Esophageal CancerEsophageal Cancer

ByByDr. Monsif IqbalDr. Monsif IqbalPGT Surgical IIPGT Surgical II

11

Case Presentation

22

PATIENT’s PROFILEPATIENT’s PROFILE

• Name: XYZ

• Age: 68 yrs.

• Sex: Male

• Address : Wah Cantt.

• D.O.A: 25-05-2012

• M.O.A: OPD

33

PRESENTING PRESENTING COMPLAINTSCOMPLAINTS

• Dysphagia 4 months

• Weight loss

44

PAST HISTORYPAST HISTORY• Seen by ENT specialist 4 months back but no diagnosis

made

• Then Upper GI endoscopy at MH Rawalpindi---- report was normal

• Upper GI endoscoscopy at POF on 16-05-2012----- revealed small nodules in lower 5 cm of esophagus and a large 10*10 cm nodule around the opening of esophagus.

• HCV positive

55

Drug HISTORYDrug HISTORY

• Not significant

66

PERSONAL HISTORYPERSONAL HISTORY

• Smoker----- 40 years (smoking 12 /day)

77

PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:

1. GPE:An old aged emaciated gentleman, lying comfortably in bedHis vitals are;– Pulse: 80/min– B.P: 130/80 mm of Hg– Oxygen Sat: 96%– Temp: AfebrileRest of GPE unremarkable.

88

Systemic ExaminationSystemic Examination

• On abdominal examination– Scaphoid abdomen– No mass palpable– Bowel sounds +ve

• Rest of the systemic examination unremarkable

99

Management planManagement plan

• Barium swallow

• CT scan chest+abdomen

1010

1111

1212

1313

1414

1515

1616

• We prepared the patient for surgery

• Routine investigations, Hb 9.8 g/dl and ALT of 73…..

• 03 units of blood arranged

• Esophagogastrectomy--06/06/2012

1717

• The operative findings were– Huge mass covering proximal 3/5th of the

stomach and lower one third of the esophagous. The stomach was adherent to the underlying structures

• It was decided per-operatively to go for esophagogastrectomy with colonic interposition using ascending colon

1818

1919

2020

2121

2222

2323

2424

2525

2626

2727

2828

2929

3030

3131

3232

3333

3434

3535

3636

• Post operatively the recovery is uneventful so far……

3737

Esophageal CancerEsophageal Cancer

3838

3939

4040

Anatomy: Normal EsophagusAnatomy: Normal Esophagus

4141

4242

Types of Esophageal CancerTypes of Esophageal Cancer

4343

Epidemiology and Etiology Epidemiology and Etiology

4444

Ten Leading Cancer Types for the Estimated New

Cancer Cases and Deaths, by Sex, US, 2010

4545

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

4646

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

4747

Risk Factor(1)Risk Factor(1)

• Age 65 or older

• Being male

• Smoking• Heavy drinking

4848

Risk Factor(2)Risk Factor(2)

• Diet:

• Obesity: increase the risk of adenocarcinoma

• Acid reflux

Clinical presentationClinical presentation

• Dysphagia

• Vomiting

• Weight loss

• Coughing

• Back pain

• Hoarseness

4949

5050

Spread of CA esophagousSpread of CA esophagous

• Local Spread

• Lymphyatic spread

• Blood spread

5151

DiagnosisDiagnosis

5252

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

5353

DiagnosisDiagnosis (1) (1)

Barium swallow (Esophagram)Barium swallow (Esophagram)

5454

5555

5656

5757

5858

DiagnosisDiagnosis (2) (2)

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

5959

Pathology diagnosis - Pathology diagnosis - Upper GI Upper GI endoscopyendoscopy

6060

6161

Endscopic ultrasonography (EUS)

6262

Endscopic ultrasonography (EUS)Endscopic ultrasonography (EUS)

6363

Endoscopic ultrasonography (EUS)Endoscopic ultrasonography (EUS)

6464

CTCT

6565

6666

DiagnosisDiagnosis and staging and staging

• MRI • PET-CT• Bronchoscopy• Laparoscopy

6767

StagingStaging

6868

Other regular tests

TNM stage

6969

T stageT stage (Tumor) (Tumor)

TisT1

T2T3

T4

Mucosa

7070

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

N0 N1

7171

M stage (metastasis)M stage (metastasis)

M1bM1a

7272

Classification of Stage Groupings Classification of Stage Groupings

for Esophageal Cancerfor Esophageal Cancer

7373

Stage I (T1N0M0) Esophageal Stage I (T1N0M0) Esophageal CancerCancer

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

• Cancer cells are in the lining of the esophagus

7474

Stage IIA (T2N0M0 or T3N0M0) Stage IIA (T2N0M0 or T3N0M0) Esophageal CancerEsophageal Cancer

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

7575

Stage IIB (T1N1M0 or Stage IIB (T1N1M0 or T2N1M0 ) Esophageal CancerT2N1M0 ) Esophageal Cancer

• Cancer is in the submucosa or muscular layer of the esophagus

• Cancer has spread to some lymph nodes near the tumor

7676

Stage III (T3N1M0 or T4anyNM0) Stage III (T3N1M0 or T4anyNM0) Esophageal CancerEsophageal Cancer

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

• Cancer has spread to lymph nodes near the tumor

7777

Stage IVA (anyTanyNM1a) Stage IVA (anyTanyNM1a) Esophageal CancerEsophageal Cancer

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

7878

Stage IVB (anyTanyNM1b) Stage IVB (anyTanyNM1b) Esophageal CancerEsophageal Cancer

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

7979

TreatmentTreatment

8080

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

8181

Treatment of Esophageal CancerTreatment of Esophageal Cancer

EMR or SurgerySurgery

Surgery+adjuvant therapy

Chemoradiotherapy

8282

RegimenRegimen

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

8383

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

• Indication of EMR

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

8484

SurgerySurgery

• The mainstay of 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

• Esophagectomy Techniques– Transhiatal (Orringer)– Ivor lewis– Three field (McKeown’s)

8585

8686

8787

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

8888

8989

RadiotherapyRadiotherapy

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

9090

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

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

9191

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

9292

Palliative TherapyPalliative Therapy

• Photodynamic Therapy

• Laser therapy

• Esophageal stenting

• Feeding gastrostomy

• Colonic interposition

• External-beam irradiation

9393

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

9494

PrognosisPrognosis

Time (month)

9595

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?

9696

SWALLOWING…….

9797

9898

THANKSTHANKS