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Ca esophagus

ESOPHAGUSIt is a tubular structure about 25 cm long.It begins as the continuation of the pharynx at the level of the 6th cervical vertebra.It pierces the diaphragm at the level of the 10th thoracic vertebra to join the stomach.It is divided into 3 parts:1- Cervical.2- Thoracic.3- Abdominal.

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AbdominalthoracicCervical

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CERVICAL PART

Posteriorly:Vertebral column.Laterally: Lobes of the thyroid gland.Anteriorly:Trachea and the recurrent laryngeal nerves. By Prof. Saeed Abuel Makarem & Dr. Jamila El Medany3RELATIONS

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THORACIC PART

In the thorax, it passes downward and to the left through superior then to posterior mediastinumAt the level of the sternal angle, the aortic arch pushes the esophagus again to the midline.By Prof. Saeed Abuel Makarem & Dr. Jamila El Medany4

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ANTERIOR RELATIONS

TracheaLeft recurrent laryngeal nerveLeft principal bronchusPericardiumLeft atriumBy Prof. Saeed Abuel Makarem & Dr. Jamila El Medany5

Thoracic part

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POSTERIOR RELATIONS

Bodies of the thoracic vertebraeThoracic ductAzygos veinRight posterior intercostal arteriesDescending thoracic aorta (at the lower end)By Prof. Saeed Abuel Makarem & Dr. Jamila El Medany6Thoracic part

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LATERAL RELATION

On the Right side:Right mediastinal pleuraTerminal part of the azygos vein.On the Left side:Left mediastinal pleuraLeft subclavian arteryAortic archThoracic duct

By Prof. Saeed Abuel Makarem & Dr. Jamila El Medany7

ESOPHAGUS AND LEFT ATRIUM There is a close relationship between the left atrium of the heart and esophagus.What is the clinical application?A barium swallow in the esophagus will help the physician to assess the size of the left atrium (dilation) as in case of long standing mitral stenosis or heart failure.

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RELATIONS IN THE ABDOMENIn the Abdomen, the esophagus descends for 1.3 cm and joins the stomach.Anteriorly, left lobe of the liver.Posteriorly, left crus of the diaphragm.9

Fibers from the right crus of the diaphragm form a sling around the esophagus.At the opening of the diaphragm, the esophagus is accompanied by:The two vagiBranches of the left gastric vesselsLymphatic vessels.

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ESOPHAGEAL CONSTRICTIONSThe esophagus has 3 anatomic constrictions.The first is at the junction with the pharynx(pharyngeoesophageal junction).The second is at the crossing with the aortic arch and the left main bronchus.The third is at the junction with the stomach.They have a considerable clinical importance.Why?

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ESOPHAGEAL STRICTURESThey may cause difficulties in passing an esophagoscope.In case of swallowing of caustic liquids (mostly in children), this is where the burning is the worst and strictures develop.The esophageal strictures are a common sites of the development of esophageal carcinoma.In this picture what is the importance of the scale?

ARTERIAL SUPPLY

Upper third by the inferior thyroid artery.The middle third by the thoracic aorta.The lower third by the left gastric artery.By Prof. Saeed Abuel Makarem & Dr. Jamila El Medany12

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VENOUS DRAINAGEThe upper third drains in into the inferior thyroid veins.The middle third into the azygos veins.The lower third into the left gastric vein, which is a tributary of the portal vein. NB. Esophageal varices.

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LYMPH DRAINAGEThe upper third is drained into the deep cervical nodes.The middle third is drained into the superior and inferior mediastinal nodes.The lower third is drained in the celiac lymph nodes in the abdomen.By Prof. Saeed Abuel Makarem & Dr. Jamila El Medany14

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NERVE SUPPLYIt is supplied by sympathetic fibers from the sympathetic trunks.The parasympathetic supply comes form the vagus nerves.Inferior to the roots of the lungs, the vagus nerves join the sympathetic nerves to form the esophageal plexus.The left vagus lies anterior to the esophagus.The right vagus lies posterior to it.By Prof. Saeed Abuel Makarem & Dr. Jamila El Medany15

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EpidemiologyEsophageal cancer is the 7th leading cause of cancer deaths.

accounts for 1% of all malignancy & 6% of all GI malignancy.

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.

Male : Female = 3.5 : 1

African-American males : White males = 5:1

Contd

Worldwide SCC responsible for most of the cases.

Adenocarcinoma now accounts for over 50% of esophageal cancer in the USA, due to association with GERD , Barrettss esophagus & obesity.

SCC usually occurs in the middle 3rd of the esophagus (the ratio of upper : middle : lower is 15 : 50 : 35).

Adenocarcinoma is most common in the lower 3rd of the esophagus, accounting for over 65% of cases.

Two most common forms of esophageal cancer are named for the type ofcellsthat become malignantSquamous cell carcinoma forms insquamous cells, the thin, flat cells lining the esophagus. This cancer is most often found in the upper and middle part of the esophagus

Adenocarcinoma begins inglandular(secretory) cells. Glandular cells in the lining of the esophagus produce and releasefluidssuch asmucus. Adenocarcinomas usually form in the lower part of the esophagus, near the stomach.

Risk Factors : 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)

Underlying esophageal disease (such as achalasia and caustic strictures, Tylosis)

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

Risk Factors: AdenocarcinomaAssociated with Barrettss 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.

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

Pattern of spread No serosal covering, direct invasion of contiguous structures occurs early.

Commonly spread by lymphatics (70%)

25% - 30% hematogenous metastases at time of presentation.

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

Median survival with distant metastases 6 to 12 months

Pathological Classification

95%

Clinical FeaturesIt 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.

Wt. loss more than 5 % of total body wt. in 40 70% pt. associated with worst prognosis.

ContdComplications:Cachexia, Malnutrition, dehydration, anaemia,.Aspiration pneumonia.Distant metastasis.Invasion of near by structures: e.g. Recurrent laryngeal nerve Hoarseness of voice Trachea Stridor & TOF cough, choking & cyanosis Perforation into the pleural cavity Empyemaback pain in celiac axis node involvement

DiagnosisThere are a plethora of modalities available to diagnose and stage esophageal cancerRadiologic tests, endoscopic procedures, and minimally invasive surgical techniques all add value to a solid staging workup in a patient with esophageal cancer.

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EsophagramA barium esophagram is recommended for any patient presenting with dysphagiais able to differentiate intraluminal from intramural lesions and to discriminate between intrinsic (from a mass protruding into the lumen) and extrinsic (from compression of a structures outside the esophagus) compression

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EsophagramThe classic finding of an apple-core lesion in patients with esophageal cancer is recognized easilyAlthough the esophagram will not be specific for cancer, it is a good first test to perform in patients presenting with dysphagia and a suspicion of esophageal cancer

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EndoscopyThe diagnosis of esophageal cancer is made best from an endoscopic biopsyany patient undergoing surgery for esophageal cancer must have an endoscopy performed by the operating surgeon before entering the operating room for a definitive resection

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Computed TomographyCT scan of the chest and abdomen is important to assess the length of the tumor, thickness of the esophagus and stomach, regional lymph node status and distant disease to the liver and lungs

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Normal CT of the Esophagus

CT Squamous Cancer in the Upper Esophagus

CT Adenocarcinoma Lower Esophagus

Positron Emission TomographyPET scan evaluates the primary mass, regional lymph nodes, and distant disease Its sensitivity and specificity slightly exceed those of CT; however, they remain low for definitive staging

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PET Scan Mid Esophagus Cancer

Endoscopic UltrasoundEUS is the most critical component of esophageal cancer staging.The information obtained from EUS will help guide both medical and surgical therapybiopsy samples can be obtained of the mass and lymph nodes in the paratracheal, subcarinal, paraesophageal, celiac region

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TreatmentChemotherpay

Radiation therap

Chemo-radiotherap

Surgical resection

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Management depends upon: Site of disease Extent of disease involvement Co-morbid conditions Patient preference.

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SurgeryPrerequisite for surgerydisease should be 5 cm beyond cricophyrangeus.

Surgery indications Lower 1/3 rd oesophageal ds involving GE junction. Tumor size