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DR. B. Ramdas Rai Prof. & Unit Chief YMCH
Carcinoma Oesophagus DR. B. Ramdas Rai Prof. & Unit Chief YMCH
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ETIOLOGY…. Alcohol Tobacco Nitrosamines Malnutrition Vitamin deficiency(A,C,Riboflavin) Anaemia Poor oral hygiene Ingestion of hot foods and Beverages
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Premalignant conditions…
Achalasia Cardia Oesophageal webs Corrosive strictures Reflux esophagitis Hiatus hernia Barrett’s esophagus
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Plummer-Vinson syndrome
Leukoplakia Esophageal diverticula Ectopic gastric mucosa Familial ---Tylosis keratosis palmaris & plantaris
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Clinical Featrures... Male to female ratio is 3:1
Age:- 6th or 7th decade of life. Recurrent onset of dysphagia is the commonest feature. For the dysphagiato develop, 2/3rd of the lumen should be occluded. Regurgitation Anorexia & loss of weight(severe), cachexia
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Contd.. Pain-substernal or in the abdomen Liver secondaries, ascites
Bronchopneumonia, malena Features of broncho-oesophageal fistula in Ca of upper third of oesophagus Left supraclavicular lymph nodes may be palpable
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Contd Hiccough due to phrenic nerve invovement
Hoarseness of voice due to involvement of RLN Back pain – due to nodal spread (paraoesophageal/coeliac nodes)
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PATHOLOGY Squamous cell carcinoma—95% Adenocarcinoma—2.5-5%
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SQUAMOUS CELL CARCINOMA
3 MORPHOLOGIC PATTERNS Protruded-60%-- a polypoid exophytic lesion
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Flat-15% rigidity, narrowing of lumen
*diffuse infiltrative form *spread within wall of esophagus *thickening, rigidity, narrowing of lumen
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Excavated *necrotic cancerous ulceration *excavates deeply
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MOST ARE MODERATE TO WELL DIFFERENTIATED
50% in middle1/3…30% in lower 1/ % in upper 1/3
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ADENOCARCINOMA Increasing in frequency Distal 1/3 Male : female = 3:1
Origin )Barrett’s mucosa )Esophageal submucosal glands )Heterotropic islands of columnar epithelium
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Macroscopically Appear as FLAT or RAISED patches of otherwise INTACT mucosa Large nodular masses Diffusely infiltrative Deeply ulcerative
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Microscopy:: Mucin-producing glandular . Showing intestinal type feat.
Diffusely infiltrative signet-ring cells of gastric type
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SQUAMOUS CELL CARCINOMA
Moderately differetiated
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ADENOCARCINOMA Intestinal type
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SPREAD Locoregional Upper1/3 and middle 1/3---tracheobronchial tree ,aorta , left RLN Lower 1/3---diaphragm, pericardium , stomach
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LYMPHATICS CERVICAL deep cervical paraesophageal posterior mediastinal
tracheobronchial LOWER coeliac splenic hilar
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Distant spread Liver Lungs
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INVESTIGATIONS Barium swallow Chest X-ray
Esophagoscopy with biopsy and brushings CT chest and abdomen Bronchoscopy
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Additional… MRI Bone and brain scan Staging mediastinoscopy
if specific symptoms or findings…..
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Barium swallow Irregular mucosal filling defect
Narrowing of lumen at site of lesion Dilatation proximally
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Upper border resembling shelf
Annular lesion—narrowed lumen irregular mucosal outline Angulation of axis of tumor above and below tumor---spread to extraesophageal sites
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CHEST X-RAYS Air-fluid level in the obstructed esophagus in the postr. Mediastinum Dilated esophagus Abnormal mediastinal soft tissue—adenopathy
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Pleural effusion Pneumonitis Lung abscess Pulmonary metastasis CAN BE NORMAL EVEN IN ADVANCED DISEASE
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Normal endoscopic view
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SQUAMOUS CELL CARCINOMA
Protruding Ulcerating
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Diffuse infiltrative type
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ADENOCARCINOMA
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CT CHEST AND UPPER ABDOMEN
Usually used for staging of the disease Wall thickness (5mm) Direct mediastinal invasion by tumor Regional lymphadenopathy
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Metastasis –lung liver adrenal and distant nodes
ESOPHAGEAL ENDOSONOGRAPHY To determine wall penetration and mediastinal invasion—more accurate
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BRONCHOSCOPY Upper and mid esophagus may invade tracheobronchial tree
Positive findings *distortion of bronchial lumen *blunting of carina *intra –bronchial tumor
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TNM STAGING Done using CT DIVIDES ESOPHAGUS INTO 4 SECTIONS
1)CERVICAL-15-18cm.lower border of cricoid cartilage to thoracic inlet 2)UPPER THORACIC—24cm thoracic inlet to carina
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Contd….…. 3)MIDDLE THORACIC—32cm.carina to ½ the distance to the esophagogastric junction 4)LOWER THORACIC—40cm.to the esophagogastric junction REGIONAL LYMPH NODES CERVICAL --cervical and supraclavicular nodes
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THORACIC --mediastinal and perigastric LN along lesser curvature ,fundus,left gastric artery
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PRIMARY TUMOR (T) TX---- can not be assessed
T0 ---no evidence of primary tumor Tis---high-grade dysplasia T1 ---invades lamina propria (T1a) muscularis mucosa(T1a) submucosa(T1b) Does not breach submucosa
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T2 ---invades muscularis propria
T3 ---invades periesophageal tissues T4 ---invades adjacent structures
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REGIONAL LYMPH NODES (N)
Nx ---regional nodes cannot be assessed N0 ---no regional node metastases N1 ---regional node metastases
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DISTANT METASTASIS (M)
Mx ---mets cannot be assessed M0 ---no distant metastases M1a ---non-regional lymph node metastases M1b ---other distant metastases
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STAGING Stage 0---Tis N0 M0 Stage l--- T1 N0 M0 Stage lla--T2 N0 M0
Stage llb—T1 N1 M0 T2 N1 M0
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Stage lll –T3 N1 M0 T4 any N M0 Stage lVa –any T any N M1 lVb –any T any N M1b
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DIFFERENTIAL DIAGNOSIS
Benign strictures Benign papillomas Polyps Granulomatous masses
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TREATMENT Surgery Radiotherapy Chemotherapy Combination
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UNRESECTABILITY Direct spread to tracheobronchial tree or aorta
Esophageal fistula Hoarseness of voice Primary tumor >10 cm.
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CHEMOTHERAPY Combination chemo:
Cisplatin,bleomycin,vindesine or methotrexate
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Cisplatin,mitoguazone,vindesine or vinblastine
Cisplatin,5-fluorouracil
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Used for metastatic and unresectable esophageal ca
11% to55%for 3-9 months Doesn’t cure the disease Best responses with squamous cell carcinoma
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RADIOTHERAPY Squamous cell ca is radiosensitive 3 objectives:
1.Palliation 2.Cure 3.An adjunct to esophagectomy 5-year survival rate—3%-9%
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Cause 1. local tumor not controlled 2.stricture formation 3.continued progression of tumor outside field of irradiation
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TREATMENT OPTIONS Intramucosal (T1a)cancers
Surgery alone – Transhiatal esophagectomy T1b N0 M0 and T2 N0 M0 esophagectomy with thoracotomy
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*Clinically N0 and found to have LN metastases at surgery—
post operative adjuvant therapy *T3 or N1 or M1a induction therapy followed by surgery *Stage 4 - palliative usually nonoperative
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SURGERIES IVOR LEWS /LEWIS TANNER OPERATION – stomach-midline incision
esophagus-rt thoracotomy
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McKEOWN OPERATION additional 3rd incision in neck
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TRANS HIATAL ESOPHAGECTOMY
*stomach—midline *esophagus-incision in neck
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3 FIELD LYMPH NODE DISSECTION –
extensive removal of regional lymph nodes in –abdomen,chest,neck
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LEFT THORACO-ABDOMINAL APPROACH
on left side above 7th rib Removal of short segment of costal cartilage
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PALLIATIVE TREATMENT INTUBATION *celestine tube *souttar tube *atkinson tube *Procter-Livingston tube 2 TYPES pulsion – passed from above traction –pulled into place
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METAL EXPANDABLE STENTS
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ENDOSCOPIC LASER BRACHYTHERAPY OTHERS bipolar diathermy argon-beam plasma coagulation alcohol injection
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COMPLICATION OF SURGERY
INTRAOPERATIVE: bleeding tracheobronchial injury hydropneumothorax RLN palsy
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POSTOPERATIVE: * anastomotic leaks * respiratory complications * chylothorax * anastomotic strictures * gastro esophageal reflux
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THANK YOU
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