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Carcinoma Esophagus

Presented By:JITHIN MAMPATTA

Epidemiology

• 9th common cancer in the world• Disease of mid to late adulthood• Most common in China, Iran, South Africa, India and the former Soviet Union.

• The incidence rises steadily with age, reaching a peak in the 6th to 7th decade of life.

• Commonly in men over 50 years of age• Worldwide SCC responsible for most of the cases.

• SCC usually occurs in the upper two third of the esophagus

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•The cause of scc in endemic areas is not definitely known but is probably due to fungal contamination of food with production of carcinogenic mycotoxin , together with nutritional deficiencies in the population

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•Supplimentation of the diet with beta carotene , vit E ,and selenium has been shown to reduce the incidence in endemic areas

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• Adenocarcinoma more common in westernised countries and is increasing in incidence due to association with GERD , Barretts’s esophagus & obesity.

•Adenocarcinoma is most common in the lower 3rd of the esophagus

Etiology : Squamous Cell Carcinoma

•Smoking and alcohol (80% - 90%)•Dietary factors–N-nitroso compounds (animal carcinogens) – Pickled vegetables and other food-products – Toxin-producing fungi – Betel nut chewing – Ingestion of very hot foods and beverages (such as tea)

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•Underlying esophageal disease (such as achalasia and caustic strictures )

•Genetic abnormalities:–p53 mutation, loss of 3p and 9q alleli, amp. Cyclin D1 & amp. EGFR

Etiology : Adenocarcinoma

• Associated with Barretts’s esophagus, GERD & hiatal hernia.

• Obesity (3 to 4 fold risk)

• Smoking (2 to 3 fold risk)

• Increased esophageal acid exposure such as Zollinger-Ellison syndrome.

Fig. Barretts’s esophagus

Barrett’s esophagus is a

metaplasia of the esophageal epithelial lining. The squamous epithelium is replaced by columnar epithelium,with 0.5% annual rate of neoplastic transformation.

Barrett’s esophagus is a

metaplasia of the esophageal epithelial lining. The squamous epithelium is replaced by columnar epithelium,with 0.5% annual rate of neoplastic transformation.

Morphology : Squamous Cell Carcinoma

•Squamous cell carcinomas are usually preceded by a long prodrome of mucosal epithelial dysplasia followed by carcinoma in situ and, ultimately, by the emergence of invasive cancer

• Early overt lesions appear as small, gray-white, plaquelike thickenings or elevations of the mucosa

•In months to years, these lesions become tumorous, taking one of three forms:

Morphology : Squamous Cell Carcinoma

•Squamous cell carcinomas are usually preceded by a long prodrome of mucosal epithelial dysplasia followed by carcinoma in situ and, ultimately, by the emergence of invasive cancer

• Early overt lesions appear as small, gray-white, plaquelike thickenings or elevations of the mucosa

•In months to years, these lesions become tumorous, taking one of three forms:

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•(1) polypoid exophytic masses that protrude into the lumen

•(2) necrotizing cancerous ulcerations that extend deeply and sometimes erode into the respiratory tree, aorta, or elsewhere and

•(3) diffuse infiltrative neoplasms that cause thickening and rigidity of the wall and narrowing of the lumen

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•Whichever the pattern, about 20% arise in the cervical and upper thoracic esophagus, 50% in the middle third, and 30% in the lower third

Morphology : Adenocarcinoma• Adenocarcinomas seem to arise from dysplastic mucosa in the

setting of Barrett esophagus. Unlike squamous cell carcinomas, they are usually in the distal one-third of the esophagus and may invade the subjacent gastric cardia.

•Initially appearing as flat or raised patches on an otherwise intact mucosa, they may develop into large nodular masses or show deeply ulcerative or diffusely infiltrative features.

Pattern of spread

•Commonly spread by lymphatics (70%)

• 25% - 30% hematogenous metastases

• Most common site of metastases are – lung, liver, pleura, bone, kidney & adrenal gland

• Median survival with distant metastases – 6 to 12 months

Clinical Features

•It is commonly associated with the symptoms of dysphagia, wt. loss, pain, anorexia, and vomiting

•Symptoms often start 3 to 4 months before diagnosis

•Dysphagia - in more than 90% pt. Odynophagia - in 50% of pt.

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Complications:•Cachexia, Malnutrition,

dehydration, anaemia,.•Aspiration pneumonia.•Distant metastasis.

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•Invasion of near by structures: e.g. –Recurrent laryngeal nerve → Hoarseness of voice

–Trachea → Stridor & TOF→ cough, choking & cyanosis

–Perforation into the pleural cavity → Empyema

–back pain in celiac axis node involvement

Diagnostic Workup

• Detailed history & Physical examination: Dysphagia, odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines, history of GERD. Examine for cervical or supraclavicular adenopathy.

• Confirmation of diagnosis: – EGD: allow direct visualization and biopsy, measure proximal & distal distance of

tumor from incisor, presence of Barrett’s esophagus.

Early, superficial cancer

Circumferential ulceration esophageal cancer

Malignant stricture of esophagus

• Staging: – CT chest and abdomen: Essential for staging because it can identify extension

beyond the esophageal wall, enlarged lymph nodes and visceral metastases.

PET Scan• most recently, proven to be valuable staging tool

• can detect up to 15–20% of metastases not seen on CT and EUS

• low accuracy in detecting local nodal disease compared to CT / EUS

• Value in evaluating response to Chemo Therapy & Radio Therapy

• addition of PET to CT can improve specificity and accuracy of non-invasive staging

Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A, Integrated CT PET demonstrates para-aortic lymph node metastases showing increased FDG uptake (arrowheads). B, Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in diameter. Based on size criteria, these lymph nodes may be considered benign on CT scan

• Barium swallow: – can delineate proximal and distal margins as well as TEF

– Helpful for correlation with simulation film.

• Bronchoscopy: rule-out fistula in midesophageal lesions.

•Routine Investigations: CBC, chemistries, LFTs.

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