1. Esophageal Cancer
Dr Pavan kumar L
15th July 2013

2. Anatomy
• The esophagus is
a thin-walled,
hollow tube
approximately 25
cm in length.

3. • The lower third (5 to 10 cm) of the esophagus
may contain glandular elements.
• Replacement of the stratified squamous
epithelium with columnar epithelium is
referred to as Barrett's esophagus, often
occurring in the lower third.

5. Esophageal wall layers
•
•
•
•
Innermost mucosa
Sub mucosa
Muscular propria
Adventitia.
• No serosal layer in esophagus, facilitating
extra esophageal spread of disease.

6. Lymphatic Drainage

7. Lymphatic drainage

8. • Lymphatics of the esophagus drain into nodes
that usually follow arteries
1. Inferior thyroid artery
2. Bronchial and esophageal arteries
3. Left gastric artery (celiac axis)

9. Epidemiology - esophageal cancer

10. Epidemiology - esophageal cancer
• Incidence rates of squamous cell esophageal
cancer can vary 100- to 200-fold among
different populations living in geographic
adjacency.
• Squamous cell esophageal cancer is the
foremost malignancy in the Bantu of Africa.
• South Africa, Japan, China, Russia, Scotland,
and the Caspian region of Iran also have
relatively high incidence rates.

11. • In many Western countries the incidence of
adenocarcinoma of the esophagus (distal
esophagus and gastroesophageal junction) is
rapidly rising and the incidence of squamous
cell cancers is declining.

12. Relative change in incidence of esophageal
adenocarcinoma and other malignancies

13. Etiology
• Carcinogens
– Tobacco and alcohol
– Human papillomavirus (HPV) infection
– Dietary carcinogens
• Plants growing in soil deficient in molybdenum have
reduced vitamin C content
• Elevated nitrates in the drinking water
• Food containing fungi: Geotrichum candidum (pickles,
air-dried corn), Fusarium sp., and Aspergillus sp. (corn)

14. Predisposing factors for squamous cell
esophageal cancer
– Lye stricture (up to 30%)
– Esophageal achalasia (30%)
– Esophageal web (20%)
– Plummer-Vinson syndrome (iron-deficiency
anemia, dysphagia from an esophageal web, and
glossitis, 10%)

15. Predisposing factors for squamous cell
esophageal cancer
– Short esophagus (5%)
– Peptic esophagitis (1%)
– Patients with head and neck cancer (Field's
cancerization theory)
– Patients with celiac disease
– Chronic esophagitis without Barrett's esophagus
– Thermal injury to the esophagus because of
drinking boiling hot tea or coffee (Russia, China,
and Middle East)

16. Predisposing factors for
adenocarcinoma of the esophagus
– Barrett's esophagus is metaplastic replacement of
squamous with intestinalized columnar
epithelium.
– Obesity
– Reflux esophagitis

17. Pathology - Histology
• Upper and middle esophagus - Squamous cell
tumors constitute 98%
• Lower esophagus - adenocarcinoma is
becoming more common.
1. Barrett's esophagus
2. Extension of a gastric adenocarcinoma.

18. SCC Location of cancer in the esophagus
• Upper – 15%
• Middle – 50%
• Lower – 35%
Adenocarcinoma is most common in the
lower third of the esophagus, accounting for
over 65% of cases.

19. Clinical course
• Esophageal cancer is highly lethal
• More than 90% of affected patients die from the
disease.
• About 75% present initially with mediastinal
nodal involvement or distant metastasis.
• Death is usually caused by local disease that
results in malnutrition or aspiration pneumonia.

20. Patterns of Spread
• Lesions in the upper esophagus can impinge
on or invade the recurrent laryngeal nerves,
carotid arteries, and trachea.
• Tumors in the lower third of the esophagus
can invade the aorta or pericardium, resulting
in mediastinitis, massive hemorrhage, or
empyema.

21. • T1 lesions -incidence of nodal spread is 14% to
21%
• T2 lesions, this rises to 38% to 60%.
• The location of involved lymph nodes is
influenced by the origin of the primary tumor.

22. • The primary direction for lymphatic flow for
the lower esophagus is toward the abdomen.
• According to the classification by Siewert

23. • Type I tumors-nodal metastases are often
seen in the mediastinum and abdomen ,
• Type II tumors are intermediate, preferentially
spreading inferiorly and less frequently into
the mediastinum.
• Type III tumors metastasize almost exclusively
inferiorly, toward the celiac axis.

24. • The primary value in the Siewert classification
is to the guidance of appropriate type surgery
• Type I tumors are generally treated with
esophagectomy and mediastinal lymph node
resection, with types II and III approached
through the abdomen.

25. Clinical Presentation
• Location of the primary tumor in the
esophagus may influence presenting
symptoms.
• Dysphagia
• Odynophagia
• Weight loss - extent of weight loss has been
associated with a worse prognosis.

26. • Hoarseness
• Cough
• Glossopharyngeal
neuralgia
• Hematemesis
•
•
•
•
Hemoptysis,
Melena,
Dyspnea,
Persistent cough tracheoesophageal or
bronchoesophageal
fistula

27. Proposed algorithm for diagnosis and staging of esophageal
cancer

28. Barium swallow
1. visualize areas of obstruction and assess stricture.
2. Extravasation of contrast may indicate a fistula
Esophagogastroduodenoscopy (EGD)
1. Direct visualization and relative location &size of the
primary tumor.
2. Cold-forceps biopsies are obtained for pathologic
diagnosis
Endoscopic ultrasound (EUS)
1. Assesses depth of invasion
2. Involvement of adjacent lymph nodes essential for
clinical staging.

29. Bronchoscopy
1. Upper and middle thoracic esophageal
lesions to exclude invasion of trachea or
bronchi.
Laparoscopy for GEJ/proximal stomach tumors
1. To exclude possible intraabdominal/peritoneal metastasis
2. Could also be used to place G- or J-tube for
patients with complete obstruction

30. Contrast computer tomography (CT) of chest and abdomen
1. to exclude presence of metastasis to the lung and liver
and locoregional spread
Bone scan
1. indicated in patients with complaints suggestive of bone
metastasis or with elevated serum alkaline phosphatase
Fluorodeoxyglucose (FDG)-PET/CT
1. initial staging workup
2. monitor response to chemoradiation treatment.
3. Detects occult metastasis in
15% of cases

31. Role of PET CT in Ca Esophagus

32. Illustration of management impact
of PET/CT.

33. Management impact
of PET/CT.

34. Role of PET CT in Ca Esophagus

35. Staging

40. Prognostic factors of esophageal
cancer
Disease related
Treatment related
1. Stage at diagnosis
• Incomplete
2. Depth of invasion
pathologic response
3. Tumor volume
to preoperative
4. Lymphovascular invasion therapy
(chemotherapy or
Patient related
chemoradiotherapy)
• Age
is a poor prognostic
• Performance status
factor.

41. Treatment related
• Incomplete pathologic response to
preoperative therapy (chemotherapy or
chemoradiotherapy) is a poor prognostic
factor.