Cancer of the EsophagusCHAIRMAN – DR. A S GODHI

CO - CHAIRMAN – DR. R. S. KOUJALAGI

PRESENTER – DR. S S K KANTH KAVIPURAPU

Introduction

Ca esophagus is the 8th most common cancer in

the world.

6th most common cause of death from cancer.

The disease is most common in countries of the so

called “Asian Esophageal cancer belt” which

stretches from eastern Turkey and east of the

Caspian sea through northern Iran, northern

Afghanistan, and the southern areas of former

Soviet Union such as Turkmenistan, Uzbekistan

and Tajikistan to northern China and India. 

Introduction

Esophageal cancer most commonly presents in

the sixth to seventh decades of life.

It is a male predominant disease with

M:F ratio of 3:1 for Sq. ca and 15:1 for Adeno Ca.

Introduction

Types of Ca Esophagus: Squamous cell carcinoma Adenocarcinoma

Less common types: Mucoepidermoid cancer

Adenosquamous cancer

Small cell cancer

Basaloid squamous cancer

Sarcomatoid cancer

Lymphoma, melanoma, and various subtypes of Stromal tumors

Etiology

Squamous Carcinoma

Smoking

Alcohol consumption

Hot beverages

N- nitroso compounds – Pickled / smoked food

Caustic ingestion

Acalasia

Bulimia tylosis

Plummer Vinson Syndrome

External beam radiation

Adenocarcinoma

Smoking

Alcohol consumption

Esophageal diverticula

GERD

Acid suppression

medication

Barretts esophagus

Malignancy of

aerodigestive tract.

Squmaous Cell carcinoma

Squamous cell carcinomas arise from the squamous mucosa that is

native to the esophagus.

Found in the upper and middle thirds of the esophagus 70% of the

time.

Male to female ratio is 3:1.

It occurs in the 5th decade of life. Infrequent before 30 years of age.

It has highest mortality in 60-70 years of age in men.

The 5-year survival rate varies but can be as high as 70% with

polypoid lesions and as low as 15% with advanced tumors

Adenocarcinoma

Adenocarcinoma now accounts for almost 70% of all esophageal

carcinomas diagnosed in the United States and Western countries.

There are a number of factors responsible for this shift in cell type:

Increasing incidence of GERD

Western diet

Increased use of acid-suppression medications

As an adaptive measure, the squamous-lined distal esophagus

changes to become lined with metaplastic columnar epithelium

(Barrett’s esophagus). Progressive changes from metaplastic

(Barrett’s esophagus) to dysplastic cells may lead to the

development of esophageal adenocarcinoma.

Adenocarcinoma

Histologically, esophageal adenocarcinoma arises from one of three sites: Submucosal glands of the esophagus

Heterotopic islands of columnar epithelium

Malignant degeneration of metaplastic columnar epithelium (Barrett’s esophagus)

Male to female ratio – 15:1

Infrequent before the age of 40 years.

Symptoms

Asymptomatic Mimic symptoms fo GERD Heartburn, regurgitation, Indigestion Dysphagia Weight loss

Advanced DiseaseChokingCoughingAspiration

Suggests tracheoesophageal fistulaHoarsenessVocal cord paralysis

Suggests invation of Recurrent Layngeal nerve.Jaundice – Liver metastasisChronic pain - Bone metastasisRespiratory symptoms – lung metastasis

Diagnosis

Esophagram: A barium esophagram is recommended for any patient presenting with dysphagia.

The esophagram provides an overview of anatomy and function.

It can differentiate intraluminal from intramural lesions and discriminate between intrinsic (from a mass protruding into the lumen) and extrinsic (from compression of a structures outside the esophagus) compression.

The classic finding of an apple core lesion in patients with esophageal cancer is recognized easily.

Diagnosis Endoscopy: The diagnosis of esophageal cancer is best made from

an endoscopic biopsy. During endoscopy, it is critical to document the following:

Location of the lesion (with respect to distance from the incisors)

Nature of the lesion (e.g., friable, firm, polypoid) Proximal and distal extent of the lesion Relationship of the lesion to the cricopharyngeus muscle,

GEJ, and gastric cardia Distensibility of the stomach.

Early, superficial cancer

Circumferential ulceration esophageal cancer

Malignant stricture of esophagus

Diagnosis

A CT scan of the chest and abdomen is important to assess the

length of the tumor,

thickness of the esophagus and stomach,

regional lymph node status (including cervical, mediastinal, and celiac lymph nodes),

distant disease to the liver and lungs.

It is also helpful for determining T4 lesions, in which the lesion is invading surrounding structures. It may identify a fistula or other anatomic variations, such as a deviated trachea. Although a CT scan is helpful, its accuracy is only 57% for T staging, 74% for N staging, and 83% for M staging.

Diagnosis

Figure Esophageal cancer with tracheal invasion. CT scan shows circumferential wall thickening of the proximal esophagus (arrowheads), which shows irregular interface with the posterior wall of the trachea (arrows), indicating direct extension into the lumen

Figure Esophageal cancer with aortic invasion. An arc (bent arrow) of the contact between the esophageal cancer (arrows) and the aorta (arrowheads) is more than 90 degrees, indicating aortic invasion.

Diagnosis

PET:

An 18F-fluorodeoxyglucose (FDG)–positron emission tomography (PET) scan evaluates the primary mass, regional lymph nodes, and distant disease.

The sensitivity and specificity of PET for evaluating metastatic disease are 88% and 93%, respectively. For evaluation of lymph node disease, has a sensitivity (72%), specificity (86%), and accuracy (76%).

MRI

MRI is helpful. It can accurately detect T4 lesions and metastatic lesions in the liver but overstages T and N status, with only a 74% accuracy.

Diagnosis

Endoscopic ultrasound: EUS is the most critical component of esophageal

cancer staging The information obtained from EUS will help guide

medical and surgical therapy. The experienced endoscopic ultrasonographer can

identify the depth and length of the tumor, degree of luminal compromise, status of regional lymph nodes, and involvement of adjacent structures.

In addition, biopsy samples can be obtained of the mass and lymph nodes in the paratracheal, subcarinal, paraesophageal, celiac, lesser curvature, and gastrohepatic regions.

Diagnosis

EUS tends to overstage T status and understage N status.

The accuracy of EUS for T staging correlates directly with increasing T stage.

T1 lesions, EUS is 84% accurate,

95% accuracy in estimating T4 lesions.

Size and location of the lymph node influence the accuracy, so that lymph nodes smaller than 1 cm tend to be evaluated less accurately.

The overall sensitivity (78%) and specificity (60%) of EUS for evaluating lymph nodes are poor but improve dramatically for evaluating celiac lymph nodes, for which the sensitivity and specificity are 72% and 97%, respectively.

Diagnosis

Bronchoscopy, mediastinoscopy, thoracoscopy, and laparoscopy are all useful staging tools

StagingPrimary Tumor (T)*

TX Primary tumor cannot be assessed

T0 No evidence of primary tumorTis High-grade dysplasia†

T1 Tumor invades lamina propria, muscularis mucosae, or submucosa

T1a Tumor invades lamina propria or muscularis mucosae

T1b Tumor invades submucosa

T2 Tumor invades muscularis propriaT3 Tumor invades adventitia

T4 Tumor invades adjacent structures

T4a Resectable tumor invading pleura, pericardium, or diaphgragm

T4b Unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc.

Regional Lymph Nodes (N)‡

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in 1-2 regional lymph nodes

N2 Metastasis in 3-6 regional lymph nodes

N3 Metastasis in seven or more regional lymph nodes

Distant Metastasis (M)M0 No distant metastasisM1 Distant metastasis

Tumor-Node-Metastasis (TNM) Staging of Esophageal CarcinomaFrom Edge S, Byrd D, Compton C, et al (eds): AJCC cancer staging manual, ed 7, New York, 2010, Springer.

Stage grouping Stage Grouping

STAGE T N M GRADE TUMOR LOCATION¶

Squamous Cell Carcinoma§

0 Tis (HGD) N0 M0 1, X Any

IA T1 N0 M0 1, X AnyIB T1 N0 M0 2-3 Any

T2-3 N0 M0 1, X Lower, X

IIA T2-3 N0 M0 1, X Upper, middle

T2-3 N0 M0 2-3 Lower, X

IIB T2-3 N0 M0 2-3 Upper, middle

T1-2 N1 M0 Any AnyIIIA T1-2 N2 M0 Any Any

T3 N1 M0 Any AnyT4a N0 M0 Any Any

IIIB T3 N2 M0 Any AnyIIIC T4a N1-2 M0 Any Any

T4b Any M0 Any AnyAny N3 M0 Any Any

IV Any Any M1 Any Any

Stage groupingAdenocarcinoma

0 Tis (HGD) N0 M0 1, X

IA T1 N0 M0 1-2, X

IB T1 N0 M0 3

T2 N0 M0 1-2, X

IIA T2 N0 M0 3

IIB T3 N0 M0 Any

T1-2 N1 M0 Any

IIIA T1-2 N2 M0 Any

T3 N1 M0 Any

T4a N0 M0 Any

IIIB T3 N2 M0 Any

IIIC T4a N1-2 M0 Any

T4b Any M0 Any

Any N3 M0 Any

IV Any Any M1 Any

Thank you.