NEOPLASMS OF NEOPLASMS OF OESOPHAGUSOESOPHAGUS

CARCINOMA OESOPHAGUSCARCINOMA OESOPHAGUS

Common in China,S.africa &Asian Common in China,S.africa &Asian countries.countries.

66 thth most common cancer. most common cancer.

Less than 1% of all cancers.7% of all GI Less than 1% of all cancers.7% of all GI malignancies.malignancies.

Karnataka & Orissa.Karnataka & Orissa.

Advanced stages – Dysphagia – palliation.Advanced stages – Dysphagia – palliation.

Surgery – Rx of choice for early growthsSurgery – Rx of choice for early growths

AETIOLOGYAETIOLOGY

Diet- deficencies(vit A, C & Riboflavin)Diet- deficencies(vit A, C & Riboflavin)Mycotoxin - common aftr 45 yrsMycotoxin - common aftr 45 yrsAlcohol & tobacco –common in menAlcohol & tobacco –common in menFungal contamination of foodFungal contamination of foodAchalasia cardiaAchalasia cardiaOesophageal websOesophageal websBarret”s oesophagusBarret”s oesophagusPlummmer vinson”s sydromePlummmer vinson”s sydromeCorrosive stricturesCorrosive stricturesTylosisTylosisNitrosaminesNitrosamines

PATHOLOGYPATHOLOGY

Common in - Middle 3Common in - Middle 3 rdrd(50%)(50%)

Lower 3Lower 3rdrd(33%)(33%)

Upper 3Upper 3 rdrd(17%)(17%)

Lower 3 cm- Adenoca common(Barrett”s Lower 3 cm- Adenoca common(Barrett”s columnar metaplasia)columnar metaplasia)

SCC – Commonest in india & AsiaSCC – Commonest in india & Asia

GROSS TYPESGROSS TYPES

Annular –(15%)Annular –(15%)

Ulcerative –(20%)Ulcerative –(20%)

Fungating-cauliflower like –(60%)Fungating-cauliflower like –(60%)

Polypoid Polypoid

Varicoid –diffuse submucosal typeVaricoid –diffuse submucosal type

SPREADSPREAD

DIRECT SPREADDIRECT SPREAD

LYMPHATICLYMPHATIC

BLOOD SPREADBLOOD SPREAD

CF CF

Recent onset of dysphagia(2/3Recent onset of dysphagia(2/3 rdrd lumen lumen occlusion)occlusion)

RegurgitationRegurgitation

Anorexia , loss of weight & cachexiaAnorexia , loss of weight & cachexia

Pain – Substernal or in the abdomenPain – Substernal or in the abdomen

Liver secondaries, ascitisLiver secondaries, ascitis

Bronchopneomonia, melaenaBronchopneomonia, melaena

Features of broncho-oesophageal fistula in CA Features of broncho-oesophageal fistula in CA upper 3upper 3rdrd oesophagus oesophagus

Left supraclavicular lymphnodes may be palpable

Hoarseness of voice

Hiccough

Backpain due to nodal (paraoesophageal or coeliac) spread

M:f- 3:1

INVESTIGATIONSINVESTIGATIONS

Ba swallow-shouldering sign n irregular Ba swallow-shouldering sign n irregular filling defectsfilling defectsOesophagoscopyOesophagoscopyBiopsy (confirmation)Biopsy (confirmation)Chest X-ray(aspiration pneumonia)Chest X-ray(aspiration pneumonia)BronchoscopyBronchoscopyOesophageal endosonographyOesophageal endosonographyCT scanCT scan

u/s abdomen

Endoscopic oesophageeal staining

Blood test

Laproscopy

PET scan

Video assisted thoracoscopic approach

TreatmentTreatment

Gastrostomy shud not b done as a Gastrostomy shud not b done as a palliative procedurepalliative procedure

For early growth without nodal spread-For early growth without nodal spread-radical oesophagectomyradical oesophagectomy

If nodes+ -multimodal aproach If nodes+ -multimodal aproach used(curative resection,radiotherapy n used(curative resection,radiotherapy n chemotherapy)chemotherapy)

Neoadjuvant therapy prior to surgNeoadjuvant therapy prior to surg

Advanced cases-palliation

Indications 4 curative treatment

1.early growth when patient is fit

2.when no involvemnt adj perioesophageal structres or distant organs

Indications for palliative therapy

1.Relieves pain

2.Relieve dysphagia

3.prevent bleeding

4.prevent aspiration

STAGING OF CA OESOPHAGUSSTAGING OF CA OESOPHAGUS

T0: no primary trT0: no primary tr

Tis:CA insituTis:CA insitu

T1: Tr involving mucosaT1: Tr involving mucosa

T2: Tr involving muscularis propriaT2: Tr involving muscularis propria

T3: Tr with paraoesophageal spreadT3: Tr with paraoesophageal spread

T4: involvement of recurrent laryngeal T4: involvement of recurrent laryngeal nerve, phrenic nerve, sympathetic nerve, phrenic nerve, sympathetic chain,azygos vein ; malignant effusionchain,azygos vein ; malignant effusion

No :No lymph nodes

N1: Mobile regional lymph nodes

M0: No distant metastasis

M1a: Upper thoracic oesophageal CA with spread to necknodes or lower oesophageal CA with spread to coeliac nodes

M1b: Upper TE CA with spread to other non regional nodes or distant spread.Middle TE CA with spread to necknodes or coeliac nodes or other npn regional nodes.Lower TE CA with spread to other nonregional nodes or distant spread.

Approaches for different level tumoursApproaches for different level tumours

Post cricoid tr(SCC) Post cricoid tr(SCC) radiotherapy radiotherapy pharynolaryngectomypharynolaryngectomyUpper 3Upper 3 rdrd growth(SCC) growth(SCC) radiotherapy radiotherapy Mc Keown three phased oesophagectomyMc Keown three phased oesophagectomyMiddle 3Middle 3 rdrd growth(SCC) Ivor growth(SCC) Ivor lewis operation palliative lewis operation palliative radiotherayradiotheray

Lower 3rd growth(SCC +Adenoca)

Partial oesophagogastrectomy

Transhiatal blind total oesophagectomy

Other approaches

Thoracoscopic – lap oesophagectomy

Radical oesophagectomy

POST OP MGMTPOST OP MGMT

Fluid & electrolyte mgmtFluid & electrolyte mgmt

Antibiotics& proper analgesiaAntibiotics& proper analgesia

Resp careResp care

Prevention of DVTPrevention of DVT

TPN only during initial postop period TPN only during initial postop period &early jejunostomy feeding for nutrition&early jejunostomy feeding for nutrition

PALLIATIVE PROCEDURESPALLIATIVE PROCEDURES

External or intraluminal RTExternal or intraluminal RT

Traction tubes like celestinTraction tubes like celestin

Pulsion tubes like selfexpandable metal Pulsion tubes like selfexpandable metal stentsstents

Endoscopic laserEndoscopic laser

ChemotherapyChemotherapy

Transhiatal oesophagectomy- orringerTranshiatal oesophagectomy- orringer

COMPLICATIONS OF COMPLICATIONS OF OESOPHAGECTOMYOESOPHAGECTOMY

5 – 10% Mortality5 – 10% MortalityHgeHgeResp infectionResp infectionSepticaemiaSepticaemiaChylothoraxChylothoraxAnastomotic leakAnastomotic leakHoarseness Hoarseness Stricture frmnStricture frmn

Terminal events in CA oesophagusTerminal events in CA oesophagus

Cancer cachexiaCancer cachexia

Sepsis , mediastinitisSepsis , mediastinitis

ImmunosupressionImmunosupression

Malignant tracheo oesophageal fistulaMalignant tracheo oesophageal fistula

Erosion into major bld vessel - bleedingErosion into major bld vessel - bleeding

PROGNOSISPROGNOSIS

NOT GOOD –early spread , longitudinal NOT GOOD –early spread , longitudinal lymphatics , aggresiveness , diff lymphatics , aggresiveness , diff approach ,late presentationapproach ,late presentation

Nodal involvement – bad prognosisNodal involvement – bad prognosis

5 yr survival rate- 10%5 yr survival rate- 10%

BENIGN TUMOURSBENIGN TUMOURS

RareRare

Grows by exapnsion .Never infiltrates or Grows by exapnsion .Never infiltrates or spreads.spreads.

Usually in submucous planeUsually in submucous plane

Obstuction, regurgitation, aspiration, Obstuction, regurgitation, aspiration, mediastinal compressionmediastinal compression

LEIOMYOMA COMMONEST (65%)LEIOMYOMA COMMONEST (65%)

Smooth , sessile , lobulated , firm ,grey white whorled appearance

Multiple localised leiomyomas can occur which can be enucleated independently

90% -in Lower 3rd

INVESTIATIONS

Ba swallow x-ray, oesophagoscopy, endosonography , CTscan

TreatmentTreatment

Enucleation is the therapy of choiceEnucleation is the therapy of choice

Oesophageal ressection for large tumoursOesophageal ressection for large tumours