1. DR. B. Ramdas Rai Prof. & Unit Chief YMCH
Carcinoma Oesophagus
DR. B. Ramdas Rai
Prof. & Unit Chief
YMCH

3. ETIOLOGY….
Alcohol Tobacco Nitrosamines Malnutrition Vitamin deficiency(A,C,Riboflavin) Anaemia Poor oral hygiene Ingestion of hot foods and Beverages

4. Premalignant conditions…
Achalasia Cardia
Oesophageal webs
Corrosive strictures
Reflux esophagitis
Hiatus hernia
Barrett’s esophagus

5. Plummer-Vinson syndrome
Leukoplakia
Esophageal diverticula
Ectopic gastric mucosa
Familial ---Tylosis keratosis palmaris & plantaris

6. 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

7. 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

8. Contd Hiccough due to phrenic nerve invovement
Hoarseness of voice due to involvement of RLN
Back pain – due to nodal spread (paraoesophageal/coeliac nodes)

9. PATHOLOGY
Squamous cell carcinoma—95%
Adenocarcinoma—2.5-5%

10. SQUAMOUS CELL CARCINOMA
3 MORPHOLOGIC PATTERNS
Protruded-60%--
a polypoid exophytic lesion

11. Flat-15% rigidity, narrowing of lumen
*diffuse infiltrative form *spread within wall of esophagus *thickening,
rigidity,
narrowing of
lumen

12. Excavated
*necrotic cancerous ulceration
*excavates
deeply

14. MOST ARE MODERATE TO WELL DIFFERENTIATED
50% in middle1/3…30% in lower 1/ % in upper 1/3

15. ADENOCARCINOMA Increasing in frequency Distal 1/3 Male : female = 3:1
Origin )Barrett’s mucosa )Esophageal submucosal glands )Heterotropic islands of columnar epithelium

16. Macroscopically
Appear as FLAT or RAISED patches of otherwise INTACT mucosa
Large nodular
masses
Diffusely
infiltrative
Deeply ulcerative

17. Microscopy:: Mucin-producing glandular . Showing intestinal type feat.
Diffusely infiltrative signet-ring cells of gastric type

18. SQUAMOUS CELL CARCINOMA
Moderately differetiated

19. ADENOCARCINOMA
Intestinal type

20. SPREAD
Locoregional
Upper1/3 and middle 1/3---tracheobronchial tree ,aorta , left RLN
Lower 1/3---diaphragm, pericardium , stomach

21. LYMPHATICS CERVICAL deep cervical paraesophageal posterior mediastinal
tracheobronchial
LOWER
coeliac
splenic hilar

22. Distant spread
Liver
Lungs

23. INVESTIGATIONS Barium swallow Chest X-ray
Esophagoscopy with biopsy and brushings
CT chest and abdomen
Bronchoscopy

24. Additional… MRI Bone and brain scan Staging mediastinoscopy
if specific symptoms or findings…..

25. Barium swallow Irregular mucosal filling defect
Narrowing of lumen at site of lesion
Dilatation proximally

27. Upper border resembling shelf
Annular lesion—narrowed lumen
irregular mucosal outline
Angulation of axis of tumor above and below tumor---spread to extraesophageal sites

28. CHEST X-RAYS
Air-fluid level in the obstructed esophagus in the postr. Mediastinum
Dilated esophagus
Abnormal mediastinal soft tissue—adenopathy

29. Pleural effusion
Pneumonitis
Lung abscess
Pulmonary metastasis
CAN BE NORMAL EVEN IN ADVANCED DISEASE

30. Normal endoscopic view

31. SQUAMOUS CELL CARCINOMA
Protruding
Ulcerating

32. Diffuse infiltrative type

33. ADENOCARCINOMA

34. CT CHEST AND UPPER ABDOMEN
Usually used for staging of the disease
Wall thickness (5mm)
Direct mediastinal invasion by tumor
Regional lymphadenopathy

35. Metastasis –lung liver adrenal and distant nodes
ESOPHAGEAL ENDOSONOGRAPHY
To determine wall penetration and mediastinal invasion—more accurate

36. BRONCHOSCOPY Upper and mid esophagus may invade tracheobronchial tree
Positive findings *distortion of bronchial lumen *blunting of carina *intra –bronchial tumor

37. 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

38. 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

39. THORACIC --mediastinal and perigastric LN along lesser curvature ,fundus,left gastric artery

40. 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

41. T2 ---invades muscularis propria
T3 ---invades periesophageal tissues
T4 ---invades adjacent structures

42. REGIONAL LYMPH NODES (N)
Nx ---regional nodes cannot be assessed
N0 ---no regional node metastases
N1 ---regional node metastases

43. DISTANT METASTASIS (M)
Mx ---mets cannot be assessed
M0 ---no distant metastases
M1a ---non-regional lymph node metastases
M1b ---other distant metastases

44. STAGING Stage 0---Tis N0 M0 Stage l--- T1 N0 M0 Stage lla--T2 N0 M0
Stage llb—T1 N1 M0
T2 N1 M0

45. Stage lll –T3 N1 M0
T4 any N M0
Stage lVa –any T any N M1
lVb –any T any N M1b

46. DIFFERENTIAL DIAGNOSIS
Benign strictures
Benign papillomas
Polyps
Granulomatous masses

47. TREATMENT
Surgery
Radiotherapy
Chemotherapy
Combination

48. UNRESECTABILITY Direct spread to tracheobronchial tree or aorta
Esophageal fistula
Hoarseness of voice
Primary tumor >10 cm.

49. CHEMOTHERAPY Combination chemo:
Cisplatin,bleomycin,vindesine or methotrexate

50. Cisplatin,mitoguazone,vindesine or vinblastine
Cisplatin,5-fluorouracil

51. Used for metastatic and unresectable esophageal ca
11% to55%for 3-9 months
Doesn’t cure the disease
Best responses with squamous cell carcinoma

52. RADIOTHERAPY Squamous cell ca is radiosensitive 3 objectives:
1.Palliation
2.Cure
3.An adjunct to esophagectomy
5-year survival rate—3%-9%

53. Cause
1. local tumor not controlled
2.stricture formation
3.continued progression of tumor outside field of irradiation

54. TREATMENT OPTIONS Intramucosal (T1a)cancers
Surgery alone – Transhiatal esophagectomy
T1b N0 M0 and T2 N0 M0
esophagectomy with thoracotomy

55. *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

56. SURGERIES IVOR LEWS /LEWIS TANNER OPERATION – stomach-midline incision
esophagus-rt thoracotomy

57. McKEOWN OPERATION
additional 3rd incision in neck

58. TRANS HIATAL ESOPHAGECTOMY
*stomach—midline *esophagus-incision in neck

59. 3 FIELD LYMPH NODE DISSECTION –
extensive removal of regional lymph nodes in –abdomen,chest,neck

60. LEFT THORACO-ABDOMINAL APPROACH
on left side above 7th rib
Removal of short segment of costal cartilage

62. PALLIATIVE TREATMENT
INTUBATION *celestine tube *souttar tube *atkinson tube *Procter-Livingston tube
2 TYPES
pulsion – passed from above
traction –pulled into place

64. METAL EXPANDABLE STENTS

65. ENDOSCOPIC LASER
BRACHYTHERAPY
OTHERS bipolar diathermy argon-beam plasma coagulation alcohol injection

66. COMPLICATION OF SURGERY
INTRAOPERATIVE:
bleeding
tracheobronchial injury
hydropneumothorax
RLN palsy

67. POSTOPERATIVE:
* anastomotic leaks
* respiratory complications
* chylothorax
* anastomotic strictures
* gastro esophageal reflux

68. THANK YOU