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Carcinoma Of The Esophagus

Hassan Bharmal
Pathologic Classification
Typing
● Squamous Cell Ca
● Adenocarcinoma
● Uncommon

Grading
TNM Classification
Staging
Epidemiology
th
● 9 most common Ca in th world
th
● 5 most common in developing countries
● Unusual high incidencies in Japan, Kazakhstan,
South Africa
● In Kenya higher incidencies reported in Western
Kenya
Epidemiology

Total number of malignancies diagnosed at MTRH from 1st


January 1997 to December 31st 2001
1. Cancer of esophagus - 407
2. Cancer of cervix - 269
3. Leukemia - 187
4. Cancer of the breast - 158
5. Cancer of the liver - 156
6. Cancer of the prostate - 138
7. Cancer of the stomach - 133
8. Nasopharyngeal carcinoma - 86
● M:F 1.5:1
● Mean Age 58.6 years (50 - 70)
● 6% are below 30 years, youngest 14 years – most
common in Kalenjin community
Associated Factors
● Excessive alcohol consumption
● Tobacco smoking
● Nutritional deficiency
● Poor dental and oral hygiene
● Hot foods and drinks
● Fungal contamination of foods

Pre Existing Conditions
● Achalasia
● Barret's esophagus
● Chronic reflux esophagitis
● HPV
● Caustic burns
Symptoms
● Progressive Dysphagia
● Hypersalivation
● Weight loss
● Regurgitation
● Odynophagia
● Halitosis
● Hoarsness
● Dyspnoea
Signs
● Usually none
● Dehydration
● Signs of metastasis
Work Up
● Lab Studies
● Imaging
– Barium Swallow
– OGD
– Endoscopic Ultrasound
– CT Scan
– Bronchoscopy
– Bone Scan
– Laparoscopy & Thorascopy
– PET
Treatment
● General health, fitness, co-morbid conditions
● Majority present in stage 3 & 4
● Can be paliative intent or curative intent
Management
● Stage 0 – 1 Surgery alone
● Stage 2 – 3 Surgery plus neoadjuvant
● Stage 4 Palliative surgery, neoadjuvant
therapy, brachytherapy, photodynamic therapy,
immunotherapy
Treatment – Curative Intent
● Tis / T1 presentation very rare
● Hence most require multimodal approach i.e
esophagectomy with neoadjuvant or adjuvant
treatment

Esophagectomy
● Operative approach depends on
– Histologic type
– Anatomic location
– Proposed extent of lymphadenectomy
Approaches
● Blunt transhiatal sub total esophagectomy
● Abdominothoraxic subtotal esophagectomy
(Tanner-Lewis)
● Mc Keown 3 phase
Rationale – Histologic Type
Squamous CA – high rate of spread through
submucosal lymphatics hence transthoraxic en bloc
eophagectomy preffered with 2 or 3 field
lymphadenectomy.
● Adenocarcinoma – transhiatal esophagectomy with
upper abdominal and infracarinal lymphadenectomy
Anatomic Location
● Cervical
– Difficult to resect
– T3 T4 can be down staged with RT/CT followed by
transthoraxic en bloc esophagectomy with gastric
tube or colon interposition
– Or local resction with jejunal inerposition
Upper thoraxic
● Metastasize to cervical, mediastinal and abdominal
lymph nodes
● Hence thoracoabdominal en bloc esophagectomy
with 2 or 3 field lymphadenectomy
● With neoadjuvant therapy especialy if T4 for down
grading
Lower Thoraxic
● Metastasize to mediastinal an abdominal lymph
nodes
● Thoraco abdominal esophagectomy with lymph
node dissection
● Celiac nodes - M1
GEJ Tumours
● GEJ – 5cm proximal & distal to muscular limit
● Siewert's type 1 – 5cm proximal & 1cm proximal
● Siewert's type 2 – 1cm proximal & 2 cm distal
● Siewert's type 3 – 2cm distal & 5cm distal
GEJ Tumours
● Siewert's type 1 – spread through submucous
lymphatics. Transhiatal or thoracoabdominal
esophagectomy
● Siewert's type 2 – total gastrectomy with perigastric
lymph node dissection,
● for extension into the esophagus – include
transhiatal distal esophagectomy
● Siewert's type 3 – similar to above.
Paliative Care
● Chemoradiotherapy
● Endoscopic
– Dilatation
– Injection therapy
– Thermal ablation
– Intubation
● By pass - retro or pre sternal
● Feeding gastrostomy or jejunostomy
Endoscopic Treatment
● EMR
● PDT
● laser
Chemotherapy
● Cisplatin based treatment with flourouracil
● Paclitaxel
● Anthracyclines
Prognosis
● Without treatment – 3 to 4 months
● After surgery – 5 year survival 5 – 15 %
● After curative surgery
● 1 year survival – 70%
● 2 year survival – 30%
● 5 year survival – 20 %