Esophageal Cancer

Background
Esophageal carcinoma was well described at the
beginning of the 19th century, and the first
successful resection was performed in 1913 by
Frank Torek

In the 1930
Ohsawa in Japan and
Marshall in the United States
were the first to perform successful 1-stage
transthoracic esophagectomies With continent
reconstruction
 Esophageal Cancer

Pathophysiology
Esophageal carcinoma arises in the mucosa

►Subsequently, it tends to invade the:

* submucosa and
* muscular layers
► and, eventually, contiguous structures such as the:
* tracheobronchial tree
* aorta or
* recurrent laryngeal nerve
 Esophageal Cancer

Pathophysiology
The tumor also tends to metastasize to the:
* periesophageal lymph nodes and
* eventually, to the:
* liver
* lungs or
* both
Physiopathology: cascades of events to cancer:
 Esophageal Cancer

Frequency
The incidence of esophageal carcinoma is approximately
3-6 cases per 100,000 persons, although certain
endemic areas appear to have higher per-capita rates
 Esophageal Cancer

Sex
Esophageal cancer is generally more common in
men than in women, with a male-to-female ratio of
7:1

Age
Esophageal cancer occurs most commonly during
the sixth and seventh decades of life

?? History ►
 Esophageal Cancer

Clinical Presentation
History
(1) Dysphagia
Is the most common presenting symptom
 Esophageal Cancer

Clinical Presentation
History
(1) Dysphagia
Is initially experienced for solids, but eventually it
progresses to include liquids
 Esophageal Cancer

Clinical Presentation
History
A complaint of dysphagia in an adult should always
prompt an ► endoscopy to help rule out the
presence of esophageal cancer

A barium swallow study is also indicated

 Esophageal Cancer

Clinical Presentation
History
(2) Weight loss
** Is the second most common symptom and
occurs in more than 50% of people with esophageal
carcinoma
 Esophageal Cancer

Clinical Presentation
History
►(3) Pain
Can be felt in the:
* epigastric or
* retrosternal area

► It can also be felt over bony structures, representing

a sign of metastatic disease
 Esophageal Cancer

Clinical Presentation
History
(4) Hoarseness
Caused by invasion of the recurrent laryngeal nerve
is a sign of unresectability
 Esophageal Cancer

Clinical Presentation
History
(5) Respiratory symptoms
Can be caused:
1) by aspiration of undigested food or

2) by direct invasion of the tracheobronchial tree by the

tumor

► The latter also is a sign of unresectability

 Esophageal Cancer

Clinical Presentation
Physical Examination
The goals of the workup are to establish the:
* diagnosis and to
* stage the cancer

The examination findings are often normal

 Esophageal Cancer
Clinical Presentation
Physical Examination
Lymphadenopathy in the:
* laterocervical or
* supraclavicular areas
represents metastasis

and, if confirmed by:

* needle aspiration or
* biopsy findings
is a contraindication to surgery
 Esophageal Cancer

Causes
The etiology of esophageal carcinoma is thought to be
related to exposure of the esophageal mucosa to:
noxious or
toxic stimuli
► resulting in a sequence of:
1) dysplasia ► 2) to carcinoma in situ►3)to carcinoma
 Esophageal Cancer
Causes
Potential contributing factors for squamous cell
carcinoma include the following:
1) Chronic ingestion of:
hot liquids or
foods is a contributing factor

2) Vitamin or
nutritional deficiencies
have been recognized as contributing factors

3) Poor oral hygiene may lead to esophageal cancer

 Esophageal Cancer
Causes (Potential contributing factors)
3) Exposure to:
nitrosamines in the environment or
food
has been linked to esophageal cancer

4) In Western cultures:
cigarette smoking and
chronic alcohol exposure
are the most common etiological factors for
squamous cell carcinoma
 Esophageal Cancer

Causes (Potential contributing factors)

5) Certain medical conditions e.g.:
* Plummer-Vinson syndrome and
* caustic injury to the esophagus
are associated with an increased incidence of esophageal
cancer

6) Human papilloma virus infection

has been recognized as a contributing factor
Causes

GERD is the most common predisposing factor for

adenocarcinoma of the esophagus

As a consequence of the irritation caused by the reflux of acid

and bile, 10-15% of patients who undergo endoscopy for
evaluation of GERD symptoms are found to have Barrett
epithelium

The risk of adenocarcinoma among patients with Barrett

metaplasia has been estimated to be 30-60 times that of the
general population
 Esophageal Cancer
Differential Diagnosis
1) Achalasia
2) Esophageal Stricture

Fig: Barium swallow demonstrating stricture due to

cancer
 Esophageal Cancer
Workup
Lab examinations
Complete blood cell count may demonstrate anemia
secondary to:
iron deficiency or
chronic disease

► Liver function tests

►Patients with squamous cell carcinomas may

demonstrate hypercalcemia
 Esophageal Cancer

Workup
Lab examinations
PT and aPTT
study findings may demonstrate:
hepatic insufficiency or
nutritional deficiencies

And are part of preoperative screening

 Esophageal Cancer
Workup
Imaging Studies
Barium swallow is very sensitive for helping
detect strictures and intraluminal masses
 Esophageal Cancer
Workup
Imaging Studies
Performing esophagogastroduodenoscopy
allows:
direct visualization and
biopsies of the tumor
 Esophageal Cancer
Workup
Imaging Studies
Endoscopic ultrasound is the most sensitive test to help
determine the:

*the depth of penetration of the tumor (T staging) and

*the presence of enlarged periesophageal lymph nodes (N

staging)
 Esophageal Cancer
Workup
Imaging Studies
* abdominal and
* chest CT scans
are useful to help exclude the presence of
metastases (M staging) to the:
* lungs and
* liver
and may be useful to help determine if adjacent
structures have been invaded
 Esophageal Cancer

Workup
Imaging Studies
Bronchoscopy
is indicated for cancers of the:
* middle and
* upper third of the thoracic esophagus
to help exclude invasion of the:
* trachea or
* bronchi
 Esophageal Cancer
Workup
Imaging Studies
Bone scan is indicated in patients with complaints
suggestive of bone metastases

laparoscopy and thoracoscopy

have a greater than 92% accuracy in staging regional
nodes
 Esophageal Cancer

Workup
Imaging Studies
A new modality for staging is positron emission
tomography scanning (PETS)
 Esophageal Cancer

Treatment
Medical Care
Nonoperative therapy is usually reserved for
patients who have:
1) esophageal carcinoma and
2) are not candidates for surgery
 Esophageal Cancer

Treatment
Medical Care
The goal of therapy for these patients is palliation
of dysphagia, allowing them to eat

A single best method of palliation cannot be applied

to every situation
Treatment
Medical Care
The most appropriate method to control dysphagia
should be tailored for each patient individually,
depending on:

► tumor characteristics

► patient preference and

► the specific expertise of the physician

Treatment
Medical Care
The following treatment modalities are available
to help achieve this goal:

* Chemotherapy
* Radiation therapy
* Laser therapy
* Intubations with expandable:
metallic or
plastic stents
 Esophageal Cancer

Treatment
Surgical Care
Esophageal resection (esophagectomy) remains a
crucial part of the treatment of esophageal cancer

It is used in patients who are considered candidates for

surgery
 Esophageal Cancer
Treatment
Surgical Care
1) Pull up with esophagogastric anastomosis

2) Colon interposition
 Esophageal Cancer
Treatment
Surgical Care
Complications occur in approximately 40% of
patients

1) Respiratory complications (15-20%) include:

* atelectasis
* pleural effusion and
* pneumonia
 Esophageal Cancer

Treatment
Surgical Care
2) Cardiac complications (15-20%) include:
* cardiac arrhythmias and
* myocardial infarction

3) Septic complications (10%) include:

wound infection
anastomotic leak and
pneumonia
 Esophageal Cancer

Treatment
Surgical Care

► Anastomotic stricture may require dilatation (20%)

►The mortality rate depends on:

a) the functional status of the patient and
b) the experience of the surgeon and
c) the team taking care of the patient
 Esophageal Cancer

Prognosis
Survival depends on the:
1) stage of the disease
2) lymph node metastases or
3) solid organ metastases
Tumor Stage
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