A comprehensive overview of CA Esophagus. The slides from made after a thorough review of many well published Medical Journals, Textbooks.

1. CARCINOMA
ESOPHAGUS
Dr. Muttahhar Dar
Resident Surgeon,
Faisalabad Medical University, Pakistan.

2. Anatomy:
• The esophagus is a muscular tube.
• Approximately 25 cm long.
• Extends from Pharynx to Stomach – C6 to T11.
• Consists of Upper and Lower Esophageal Sphincters.
 Histologically it consists of:
• Mucosa - Lined by Epithelium.
• Submucosa – esophageal glands and papillae.
• Muscularis – Striated and Smooth Muscles.
• Adventitia - fibroareolar adventitia.
 Lined by non-keratinized Stratified Squamous Epithelium.

3. ESOPHAGUS
Neoplasia Of

4. NEOPLASMS OF THE OESOPHAGUS:
 Benign Tumors:
• They are relatively rare.
• Mostly small and asymptomatic.
• Biopsies must be taken – to ensure its not malignant.
• Papilloma ∘ Adenomas ∘ Hyperplastic Polyps ∘ GIST.
 Malignant Tumors:
• Epithelial:
• Squamous Cell Carcinoma - affects the upper two-thirds.
• Adenocarcinoma - affects the lower-third.
• Non-Epithelial – These are very rare.
• Secondary Malignancies – Bronchogenic Carcinoma.

5. CARCINOMA OF ESOPHAGUS:
• It is the 6th most common CA in the world.
• Disease of mid to late adulthood.
• Has a poor survival rate – only 5-10% Survival for 5 years.
• It has 2 Types:
• Squamous Cell Carcinoma – most common type.
• Adenocarcinoma – common in west.
• Obesity and Barrett’s Esophagus add to the risk factor.

6. Gross Type:
 In its Gross structure, the Tumor can present in following forms:
• Annular: 15%
• Ulcerative: 20%
• Fungating: 60%
• Polypoid.
• Diffuse.

7. Clinical Features:
 Symptoms due to local growth:
• Recent onset of Dysphagia – most common.
• Regurgitation.
• Anorexia & Weight loss.
• Substernal or Abdominal Pain.
 Symptoms due to
• Hoarseness of voice – involvement of RLN.
• Ascites – Liver metastasis.
• Bronchopneumonia or Broncho-esophageal Fistula.
• Palpable Supraclavicular Lymph nodes.

8. Tumor Spread:
• Tumor can via following ways:
• Direct Spread:
• Lack of serosal layer in esophagus favors local extension.
• Left Main Bronchus, Trachea.
• Left Recurrent Laryngeal Nerve – Hoarseness
• Aorta and Branches - Hemorrhage
• via Bloodstream:
• Liver, Lungs, Brain and Bone.
• via Lymphatics:
• Important determinant of Surgical management.

9. Investigations:
• Endoscopy – First line of treatment.
 Allows direct visualization of tumor.
 Biopsy & Cytology sample of lesion can be taken.
• Endoscopic Ultrasound – To look for involvement of Esophageal Layers involved.
• CT-Scan – it has a 95% accuracy.
 Local Extension & Nodal Status.
 Vascular Infiltration.
 Tracheobronchial tree - in Squamous Cell Carcinoma.
• Chest Xray: Aspiration Pneumonia or Fistula
• USG Abdomen: Liver and Abdominal Lymph Nodes.
• Laparoscopy: To see peritoneal spread and take Biopsy if needed.
• PET Scan.

10. ENDOSCOPIC VIEW OF CARCINOMA
ENDOSONOGRAPHY IMAGE

11. Management:
Principles of management of CA Esophagus.

12. Principles Of Management:
• At the time of diagnosis, 2/3rd of all patient will have incurable disease.
• Aim is to overcome debilitating and distressing symptoms.
• Since Dysphagia is the most prominent symptom,
• Aim is to restore swallowing.
• Depending on the extend of disease, following options are available:
• Surgical Treatment.
• Chemoradiotherapy.
• Palliative Management.
MANAGEMENT
ALGORITHM

13. Surgical Management
CA Esophagus.

14. Principles of Surgical Management:
• The principle of esophagectomy is to:
• Remove the Local Tumor.
• Adequate Lymphadenectomy.
• Minimize the risk of local recurrence.
• Tumor resection should ideally be:
• 10 cm above the lesion.
• 5 cm below the lesion.
• Surgical Approaches for CA Esophagus are:
1. Two-phase Esophagectomy – Iver Lewis.
2. Three-phase Esophagectomy – McKewon.
3. Trans Hiatal Esophagectomy.

15. Surgical Management
CARCINOMA ESOPHAGUS
• Two-Phase Esophagectomy:
• Stomach is mobilized by midline incision.
• Thoracotomy is done to mobilize the
Intrathoracic Esophagus.
• Tumor is resected.
• Esophago-gastric anastomosis is made.
• Keep patient NPO for 5-7 days.
• Useful for lesions of Middle & Lower
Esophagus.
• Trans-hiatal Esophagectomy:
• Stomach is mobilized by midline incision.
• Cervical Esophagus mobilized via neck.
• Diaphragm is opened through abdomen.
• Lower Esophagus mobilized and Tumor is
removed.
• Esophago-gastric anastomosis is made.
• Useful for lesions of Lower Esophagus.

16. Midline Incision
Thoracotomy
Incision
Esophageal
Mobilization
Tumor Resection
Gastro-esophageal
Anastomosis

17. Non-Surgical Management:
• Chemotherapy.
• Chemoradiation Therapy.
• Radiation Therapy:
• External Radiations.
• Brachytherapy: Intraluminal radiation with a short penetration distance.
• Electrocoagulation.
• Immunotherapy.
BRACHYTHERAPY

18. Palliative Management:
• Used when Surgery or Chemoradiotherapy is not suitable.
• Due to extensive spread of disease.
• Patient’s general health and fitness.
• Patient’s quality of life.
• Palliative approaches to improve patient’s quality of life are:
• Intubation: Aim is to restore swallowing. Different methods are available.
• Souttar Tube.
• Expanding Metal Stents.

19. Palliative Management:
• Used when Surgery or Chemoradiotherapy is not suitable.
• Due to extensive spread of disease.
• Patient’s general health and fitness.
• Patient’s quality of life.
• Palliative approaches to improve patient’s quality of life are:
• Intubation: Aim is to restore swallowing. Different methods are available.
• Souttar Tube.
• Expanding Metal Stents.
• Endoscopic Laser:
• Make a channel through the tumor.
• May also used to unblock the Stent.

20. THANK YOU!
MuttahharD@gmail.com