Oesophageal cancer is a disease that affects the esophagus. The document provides details about:
1) The anatomy, histology, blood supply, lymphatic drainage and functions of the esophagus.
2) Risk factors, symptoms, epidemiology, macroscopic and microscopic appearance of oesophageal cancer.
3) Diagnostic tests and staging of oesophageal cancer including endoscopy, imaging, and biopsy.
4) Treatment options for oesophageal cancer including surgery, chemotherapy, radiation therapy and palliative care based on the cancer stage. Prognostic factors and performance status scales are also discussed.
2. Anatomy of Oesophagus
• Muscular tube, approximately 25cm in length
• It originates at the inferior border of
the cricoid cartilage, C6, descends through
posterior mediastinum, extending to the
cardiac orifice of the stomach, T11
• Enters the abdomen by piercing the muscular
right crus of the diaphragm, through
the oesophageal hiatus at the T10 level.
3. • Diameter: Varies with bolus of food/ fluid passes
– At rest in adults 20 mm, At birth it is 5mm & at 5 yrs
it is 15mm
• Oesophagus is the narrowest region of alimentary
tract except vermiform appendix. During its course it
has three indentations:
– At 15 cm from incisor teeth is crico-pharyngues
sphincter (normally closed) (UES)
– At 25 cm aortic arch and left main bronchus
– At 40 cm where it pierces the diaphragm where a
physiological sphincter is sited (LES)
4. Cricopharyngeal constriction
Aortic & Bronchial constriction
Lower Oesophegal Splincture
Cervical Oesophagus: Right & Left
superior & inferior thyroid arteries.
Thoracic Oesophagus: Upto tracheal
bifurcation Right & Left inferior
thyroid Artery, below direct supply
from thoracic aorta (tracheo-
bronchial tree)
Abdominal Oesophagus 11 branches
of Lt gastric artery and Branches of
splenic artery posteriorly
5. Histology of Oesophagus
• Stratified Squamous epithelium
• The esophagus is a very thin-walled organ, measuring
about 2 mm wide
• Oesophageal wall has four layers: From in to out:
– Mucous Membrane,
– Sub-mucosa,
– Muscle coat and
– Outer most fibrous layer
• Unlike other areas of the gut, it does not have a
distinct serosal covering, but is covered by a thin layer
of loose connective tissue
7. Lymphatic drainage
• In the proximal third of the esophagus,
lymphatics drain into the deep cervical lymph
nodes,
• In the middle third, drainage is into the superior
and posterior mediastinal nodes.
• The distal-third lymphatics follow the left gastric
artery to the gastric and celiac lymph nodes
• Submucosal lymphatics explains, tumours may
extend long distance before obstructing lumen
8. Nerve supply
• Parasympathetic
– Vagus: secretomotor to glands
• Sympathetic
– From cervical & thoracic sympathetic chain
– Contraction of sphincters, wall relaxation, peristalsis
• Intramural
– Combination of all innervation from plexuses &
ganglia
– In muscular layers (myenteric or Auerbach’s plexus)
– In submucosa (Meissner plexus)
9. Functions
• Primary function: transport food material
from the pharynx to the stomach.
• Secondary functions:
constrain the amount of air that is swallowed
constrain the amount of material that is refluxed
10. Symptoms of Oesophageal disease
• Difficulty in Swallowing described as food or
fluid sticking (oesophegal dysphagia)
– Must rule out malignancy
• Pain on Swallowing (odenophagia)
– Suggest inflamation and ulceration
• Regurgitation or reflux (heartburn)
– Common in GERD
• Chest Pain
– Difficult to distinguish from cardiac pain
11. Epidemiology of Carcinoma Oesophagus
• Worldwide, an estimated 455,800 new cases of
esophageal cancer is diagnosed each year
• Estimated 400,200 deaths occurred
• Seventh leading cause of death
• Risk increases with age
o Mean age at diagnosis 67yrs
• Lifetime risk
– 0.7% for men
– 0.3% for women
12. Changing trends
• Until the 1970s
– Squamous Cell Carcinoma 75%
– Adenocarcinoma 25%
• Past 20-30yrs
– Incidence of SCC has decreased both in Asian and
Caucasian
– Incidence of Adenocarcinoma increased by 45% in
Caucasian and 40% in Asian
– In 2002 60% of all esophageal cancers were
adenocarcinoma.
13. • Adenocarinoma : 75% carcinoma in distal
oesophagus
• Squamous Cell Ca: mostly in upper and middle
oesophagus.
• AT DIAGNOSIS: More than 50% have
unresectable tumors or radiographically
visible metastasis
14. Macroscopic appearance
• polypoid/fungating (most common)
– sessile/pedunculated tumour
– lobulated surface protruding
– irregular, polycyclic, overhanging, step-like "apple
core" lesion
• ulcerating: large ulcer within bulging mass
• infiltrating: gradual narrowing with a smooth
transition
• superficial spreading carcinoma
15. Risk Factor
• Male Gender (3:1- SCC, 15:1- adeno)
• Tobacco use (squamous cell carcinoma)
• Alcohol use (squamous cell carcinoma)
• GERD and Barrett esophagus (adenocarcinoma)
• Hiatal hernia (adenocarcinoma)
• Past history of esophageal, oral, or pharyngeal
cancer (squamous cell carcinoma)
• Low socioeconomic status
• High-temperature beverages and foods
(squamous cell carcinoma)
• Corrosive injury (SCC)
16. Risk Factor
• Obesity (adenocarcinoma)
• Human papillomavirus (squamous cell carcinoma)
• Achalasia (squamous cell carcinoma)
• Nitroglycerin, anticholinergics, beta-adrenergics,
aminophyllines, benzodiazepines
(adenocarcinoma)
• Vitamin and mineral deficiencies (squamous cell
carcinoma)
• Low intake of fresh fruit and vegetables
• Poor oral hygiene
17. Tobacco smoking
• Carcinogens, such as polycyclic aromatic
hydrocarbons, nitrosamines, and acetaldehyde,
which are present in tobacco smoke.
• Tobacco use is more strongly associated with
Oesophageal SCC (a 3-fold to 7-fold increase in
risk) than it is with Oesophageal Adenocarcinoma
(a 2-fold increase).
• Synergistic effect: Individuals drinking >1.5
bottles of wine and smoking 10 to 30 cigarettes
daily have about a 150-fold increased risk of
esophageal cancer.
18. • Alcohol consumption
Excessive alcohol consumption (3 or more drinks
per day) is one of the strongest predisposing
factors to developing Oesophageal SCC.
It typically increases the risk 3-fold to 5-fold.
• Dietary factors
Diets high in total fat, saturated fat, and
cholesterol seem associated with an increased risk
of this cancer.
Antioxidant supplements are effective in
decreasing gastrointestinal cancers.
19. Barrett Oesophagus
• Stratified squamous epithelium that normally
lines the distal esophagus is replaced by
abnormal columnar epithelium, (metaplasia)
• Caused by longstanding gastroesophageal reflux,
and is considered a premalignant condition for
the development of adenocarcinoma
• Increasing frequency, duration, and severity of
reflux symptoms are positively associated with
the risk of developing EA
20. Clinical Symptoms
• Dysphagia
• Odynophagia
• Weight loss
• Less often: Dyspnea, cough, hoarseness and
pain in retro-sternal, back or right upper
abdominal
• Metastatic Disease: Lymphadenopathy
(Virchow’s node), hepatomegaly, pleural
effusion
21. 1st investigation of choice is UGI
endoscopy
• Allows assessment of any obstruction, and
biopsy to confirm the histology of mucosal
lesions.
• Confocal laser endoscopy with targeted biopsy
can improve the diagnostic yield for neoplasia
24. Radiology
• A combination of CT scan, transoesophageal
ultrasound and PET/CT scan are used for staging of
the disease.
• CT is the best initial modality for detection of the
distant metastasis, gross direct invasion, and
enlarged lymph nodes.
• Ultrasound is the most sensitive modality for
assessment of the depth of invasion and regional
enlarged lymph nodes.
• PET can be useful for re-staging after the initial
neoadjuvant therapy
25. Esophagogram (Barium Enema)
Showing a Malignant Esophageal
Stricture
• irregular stricture
• pre-stricture dilatation with
'hold up'
• shouldering of the stricture
26. CT scan of the chest and abdomen
• Performed if the suspicion of esophageal cancer is
high or biopsy confirms the diagnosis.
• The CT scan plays a key role in assessing tumor bulk
and in monitoring tumor response to therapy.
• CT can define whether the tumor has spread from
the esophagus to regional lymph nodes and/or
contiguous structures, and indicate the presence of
distant metastases.
27. Endoscopic US
• It is the most accurate imaging modality for
the T staging of oesophageal cancer
• It defines the layers of the oesophageal wall
hence can differentiate T1, T2, and T3 tumors
28. TREATMENT
• Treatment of oesophageal cancer need a
team of doctors and expers.
• Pathologist: an expert in testing tissue to find
disease
• Radiologist: an expert in reading imaging tests
• Surgeon: an expert in oesophageal surgery.
• Medical oncologist
• Radiation oncologist
29. • Integrative medical doctor: an expert in
mind-body treatment
• Nutritionist: an expert in food and drinks
• Nurses: an expert trained to care for the
sick
30. TNM Staging
• T staging – depth of invasion of tumor
• Tx: primary tumour cannot be assessed
• T0: no evidence of primary tumour
• Tis: high - grade dysplasia
• T1: invades lamina propria, muscularia
mucosa or submucosa
– T1a: invades lamina propria or muscularis mucosae
– T1b: invades submucosa
• T2: invades muscularis propria
• T3: invades adventitia
• T4: direct extension into adjacent structures
– T4a: (resectable) invades pleura, pericardium or diaphragm
– T4b: (unresectable) invades other structures,
e.g. aorta, trachea
33. TNM staging
M Staging
• Mx: metastatic disease cannot be assessed
• M0: no distant metastases
• M1: distant metastases
34. Histologic grade (G)
• GX - Grade cannot be assessed ( often because
there’s not enough tissue)
• G1 - Well differentiated (cancer cells look similar
to healthy cells)
• G2 - Moderately differentiated (cancer cells looks
somewhat different from healthy cells)
• G3 - Poorly differentiated ( cancer cells barely
looks like healthy cells)
• G4 - Undifferentiated ( cancer cells don’t look
anything like healthy cells)
37. Predictorsof prognosis.
• Staging of disease at diagnosis
• Weightloss of more than 10 percent of body
mass
• Dysphagia
• Largetumors
• Advanced age
• lymphatic micrometastases (identified by
immunohistochemical analysis)
38. • At the time of diagnosis around 2/3 of all
patient with Oesophageal cancer will already
have incurable disease.
• The aim of Palliative treatment is to overcome
debilitating or distressing symptoms while
maintaining the best quality of life possible for
the patient ( i.e restore swallowing)
39. Treatment of cancer esophagus
InoperableOperable
Palliative
procedure
Radical surgery
followed by
chemoradiotherapy
40. Overview of treatment
• Endoscopic treatment
• Surgical treatment
• Radiation therapy
• Chemotherapy
• Supportive Care
41. Endoscopic treatment
• Tumors confined to the first layer of the
esophageal wall i.e T stage: Tis and T1
• Endoscopic treatment for esophageal cancer
includes endoscopic mucosal resection
endoscopic resection
endoscopic submucosal dissection
Ablation : cryoablation, Radiofrequency
ablation, photodynamic ablation
42. Surgical treatment
• The goal of surgery is to remove entire tumor
and some normal looking tissue around it.
• Esophagectomy removes some or the entire
esophagus along with nearby lymph nodes &
depends on the cancer stage.
• Esophagogastectomy removes lower
esophagus, upper stomach and nearby lymph
nodes.
43. Types of esophagectomies
• Transhiatal
• Exposure is provided by an
upper midline laparotomy and
a left neck incision.
• The thoracic esophagus is
bluntly dissected, and a
cervical anastomosis created;
thoracotomy is not required.
• Drawbacks: inability to
perform a full thoracic
lymphadenectomy, and lack of
visualization of the
midthoracic dissection.
• Transthoracic
• The Ivor Lewis esophagectomy
combines a laparotomy with
right thoracotomy, and
produces an intrathoracic
anastomosis.
• This technique permits direct
visualization of the thoracic
esophagus, and allows the
surgeon to perform a limited
lymphadenectomy.
**McKeown esophagectomy involves cut in chest, abdomen and neck
44. Radiotherapy
• Radiotherapy : In patient with SCC of
esophagaus and poor surgical candidates
– Advantage: avoidance of perioperative morbidity
and mortality
– Not as effective palliative maneuver as surgery for
dysphagia and odynophagia
– higher probability of local complications like
esophagotracheal fistula
45. Chemotherapy
• Chemotheraptic durgs commonly used are
Cisplatin, 5-Fluorouracil, etoposide,
Irinotecan, Paclitaxel, Epirubicin, carboplatin
etc
• Regimens
Cisplatin and 5 FU
Paclitaxel and Carboplatin
Irinotectan and Carboplatin
52. Review of treatment
• Endoscopic treatment is preferred for Tis and
T1a tumors
• For T1b tumors esophagectomy is
recommended if surgery is possible. If not,
endoscopic treatment. After an esophagectomy
chemotherapy recommended.
• Invasive cancers are often treated with
chemoradiation and later esophagectomy.
53. • Follow up after treatment is mandatory and
blood and imaging investigations to do done.
• Cancer that return after local treatment near
to esophagus may be curable with surgery or
chemo radiation.
• Cancer that is unable to be cured can be
treated with supportive care.
54. ECOG (Eastern Cooperative Oncology
group) Performance Status.
• scales and criteria used to assess how a patient's
disease is progressing, assess how the disease
affects the daily living abilities of the patient, and
determine appropriate treatment and prognosis.
• grade 0: fully active, able to carry on all pre-
disease performance without restriction
• grade 1 : restricted in physically strenuous activity
but ambulatory and able to carry out work of a
light or sedentary nature, e.g., light house work,
office work
55. • grade 2 : ambulatory and capable of all
selfcare but unable to carry out any work
activities, up and about more than 50% of
waking hours
• grade 3 : capable of only limited selfcare,
confined to bed or chair more than 50% of
waking hours
• grade 4 : completely disabled, cannot carry on
any selfcare, totally confined to bed or chair
• grade 5 : dead
59. Supportive Therapy
• Pain relief with opiates
• Psychological support- patient is anxious and
worried and needs lot of moral and mental
support by family, friends, psychiaterist.
60. Nutrition
• Diet modification is needed.
• Nasogastric feeding or jejunal feeding before
stenting. Stent placement is recomended for
palliative treatment.
• Protein and albumin should be corrected.
• Carbohydrate and fat supplementation
62. Conclusion
• The literature suggests that preoperative
chemoradiotherapy followed by surgery
results in optimal outcome while managing
locally advanced esophageal cancer.
64. • The results from this trial reflect a long-term
survival advantage with the use of
chemoradiotherapy followed by surgery in the
treatment of esophageal cancer, and support
trimodality therapy as a standard of care for
patients with this disease.
Conclusion
65. • During the past decade, outcomes with surgery
have improved resulting in a better 5 year survival
due to:
–Better staging techniques
–Improved surgical technique
• Recent Data
–Rate of curative resection : 54 to 69%
–Rate of operative mortality :4 to 10%
–perioperative complications : 26 to 41%
66. References
• Bailey and Love’s Short Practice of
Surgery
• Sabiston Textbook of Surgery
• UpToDate
• Medscape
• NCCN Guidelines of Esophageal
carcinoma