Esophageal cancer

1. Esophageal cancer

3. The Esophagus • Muscular tube • At least 12 inches (30cm) long in adults • Beginning at the cricocartilage level, C6, and ending by penetrating the diaphragm and joining the cardia of the stomach, opposite T10.

4. Wall of the esophagus has several layers • Mucosa • Epithelial lining • Lamina propria • Submucosa • Muscularis • Inner circular • Outer longitudinal • No serosal layer

5. Compared to the remaining gastrointestinal tract, the esophagus lacks a fourth serosal layer. Without the serosa covering, neoplasms that arise in the esophagus can spread unimpeded to other tissues.

6. The lymphatic drainage of the esophagus is conducted by a vast network of vessels originating in the mucosal plexus which communicates with a submucosal plexus. These two then coalesce with lymph channels of the muscularis layer. The lymph channels eventually drain into a number of lymph nodes: internal jugular, cervical, supraclavicular, paratracheal, hilar, subcarinal, paraesophageal, para-aortic, paracardial, lesser curvature, left gastric, and celiac.

8. The American Cancer Society estimates that during 2005 approximately 14,520 new esophageal cancer cases will be diagnosed in the United States • 3-4 times more in men • Blacks more than whites

9. Over consumption of:TobaccoAlcohol Under consumption of:FruitsVegetablesFresh meatFresh fishRiboflavinNiacinBeta-CaroteneVitamin AVitamin CVitamin B'sMagnesiumZinc Predisposing Conditions:TylosisAchalasiaBarrett's EsophagusCaustic InjuryEsophageal DiverticulaEsophageal Webs Other factors:AsbestosIonizing radiationDrinking exceptionally hot beverages Risk Factors of Esophageal Carcinoma

10. Symptoms of Esophageal Carcinoma

11. Types of tumors • Squamous cell carcinoma • Adenocarcinoma

12. Types of tumors • Squamous cell carcinoma • No longer the leading form of esophageal cancer • Blacks > Whites • Male > female (4 – 6) • Cigarette smoking and alcohol consumption • Affects thoracic part of esophagus mainly • Very low distal occurrence

13. Neoplasms can be of four major types • Fungating-type • Ulcerating-type • Infiltrating-type • Polypoid

14. Neoplasms can be of four major types • Fungating-type • Intraluminal growth with surface ulceration and extreme friability • Invades mediastinal structures • 11 to 60% of cases

15. Neoplasms can be of four major types • Ulcerating-type • Flat based ulcer with slightly raised edges • Hemorragic and friable • Surrounding induration and erythema • 25 to 63% of patients

16. Neoplasms can be of four major types • Infiltrating-type • Dense firm logitudinal and circumferential intramural growth pattern • The infiltrating type is found in 15 to 26% of squamous cell carcinoma tumors.

17. Neoplasms can be of four major types • Polypoid • Intraluminal polypoid growth with a smooth surface on a narrow stalk • 2 - 8% of cases • Five year survival of 70% compared to less than 15% for other types

18. Types of tumors • Adenocarcinoma • Now is the leading cell type of this type of cancer • Derived from glandular tissue • From three sources: • superficial and deep glands of the esophagus such as mucous glands • embryonic remnants of glandular epithelium • metaplastic glandular epithelium

19. Types of tumors • Adenocarcinoma • Limited mainly to the lower third • Arises mainly from the premalignant condition, Barrett's esophagus • White > Black (4 times) • Men > Women (8 folds) • long history of smoking and alcoholic consumption

20. Upon endoscopy and pathological evaluation it appears as reddish mucosa extending from the gastroesophageal junction into the light brown gastric mucosa. The reddish columnar mucosa is in sharp contrast to the pale-pink mucosa of the esophagus

21. Other types • Small cell carcinoma • Melanoma • Leiomyosarcoma • Lymphoma

23. Diagnosis • By the time symptoms have occurred, the tumor may be advanced sufficiently so that it can be identified on a chest radiograph. • The most common finding is an abnormal azygoesophageal recess. • The next most frequent is widening of the mediastinum or posterior tracheal indentation

24. Barium Swallow or Upper GI (gastrointestinal) X-rays • A barium swallow can locate and describe any irregularities in the normally smooth surface of the esophageal wall • First diagnostic test in people having trouble swallowing. • Early cancers can look like small round bumps, can appear as a flat, raised area called a plaque. • Advanced cancers look like large irregular areas and cause a narrowing of the width of the esophagus.

26. Upper Endoscopy • Diagnose and determine the extent of longitudinal intramural tumor spread. • Samples may be obtained for histological analysis. • Biopsy and brush cytology may be performed. • The accuracy of brush cytology alone is about 85-97% and biopsy alone ranging from 83-90%. • The accuracy for the combination brush cytology and biopsy is 97-100%. • Stinting in cases of fistula formation

29. Computed Tomography (CT) • In determining the extent, or stage, of the cancer. • Shows the esophagus clearly and often can confirm the location of the esophageal cancer. • Help to determine whether surgery is a good treatment option. • Helps even more with use of oral and IV contrast. • CT-guided needle biopsy

30. The CT scan on the right reveals a distended proximal esopahgus (white arrow). • A more caudal cut shows significant wall thickening of the esophagus (red arrows).

32. Endoscopic Ultrasound • According to recent studies, might be even more accurate than CT scans and upper endoscopy in determining an esophageal cancer’s size and how far it has spread into nearby tissues. • Including nearby lymph nodes

34. Bronchoscopy • Similar to an upper endoscopy except in this instance into the trachea and bronchi. • To determine whether the cancer has grown into these structures

37. Positron Emission Tomography • Radioactive glucose is injected into the patient's vein. • Cancers use sugar much faster than normal tissues. • A scanner can spot the radioactive deposits.

38. Positron Emission Tomography • Useful for: • Spread to nearby lymph nodes • Sites distant from the esophagus • Staging the cancer

40. 56 year-old female with history of esophageal carcinoma • abnormal intensity uptake in the esophagus at the junction of the high thoracic/low cervical segments • consistent with esophageal carcinoma. Indeterminate focus of uptake in the right hilum, likely a lymph node

41. Thoracoscopy (and Laparoscopy) • Minimally invasive technique that involves making two or three small incisions (approximately one inch) in between the ribs. • Surgeon can operate instruments through the tube and remove lymph node samples for testing to see whether they contain cancer cells.

43. TNM Classification of Esophageal Carcinomas • TX: primary tumor cannot be assessed • T0: no evidence of primary tumor • Tis: carcinoma in situ (the tumor has not invaded beyond the epithelium, the first or innermost layer of the esophagus) • T1: tumor invades the lamina propria (second layer) or submucosa (third layer) • T2: tumor invades the muscularis propria (fourth layer) • T3: tumor invades the adventitia (fifth and outermost layer) • T4: tumor invades nearby structures

44. NX: nearby lymph nodes cannot be assessed N0: no spread to nearby lymph nodes N1: spread to nearby lymph nodes • MX: spread to other organs cannot be assessed M0: no spread to distant organs M1a: spread to lymph nodes beyond nearby ones M1b: spread to distant organs

45. Stage 0(Tis, N0, M0) • Stage I (T1, N0, M0) • Stage II • Stage IIA (T2 or 3, N0, M0) • Stage IIB (T1 or 2, N0, M0) • Stage III (T3 or 4, N0 or 1, M0) • Stage IV • Stage IVA (Any T, any N, M1a) • Stage IVB (Any T, any N, M1b)

46. Survival Rates by Stage

47. Treatment

48. Complications of surgery • A heart attack or a blood clot in the lungs or the brain can occur during the operation • Leak at the Anastamosis site • Recurrent nausea and vomiting • Infection • Strictures • Death (3% in one month post op Experienced hands to around 17% in inexperienced hands)

49. Chemotherapy • Primary chemotherapy will usually not cure esophageal cancer unless radiation therapy and, in some cases, surgery is also used. • There are 3 situations in which chemotherapy is used: • Palliative therapy • control symptoms • Preoperative therapy • reduce the tumor size • Chemoradiotherapy • Both ways

50. Radiation Therapy • A very effective therapy for dysphagia. • Can also be used to ease symptoms of esophageal cancer such as pain, bleeding. • Symptoms caused by esophageal cancer that has spread to the brain.