Esophageal Cancernote

Introduction

• Carcinoma of esophagus – 9th most common cancer in the world (1) & 15th most common cancer in Malaysia (2.1%).

• Disease of mid to late adulthood, with poor survival rate (2) .

1) Bailey & Love; SHORT PRACTICE OF SURGERY, 24th Edition 2) Report Of The National Cancer Registry - Cancer Incidence In

Malaysia 2003

Aetiology

Modifiable• Tobacco smoking• Alcohol intake• Gastroesophageal reflux

disease (GERD) and its resultant Barrett's esophagus

• Others – radiation therapy, Plummer-Vinson syndrome, nitrosamine ingestion.

Non-modifiable• Age – higher risk in >60 y/o• Sex – common in male• Family history of cancer

Clinical Manifestation

• Dysphagia is the first symptom in most patients, odynophagia may be present.

• Substantial weight loss.

Diagnostic test/Investigation

• Barium swallow• Esophagogastroduodenoscopy (EGD)• Biopsy taken & examined histologically• CT-scan of chest• Endoscopic ultrasound• PET-scan

• Nausea and vomiting, regurgitation of food may present due to disruption normal peristalsis.

• Look signs & symptoms of spread – lung (recurrent pneumonia, effusion), liver (jaundice, ascites, lymph node enlargement)

Clinical Manifestation

Endoscopy demonstrating intraluminal esophageal cancer.

Chest CT scan showing invasion of the trachea by esophageal cancer

Endoscopy and radial endoscopic ultrasound images of submucosal tumour in mid-esophagus.

This specimen depicts a cancer at the area of the junction between the esophagus and stomach. It is a large irregular mass. The objective of endoscopic surveillance in Barrett's esophagus is to detect these processes early on when there is a high probability for cure.

Squamous cell carcinomaNormal esophageal epithelium

Adenocarcinoma of esophagus

Staging - TMN

Staging

Treatment option

• General approaches– adequate nutrition needs to be assured

• Definitive treatment/Surgery– Esophageal resection (esophagectomy) remains a

crucial part of the treatment of esophageal cancer.

Surgery

– Indication• Diagnosis of esophageal cancer must be made in a patient who is a candidate for

surgery.• Surgery is indicated when high-grade dysplasia is present in a patient with Barrett

esophagus. As many as 50-70% of such patients are found to have cancer when the esophagus is resected.

– Contraindicationo Metastasis to N2 nodes (ie, celiac, cervical, or supraclavicular lymph nodes) or solid

organs (eg, liver, lungs) is a contraindication.o Invasion of adjacent structures (eg, recurrent laryngeal nerve, tracheobronchial tree,

aorta, pericardium) is a contraindication.o Severe associated comorbid conditions (eg, cardiovascular disease, respiratory

disease) can decrease a patient's chances of surviving an esophageal resection.o Cardiac function and respiratory function are carefully evaluated preoperatively. A

forced expiratory volume in 1 second of less than 1.2 L and a left ventricular ejection fraction of less than 0.4 are relative contraindications to the operation.

http://emedicine.medscape.com/article/277930-treatment

Surgery

• 2 types; • transthoracic esophagectomy [TTE]• transhiatal esophagectomy [THE]

Historical standard chest and abdominal incisions used in the past to remove tumors of the esophagus. (A) Either one continuous incision from the chest onto the abdomen or separate chest and abdominal incisions are used. (B) Portion of esophagus to be removed is shown in the colored area. (C) Completed esophageal replacement using the stomach connected to the esophagus high in the chest. The pylorus (muscle at the outlet of the stomach) has been cut to insure that the stomach empties adequately after the operation. (From Orringer MB. Chapter 20 Tumors, injuries, and miscellaneous conditions of the esophagus in Greenfield LJ, Mulholland MW, Oldham KT, et al, eds. Surgery Scientific Principles and Practice, 3rd Edition, Lippincott Williams & Wilkins, Philadelphia, 2001, pg 706 with permission, modified from Ellis FH Jr. Treatment of carcinoma of the esophagus and cardia. Mayo Clin Proc 1960;35:653

(A) Transhiatal removal of the esophagus being performed through an abdominal incision and a neck incision without the need to open the chest. (B) Side view showing the surgeon's hand proceeding upward into the chest through the abdomen as an instrument with a sponge at the end of it is used to dissect the esophagus from above. (From Orringer MB. Chapter 20 Tumors, injuries, and miscellaneous conditions of the esophagus in Greenfield LJ, Mulholland MW, Oldham KT, et al, Eds, Surgery Scientific Principles and Practice, 3rd Edition, Lippincott Williams & Wilkins, Philadelphia, 2001, pg 707 with permission, modified from Orringer MB, Sloan H. Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg 1978;76:643

Other modalities

• Neoadjuvant & Adjuvant therapy– Chemotherapy; cisplatin, 5-fluorouracil (5-FU),

paclitaxel, and anthracyclines.– Radiotherapy; can improve dysphagia

• Stent; to relieve the obstruction or close the fistula.

• Laser therapy & Photodynamic therapy (PDT)

http://emedicine.medscape.com/article/277930-treatment

PrognosisIn general, the prognosis of esophageal cancer is quite poor, because so many patients present with advanced disease: The overall five-year survival rate (5YSR) is less than 5%.

http://en.wikipedia.org/wiki/Esophageal_cancer

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