Carcinoma Oesophagus

1. Carcinoma Oesophagus DR. B. RamdasRai Prof. & Unit Chief YMCH

3. ETIOLOGY…. Alcohol Tobacco Nitrosamines Malnutrition Vitamin deficiency(A,C,Riboflavin) Anaemia Poor oral hygiene Ingestion of hot foods and Beverages

4. Premalignant conditions… Achalasia Cardia Oesophageal webs Corrosive strictures Reflux esophagitis Hiatus hernia Barrett’s esophagus

5. Plummer-Vinson syndrome • Leukoplakia • Esophageal diverticula • Ectopic gastric mucosa • Familial ---Tylosis keratosis palmaris&plantaris

6. Clinical Featrures... Male to female ratio is 3:1 Age:- 6th or 7th decade of life. Recurrent onset of dysphagia is the commonest feature. For the dysphagiato develop, 2/3rd of the lumen should be occluded. Regurgitation Anorexia & loss of weight(severe), cachexia

7. Contd.. • Pain-substernal or in the abdomen • Liver secondaries, ascites • Bronchopneumonia, malena • Features of broncho-oesophageal fistula in Ca of upper third of oesophagus • Left supraclavicular lymph nodes may be palpable

8. Contd Hiccough due to phrenic nerve invovement Hoarseness of voice due to involvement of RLN Back pain – due to nodal spread (paraoesophageal/coeliac nodes)

9. PATHOLOGY • Squamous cell carcinoma—95% • Adenocarcinoma—2.5-5%

10. SQUAMOUS CELL CARCINOMA • 3 MORPHOLOGIC PATTERNS • Protruded-60%-- • a polypoid exophytic lesion

11. Flat-15% *diffuse infiltrative form *spread within wall of esophagus *thickening, rigidity, narrowing of lumen

12. Excavated *necrotic cancerous ulceration *excavates deeply

14. MOST ARE MODERATE TO WELL DIFFERENTIATED 50% in middle1/3…30% in lower 1/3 20% in upper 1/3

15. ADENOCARCINOMA • Increasing in frequency • Distal 1/3 • Male : female = 3:1 • Origin---- 1)Barrett’s mucosa 2)Esophageal submucosal glands 3)Heterotropic islands of columnar epithelium

16. Macroscopically • Appear as FLAT or RAISED patches of otherwise INTACT mucosa • Large nodular masses • Diffusely infiltrative • Deeply ulcerative

17. Microscopy:: • Mucin-producing glandular . Showing intestinal type feat. • Diffusely infiltrative signet-ring cells of gastric type

18. SQUAMOUS CELL CARCINOMA • Moderately differetiated

19. ADENOCARCINOMA • Intestinal type

20. SPREAD Locoregional • Upper1/3 and middle 1/3---tracheobronchial tree ,aorta , left RLN • Lower 1/3---diaphragm, pericardium , stomach

21. LYMPHATICS • CERVICAL deep cervical paraesophageal posterior mediastinal tracheobronchial LOWER paraesophageal coeliac splenic hilar

22. Distant spread • Liver • Lungs

23. INVESTIGATIONS • Barium swallow • Chest X-ray • Esophagoscopy with biopsy and brushings • CT chest and abdomen • Bronchoscopy

24. Additional… • MRI • Bone and brain scan • Staging mediastinoscopy if specific symptoms or findings…..

25. Barium swallow • Irregular mucosal filling defect • Narrowing of lumen at site of lesion • Dilatation proximally

27. Upper border resembling shelf • Annular lesion—narrowed lumen irregular mucosal outline • Angulation of axis of tumor above and below tumor---spread to extraesophageal sites

28. CHEST X-RAYS • Air-fluid level in the obstructed esophagus in the postr. Mediastinum • Dilated esophagus • Abnormal mediastinal soft tissue—adenopathy

29. Pleural effusion • Pneumonitis • Lung abscess • Pulmonary metastasis • CAN BE NORMAL EVEN IN ADVANCED DISEASE

30. Normal endoscopic view

31. SQUAMOUS CELL CARCINOMA • Protruding • Ulcerating

32. Diffuse infiltrative type

33. ADENOCARCINOMA

34. CT CHEST AND UPPER ABDOMEN • Usually used for staging of the disease • Wall thickness (5mm) • Direct mediastinal invasion by tumor • Regional lymphadenopathy

35. Metastasis –lung liver adrenal and distant nodes • ESOPHAGEAL ENDOSONOGRAPHY To determine wall penetration and mediastinal invasion—more accurate

36. BRONCHOSCOPY • Upper and mid esophagus may invade tracheobronchial tree • Positive findings *distortion of bronchial lumen *blunting of carina *intra –bronchial tumor

37. TNM STAGING • Done using CT • DIVIDES ESOPHAGUS INTO 4 SECTIONS • 1)CERVICAL-15-18cm.lower border of cricoid cartilage to thoracic inlet • 2)UPPER THORACIC—24cm. thoracic inlet to carina

38. Contd….…. • 3)MIDDLE THORACIC—32cm.carina to ½ the distance to the esophagogastric junction • 4)LOWER THORACIC—40cm.to the esophagogastric junction • REGIONAL LYMPH NODES • CERVICAL --cervical and supraclavicular nodes

39. THORACIC --mediastinal and perigastric LN along lesser curvature ,fundus,left gastric artery

40. PRIMARY TUMOR(T) • TX---- can not be assessed • T0 ---no evidence of primary tumor • Tis---high-grade dysplasia • T1 ---invades lamina propria (T1a) muscularis mucosa(T1a) submucosa(T1b) • Does not breach submucosa

41. T2 ---invades muscularis propria • T3 ---invades periesophageal tissues • T4 ---invades adjacent structures

42. REGIONAL LYMPH NODES (N) • Nx ---regional nodes cannot be assessed • N0 ---no regional node metastases • N1 ---regional node metastases

43. DISTANT METASTASIS (M) • Mx ---mets cannot be assessed • M0 ---no distant metastases • M1a ---non-regional lymph node metastases • M1b ---other distant metastases

44. STAGING • Stage 0---Tis N0 M0 • Stage l--- T1 N0 M0 • Stage lla--T2 N0 M0 T3 N0 M0 Stage llb—T1 N1 M0 T2 N1 M0

45. Stage lll –T3 N1 M0 T4 any N M0 • Stage lVa –any T any N M1 lVb –any T any N M1b

46. DIFFERENTIAL DIAGNOSIS • Benign strictures • Benign papillomas • Polyps • Granulomatous masses

47. TREATMENT • Surgery • Radiotherapy • Chemotherapy • Combination

48. UNRESECTABILITY • Direct spread to tracheobronchial tree or aorta • Esophageal fistula • Hoarseness of voice • Primary tumor >10 cm.

49. CHEMOTHERAPY • Combination chemo: • Cisplatin,bleomycin,vindesine or methotrexate

50. Cisplatin,mitoguazone,vindesine or vinblastine • Cisplatin,5-fluorouracil