Carcinoma of the esophagus

1. Carcinoma Esophagus –for MD5
Dr Amos Brighton- MD, resident-General surgery (MUHAS)
Dr. Lutege William-MD, MMed Surgery, Fellow Surgical Gastroenterology and
Hepatology(MUHAS)

2. Anatomy and Physiology
of the Esophagus
• Esophagus serves as a one
way tube for food transport
from pharynx to stomach.
• It starts at the level of C6 at
the base of pharynx and ends
at the cardia of stomach at
T11.

3. Anatomy and Physiology
of the Esophagus
• The diameter of the
esophagus varies from 1.6 to
2.5 cm.
• There are three narrowing:
• (1) cricopharyngeus—14 mm,
• (2) bronchoaortic constriction
just below carina—15–17 mm
and
• (3) diaphragmatic
constriction—16–19 mm.

4. Anatomy and Physiology
of the Esophagus

5. Anatomy and Physiology
of the Esophagus

6. WHO histological classification of
oesophageal tumours

7. EPIDEMIOLOGY
• Esophageal cancer is the 7th leading cause of cancer
deaths.
• Its incidence is highly variable, ranging from
approximately 20 per 100,000 in the United States and
Britain, to 160 per 100,000 in certain parts of South Africa
and the Henan Province of China, and even 540 per
100,000 in the Guriev district of Kazakhstan.

8. EPIDEMIOLOGY
• A region called “Esophageal Cancer Belt” encompasses
areas such as Turkey, Iran, Kazakhstan and northern and
central China is even since antiquity the highest risk region
• Male:Female; 3.5:1
• African-America males:White males ; 5:1
• Worldwide SCC responsible for most of the cases
• Scc usually occurs in the middle 3rd of the esophagus (ratio of
upper:middle:lower is 15:50:35)
• Adenocarcinoma is most common in the lower 3rd of the
esophagus account over 65% of cases

9. Epidemiology of EC in Tanzania
• Globocan estimates show an age-standardized rate of EC
incidence in Tanzania for both sexes of 9.2 per 100000,
• which is the second highest cancer in Tanzania
• The median age was 60 years
• Over 50% of the EC patients smoke tobacco or consumed
alcohol
• SCC represented 90.9% of histopathologic types of tumors.
• The median overall survival for all patients was 6.9 months
(95% CI, 5.0 to 12.8), regardless of stage at presentation.
• The administrative regions in the central and eastern parts of
Tanzania had higher incidence rates than western regions,
specifically administrative regions of Kilimanjaro, Dar es
Salaam, and Tanga had the highest rates.
Gabel JV, Chamberlain RM, Ngoma T, et al. Clinical and epidemiologic variations of
esophageal cancer in Tanzania. World J Gastrointest Oncol. 2016;8(3):314-320.
doi:10.4251/wjgo.v8.i3.314

10. Geographic distribution of overall esophageal
cancer incidence in Tanzania, 2006-2013.
Gabel JV, Chamberlain RM, Ngoma T, Mwaiselage J, Schmid KK, Kahesa C, Soliman AS. Clinical and
epidemiologic variations of esophageal cancer in Tanzania. World J Gastrointest Oncol 2016; 8(3): 314-320
[PMID: 26989467 DOI: 10.4251/wjgo.v8.i3.314]

11. Risk factors for squamous carcinoma
• Smokinga nd Alcohol (80-90%)
• Diet and nutrients:
– N-nitroso compounds
– Pickled vegetables and other food products
– Mycotoxins
– Betal nut chewing
– Ingestion of very hot foods and beverages
– Vit A and C def, Zn, Mg,Molybdenum
• Underlying esophageal disease such as achalasia and caustic
strictures
• Genetic abnomalities p53 mutation, loss of 3p and 9q alleli
cyclin D1 and EGFR mutations

12. Risk factors for squamous carcinoma
• HPV 16,18
• Plummer-Vinson syndrome
• Tylosis -RHBDF2 gene
• Fanconi anemia-FANCD And BRCA2 gene

13. Risk factors for esophageal
adenocarcinoma
• Associated with GERD, Barrett’s esophagus and hiatal hernia
– BE is a pre-malignant lesion that develops in 6%-14% of
patients with GERD and of which, around 0.5%-1% will develop
adenocarcinoma
• Obesity (3 to 4 fold risk)
• Smoking (2 to 3 fold risk)
• Increased esophageal acid exposure such as Zollinger –Ellison
syndrome
Wheeler JB, Reed CE. Epidemiology of esophageal cancer. Surg Clin North Am.
2012; 92: 1077-1087.

14. Pathological classification

15. Pattern of Spread
1. Direct; No serosal covering, direct invasion of
contiguous structures occurs early
2. Commonly spread by lymphatics (70%)
– Lymh node involvement increases with T stage.
3. Hematogenous metastases 25-30%at time of
presentation
• Most common site of metastases are Lung, liver, pleura,
bone, kidney and adrenal gland
• Median survival with distant metastases 6-12 months

16. TNM staging classification for carcinoma of the
esophagus 8th ed ,2017 SCC, and adenocarcinoma

18. AJCC prognostic stage groups
Squamous cell cancer

19. AJCC prognostic stage groups
Adenocarcinoma

20. Clinical Manifestations
• Dysphagia; cardinal symptoms characterized by:
– Onset; Late onset
– Course; Continuous and progressive
– Duration; short duration(Few months)
– First to; Solid but not fluids, later to both fluids and solids
– Associated with ; very bad general condition
• Regurgitation
• Pain usually late
• Weight loss

21. Complications
• Malnutrition, Cachexia, Dehydration, Anemia
• Aspiration pneumonia
• Distant metastasis
• Invasion of near structures eg
Recurrent laryngeal nerve-Hoarseness of voice
Trachea-Stridor & trachea/esophageal fistula- Cough, chocking &
cyanosis
Perforation of the pleural cavity-Empyema
Back pain in celiac axis node involvement
Hiccough due to phrenic nerve involvement

22. Diagnosis
• Detailed History and Physical examinations
• Upper GI Endoscopy (Esophagoscopy) and Biopsy;
Allow direct visualization and Biopsy for histological
confirmation

23. Diagnosis
• Barrium Swallow
o Fungating and ulcerative mass ; narrowed irregular filling defect
o Annular mass
– Middle stricture; Apple core appearance with evidence of
shouldering
– Lower stricture ; rat tail appearance

24. Diagnosis
• Chest /Abdominal CT with oral and IV contrast
– Staging; Extent of esophageal involvement, tumour spread to
adjacent structures and metastasis to regional LN and distant
organs
• FDG-PET/CT if no evidence of M1 disease
– Evaluation of questionable lesions seen on CT
– Can detect up to 15-20% 0f metastases not seen on CT and
EUS
– Evaluating response to chemotherapy and radiotherapy

25. Diagnosis
• Endoscopic ultrasound (EUS) helps in accurate T
staging and in evaluation of regional nodes and permits
sampling by a guided fine needle aspiration.
– Reported pooled sensitivity and specificity are 81.6% and
99.4%, respectively, for T1 classification; 81.4% and 96.3% for
T2; 91.4% and 94.4% for T3; and 92.4% and 97.4% for T4
Puli SR, Reddy JB, Bechtold ML, Antillon D, Ibdah JA, Antillon MR.Staging accuracy of
esophageal cancer by endoscopic ultrasound: a meta-analysis and systematic review.
World J Gastroenterol.2008;14:1479-90.

26. Diagnosis
• Endoscopic Resection is essential for the
accurate staging of early –stage cancers(T1a
or T1b)
• Broncoscopy if tumour is at or above the
carina with no evidence of M1 disease
• Laryngoscopy assess local disease extent
and to detect a synchronous malignancy of
the head and neck
• Routine investigation CBC and chemistry
profile, LFTs
National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in
oncology.ttps://www .nccn.org/professionals/physician_gls (Accessed on October 14, 2020).

27. Staging Laparoscopy
• Laparoscopy was reported to change therapy in 10% of
patients, allowing resection in 2% who are over-staged
and avoiding resection in 8% with newly detected M1
cancer

28. Treatment
• It may be Surgery, Radiotherapy, Chemotherapy or
Combined Chemoradiation
• Treatment may be curative or palliative

29. Principles of management
• Selection of curative versus palliative approach depends
on
– Location of tumour
– Patient’s age and health status
– Extent of disease
– Preoperative staging

30. SURGERY
• The fundamental aim of surgical management of
esophagealcarcinoma is to achieve R0 resection at
acceptable morbidity and minimal mortality rates.
• Surgery still remains the cornerstone of curative
management.
• Types of Surgery
o Transthoracic esophagectomy (TTE)53
Ivor Lewis Approach
McKeown approach
o Transhiatal esophagectomy (THE) .
o Minimally invasive esophagectomy (MIE)
Two field
Three field

31. MULTIMODALITY THERAPY
• Definitive Chemoradiotherapy (CRT)
– This is an alternative to surgery for SCC,
especially located in the upper third of the
esophagus
• Neoadjuvant Therapy
– While surgery is alone sufficient in T1 and most
T2 tumors, neoadjuvant therapy is the standard of
care in T
• Perioperative Chemotherapy
– Perioperative chemotherapy is the standard of
care in resectable adenocarcinoma of the lower
esophagus, GEJ, or stomach T3 and T4a tumors.

32. PALLIATION OF ESOPHAGEAL CANCER
• Majority (~80%) of the cases of esophageal cancer will not be
amenable to curative treatment
• Esophageal Stenting
• most widespread modality for palliation of dysphagia in
advanced tumors and can be use even in patients with poor
performance status or recurrent tumors
• A feeding jejunostomy or gastrostomy is an excellent
option for providing nutritional support in patients with
advanced tumors discovered at surgery/staging laparoscopy.

33. PALLIATION OF ESOPHAGEAL CANCER
• External Beam Radiotherapy It is useful for the palliation
of dysphagia if the life expectancy is low (~3–6 months).
• Photodynamic Therapy
– It provides good palliation of dysphagia in patients, with
improvement in 85% and a dysphagia free interval of 66 days.
– It also provided control of bleeding in over 90% of the cases.
– Additional sessions/stent placement can be done in patients
who develop recurrent dysphagia

34. PALLIATION OF ESOPHAGEAL CANCER
• Laser Therapy
– Treatment with the Nd:YAG laser can provide short term relief
of dysphagia in up to 90% of the patients

35. Algorithm depicting management strategies for esophageal
carcinoma stratified by T, N stage

36. Prognosis
• The N stage perhaps is the best prognostic marker and
patients with N3 disease (≥7 lymph nodes) have poor
survival