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Carcinoma Esophagus
Presented By:
JITHIN MAMPATTA

3. Epidemiology
• 9th
common cancer in the world
• Disease of mid to late adulthood
• Most common in China, Iran, South Africa,
India and the former Soviet Union.

4. • The incidence rises steadily with age,
reaching a peak in the 6th
to 7th
decade of life.
• Commonly in men over 50 years of age
• Worldwide SCC responsible for most of the
cases.
• SCC usually occurs in the upper two third
of the esophagus
Contd…

5. Contd…
• The cause of scc in endemic areas is not
definitely known but is probably due to
fungal contamination of food with production
of carcinogenic mycotoxin , together with
nutritional deficiencies in the population

6. Contd…
• Supplimentation of the diet with beta
carotene , vit E ,and selenium has been
shown to reduce the incidence in endemic
areas

7. Contd…
• Adenocarcinoma more common in
westernised countries and is increasing in
incidence due to association with GERD ,
Barretts’s esophagus & obesity.
• Adenocarcinoma is most common in the
lower 3rd
of the esophagus

8. Etiology : Squamous Cell Carcinoma
• Smoking and alcohol (80% - 90%)
• Dietary factors
–N-nitroso compounds (animal carcinogens)
– Pickled vegetables and other food-products
– Toxin-producing fungi
– Betel nut chewing
– Ingestion of very hot foods and beverages (such as
tea)

9. Contd…
•Underlying esophageal disease (such
as achalasia and caustic strictures )
• Genetic abnormalities:
–p53 mutation, loss of 3p and 9q alleli, amp.
Cyclin D1 & amp. EGFR

10. Etiology : Adenocarcinoma
• Associated with Barretts’s esophagus, GERD &
hiatal hernia.
• Obesity (3 to 4 fold risk)
• Smoking (2 to 3 fold risk)
• Increased esophageal acid exposure such as
Zollinger-Ellison syndrome.
Fig. Barretts’s
esophagus
Barrett’s esophagus is a
metaplasia of the esophageal epithelial lining. The
squamous epithelium is replaced by columnar
epithelium,with 0.5% annual rate of neoplastic
transformation.
Barrett’s esophagus is a
metaplasia of the esophageal epithelial lining. The
squamous epithelium is replaced by columnar
epithelium,with 0.5% annual rate of neoplastic
transformation.

11. Morphology : Squamous Cell
Carcinoma
• Squamous cell carcinomas are usually preceded by
a long prodrome of mucosal epithelial dysplasia
followed by carcinoma in situ and, ultimately, by
the emergence of invasive cancer
• Early overt lesions appear as small, gray-white,
plaquelike thickenings or elevations of the mucosa
• In months to years, these lesions become tumorous,
taking one of three forms:

12. Morphology : Squamous Cell
Carcinoma
• Squamous cell carcinomas are usually preceded by
a long prodrome of mucosal epithelial dysplasia
followed by carcinoma in situ and, ultimately, by
the emergence of invasive cancer
• Early overt lesions appear as small, gray-white,
plaquelike thickenings or elevations of the mucosa
• In months to years, these lesions become tumorous,
taking one of three forms:

13. Contd…
• (1) polypoid exophytic masses that
protrude into the lumen
• (2) necrotizing cancerous ulcerations that
extend deeply and sometimes erode into the
respiratory tree, aorta, or elsewhere and
• (3) diffuse infiltrative neoplasms that
cause thickening and rigidity of the wall and
narrowing of the lumen

14. Contd…
• Whichever the pattern, about 20% arise in
the cervical and upper thoracic esophagus,
50% in the middle third, and 30% in the
lower third

15. Morphology : Adenocarcinoma
• Adenocarcinomas seem to arise from dysplastic mucosa in the setting
of Barrett esophagus. Unlike squamous cell
carcinomas, they are usually in the distal one-third of
the esophagus and may invade the subjacent gastric
cardia.
• Initially appearing as flat or raised patches on an
otherwise intact mucosa, they may develop into
large nodular masses or show deeply
ulcerative or diffusely infiltrative features.

16. Pattern of spread
• Commonly spread by lymphatics (70%)
• 25% - 30% hematogenous metastases
• Most common site of metastases are
– lung, liver, pleura, bone, kidney & adrenal gland
• Median survival with distant metastases – 6 to 12
months

17. Clinical Features
• It is commonly associated with the
symptoms of dysphagia, wt. loss,
pain, anorexia, and vomiting
• Symptoms often start 3 to 4 months
before diagnosis
• Dysphagia - in more than 90% pt.
Odynophagia - in 50% of pt.

18. Contd…
Complications:
• Cachexia, Malnutrition, dehydration,
anaemia,.
• Aspiration pneumonia.
• Distant metastasis.

19. Contd…
• Invasion of near by structures: e.g.
–Recurrent laryngeal nerve → Hoarseness of
voice
–Trachea → Stridor & TOF→ cough, choking &
cyanosis
–Perforation into the pleural cavity → Empyema
–back pain in celiac axis node involvement

20. Diagnostic Workup
• Detailed history & Physical examination: Dysphagia,
odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines, history
of GERD. Examine for cervical or supraclavicular adenopathy.
• Confirmation of diagnosis:
– EGD: allow direct visualization and biopsy, measure proximal & distal distance of tumor
from incisor, presence of Barrett’s esophagus.
Early, superficial
cancer
Circumferential ulceration
esophageal cancer
Malignant stricture
of esophagus

21. • Staging:
– CT chest and abdomen: Essential for staging because it can identify extension
beyond the esophageal wall, enlarged lymph nodes and visceral metastases.

22. PET Scan
• most recently, proven to be valuable staging tool
• can detect up to 15–20% of metastases not seen on CT and EUS
• low accuracy in detecting local nodal disease compared to CT / EUS
• Value in evaluating response to Chemo Therapy & Radio Therapy
• addition of PET to CT can improve specificity and accuracy of non-
invasive staging
Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A,
Integrated CT PET demonstrates para-aortic lymph node metastases showing increased FDG uptake
(arrowheads). B, Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in
diameter. Based on size criteria, these lymph nodes may be considered benign on CT scan

23. • Barium swallow:
– can delineate proximal and distal margins as well as TEF
– Helpful for correlation with simulation film.
• Bronchoscopy: rule-out fistula in midesophageal lesions.
• Routine Investigations: CBC, chemistries, LFTs.
Cancer lower 1/3Cancer lower 1/3
Filling defect (ulcerative type)Filling defect (ulcerative type)Rat tail appearance
Apple core appearance