Transcript esophageal cancer

ESOPHAGEAL CARCINONA
Anatomy Of Esophagus
Anatomy Of Esophagus
Anatomy Of Esophagus
Anatomy Of Esophagus
Histology Of Esophagus
Esophageal Cancer
Esophageal cancer is the seventh leading cause
of cancer death worldwide. Incidence of
esophageal carcinoma can be as high as 30-800
cases per 100,000 persons in particular areas of
northern China, some areas of southern Russia,
and northern Iran. Unlike in the United States,
squamous cell carcinoma is responsible for 95%
of all esophageal cancers worldwide.
Esophageal Cancer
Esophageal cancer is generally more common in
men than in women, with a male-to-female ratio
of 3-4:1.
Esophageal cancer occurs most commonly
during the sixth and seventh decades of life.
The disease becomes more common with
advancing age; it is about 20 times more
common in those older than 65 years than in
persons younger than 65 years.
Risk Factors
A- Dietary Factors
1-deficiency of Vitamins(A,C,B1,2,6)
2-deficiency of trace elements(Zinc)
3-Fungal contamination of foodstuffs
4-High contents of nitrites/nitrosamines
B-Lifestyle
1-burning hot beverages or foods
2-Alcohol consumption
3-Tobacco use
Risk Factors
C- Precancerous conditions
1-Barrett Esophagus
2-Tylosis palmaris
3-Achalasia cardia
4-Plummer-Vinson Syndrome
5-Caustic Strictures
D- Genetic Predisposition
1-Ectodermal dysplasia (Ectodermal
dysplasia is a group of conditions in which there
is abnormal development of the skin, hair, nails,
teeth, or sweat glands.)
Risk Factors
2- Racial Predisposition
• Areas of northern China ( Linxian in Henan
province ), some areas of southern Russia, and
northern Iran.
3-Epidermolysis bullosa
(Epidermolysis bullosa (EB) is a group of
inherited bullous disorders characterized by
blister formation in response to mechanical
trauma).
TYLOSIS PALMARIS
Epidermolysis Bullosa
Esophageal ring
Caustic strictures
Types Of Cancer
•
Squamous cell Carcinoma
( cigarette smoking and alcohol )
•
Adenocarcinoma
( GERD )
Types Of Cancer
By far the commonest type is Squamous cell
carcinoma comprising about 90-95% of all
esophageal carcinomas outside united States.
In US Adenocarcinoma contribute to about
50% of all esophageal carcinomas.
Incidence of Adenocarcinoma is increasing
throughout the world with a concomitant
increase in the incidence of GERD, the link being
the Barrett esophagus.
Squamous Cell Carcinoma
Sites
50% in the Middle 1/3
20% in the upper 1/3
30% in the lower 1/3
Patterns
1-polypoid exophytic lesions- 60%
2-diffuse infiltrative type - 15%
3-Excavated(Ulcerated type) - 25%
Clinical Features
1- Dysphagia
The most common presenting
symptom.Dysphagia is initially experienced for solids,
but eventually it progresses to include liquids.
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.
2- Weight loss is the second most common
symptom and occurs in more than 50% of people with
esophageal carcinoma
Clinical Features
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.
4- Hoarseness caused by invasion of the recurrent
laryngeal nerve is a sign of unresectability. Patients
may have a persisting cough.
5- Respiratory symptoms can be caused by
aspiration of undigested food or by direct invasion of
the tracheobronchial tree by the tumor. The latter is
also a sign of unresectability.
Physical Finings
The examination findings are often normal.
Emaciation i-e weight loss and weakness.
Pallor- due to chronic anemia due to bleeding
Hepatomegaly may result from hepatic metastases.
Lymphadenopathy in the laterocervical or
supraclavicular( Troisier’s sign ) areas represents
metastasis and, if confirmed by needle aspiration or
biopsy findings, is a contraindication to surgery.
Spread
1- Local or Direct spread
The cancer starts as mucosal ulceration which
spreads to submucosa. The spread occurs transversely
and longitudinally. Once it invades all the layers, the
structures in the vicinity are involved.
Trachea- Tracheo-esophageal fistula develops from
invasion of trachea in case of carcinoma upper 1/3 .
Bronchi- Trancheo-bronchial fistula from carcinoma
middle 1/3.
Aorta- Esophago-aortic fistula Results in massive
bleeding( one of the cause of death ).
Spread
2- Lymphatic
Cervical part drains into Left and Right
Supraclavicular nodes .
Thoracic part drain into Tracheo-esophageal
Para-esophageal nodes.
Abdominal part drain into Nodes along the
lesser curvature and then into celiac nodes.
Accordingly Lymphatic spread may occur into these
nodes according to the site of involvement of
esophagus.
Spread
3- Hematogenous
It results in secondary deposits in Liver which
clinically appears as Nodular Enlarged Liver.
Later, Ascitis and recto-vesical deposits occur.
Investigations
1- CBC may show Anemia
2- LFTs – if secondaries in liver occur –Increased ALP
3- USG abdomen done to r/o liver secondaries, lymph
nodes in the porta hepatis, celiac nodes etc.
4- Barium swallow demonstrates irregular persistent
intrinsic filling defects.
5- esophagoscopy to visualize the growth and to take
biopsy.
6- Multiple biopsies- in high risk areas like China
Endoscopic staining with supravital dyes
(indigocarmine)is done 2 identify dysplasticepithelium
Investigations
7- CXR to r/o aspiration pneumonia and mediastinal
widening and posterior tracheal indentation.
8- Bronchoscopy to r/o involvement of bronchus.
9- CT-Scan of chest to find out local infilteration. It is
very useful before doing esophagectomy to asses the
vital structures involvement like bronchus,airway etc.
10- Endoscopic Ultrasound to know the depth of the
wall involvement,to detect mediastinal lymph nodes
etc.
Endoscopic Ultrasound
Treatment
Non-Surgical
Majority of esophageal cancers are
advanced at the time of diagnosis. In such
situation the goal of treatment is Palliation
of Dysphagia allowing the patients to eat.
Various modalities are available.
1- Radiotherapy
successful in relieving dysphagia in
about 50% of cases combined with chemo.
2- Laser therapy
Can help achieve temporary relief of
dysphagia in as many as 70% of patients. Multiple
sessions are usually required.
3- Chemotherapy
Chemotherapeuting agents with promising
response are Cisplatin,5-FU and Paclitaxel.
4- Photodynamic therapy
offer an interesting non-surgical form of
therapy.Activation of photosensitizer by Light in the
desired area which causes biologic damage to
abnormal tissue.
5- Metallic self expandable stents are currently the
choice of tubes to relieve Dysphagia.
Surgical Treatment
Esophageal resection (esophagectomy) remains a
crucial part of the treatment of esophageal cancer. It
is used in patients who are considered candidates for
surgery.
An esophagectomy can be performed by using an
abdominal and a cervical incision with blunt
mediastinal dissection through the esophageal hiatus
i-e transhiatal esophagectomy [THE] or by using an
abdominal and a right thoracic incision i-e
transthoracic esophagectomy [TTE].
T-H-E
Trans-haital esophagectomy is usually done in a
mobile growth of Lower 1/3 of Esophagus without
Thoracotomy.
Esophagus and part of stomach and the
involved lymph nodes are removed F/B Gastric pull-up
And anastomosis in neck.
THS
T-T-E ( Ivor-Lewis Operation)
After exploring the peritoneal cavity for metastatic disease (if metastases are found,
the operation is not continued), the stomach is mobilized. The right gastric and the
right gastroepiploic arteries are preserved, while the short gastric vessels and the left
gastric artery are divided.
Next, the gastroesophageal junction is mobilized, and the esophageal hiatus is
enlarged. A pyloromyotomy is performed, and a feeding jejunostomy is placed for
postoperative nutritional support.
After closure of the abdominal incision, the patient is repositioned in the left lateral
decubitus position and a right posterolateral thoracotomy is performed in the fifth
intercostal space
The azygos vein is divided to allow full mobilization of the esophagus. The stomach is
delivered into the chest through the hiatus and is then divided approximately 5 cm
below the gastroesophageal junction.
An anastomosis (hand-sewn or stapled) is performed between the esophagus and the
stomach at the apex of the right chest cavity. Then, the chest incision is closed.
McKeown Operation
Three phase esophagectomy which is more appropriate for more proximal tumors.It
also Permits Lumphadenectomy in this region.
TTE
Causes of Death
•
•
•
•
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1- cancer cachexia
2- bronch-pleural fistula
3- aspiration pneumonia
4- hematemesis due to erosion of aorta
5- perforation of growth and mediastinitis
•
5-Year Survival Rate
• After curative resection is Around 10%