Esophageal carcinoma
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Benign tumors of the esophagus include leiomyomas, cysts, and polyps. Leiomyomas are the most common benign tumor, usually occurring in the lower two-thirds of the esophagus in males. Esophageal cysts often present in childhood and are located along the right side. Malignant esophageal tumors are usually advanced at diagnosis and involve the muscular wall. Squamous cell carcinoma is most common and risk factors include smoking and alcohol. Diagnosis involves endoscopy with biopsy and imaging such as CT scan. Treatment options include surgery, chemotherapy, and radiation, but long-term survival remains low given late-stage presentation.
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Esophageal carcinoma
- 1. Tharindu Gunasiri group 1 TUMORS OF THE ESOPHAGUS
- 2. Benign Esophageal Tumors and Cysts • Benign tumors are rare (< 1 %) • Classified in two groups – Mucosal – Extramucosal (intramural) • More useful classification: – 60% of benign neoplasms are leiomyomas – 20% are cysts – 5% are polyps – Others (< 2 percent)
- 3. Leiomyomas • Most common benign tumor of the esophagus • Intramural in the circular muscle layer • Average age at presentation is 38; twice as common in males • 90% occur in lower 2/3 of esophagus • Obstruction and regurgitation may occur in large lesions • Dx: – barium swallow is the most useful method – CXR – endoscopy • Tx: majority can be removed by simple enucleation; large tumors or those involving the GEJ may require esophageal resection
- 4. Esophageal Cysts • Arise as diverticula of the embryonic foregut of this cyst present in childhood • Over 60% are located along the right side of the esophagus • Enteric and bronchogenic cysts are the most common • 60% present in the first year of life with either respiratory or esophageal symptoms • Cyst found in the upper third of the esophagus present in infancy while lower third lesions present later in childhood • Surgical excision by enucleation is the preferred treatment
- 5. Pedunculated Intraluminal Tumors (Polyps) • Benign polyps are rare • Usually occur in older men and may cause intermittent dysphagia • Are sometimes easily missed with barium swallow and esophagoscopy
- 6. Malignant Tumors of the Esophagus • Usually are in advanced stages at the time of diagnosis (involving the muscular wall and extending into adjacent tissues) • Alcohol consumption and cigarette smoking seem to be the most consistent risk factors • Esophageal squamous cell carcinoma (95% of all esophageal cancers) is a disease of men (5: 1) • Squamous cell esophageal cancer occurs least frequently in the cervical esophagus and • Squamous cell esophageal cancer occurs most often in the upper and midthoracic segments
- 7. Malignant Tumors of the Esophagus • Adenocarcinoma constitute approximate 8% of primary esophageal cancers • Most often occur in the distal third of the esophagus in the 6th decade of life, but now occurs not only more frequently but in younger patients and is often detected at an earlier stage • Male to female ratio is 3:1 • Patients with Barretts metaplasia are 40 times more likely to develop adenocarcinoma • These tumors are aggressive as well
- 8. Clinical Presentation • Dysphagia is the presenting complaint in 80- 90% of patients with esophageal carcinoma • Early symptoms are sometimes nonspecific retrosternal discomfort or indigestion • As the tumor enlarges, dysphagia becomes more progressive. • Later symptoms include weight loss, odynophagia, chest pain and hematemesis
- 9. Diagnosis • Barium swallow has 92% accuracy – Identify abn peristalsis, mucosal irregularity and annular constructions • Fiberoptic endoscopy with biopsy and washings is confirmatory in 95% of cases • Bronchoscopy with biopsyto r/o involvement of bronchus in upper 2/3 tumors and synchronous lung primary • Nasopharyngoscopy and direct laryngoscopy to r/o synchronous head and neck lesions and vocal cord involvement • CT scan of chest with extension to liver and adrenals to assess tumor spread
- 10. Staging of Tumors • Endoscopic ultrasound-to define the depth of invasion and presence of paraesophageal lymph nodes • Chest x-ray ± abnormal findings • CT scan (most widely used and now standard radiographic means of a staging) • Bronchoscopy for tumors which are proximal to the trachea
- 11. The TNM classification • (a) “T” (depth of invasion of the primary tumor). • (b) “N” (regional lymph involvement). • (c) “M” (presence or absence of distant metastases).
- 12. Primary Tumors (T) • Tx Primary tumor cannot be assessed (cytologically positive tumor not evident endoscopically or radiographically) • T0 No evidence of primary tumor (e.g., after treatment with radiation and chemotherapy) • Tis Carcinoma in situ • T1 Tumor invades lamina propria or submucosa, but not beyond it • T2 Tumor invades muscularis propria • T3 Tumor invades adventitia • T4 Tumor invades adjacent structures (e.g., aorta, tracheobronchial tree, vertebral bodies, pericardium)
- 13. Regional Lymph Nodes (N) A. Nx Regional nodes cannot be assessed B. N0 No regional node metastasis C. N1 Regional node metastasis
- 14. Distant Metastasis (M) 1. M0 No metastasis 2. M1 Distal metastasis
- 15. Stage Grouping STAGE T N M Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage IIA T2 T3 N0 N0 M0 M0 Stage IIB T1 T2 N1 N1 M0 M0 Stage III T3 T4 N1 N1 M0 M0 Stage IV Any T Any N M1
- 16. Treatment • Local tumor invasion or distant metastatic disease precludes cure. • Esophageal Ca is a systemic disease when it is diagnosed; local therapy (radiation or operation) is simply unable to eradicate this malignancy. • The 5-year survival rate in Western countries from esophageal Ca treated by either radiation or surgery is generally < 10% • More than 80% of the patients die within 1 year of diagnosis. Consequently, until very recently, the primary aim of therapy for esophageal carcinoma has been palliation (restoring the patient's ability to swallow). • Esophageal Ca is notorious for its ability to spread in the submucosal lymphatics well beyond the gross extent of the tumor • Resection to clear margins are therefore desirable to minimize the possibility of recurrent tumor at the anastomotic suture line.
- 17. Surgery • Resection provides the best palliation for most patients with localized carcinoma. • Esophageal resection and reconstruction remain formidable operations in patients whose nutritional and pulmonary status have been compromised by impaired swallowing.
- 18. Surgery Left thoracoabdominal incision – Is the approach to distal esophageal Ca. – Distal esophagus, proximal stomach, and adjacent LN-bearing tissues are resected, and intrathoracic esophagogastric anastomosis is performed. IVOR-LEWIS ESOPHAGECTOMY – high intrathoracic esophagogastric anastomosis is performed. In either case, a gastric drainage procedure (pyloromyotomy or pyloroplasty) is recommended to prevent subsequent postvagotomy gastric outlet obstruction due to pylorospasm. – approach for higher thoracic esophageal tumors Transhiatal esophagectomy without thoracotomy (limited exposure of the intrathoracic esophagus and its blood supply and the risk of hemorrhage and the inability to carry out a complete mediastinal lymph node dissection ). Laryngopharyngocesophagectomy. For treatment of Ca involving the cervicothoracic esophagus (and frequently the larynx).
- 19. Transhiatal esophagectomy without thoracotomy • Cervical (arrowhead) and upper abdominal midline (arrow) incisions are made. • Mobilization of the stomach for esophageal replacement is performed through a laparotomy with pyloroplasty. • The esophagus is mobilized from the back wall of the trachea through the cervical incision. • From below, the surgeon’s hand passes through the widened hiatus. Any remaining attachments of the muscular esophageal tube are avulsed from the esophageal wall.
- 20. Transhiatal esophagectomy without thoracotomy Disadvantages: • limited exposure of the intrathoracic esophagus & its blood supply • the risk of hemorrhage • the inability to carry out a complete mediastinal lymph node dissection
- 21. Transhiatal esophagectomy without thoracotomy (Orringer Technique) • The cervical esophagus is clamped, leaving adequate length for reconstruction • The esophagus is then extracted from the mediastinum. • The stomach is divided at the proximal region with a stapler or clamp Pyloromyotomy is performed at the distal portion • Remaining portion of the stomach is advanced to the neck for esophagogastric anastomosis.
- 22. Left thoracoabdominal esophagectomy • the approach to distal esophageal Ca • Distal esophagus, proximal stomach, and adjacent LN-bearing tissues are resected • intrathoracic esophagogastric anastomosis is performed.
- 23. IVOR-LEWIS ESOPHAGECTOMY • approach for higher thoracic esophageal tumors • high intrathoracic esophagogastric anastomosis is performed • In either case, a gastric drainage procedure (pyloromyotomy or pyloroplasty) is recommended to prevent subsequent postvagotomy gastric outlet obstruction due to pylorospasm.
- 24. Chemotherapy • No data proved that chemotherapy alone provides improved survival or palliation. • Single-agent chemotherapy used to treat many patients with esophageal Ca who present with distant disease, with cisplatin, mitomycin, and 5-fluorouracil achieving reported response rates of 35%. • Combination chemotherapy regimens such as: cisplatin, bleomycin, and vindesine or methotrexate; cisplatin, mitoguazone, and vindesine or vinblastine; and cisplatin and 5-fu used for metastatic or unresectable esophageal Ca, with reported response rates of 11- 55% for 3-9 months. • Combination chemotherapy has been used preoperatively in a combined modality approach to esophageal Ca in hopes of controlling occult metastatic disease and improving the resectability rate.
- 25. Multimodality therapy • Because most patients have systemic or locally invasive disease that precludes cure, there is efforts to improve survival with multimodality therapy. • Experience with combined preoperative radiation therapy and chemotherapy, as well as preoperative chemotherapy and postoperative adjuvant radiation, are encouraging. • This therapy provide better local-regional control of the tumor than can be achieved by radical resection of the esophagus alone.
- 26. Transoral intubation • Uses a variety of tubes (Souttar, Mackler, Mousseau, Fell, and Celestin) and the Wilson-Cook and self-expanding stents, have been used to provide palliation. • Esophageal intubation carries an overall reported mortality that ranges from 3-15% and a complication rate of 20%. Complications: • 1. perforation of the esophagus • 2. migration of the tubes • 3. obstruction of the tubes by food • or tumor overgrowth.
- 27. • Endoscopic laser therapy improves dysphagia, but multiple treatments are required and long- term benefit is seldom achieved. • Palliative internal bypass. Bypass of unresectable Ca with colonic interposition, gastric tubes or retrosternal gastric bypass as a method of palliation. • These procedures are of considerable magnitude and carry a high mortality rate and survival in these patients’ averages < 6 months.
- 28. Thank you !!!