 138
7. Cancer of the stomach - 133
8. Nasopharyngeal carcinoma - 86
●
M:F 1.5:1
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Mean Age 58.6 years (50 - 70)
●
6% are below 30 years, youngest 14 years – most
common in Kalenjin community
 Associated Factors
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Excessive alcohol consumption
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Tobacco smoking
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Nutritional deficiency
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Poor dental and oral hygiene
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Hot foods and drinks
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Fungal contamination of foods
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 Pre Existing Conditions
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Achalasia
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Barret's esophagus
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Chronic reflux esophagitis
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HPV
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Caustic burns
 Symptoms
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Progressive Dysphagia
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Hypersalivation
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Weight loss
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Regurgitation
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Odynophagia
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Halitosis
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Hoarsness
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Dyspnoea
 Signs
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Usually none
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Dehydration
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Signs of metastasis
 Work Up
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Lab Studies
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Imaging
– Barium Swallow
– OGD
– Endoscopic Ultrasound
– CT Scan
– Bronchoscopy
– Bone Scan
– Laparoscopy & Thorascopy
– PET
 Treatment
●
General health, fitness, co-morbid conditions
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Majority present in stage 3 & 4
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Can be paliative intent or curative intent
 Management
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Stage 0 – 1 Surgery alone
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Stage 2 – 3 Surgery plus neoadjuvant
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Stage 4 Palliative surgery, neoadjuvant
therapy, brachytherapy, photodynamic therapy,
immunotherapy
 Treatment – Curative Intent
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Tis / T1 presentation very rare
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Hence most require multimodal approach i.e
esophagectomy with neoadjuvant or adjuvant
treatment
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 Esophagectomy
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Operative approach depends on
– Histologic type
– Anatomic location
– Proposed extent of lymphadenectomy
 Approaches
●
Blunt transhiatal sub total esophagectomy
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Abdominothoraxic subtotal esophagectomy
(Tanner-Lewis)
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Mc Keown 3 phase
 Rationale – Histologic Type
Squamous CA – high rate of spread through
submucosal lymphatics hence transthoraxic en bloc
eophagectomy preffered with 2 or 3 field
lymphadenectomy.
●
Adenocarcinoma – transhiatal esophagectomy with
upper abdominal and infracarinal lymphadenectomy
 Anatomic Location
●
Cervical
– Difficult to resect
– T3 T4 can be down staged with RT/CT followed by
transthoraxic en bloc esophagectomy with gastric
tube or colon interposition
– Or local resction with jejunal inerposition
 Upper thoraxic
●
Metastasize to cervical, mediastinal and abdominal
lymph nodes
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Hence thoracoabdominal en bloc esophagectomy
with 2 or 3 field lymphadenectomy
●
With neoadjuvant therapy especialy if T4 for down
grading
 Lower Thoraxic
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Metastasize to mediastinal an abdominal lymph
nodes
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Thoraco abdominal esophagectomy with lymph
node dissection
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Celiac nodes - M1
 GEJ Tumours
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GEJ – 5cm proximal & distal to muscular limit
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Siewert's type 1 – 5cm proximal & 1cm proximal
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Siewert's type 2 – 1cm proximal & 2 cm distal
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Siewert's type 3 – 2cm distal & 5cm distal
 GEJ Tumours
●
Siewert's type 1 – spread through submucous
lymphatics. Transhiatal or thoracoabdominal
esophagectomy
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Siewert's type 2 – total gastrectomy with perigastric
lymph node dissection,
●
for extension into the esophagus – include
transhiatal distal esophagectomy
●
Siewert's type 3 – similar to above.
 Paliative Care
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Chemoradiotherapy
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Endoscopic
– Dilatation
– Injection therapy
– Thermal ablation
– Intubation
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By pass - retro or pre sternal
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Feeding gastrostomy or jejunostomy
 Endoscopic Treatment
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EMR
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PDT
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laser
 Chemotherapy
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Cisplatin based treatment with flourouracil
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Paclitaxel
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Anthracyclines
 Prognosis
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Without treatment – 3 to 4 months
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After surgery – 5 year survival 5 – 15 %
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After curative surgery
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1 year survival – 70%
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2 year survival – 30%
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5 year survival – 20 %