11 esophageal cancer

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Esophageal CancerEsophageal Cancer

Xiaodong Li 04-02-2010

Thoracic Oncology Department,Cancer center,Sun Yat-Sen University

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Anatomy: Normal EsophagusAnatomy: Normal Esophagus

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Types of Esophageal CancerTypes of Esophageal Cancer

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Epidemiology and Etiology Epidemiology and Etiology

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Ten Leading Cancer Types for the Estimated New

Cancer Cases and Deaths, by Sex, US, 2003

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Worldwide estimates of cancer incidence

Int. J. Cancer 1999, 80:827-841

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Epidemiology and Etiology(1)Epidemiology and Etiology(1)

• An estimated 16,470 new cases in the United States in 2008

• Nearly four times more common among men than women

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Epidemiology and Etiology(2)Epidemiology and Etiology(2)

• Incidence of esophageal cancer has increased six-fold in the past three decades

• Incidence rates of adenocarcinoma have increased recently, especially in the Western hemisphere

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Risk Factor(1)Risk Factor(1)

• Age 65 or older

• Being male

• Smoking• Heavy drinking

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Risk Factor(2)Risk Factor(2)

• Diet:

• Obesity: increase the risk of adenocarcinoma

• Acid reflux

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Symptoms and SignsSymptoms and Signs

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Symptoms of Esophageal CancerSymptoms of Esophageal Cancer

• Dysphagia• Vomiting• Weight loss• Coughing• Back pain• Hoarseness

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Signs Signs of Esophageal Cancerof Esophageal Cancer

• Supraclavicular lymph node metastasis

• Liver mass

• Bone metastasis

• Hydrothorax

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DiagnosisDiagnosis

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How is Esophageal Cancer Diagnosed?How is Esophageal Cancer Diagnosed?

• Barium swallow (esophagram)• Upper endoscopy (Esophagoscopy) and biopsy

(Diagnosis is confirmed with a biopsy)• Endoscopic ultrasound• Bronchoscopy• Computed tomography (CT) scan• Magnetic resonance imaging (MRI)• Positron emission tomography (PET) scan

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DiagnosisDiagnosis (1) (1)

Barium swallow (Esophagram)Barium swallow (Esophagram)

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DiagnosisDiagnosis (2) (2)

Upper EndoscopyUpper Endoscopy (Esophagoscopy) (Esophagoscopy) and Biopsy and Biopsy

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Pathology diagnosis - Pathology diagnosis - Upper endoscopyUpper endoscopy

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Diagnosis (3)

Endscopic ultrasonography (EUS)

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Endscopic ultrasonography (EUS)Endscopic ultrasonography (EUS)

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Endoscopic ultrasonography (EUS)Endoscopic ultrasonography (EUS)

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DiagnosisDiagnosis (4) (4)

CTCT

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DiagnosisDiagnosis (5) (5)

• MRI • PET-CT• Bronchoscopy• Laparoscopy

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StagingStaging

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Other regular tests

TNM stage

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T stageT stage (Tumor) (Tumor)

TisT1

T2T3

T4

Mucosa

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T1T1

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T2T2

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T3T3

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N stage (lymph node)N stage (lymph node)

N0 N1

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M stage (metastasis)M stage (metastasis)

M1bM1a

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Classification of Stage Groupings Classification of Stage Groupings

for Esophageal Cancerfor Esophageal Cancer

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Stage I Esophageal CancerStage I Esophageal Cancer

• Cancer is in the mucosa and submucosa (the two inside layers of the esophagus)

• Cancer cells are in the lining of the esophagus

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Stage IIA Esophageal CancerStage IIA Esophageal Cancer

• Cancer is in either of the two outer layers of the esophagus

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Stage IIB Esophageal CancerStage IIB Esophageal Cancer

• Cancer is in the inner layers of the esophagus

• Cancer has spread to some lymph nodes near the tumor

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Stage III Esophageal CancerStage III Esophageal Cancer

• Cancer is in the outside layer of the esophagus or in the tissue near the esophagus

• Cancer has spread to lymph nodes, either near the tumor or somewhere

else in the body

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Stage IVA Esophageal CancerStage IVA Esophageal Cancer

• Cancer has spread to the lymph nodes in the abdomen or neck

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Stage IVB Esophageal CancerStage IVB Esophageal Cancer

• Cancer has spread to other parts of the body besides the lymph nodes

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TreatmentTreatment

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How to design the treatment planHow to design the treatment plan

• Stagingwhether the cancer has invaded nearby structureswhether the cancer has spread to lymph nodes or other organs

• where the cancer is located within the esophagus

• The general health of patient

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Treatment of Esophageal CancerTreatment of Esophageal Cancer

EMR or SurgerySurgery

Surgery+adjuvant therapy

Chemoradiotherapy

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RegimenRegimen

• Endoscopic Mucosal Resection(EMR)• Surgery• Chemotherapy• Radiotherapy• Combined-modality therapy• Palliative Therapy

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Endoscopic Mucosal Resection(EMR)Endoscopic Mucosal Resection(EMR)

• What’s EMR?

• Indication of EMR

Tis or T1a (defined as tumor involving the mucusa but not involving submucosa)

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SurgerySurgery

• The most common treatment

• 5-year survival rates of 15% to 30% are reported

• Esophagectomy: removal of part of the esophagus; remaining portion is connected to the stomach

• Lymph nodes around the esophagus may also be removed

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Indication of operationIndication of operation

1 early stage ( stage 0, 1)1 early stage ( stage 0, 1)2 middle stage (stage 2, 3)2 middle stage (stage 2, 3)3 tumor recurrence after radiotherapy 3 tumor recurrence after radiotherapy (no distal metastasis). (no distal metastasis). 4 palliative treatment 4 palliative treatment

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Contraindications of operationContraindications of operation

1 the lesion is extensive,or 1 the lesion is extensive,or involvement of adjacent structures involvement of adjacent structures such as trachea, lung, mediastinum.such as trachea, lung, mediastinum.2 left supraclavicular lymph nodes 2 left supraclavicular lymph nodes metastasis or other distal metastasis.metastasis or other distal metastasis.3 serious functional defection of heart 3 serious functional defection of heart lung and liver. serious cachexia. lung and liver. serious cachexia.

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RadiotherapyRadiotherapy

• Squmous cell carcinoma of the esophagus are radiosensitive and potentially radiocurable

• Radiotherapy to a dose of 6000 cGy resulted in 1-,2-,3- and 5-year survival rates of 33%,12%,8% and 7%

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ChemotherapyChemotherapy

• Chemotherapy alone is seldom an effect palliative modality in patient. Commonly in combination with radiotherapy

• Methotrexate,bleomycin,cisplatin,5-fluorouracil have been used in squmous cell carcinoma

• cancerChemotherapy may be given after surgery (adjuvant), before surgery (neoadjuvant) or if surgery is not possible; in this case, cisplatin and 5-FU are used.

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Combined-modality therapy:Combined-modality therapy:

• Is the best treatment for advanced esophageal cancer. Combined-modality therapy can improve the 3- and 5-year survival rates.

• Including: Surgery+chemotherapy Surgery+radiotherapy Chemotherapy+radiotherapy Radiochemotherapy+surgery

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Palliative TherapyPalliative Therapy

• Photodynamic Therapy

• Laser therapy

• Esophageal stenting

• Feeding gastrostomy

• Colonic interposition

• External-bean irradiation

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What Is the Prognosis for What Is the Prognosis for Esophageal Cancer?Esophageal Cancer?

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PrognosisPrognosis

Time (month)

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In summaryIn summary

• What’s the sympotom and signs of esophageal cancer?

• What’s the main pathologic type of esophageal cancer?

• How can we design the treatment according the staging of esophageal cancer?

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ThanksThanks