dr vivek garg

8/8/2019 dr vivek garg

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Intr cti n

Classificati n

Epi emi logyand emographics

athology Ris factors

Symptoms and Signs

Investigations Staging

Treatment

References


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When cancer of theWhen cancer of theoesophagusoesophagus becomesbecomes

symptomatic, it is alreadysymptomatic, it is alreadythree minutes untilthree minutes untilmidnightmidnight

Julius L. Stoller


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6th most common cancer in the world.

Black/White: 5/1

Male/Female: 5/1 Men have esophageal cancer 3-5 times

more often than women

The mean age at diagnosis is 60 year


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BENIGNTUMORS MALIGNANT TUMOURS

Epithelial

apillomas

esenchymal Leiomyomas

Hemangiomas

Lymphangiomas

Fi romas Lipomas

yxomas

Ne rofi romas

Epithelial (carcinoma)

Sarcoma

Carcino-sarcoma

Metastatic


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CL SSIFICATIONCLASSIFICATION--

(a)(a) SquamousSquamous cell carcinomacell carcinoma (60%)(60%) (b)(b) AdenocarcinomaAdenocarcinoma (40 %)(40 %)

(c) Rare types(c) Rare types::1.Mucoepidermoid carcinoma,

2.Adenoid cystic carcinoma,3.Small cell carcinoma,

4.undifferentiated carcinoma


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Divides the EJs tumor

1. EJs-1

2. EJs-2

3. EJs-3


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Ris factors- Tabaco smoking Excessive alcohol consumption Nutritionaldeficiency(iron,vit.A) oor dentalhygiene

Long term use of spicy foodandhot drinks Fungal contaminationof food Obesity Fresh fruits andvegetables are protective Occuapational exposure of asbestos,combustion product

re-existing conditions---- Achalasia (3-5%) Barrets esophagus Chronic reflux esophagitis Caustic burns Tylosis


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Human papilloma virus HPV serotype16 was identified in 9 percent of resection specimens

from 70 Chinese patients with esophageal SCC.

Controversial, but HPV has got some protectivevalue in case of adenocarcinoma.

Keratosis palmaris et

plantaris(tylosis) rare disease associatedwith hyperkeratosis of the palms of the hands andsoles of the feet and a high rate of esophageal SCC.

AD

Mapped on ch band 17q25


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NEJM,2003NEJM,2003NEJM,2003


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Upper third: 20%

Middle third- 30%

Lower third: 50%


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Histologically, characterizedby invasive sheetsof cells that run together andare polygonal,oval,or spindle-shaped withadistinct or

ragged stromal-epithelial interface.


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AA-- Cauliflower type(Cauliflower type(fungatingfungating) (60%):) (60%):

BB-- Ulcerative type :Ulcerative type : raised everted edge-

necrotic floor- indurated base

CC--Annular typeAnnular type :: more common in

lower 1/3.

Pattern of GrowthPattern of Growth


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A 5-year survivalof 70% is associated with thepolypoid tumor compared withaless than15%5-year survival for allother types


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Arises from the superficialanddeepglands

of the esophagus, mainly in the lower third

of the esophagus, especiallynear thegastroesophageal junction


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Mayhave one of three origins:

Malignant degenerationof metaplasticcolumnar epithelium (Barrett's mucosa)

Heterotopic islands of columnar

epithelium

The esophageal submucosal glands


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Anaplastic small cell (oat cell) carcinomaarisein the esophagus from same argyrophilic cellsfound in the lung.

Adenoid cystic esophageal carcinoma

Primary malignant melanomaof esophagus

Carcinosarcoma, features of SSCand malignant

spindle cell sarcoma.


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Progressive dysphagia - 87-95 % Weight loss Sialorrhea (Hypersalivation) Regurgitation Pain (Odynophagia) Halitosis Dehydration

RespiratoryProductive coughingHoarsenessDyspnea


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Difficulty in swallowingDifficulty in swallowing

Dysphagia in male > 50 years > 2 wks isconsidered cancer esophagus untill

proved otherwise


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Usuallyno signs

Evidence of weight loss

Cervical LAM

Other signs of dissemination

Hepatomegaly

Jaundice

Cardiac arrhytmias

Ascites


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(1)(1) Direct:Direct: ((main methodmain method):): to the surrounding

(2)(2) LymphaticLymphatic:: mainly inadownwarddirection.

Cervical esophagus lower deep cervical L.N.

Thoracic esophagus para-oesophageal & tracheo-bronchial lymph nodes

Abdominal esophagus lymphnodes along the lessercurvature of the stomach coeliac axis L.N.

(3) Blood (rare):(3) Blood (rare):

Liver,lung,bone,brain


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Obstruction

Perforation

Pulmonary- Pneumonia,lungabscess,

Esophago-tracheal/bronchial fistula

- Cardiovascular- Bleeding, myo-pericardial met,S C syndrome

Neural-Rec. Laryngeal,vagal,phrenic nerveinvolvement,

Claude Bernard Horner syndrome


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HematologicalEx.

Barium swallow

CT Scan

MRI

PET

Endoscopy

Esophagoscopy(biopsy)

EndoscopicUS

Bronchoscopy


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- Non invasive methodof detectingprimary,nodal,distant metastases &locally recurrenttumor

- The technique estimates areaof highglucose

metabolism (the tumor) by measurement of theuptake of radiotracer (Flurodeoxyglucose FDG).


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Lugol's iodide reacts with the glycogen

components of normal squamous mucosa to

produce a greenish brown color, while

neoplastic tissue is depleted of glycogen andremains unstained


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Relief fromdysphagia

Long dysphagia free

interval Relief from pain

Improved quality oflife

Improved long-termsurvival


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Surgery

Chemotherapy

Radiotherapy


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SURGERY----

Most effective treatment

Overall resectability50%

Operative mortality5-10% Lymphnode involvement % 80

Routes

Trans-thoracic

Thoraco-abdominal Transhiatal

Lapassistedoesophagectomy


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Mainlydepends onlocationof tumor

CERVICAL Lesion-pharyngogastrostomyanastomosis is preferred.

UPPEROesophagus-Tri Incisional approach

MIDDLEOesophagus-Tri/Ivor Lewis

LOWEROesophagus-Tri/Ivor

Lewis/Transhiatol approach


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Stomach

Lt colon

Rt colon

Jejunum


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Anastomotic leak,

Anastomotic stricture,

Recurrent laryngealnerve palsy,

Respiratory complication,

Bleeding,

Chyle leak,

Impaired conduit emptying


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UnresectabilityCriterias----

Tracheo-esophageal fistula

Hoarseness

Tumor> 10 cm

Malignant pleural effusion

Claude Bernard Horner syndrome

Paralysis of diaphragm Invasionof surrounding structures

Distant metastases


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RT/CT

Dilation withbougie

Atkinson

Souttar Tube

Procter-Livingstone

Self expanding metalstents(SEMS)

Photodynamic therapy (PDT)

Surgery-Bypass procedure(Retro/presternal colonic by-pass)

Feedinggastrostomy orjejunostomy


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Pt withM-1disease have a median survivalof 6to12 months.

Inpt without systemic metastases,a complete R0resection is best.

Pt withanR1(positive microscopic margin) orR2(gross left behind) resectionhave survivalsimilar to those pt havingM1disease.

After surgery: 5-year overall survival

10-20

1-year survival 70%

2-year30%

5-year20%


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Cisplatin 75 mg/m2 bolus givenover 30 min withadequate prehydration,mannitol andantimetics onday1,

5-FU1000 mg/m2/daygivenas continiousinfusiononday1 through4,

Cycle repeated every28days,

Four cycles planned-first 2 withRT,last 2 withoutRT.


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1. Multiple field technique-1.8Gy/day withtarget upto 50.4Gy.

2.Highdose target volume-14.4Gy/day with

target upto 64.8Gy.


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1.Bailey& Loves short practice of surgery,2.Sabiston text bookof surgery,

3.Maingot AbdominalOperation,

4.Devita,Hellman&Rosenbergs cancer principal&practice of oncology,

5.Lee McGregors synopsis of surgicalanatomy,

6.Dx/Rxupper gastrointestinal malignancies:

cancer of the stomach& esophagus-Dr.ManishA.Shah,

7.Schwartz's Principles of Surgery


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dr vivek garg

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