General surgery by Suza

1. CARCINOMA
OESOPHAGUS
Md-3
16/12/2020

2. CARCINOMA OESOPHAGUS
• A disease in which cells in the lining of the
esophagus grow uncontrollably and form a
tumor.
• Carcinoma oesophagus is common in China,
South Africa and Asian countries.
• It is 6th most common cancer in the world.
• It is less than 1% of all cancers. It is 7% of all GI
malignancies.
• It is less common in America and European
countries.

3. • When patient presents with dysphagia, often it is
fairly advanced and inoperable and only palliation
is the possibility.
• But then surgery is the treatment of choice in early
growths.
Types of Esophageal Cancer;
• Two major types of esophageal cancer: squamous
cell carcinoma and adenocarcinoma
• Squamous cell carcinoma starts in squamous cells
that line the esophagus and usually develops in
the upper and middle part of the esophagus

4. • Adenocarcinoma begins in the glandular tissue
in the lower part of the esophagus at the junction
between the esophagus and the stomach
• Treatment is similar for both of these types
• Rare tumors of the esophagus occur in less than
1% of cases and include small cell
neuroendocrine cancer, lymphoma, and
sarcoma

5. What are the Risk Factors for
Esophageal Cancer;
• Age
• Gender
• Race
• Tobacco
• Alcohol
• Barrett’s esophagus, a condition that can
develop in people with chronic
gastroesophageal reflux disease (GERD) or
esophagitis (inflammation of the esophagus)
• Diet

6. • Obesity
• Lye ingestion
• Achalasia (a condition when the lower muscular
ring of the esophagus fails to relax during
swallowing of food)

7. Pathology;
• Common in:
Middle third—50%.
Lower third—33%.
Upper third—17%.
• Lower 3 cm of oesophagus is lined by columnar
epithelium and so adenocarcinoma is common
here.
• Barrett’s columnar metaplasia which occurs in
lower third of oesophagus is also more prone for
adenocarcinoma.
• Squamous cell carcinoma is commonest type in
India and Asian countries.

8.  How do you stage carcinoma esophagus?
 Primary tumor—T
 „T1—Tumor invaded to the lamina propria and
submucosa.
 „T2—Tumor invaded to the muscularis propria.
 „T3—Tumor extending to the adventitial coat.
 „T4—Tumor extending to the adjacent
structures.
 Lymph nodes—n
 „n0—no regional lymph node metastasis.
 „n1—Regional lymph node metastasis present.

9. Distant metastasis—M
 „M0—no distant metastasis.
 „M1—Distant metastasis present.
 Endoscopic USG is very helpful to assess the
primary tumor and lymph node spread.
 CT scan is helpful to delineate the lymph node
and distant metastasis.

10. How does the carcinoma esophagus
spreads?
Direct spread ;
• Spread both circumferentially and
vertically.
• The submucosal spread vertically may
form satellite nodules.
• The tumor may invade through the
adventitia and involve the adjacent
structures—trachea, lungs and other
mediastinal structures.

11. Lymphatic spread: May spread to the
regional lymph nodes.
Distant spread:
• Via hematogenous spread to the liver, lungs and
bones. Involvement of celiac
• lymph node from a lesion of intrathoracic
esophagus is regarded as distant metastasis
rather than regional lymph node metastasis.
Similarly involvement of cervical lymph nodes
from intrathoracic esophagus is regarded as
distant metastasis.

12. Clinical Features
• Recent onset of dysphagia is the commonest
feature.
- For the dysphagia to develop, two-third of the lumen
should be occluded.
• Regurgitation.
• Anorexia and loss of weight (severe), cachexia.
• Pain-substernal or in the abdomen.
• Ascites.
• Melena.
• Features of broncho-oesophageal fistula in
carcinoma of upper third oesophagus (30%).

13. • Left supraclavicular lymph nodes may be
palpable.
• Hoarseness of voice due to involvement of
recurrent laryngeal nerve.
• Hiccough, due to phrenic nerve involvement.
• Back pain—due to nodal spread
(paraoesophageal/coeliac nodes).
• Male to female ratio is 3:1. In adenocarcinoma, it
is 15:1.

14. Investigations;
• Barium swallow:
-Shouldering sign and irregular filling defect.
-Rat tail lesion on fluoroscopy is typical.
• Oesophagoscopy—to see the lesion, extent and
type.
• Biopsy—for histological type and confirmation.
• Chest X-ray—to look for aspiration pneumonia
• Bronchoscopy to see invasion in the upper 1/3rd
carcinoma of oesophagus; laryngoscopy to identify
vocal cord palsy.

15. • CT scan (95% accuracy)—to look for local
extension, nodal status,
perioesophageal/diaphragmatic/pericardial(1%)
-vascular infiltration, obliteration of mediastinal
fat and status of tracheobronchial tree in case of
upper third growth.
• Ultrasound abdomen—to look for liver and
lymph nodes status in abdomen
• Laparoscopy: It is useful to see peritoneal
spread, liver spread and nodal spread.
• Blood tests: FBP; ESR; Liver function tests, RFT
and Electrolyte

16. • Oesophageal endosonography—to look for the
involvement of layers of oesophagus, nodes,
cardia and left lobe of the liver.
• Magnetic resonance imaging (MRI)
• Positron emission tomography (PET) scan

17. TREATMENT MODALITIES
• Treatment depends on stage of cancer
• More than one treatment may be used
• Surgery
• Chemotherapy
• Radiation therapy
• Photodynamic therapy

18. • The most common treatment
• Esophagectomy: removal of part of the esophagus;
remaining portion is connected to the stomach
• Lymph nodes around the esophagus may also be
removed
• Rarely, surgery may also be used to create a new
pathway to the stomach, insert a feeding tube, or
other methods to help a person if unable to eat

19. • CHEMOTHERAPY
• Use of drugs to kill cancer cells
• A combination of medications is often used
• Systemic chemotherapy is delivered through the
bloodstream, targeting cells throughout the body
• Side effects include fatigue, risk of infection,
nausea and vomiting, loss of appetite, and
diarrhea

20. RADIATION THERAPY
• The use of high-energy x-rays to destroy cancer
cells
• Different methods of delivery
• External beam: outside the body
• Internal radiation or brachytherapy: radiation is
given by temporarily inserting a radioactive wire
into the esophagus
• Side effects may include fatigue, mild skin
reactions, upset stomach, and loose bowel
movements

21. • PHOTODYNAMIC THERAPY
• Lasers or light therapy to destroy cancerous
tissue and relieve blockages
• Used in people who cannot or choose not to
receive surgery, radiation therapy or
chemotherapy
• Often used to relieve swallowing problems, not
as a curative therapy

22. REFFRENCES;
• SRB’s manual of surgery 5th edition
• National Cancer Institute
(www.cancer.gov/clinical_trials)
• Bedside clinics in surgery 2nd edition.