Azam Haseen Associate Professor DO Cardiothoracic surgery JNMCAMUAligarh Introduction U ncommon but extremely lethal malignancy More common in blacks than whites More common in males than females ID: 913393
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Slide1
CA Esophagus
Dr.
Mohd
Azam
Haseen
Associate Professor
D/O Cardiothoracic surgery
JNMC,AMU,Aligarh
Slide2Introduction
U
ncommon but extremely lethal malignancy
More common in blacks than whites
More common in males than females;
Appears most often after age 50
8
th
most common malignancy
6
th
most common cause of cancer related deaths
More incidence in
china,Japan,India
,UK, Belgium
Slide3Etiologic Factors Believed to Be Associated with
Esophageal
CA
Excess alcohol consumption
Cigarette smoking
Smoked opiates
Fungal toxins in pickled vegetables
Mucosal damage from physical agents- Hot tea
Lye ingestion
Radiation-induced strictures
Chronic
achalasia
Slide4Etiologic Factors Believed to Be Associated with
Esophageal
CA
Increased Host susceptibility
Esophageal
web with
glossitis
and iron deficiency (i.e., Plummer-Vinson or Paterson-Kelly syndrome)
Congenital hyperkeratosis and pitting of the palms and soles (i.e.,
tylosis
palmaris
et
plantaris
)
Dietary deficiencies of selenium, molybdenum, zinc, and vitamin A
Celiac
sprue
Chronic gastric reflux (i.e., Barrett's
esophagus
) for
adenocarcinoma
Slide5Site of cancer
10% in the upper third
35% in the middle third,
55% in the lower third
Slide6Spread
(1) Direct: (main method): to the surrounding
(2) Lymphatic: mainly in a downward direction.
** Cervical esophagus → lower deep cervical L.N. ** Thoracic esophagus → para-oesophageal & tracheo-bronchial lymph nodes ** Abdominal esophagus → lymph nodes along the lesser curvature of the stomach → coeliac axis L.N.
(3) Blood (rare): Liver, lung, bone, brain
Slide7Classification – L/E
A- Annular type: more common in lower 1/3.
B- Ulcerative type: raised
everted
edge- necrotic floor- indurated base C- Cauliflower type (60%): fungating mass.
A B C
Slide8Classification -M/E
(a)
Squamous
cell carcinoma (60%)
(b) Adenocarcinoma (40 %) in the lower end of the oesophagus from: (c) Rare types: adenoid cystic, and mucoepidermoid carcinoma, melanoma, carcinoid,
small cell carcinoma
Slide9Clinical features
Progressive
dysphagia
- initially occurs with solid foods
Weight loss Odynophagia, Pain radiating to the chest and/or backCachexia, Malnutrition, dehydration, anaemia,.Invasion of near by structures: e.g.
1. Recurrent laryngeal nerve → Hoarseness of voice
2. Trachea →
Stridor
& TOF→ cough, choking & cyanosis
3. Perforation into the pleural cavity →
Empyema
Slide10Dysphagia
in male > 50 years > 2 wks considered cancer esophagus until proved otherwise.
Slide11Investigations for diagnosis
(1) Barium swallow:
Fungating
and ulcerative mass: narrowed irregular filling defect.
Annular mass
:
- If middle stricture:
Apple core appearance
with evident shouldering
- If lower stricture:
Rat tail appearance
.
Slide12Rat
tail appearance
Slide13Cancer lower 1/3
Filling defect (ulcerative type)
Slide14Investigations for diagnosis
(2)
Esophagoscopy
+ Biopsy and cytology
(the most important)
Slide15For evaluation of
resectability
:
(1)
Endoluminal
endoscopic US:
to detect wall penetration and regional LN status.
T4 esophageal cancer
Slide16For evaluation of
resectability
:
(2) CT and MRI.
Slide17For evaluation of
resectability
:
(3) Thoracoscopy or laparoscopy:
to detect Intrathoracic and intrabdominal disease.
Slide18For evaluation of
resectability
:
4)PET scan
Non invasive method of detecting primary, nodal, distant metastases & locally recurrent tumor The technique estimates area of high glucose metabolism (the tumor) by measurement of the uptake of radiotracer
(
Flurodeoxyglucose
FDG).
Slide19Lung
: chest x-ray & C.T
Liver
: US
Bone
: Bone scan & Bone survey
Brain
: C.T
For
staging:
Slide20TNM Staging
Tx
→ Primary tumor cannot be assessed
TO
→ No evidence of primary tumor
Tis
→
Carcinoma in situ
T1
→
Tumor invades mucosa or
submucosa
(T1a/b)
T2
→
Tumor invades
muscularis
T3
→
Tumor invades adventitia.
T4a
→
Tumor invades adjacent structures (pleura/pericardium/diaphragm)
T4b-
Tumor invades adjacent structures which cant be
resected
lihe
aorta/trachea/spine /others
Slide21TNM staging contd..
Regional lymph nodes (N)
NX:
Nearby lymph nodes can't be assessed.
N0: The cancer has not spread to nearby lymph nodes.N1: The cancer has spread to 1 or 2 nearby lymph nodes.N2: The cancer has spread to 3 to 6 nearby lymph nodes.N3: The cancer has spread to 7 or more nearby lymph nodes
Distant metastasis (M)
Mx
→
Presence of distant metastasis cannot be assessed
M0:
The cancer has not spread (metastasized) to distant organs or lymph nodes.
M1:
The cancer has spread to distant lymph nodes and/or other organs
Slide22Algorithm for Esophageal
Cancer
CT ,
PET/CT, EUS
T4 or Metastases T1N0
Esophagectomy
T2-T3 Chemo/XRT
,
esophagectomy
N1
Chemo/XRT,
esophagectomy
Photodynamic therapy
Esophageal
stenting
Palliative CTX/XRT
Slide23Treatment
Criteria of
inoperability
Unfit patient
Presence of distant metastases
Unresectable tumor
Infiltration of important structure as
trachea, aorta
Slide24Treatment
Operable cancer esophagus
Upper 1/3
Lower 1/3
Total
esophagectomy
Subtotal
esophago-gastrectomy
Middle 1/3
Partial
esophago-gastrectomy
+ appropriate LN dissection
Slide25Treatment
Inoperable cancer esophagus
Non-obstructed
Obstructed
Palliative chemo-radiotherapy
1. LASER tunneling with endoluminal stenting
2. Photodynamic therapy
3. Intubation
4. Jejunostomy or Gastrostomy for feeding
Slide26Surgical Options
Conduit
Stomach
Colon
JejunumSkin TubeRoutePost. Mediast.
Retrosternal
Subcutaneous
Approach
Transhiatal
Transthoracic
Three Field
Minimally Invasive
En Bloc
Anastomosis
Neck
Chest
Abdomen
Slide27Transhiatal Esophagectomy
Slide28Transhiatal Esophagectomy
Experienced centers report <5% mortality
Overall survival: 20-25%
Stage I: 60-70%
Stage III: 5%40% rate of local recurrenceMajor complication rate of 30-40%
Slide29Ivor Lewis Esophagectomy
Slide30Comparison of Approach
Transhiatal vs. Transthoracic
No difference in operative time, blood loss, morbidity or mortality
Survival similar
Anastomotic Leak rateCervical 11%Thoracic 6%
Putnam et al., Annal Thor Surg, 1994
Slide31Technique
Divided mesentery
Slide32Slide33Summary
Debate continues as to optimal approach
Transhiatal
Pros: Avoid thoracotomy
Technically easier operationCons: Increase rate of anastomotic leak Recurrent laryngeal nerve injury (aspiration) Limited thoracic lymphadenectomy
Slide34Summary
Transthoracic (Ivor Lewis)
Pros: Lower rate of leaks, More extensive lymphadenectomy, decreased stricture rate, no risk to recurrent laryngeal nerve
Cons: Increased pain (thoracotomy)
Intrathoracic leak not associated with increased mortality
Slide35Summary
Overall survival still poor in patients with esophageal cancer
Surgery remains mainstay of treatment
In order for surgery to have an impact on survival
peri-operative mortality and morbidity must be lowThere is no ideal approach to
esophagectomy
Outcomes are best when performed in high volume centers
Slide36Chemo and radiotherapy
The efficacy of 5500–6000
cGy
for
squamous cell carcinomas is similar to that of radical surgery good response in 15–25% of patients given single-agent treatment and in 30–60% of patients treated with drug combinations that include cisplatin. When administered along with radiation therapy, chemotherapy produces a better survival outcome than radiation therapy alone.
Slide37Palliative therapy
Management of
dysphagia
, malnutrition, and
tracheoesophageal fistulas are major issues. Repeated endoscopic dilatation Surgical placement of a gastrostomy or jejunostomy for hydration and feedingEndoscopic placement of an expansive metal stent to bypass the tumor. Endoscopic fulguration of the obstructing tumor with lasers
Slide38Prognosis
Fewer than 5% of patients survive 5 years after the diagnosis
total resection is feasible in only 45% of cases.
About 20% of patients who survive a total resection live 5 years.