11

Esophageal CancerEsophageal Cancer

Xiaodong Li 04-02-2010

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

22

33

Anatomy: Normal EsophagusAnatomy: Normal Esophagus

44

55

Types of Esophageal CancerTypes of Esophageal Cancer

66

Epidemiology and Etiology Epidemiology and Etiology

77

Ten Leading Cancer Types for the Estimated New

Cancer Cases and Deaths, by Sex, US, 2003

88

Worldwide estimates of cancer incidence

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

99

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

1010

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

1111

Risk Factor(1)Risk Factor(1)

• Age 65 or older

• Being male

• Smoking• Heavy drinking

1212

Risk Factor(2)Risk Factor(2)

• Diet:

• Obesity: increase the risk of adenocarcinoma

• Acid reflux

1313

Symptoms and SignsSymptoms and Signs

1414

Symptoms of Esophageal CancerSymptoms of Esophageal Cancer

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

1515

Signs Signs of Esophageal Cancerof Esophageal Cancer

• Supraclavicular lymph node metastasis

• Liver mass

• Bone metastasis

• Hydrothorax

1616

DiagnosisDiagnosis

1717

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

1818

DiagnosisDiagnosis (1) (1)

Barium swallow (Esophagram)Barium swallow (Esophagram)

1919

2020

2121

DiagnosisDiagnosis (2) (2)

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

2222

Pathology diagnosis - Pathology diagnosis - Upper endoscopyUpper endoscopy

2323

2424

Diagnosis (3)

Endscopic ultrasonography (EUS)

2525

Endscopic ultrasonography (EUS)Endscopic ultrasonography (EUS)

2626

Endoscopic ultrasonography (EUS)Endoscopic ultrasonography (EUS)

2727

DiagnosisDiagnosis (4) (4)

CTCT

2828

2929

3030

DiagnosisDiagnosis (5) (5)

• MRI • PET-CT• Bronchoscopy• Laparoscopy

3131

StagingStaging

3232

Other regular tests

TNM stage

3333

T stageT stage (Tumor) (Tumor)

TisT1

T2T3

T4

Mucosa

3434

T1T1

3535

T2T2

3636

T3T3

3737

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

N0 N1

3838

3939

M stage (metastasis)M stage (metastasis)

M1bM1a

4040

Classification of Stage Groupings Classification of Stage Groupings

for Esophageal Cancerfor Esophageal Cancer

4141

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

4242

Stage IIA Esophageal CancerStage IIA Esophageal Cancer

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

4343

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

4444

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

4545

Stage IVA Esophageal CancerStage IVA Esophageal Cancer

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

4646

Stage IVB Esophageal CancerStage IVB Esophageal Cancer

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

4747

TreatmentTreatment

4848

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

4949

Treatment of Esophageal CancerTreatment of Esophageal Cancer

EMR or SurgerySurgery

Surgery+adjuvant therapy

Chemoradiotherapy

5050

RegimenRegimen

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

5151

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)

5252

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

5353

5454

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

5555

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.

5656

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%

5757

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.

5858

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

5959

Palliative TherapyPalliative Therapy

• Photodynamic Therapy

• Laser therapy

• Esophageal stenting

• Feeding gastrostomy

• Colonic interposition

• External-bean irradiation

6060

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

6161

PrognosisPrognosis

Time (month)

6262

6363

6464

6565

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?

6666

ThanksThanks