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Oesophageal Cancer
Dr ROJAN ADHIKARI
FCPS II RESIDENT
GENERAL SURGERY
KATHMANDU MODEL HOSPITAL
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.
• 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)
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
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
Esophageal cancer
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
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)
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
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
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
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.
• 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
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
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)
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
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.
• 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.
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
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
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
Esophageal cancer
Esophageal cancer
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
Esophagogram (Barium Enema)
Showing a Malignant Esophageal
Stricture
• irregular stricture
• pre-stricture dilatation with
'hold up'
• shouldering of the stricture
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.
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
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
• 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
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
Esophageal cancer
TNM Staging
N staging
• Nx: regional nodes cannot be assessed
• N0: no regional lymph node metastases
• N1: 1-2 regional nodes involved
• N2: 3-6 regional nodes involved
• N3: >7 regional nodes involved
TNM staging
M Staging
• Mx: metastatic disease cannot be assessed
• M0: no distant metastases
• M1: distant metastases
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)
Esophageal cancer
Esophageal cancer
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)
• 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)
Treatment of cancer esophagus
InoperableOperable
Palliative
procedure
Radical surgery
followed by
chemoradiotherapy
Overview of treatment
• Endoscopic treatment
• Surgical treatment
• Radiation therapy
• Chemotherapy
• Supportive Care
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
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.
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
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
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
TREATMENT OF SQUAMOUS CELL
CARCINOMA
OF ESOPHAGUS
Early SCC
Stage O
Stage IA
Stage IB
Invasive SCC
TREATMENT FOR ADENOCARCINOMA
ESOPHAGUS
Initial Stages Adenocarcinoma
Invasive Stages Adenocarcinoma
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.
• 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.
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
• 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
Supportive
Supportive Care
• Methods to releive dysphagia
 Intubation
1. Intra esophageal tubes-Souttar Celestin, Atkinson,
MB tube, Proctor Livingstone
2. Expanding Stents
 Laser therapy – Photodynamic therapy
 Radiation- Brachytherapy
 Bipolar Diathermy
 Balloon dilatation
 Alcohol injection
Stent
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.
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
Esophageal cancer
Conclusion
• The literature suggests that preoperative
chemoradiotherapy followed by surgery
results in optimal outcome while managing
locally advanced esophageal cancer.
Esophageal cancer
• 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
• 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%
References
• Bailey and Love’s Short Practice of
Surgery
• Sabiston Textbook of Surgery
• UpToDate
• Medscape
• NCCN Guidelines of Esophageal
carcinoma
THANK YOU

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Esophageal cancer

  • 1. Oesophageal Cancer Dr ROJAN ADHIKARI FCPS II RESIDENT GENERAL SURGERY KATHMANDU MODEL HOSPITAL
  • 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
  • 32. TNM Staging N staging • Nx: regional nodes cannot be assessed • N0: no regional lymph node metastases • N1: 1-2 regional nodes involved • N2: 3-6 regional nodes involved • N3: >7 regional nodes involved
  • 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
  • 46. TREATMENT OF SQUAMOUS CELL CARCINOMA OF ESOPHAGUS
  • 47. Early SCC Stage O Stage IA Stage IB
  • 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
  • 57. Supportive Care • Methods to releive dysphagia  Intubation 1. Intra esophageal tubes-Souttar Celestin, Atkinson, MB tube, Proctor Livingstone 2. Expanding Stents  Laser therapy – Photodynamic therapy  Radiation- Brachytherapy  Bipolar Diathermy  Balloon dilatation  Alcohol injection
  • 58. Stent
  • 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