1. Professor of general and oncology surgery Mansoura Faculty of Medicine
Oncology center -
Masoura university
OCMU O !
M e d i c a l L e c t u r e
M e d i c a l L e c t u r e
M e d i c a l L e c t u r e
Cancer Esophagus
M e d i c a l L e c t u r e !
Professor. Nazem Shams ! !
Cancer Esophagus O ! !
M e d i c a l L e c t u r e ! ! ! !
Professor
Nazem Shams
Professor of general and oncology surgery
OCMU
Mansoura Faculty of Medicine ! !
M e d i c a l L e c t u r e
M e d i c a l L e c t u r e
M e d i c a l L e c t u r e
M e d i c a l L e c t u r e

2. 8 6 Oncology center - Cancer Esophagus Masoura university Incidence th
OCMU
Cancer Esophagus
Professor. Nazem Shams
Worldwide, esophageal cancer is the most common malignancy
most common cause of cancer-related death. 8 th
Incidence 6 th

3. Sepsis, Syphilis, Spirits, Spices, Smoking. (5 S)
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
3- Precancerous conditions:
1. Reflux disease and Barrett’s esophagus (the most important)
2. Achalasia
3. Ectopic gastric epithelium
4. Previous irradiation
5. Corrosive strictures.
2. Dietary:
a. Ingestion of exogenous carcinogens and promoting factors as:
- Polyhydrophenols
- Nitrates and nitrosamines
- Aflatoxine.
b. Absence of protective substances in fruits and green vegetables:
As vitamin A, B2, C, E, and iron, zinc
1. Chronic irritation:
Sepsis, Syphilis, Spirits, Spices, Smoking. (5 S)
Etiology

4. Oncology center - Cancer Esophagus Masoura university Site: Pathology
OCMU
Cancer Esophagus
Professor. Nazem Shams
Site:
a. Upper third: 20%
b. Middle third: 30%
c. Lower third: 50%
Pathology

5. Oncology center - Cancer Esophagus Masoura university N/E: Pathology
OCMU
Cancer Esophagus
Professor. Nazem Shams
N/E:
A- Annular type: more common in lower 1/3.
B- Ulcerative type: raised everted edge- necrotic floor- indurated base
C- Cauliflower type (60%): fungating mass.
Pathology
A B C

6. Oncology center - Cancer Esophagus Masoura university M/E: Pathology
OCMU
Cancer Esophagus
Professor. Nazem Shams
M/E:
(a) Squamous cell carcinoma (60%)
(b) Adenocarcinoma (40 %) in the lower end of the oesophagus from:
1- Barrett’s esophagus (commonest)
2- Heterotropic gastric mucosa
3- Adenocarcinoma of the stomach spreading upwards.
4- Adenocarcinoma arising from esophageal submucosal glands.
(c) Rare types: adenoid cystic, and mucoepidermoid carcinoma, melanoma, carcinoid, small cell carcinoma
Pathology

7. Oncology center - Cancer Esophagus Masoura university Spread:
OCMU
Cancer Esophagus
Professor. Nazem Shams
Spread:
(1) Direct: (main method): to the surrounding
(2) Lymphatic: mainly in a downward direction.
** Cervical esophagus → lower deep cervical L.N.
** Thoracic esophagus → para-oesophageal & tracheo-bronchial lymph nodes
** Abdominal esophagus → lymph nodes along the lesser curvature of the stomach → coeliac axis L.N.
(3) Blood (rare):
Liver, lung, bone, brain
Pathology

8. Regional lymph nodes (N) Distant metastasis (M)
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
TNM staging
Primary tumor (T)
Tx → Primary tumor cannot be assessed
TO→ No evidence of primary tumor
Tis→ Carcinoma in situ
T1 → Tumor invades mucosa or submucosa
T2→ Tumor invades musculosa
T3→ Tumor invades adventitia.
T4→ Tumor invades adjacent structures.
Regional lymph nodes (N)
Nx→ Regional nodes cannot be assessed
NO→ No regional node metastasis
N1 → Regional node metastasis
Distant metastasis (M)
Mx→ Presence of distant metastasis cannot be assessed
MO→ No distant metastases
M1 → Distant metastasis
Pathology

9. Cancer Esophagus Pathology
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
Pathology

10. Cancer Esophagus Pathology
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
Pathology

11. More common in Old male than female
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
More common in Old male than female
(> 45 years)
Presentation

12. (difficult in swallowing)
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
(1) Dysphagia (the cardinal symptom):
(difficult in swallowing)
Dysphagia in male > 50 years > 2 wks considered cancer esophagus until proved otherwise.
characterized by
a- Onset: Late onset
b- Course: Continuous and progressive course
c- Duration: Short duration (few months).
d- First to: solid but not to fluids, later to both fluids & solids
e- Associated with: very bad general condition
Presentation

13. (characterized by pointing pain)
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
(4) Complications.
(1) Cachexia, Malnutrition, dehydration, anaemia,.
(2) Aspiration pneumonia.
(3) Distant metastasis.
(4) Invasion of near by structures: e.g.
1. Recurrent laryngeal nerve → Hoarseness of voice
2. Trachea → Stridor & TOF→ cough, choking & cyanosis
3. Perforation into the pleural cavity → Empyema
(3) Pain: usually a late manifestation.
(characterized by pointing pain)
(2) Regurgitation
(Regurgitation is effortless while vomiting is forcible)
Presentation

14. Cancer Esophagus Investigations
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
Apple core appearance
Rate tail appearance
Cancer lower 1/3
Filling defect (ulcerative type)
A- For diagnosis:
(1) Barium swallow:
Fungating and ulcerative mass: narrowed irregular filling defect.
Annular mass:
- If middle stricture: Apple core appearance with evident shouldering
- If lower stricture: Rat tail appearance.
Investigations

15. Cancer Esophagus Investigations
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
A- For diagnosis:
(2) Esophagoscopy + Biopsy and cytology
(the most important)
Investigations

16. Cancer Esophagus Investigations
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
B- For evaluation of resectability:
(1) Endoluminal endoscopic US:
to detect wall penetration and regional LN status.
T4 esophageal cancer
(2) CT and MRI.
(3) Thoracoscopy or laparoscopy:
to detect Intrathoracic and intrabdominal disease.
Investigations

17. Cancer Esophagus Investigations
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
C- For staging:
Lung: chest x-ray & C.T
Liver: US
Bone: Bone scan & Bone survey
Brain: C.T.
Investigations

18. Cancer Esophagus Investigations
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
D- Laboratory:
1- Complete blood picture:
iron deficiency anemia.
2- Occult blood in stool
3- Tumor markers: CEA - CA15-3
Investigations

19. Cancer Esophagus Investigations
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
E- Positron emission tomography (PET):
- Non invasive method of detecting primary, nodal, distant metastases & locally recurrent tumor
- The technique estimates area of high glucose metabolism (the tumor) by measurement of the uptake of radiotracer (Flurodeoxyglucose FDG).
Investigations

20. Cancer Esophagus Treatment
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
Treatment of cancer esophagus
Treatment
Operable
Inoperable
Radical surgery followed by chemoradiotherapy
Palliative procedure

21. Criteria of inoperability
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
Unfit patient
Presence of distant metastases
Criteria of inoperability
Treatment
Unresectable tumor
Infiltration of important structure as
trachea, aorta

22. + appropriate LN dissection
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
Operable cancer esophagus
Upper 1/3
Middle 1/3
Lower 1/3
Treatment
Total esophagectomy
Partial esophago-gastrectomy
Subtotal esophago-gastrectomy
+ appropriate LN dissection

23. The esophagus is replaced by
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
After esophagectomy
The esophagus is replaced by
Gastric pull up
Colon interposition
1. Gastric pull up in the neck: the best
2. Colon interposition:
3. Free jejunal replacement:
Treatment

24. Palliative chemo-radiotherapy
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
Inoperable cancer esophagus
Non-obstructed
Obstructed
Treatment
Palliative chemo-radiotherapy
1. LASER tunneling with endoluminal stenting
2. Photodynamic therapy
3. Intubation
4. Jejunostomy or Gastrostomy for feeding

25. Very bad (5 year survival rate 5%) due to:
Oncology center -
Masoura university
OCMU
Cancer Esophagus
Professor. Nazem Shams
Very bad (5 year survival rate 5%) due to:
1- Old age
2- Bad general condition before operation
3- Early local spread
4- High morbidity after operation e.g. empyema, leakage from anastomosis
Prognosis

26. Cancer Esophagus By
Professor
Nazem Shams
Professor of General and Oncology surgery
Oncology Center - Mansoura University
(OCMU)
2009©
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