Dr. Baddigam Anjali

1. Carcinoma oesophagus
Presenter: Dr. Anjali (2nd yrPG)
Guide :Dr. Y.prabhakara rao M.s,M.ch.,
professor , General surgery Department
NRI general hospital ,chinakakani
Dr.M. Prasanna kumar M.S
Dr.sai prasuna (final year postgraduate)

2. Contents
• Introduction
• Epidemiology
• Etiology
• Oesophageal tumours
• Premalignant lesions
• Pathological classification
• Clinical features
• Staging
• Diagnosis
• Management

3. Introduction
• Oesophagus cancer is the eighth most common cancer worldwide.
• sixth most common cause of death from cancer.
• Most commonly present in 6th -7th decade of life.
• M : F (7:1)
• 1% of all malignancies , 7% of all GI malignancies.
• Esophageal cancer remains one of the deadliest cancers with an overall 5-year survival rate
estimated to be less than 18%

4. Epidemiology
The highest-risk area, referred to as the esophageal cancer belt -
>100cases/1,00,000 annually.
M/c benign tumor of esophagus : leiomyoma
M/c esophageal cancer in India : squamous cell carcinoma
M/C esophageal carcinoma in western countries : adenocarcinoma
M/C esophageal cancer in the world : squamous cell carcinoma

5. ETIOLOGY
FACTOR SQUMOUS CELL CARCINOMA ADENOCARCINOMA
SMOKING ++++ +
ALCOHOL ++++ --
HOT BEVERAGES + --
HISTORY OF AERODIGESTIVE
MALIGNANCIES
+++ --
CHEWING BETEL NUT + --
ACHALASIA + --
PLUMMER VINSON SYNDROME + --
LOW SOCIO ECONOMIC GROUP + --
LYE CORROSIVE STRICTURE + --
H/O RADIATION TO MEDIASTINUM + +
DEFICIENCY OF VITAMIN A ,B AND E + --
OBESITY -- ++
GERD -- +++
BARRETS ESOPHAGUS -- ++++

6. ETIOLOGY
• Genetic predisposition
TYLOSIS (hovels – evans syndrome)
• Human papilloma virus (16,18)
• Geotrichum candidum fungi, mycotoxins.
• NSAIDS and H. pylori infection – protective role.

7. Anatomical distribution of ca.esophagus
M/C esophageal carcinoma in
upper 1/3rd : SCC
M/C esophageal carcinoma in
middle 1/3rd : SCC
M/C esophageal carcinoma in
lower 1/3rd : adenocarcinoma
m/c site of esophageal cancer :
middle 1/3rd

8. Oesophageal tumours – 1% of all tumours. 7% of all GI tumours.
Benign tumours (rare)
 leiomyomas(<1%)
 Granulosa cell tumours
Fibrovascular polyps
Squmous papillomas
Lipoma
Hemangioma
Neural tumours
Malignant tumours
Squmous cell carcinoma
Adenocarcinoma
Small cell carcinoma
Primary melanoma of the
oesophagus
GIST and leiomyosarcoma
lymphoma

9. Pre malignant lesions of esophagus
SCC
• Squamous cell dysplasia
• Plummer vinson syndrome
• Tylosis
• Achalasia
• Oesophageal strictures and
diverticula
• P53 gene mutation
EAC
• Barretts oesophagus
• GERD

12. Clinical features
Early lesions are usually
asymptomatic are
incidental findings on
endoscopy for barrett’s
oesophagus .
Advanced cases :
Dysphagia (74%)
progressive (solids
>semisolids>liquids)
weight loss (57%)
Odynophagia(17%) H/o reflux symptoms Hoarseness Anemia
Aspiration pneumonia
Malignant tracheo
oesophageal fistula
Hepatomegaly ,pleural
effusion , cervical
lymphadenopathy.

13. Spread
 Direct
Lack of serosal layer
Upper 1/3rd -- left main bronchus ,trachea, left recurrent laryngeal nerve,
aorta or its branches.
Lymphatic
Hematogenous spread

15. STAGING
• squamous cell carcinoma :epithelial tumour with squamous cell differentiation
containing keratinocyte like cells microscopically with keratinisation or
intercellular bridges.
Adenocarcinoma :epithelial tumour with glandular differentiation.
 T stage indicates tumour infiltration from mucosa to adventitia &beyond
esophagus.
N stage – regional lymphnodes
M stage –distant metastases.

19. N staging
• Nx: regional nodes cannot be assessed
• N0: no regional lymph node metastases
• N1: 1-2 regional nodes involved
• N2: 3-6 regional nodes involved
• N3: >7 regional nodes involved

20. M Staging
• Mx: metastatic disease cannot
be assessed
• M0: no distant metastases
• M1: distant metastases

21. HISTOLOGICAL GRADING

23. Identification of location of tumour
During endoscopy, the location
of the tumor relative to the
incisors and GEJ should be
noted. as well as the length of
the tumor and degree of
obstruction.

25. Diagnosis
• Standard initial investigation in patient c/o
dysphagia and wt.loss
• Endoscopy should be performed in any patient
with dysphagia, even if the barium
oesophagogram is suggestive of a motility
disorder.
• Upper GI endoscopy and Biopsy :
Findings: ulceration or nodularity (early lesions)
friable ulcerated mass (advanced lesions)
To obtain length of lesion
 distance of lesion from incisors and GEJ
 %of circumferential involvement and most
proximal extent as for barrets – PRAGUE criteria

27. Barium studies
• The diagnostic accuracy of the double-contrast barium esophagogram is
70%. Before endoscopy and as a road map (not a routine).
• This radiological technique is capable of documenting stricture length,
diameter, location, and contour, axis of the esophagus and prescence of
other pathology (hernia & diverticulum).
• Findings :
Irregular narrowing
Mucosal irregularity
Shouldered margins
Rat tail appearance
Apple core constrictions

29. CT Imaging
• It is performed as the first radiologic test in the staging evaluation of an
endoscopically diagnosed esophageal cancer.
• >5mm thickness is abnormal.
• T1 -2 :5-10 mm thickness , T3 - >15mm thickness
• Advantages:
To identify the lesion
Surrounding structures
Regional organ invasion
Lymph nodal status
distant metastasis,
Area of contact b/w oesophagus & aorta extends beyond the 90 degrees of
circumference then 80% accuracy of infiltration is reported.

30.  Axial and coronal CECT Thorax images showing
concentric esophageal wall thickening, hold up of
contrast (HC) and dilatation of proximal
esophagus (PD), involving the middle thoracic
esophagus with a periesophageal lymph node
(PLN).
 Metastases to lung and liver are also shown on
Pulmonary window and axial CECT image of
upper abdomen respectively

31. Disadvantages
• Sensitivity and specificity is less.
• Lymph nodal detection is suboptimal with CT as normal sized LN may be
metastatic & sometimes abnormal enlargement maybe due to reactive or
inflammatory lesions.
• It is inferior to laparoscopy in detecting peritoneal metastasis.

32. PET –CT SCAN
Advantages:
• It can detect primary tumour & provide functional assessment of lymphnodes &metastatic
sites.
• Distinguish b/w inflammatory and malignant lymphnodes.
Disadvantages :
• Histologically, SCCs were found to highly accumulate FDG at the primary tumor site in contrast
to adenocarcinomas, which demonstrate more limited FDG accumulation.
• PET does not provide enough definition of the esophageal wall and thus has no value in T
staging.
• Overall sensitivity ranges from 78-95% with high false negative rates with T1 & small T2
tumors.

33. PET/CT improves the detection of metastatic
disease and, thus, can often result in a change of the
management strategy

34. Endoscopic ultra sound
ADVANTAGES
• Only modality able to distinguish 5 layers of oesophageal wall.
• Oesophagus seen as alternate hypo and hyperechoic layers.
• Helpful in detecting lymph nodal staging and also helps to take FNAC from
suspicious nodes.
• It is best for detecting paraesophageal nodes
• EUS OF LN :HYPOECHOIC , SMOOTH & ROUNDED SIZE >5—10 mm
• Best for detecting paraesophageal nodes.
DISADVANTAGES
• Accuracy is operator dependent
• False –ve results will come if peritumoral oedema present.

35. Endoscopic ultrasound

36. BRONCHOSCOPY (Tracheo bronchial ultrasound)
• Tracheo bronchial tree is involved in advanced cases of proximal 1/3rd of
esophageal lesions.
• Findings on bronchoscopy
Widening of carina
Extrinsic compression Particularly posterior wall
of trachea.
Tumour infiltration fistulisation (unresectable)
Laryngoscopy – in case of hoarseness

38. Laparoscopy
• For visual inspection of liver surfaces & peritoneal cavity
• Collection of peritoneal fluid for biopsy
• Celiac lymphnodal biopsy.
• DISADVANTAGE: requires GA

39. Thoracoscopy
• Thoracoscopic staging usually involves a right-sided approach, with opening of
the mediastinal pleura from below the subclavian vessels to the inferior
pulmonary vein with lymph node sampling.
• Disadvantage : requires GA , ONE lung ventilation & hospital stay
• Only to improve preoperative staging are done if +ve conformation of metastatic
disease is not otherwise obtainable & is essential for treatment planning.

40. Predictors ofprognosis.
 Staging of disease at diagnosis
 Weight loss of more than 10 percent of body mass
 Dysphagia
 Large tumors
 Advanced age
 lymphatic micrometastases (identified by immunohistochemical
analysis)
 At the time of diagnosis around 2/3 of all patient with Oesophageal
cancer will already have incurable disease.

41. Treatment
• Endoscopic treatment
• Surgical treatment
• Radiation therapy
• Chemotherapy
• Palliative surgery

42. Treatment of Squamous cell carcinoma
Early carcinoma Management
ENDOSCOPIC SUBMUCOSAL RESECTION
ENDOSCOPIC SUBMUCOSAL DISSECTION
T1a-MM or T1b-SM1 (200 μm deep from the
muscularis mucosa) but without evidence of
nodal spread in pretreatment staging
investigation. EMR AND ESD
There is a moderate chances of nodal involvement
Hence treated as advanced carcinoma.

43. Locally advanced carcinoma(T1b N1 +T2 –T4a)
• Surgical resection is first line.
• Low risk lesions esophagectomy
• High risk lesions
<5cm from cricopharyngeal muscle
PLAN : CHEMORADIOTHERAPY
F/B SURGERY
Cervical oesophagus
NON CERVICAL OESOPHAGUS
PREOPERATIVE CHEMORADIOTHERAPY
F/B SURGERY
F/B CONCURRENT POSTOP CHEMORADIOTHERAPY

44. ADENOCARCINOMA
• EARLY CARCINOMA
ENDOSCOPIC MUCOSAL RESECTION (OR)ENDOSCOPIC SUBMUCOSAL DISSECTION
OR
RADIOFREQUENCY ABLATION (OR ) PHOTO DYNAMIC ABLATION
BEST TRT : EMR f/b RFA

45. ADVANCED CARCINOMA
• Low risk --- oesophagectomy
• High risk
Thoracic oesophagus preop CRT + SURGERY +postop CRT
Tumours at GEJ

46. Endoscopic treatment
Types
1)Endoscopic mucosal resection
2)Endoscopic submucosal dissection
Indications
 Well differentiated superficial lesions (T1a , T1b).
No nodal involvement
Nodular barrett oesophagus (high grade dysplasia)
Lesions which are <2cm in maximum dimension.

47. • Limitations :
lesions >2cm are removed
by piecemeal resection and
increases the chances of
recurrence.

48. Endoscopic submucosal dissection
•Procedure
Mark lesion by electrocautery
Submucosal injection of solution
Precut the mucosal edges along the
marking
Submucosal dissection
Secure hemostatsis.
LIMITATIONS :
 higher bleeding and perforation rates
Technical difficulties

49. • ESD Vs EMR
ENDOSCOPIC
MUCOSAL
RESECTION
ENDOSCOPIC
SUBMUCOSAL
DISSECTION
LESS CHANCE OF +VE MARGINS
MORE ENBLOCK RESECTION
LOW RECURRENCE RATES

50. COMPLICATIONS OF ENDOSCOPIC THERAPY
Bleeding (2%)
PERFORATION (0.2%)
STRICTURE FORMATION (IF >50% CIRCUMFERENCE OF
TIISUE REMOVED)

51. Endoscopic cryoablation
Endoscopic cryotherapy is a relatively new thermal ablative modality used for the
treatment of neoplastic lesions of the esophagus. It relies on cycles of rapid cooling and thawing
to induce tissue destruction with a cryogen (liquid nitrogen or carbon dioxide) leading to intra and
extra-cellular damage and thrombi formation in the blood vessels inducing apoptosis and
ischemia.
Cryoballoon focal ablation using liquid nitrogen is a novel mode of cryogen delivery which has
been used for the treatment of BE with dysplasia and squamous cell carcinoma.
The truFreeze system delivers liquid nitrogen through a low-pressure, non-contact, 213 cm long,
7F spray catheter and results in flash freezing the mucosa to -196 °C
Complications
No specimen for HPE
c/o chest pain
Stricture formation
Requires repeated sessions &intense surveillance for recurrence.

52. • Mechanisam: thermal energy to promote coagulative
necrosis. Implies destruction and ultimately removal of
tissue.
• A balloon catheter covered with electromagnetic coils is
inserted into the esophagus and inflated at the place where
the abnormal cells are found. Radio wave energy passing
through the coils then burns away the affected tissue,
leaving normal tissue undamaged.
• After treatment, participants were followed for a year with
biopsies.
Radiofrequency
ablation

53. SURGICAL TREATMENT
Surgical approach depends on
Tumour location
Tumour stage
Patient risk profile
Surgeon preference &experience.

54. Choice of surgery approach
• Lesions involving cervical oesophagus
pharyngo laryngo oesophagectomy f/b pharyngo gastric anastomosis.
• Pharyngolaryngoesophagectomy (PLE), with or without adjuvant radiotherapy, has been the
gold standard of treatment since first reported by Ong and Lee in 1960.75 The procedure
involves cervical and abdominal incisions and a thoracotomy.
• Tumors located at the hypopharyngeal and cervical esophageal regions were resected
together with the whole length of the esophagus, and the gastric tube was pulled up to the
neck via the posterior mediastinum for pharyngogastric anastomosis.
• A permanent end tracheostomy was created. Modern technique replaces the thoracotomy
part with a transhiatal or minimally invasive approach.

55. • Other alternative reconstructive procedures :
free jejunal inter positional graft.
PMMC flap
anterolateral thigh flap
free post tibial flap
• With the possibility of laryngeal preservation when treated by chemoradiation
therapy, however, surgery is often not the preferred first choice of treatment.
Therefore, the current role of surgery for cervical esophageal cancer is mainly for
salvage after incomplete response or recurrent disease after chemoradiotherapy.

56. surgery for Intrathoracic and abdominal oesophageal lesions
Upper 1/3rd
- McKeown -3-phase oesophagectomy
Middle 1/3rd
-Ivor Lewis or lewis tanner-2-phase oesophagectomy
Lower 1/3rd
-Orringer transhiatal oesophagectomy with anastomosis in neck.
Extent of resection: To achieve R0 resection ,resection should be 10cm proximal
and 5cm distal to the tumour and also the adventitial margins for primary
tumour+ radical clearance of lymphatic system.

57. Mckeown -3-phase oesophagectomy
• Includes
Right thoracotomy (To mobilise oesophagus)
Laparotomy(conduit preparation)
right side cervical incision
Ivor lewis -2-phase or lewis tanner operation
• Includes – laparotomy + rt . thoracotomy = anastomosis in mediastinum
Orringer transhiatal oesophagectomy
Includes laparotomy + left sided neck dissection = anastomosis on left side of
the neck .

63. • Siewert type 1 tumours
Trans hiatal oesophagectomy + mediastinal lymphadenectomy
• Siewert type 2 &3 tumours
Distal gastrectomy with roux –en-Y jejunal loop reconstruction + celiac nodal
dissection.

64. Extent of lymphadenectomy
• Lymph node invasion is more with squamous cell carcinoma than adeno
• Extent of lymphadenectomy differs based on tumour location and its histology .
• Performed along three fields
Single field
Abdominal Ln
around celiac
axis for siewert
type 2 and 3
tumours
Three field
Abdomen +
mediastinal + b/l
cervical LN’S
dissection done for
intrathoracic SCC in
japan

65. Two field lymphadenectomy
•
• Infracarinal +b/l bronchial bifurcation +celiac trifurcation
• +superior mediastinal nodes along with
• right paratracheal +right recurrent
laryngeal nodes
+ left paratracheal + left recurrent
laryngeal nodes
Standard
extended standard
Total extended

66. Reconstruction after oesophagectomy
• Choice of oesophageal substitute : The most commonly used conduit is the gastric tube, and
of the many configurations, an isoperistaltic tube based on the greater curvature with
preservation of the right gastric and right gastroepiploic vessels is most reliable.
• The simplicity of preparation, adequate length, and robust blood supply make it the first
choice as the esophageal substitute. Based on right.gastric and right.gastro epiploic arteries.
Disadvantages
postprandial discomfort
early satiety
acid reflux with possible ulceration
esophagitis
inadequate gastric anastomosis

67. Colon as substitute
Conduit of choice in benign disorders of stomach
Left (left colic artery ) > rt.colon (middle colic artery)
Advantages
 Good longterm swallowing function
 active peristalsis.
 avoids acid reflux
 If distal stomach retained ,colo gastric
anastomosis provides additional
reservoir function.
Disadvantages
• Need more complex mobilisation
• Less reliable blood supply- increases
conduit necrosis
• Requirement of 3 anastomosis
• Longer operation time ,more blood
loss
• High chances of anastomotic leak
• Colon ischemia

69. Jejunum as substitute
• The jejunum is used most frequently after distal esophagectomy and total
gastrectomy for cancer of the lower esophagus and gastric cardia.
• A Roux-en-Y configuration seems best, as it prevents bile reflux to the esophagus.
DISADVANTAGES
Tedious preparation
less reliable vasculature
microvascular anastomosis to
cervical vessels may be required.

70. Route of reconstruction of esophagus
1) orthotopic- preferred route
Advantage :better nutritional status
Disadvantage :chances of recurrence.
2) Retrosternal:
Advantage : less recurrence , best route if post op RT is planned.
Disadvantage : postoperative cardiopulmonary morbidity and mortality
3)Sub cutaneous : cosmetically unsighty.

71. Complications of oesophagectomy
• Anastomotic leak (MC) – higher with cervical anastomosis than intrathoracic.
• Anastomotic stricture
• Pulmonary complications – MC after THE
• RLN palsy
• Chylothorax

72. • Chemotherapy
 neoadjuvant
Adjuvant
Both associated with significant results
in both SCC and EAC
Doublet regimens (5fu+cisplatin)
most preferred.
Triplet regimen (5fu+cisplatin+anthracyclin)
Preferred in medically fit with good physical
status.
Oxaliplatin >cisplatin.

73. Radiotherapy
• Neoadjuvant radiotherapy
Stage T3 or higher
Nodes +ve
Dose : 45-50gy
• Adjuvant
cervical esophagus : 60-66gy
Thoracic/ge junction : 50-54gy
• Palliative
c/o dysphagia
30-35gy
• Complications
Oesophagitis
Oesophageal stricture
Radiation pneumonitis
Pericarditis
Radiation nephritis

74. Palliative therapy
• The aim of Palliative treatment is to overcome debilitating or distressing
symptoms while maintaining the best quality of life possible for the
patient ( i.e restore swallowing).
• Nodes >5 involvement
• Invasive, poorly differentiated grade
• Length of involvement >8 cm
• Abnormal oesophageal axis in barium study
• Horner's syndrome
• Loss of weight >20%
• Metastatic disease
To palliate
Pain
Dysphagia
Prevent bleeding
Prevent aspiration

75. • Endoscopic palliative treatments for more advanced tumors include
 oesophageal dilatation
self expanding metal stents(SEMS)
Endoscopic laser
Photodynamic therapy
Chemotherapy
Radiotherapy
Cryoablation
Orringer Trans hiatal blind oesophagectomy
 The aim of Palliative treatment is to
overcome debilitating or distressing
symptoms while maintaining the best
quality of life possible for the patient (
i.e restore swallowing)

76. SEMS
Indication : malignant severe dysphagia.
These are passed through endoscope under C-arm guidance. It is the ideal method of palliation.
Stent is collapsed during insertion and released once it is placed in proper position. There is no
need to dilate oesophagus more than 8 mm to pass this expanding stent and so chances of
perforation is minimal.
Uncovered SEMS-here tissues project through the mesh to have a better grip with less chances
of migration. But stent occlusion is more.
• Plastic covered SEMS-it shows less stent occlusion and friction. Stent migration is more.
• Problems of stents are-aspiration, displacement, erosion, bleeding, tumour growth across or
beyond mesh, food bolus obstruction, retrosternal pain, need for reinsertion (40%). Mortality
is 1- 2%.

78. Endoscopic laser
It is used to core a channel through the tumour to improve dysphagia and to control
bleeding (Nd YAG laser; Diode laser). It causes thermal destruction of tumour.
It improves dysphagia but needs repeated laser ablation. It may be used more effectively
to remove tumour block in previously placed stents.
• Exophytic tumour less than 6 cm is suitable for laser. Noncontact high power Nd:YAG 50-100
W laser from distal to proximal end facilitates visualisation of lumen and also reduces the
chances of perforation.
• Contact low power Nd:YAG 10-20 W laser is used for fully occluded tumour with less smoke
formation and less perforation chance.
• Success rate of palliation is 85%.
• Problems are- fever, chest pain, 3% mortality, perforation(2%) and fistula formation 5%,
costly, takes one week to relieve dysphagia

80. Endoscopic dilatation
• 1)savary bougie dilators
Both radial and longitudinal force
better for more focal anastomotic or post fundoplication stricture.
2)Baloon dilatation
only radial force better for long stricture like malignant.
Complications :
fever
pain
chance of perforation (pneumo mediastinum, pneumothorax)

82. Intubation
Intubation was described by Symmonds in 1887. It is commonly used method. Guidewire is passed across the
growth under X-ray screening or C-arm guidance; flexible introducer and prosthetic tube is pushed across the
tumour along the guidewire. It carries 90% success rate.
Complications :
• Tube intolerance
• poor drainage,
• airway compression,
• reflux, aspiration, displacement, food blockage,
• Tumour overgrowth beyond the prosthesis causing its failure.
Intubation is used for trachea-oesophageal fistula or external compression. Prosthesis with a sponge-filled
balloon is used for fistula closure. Standard tube wrapped with multilayered polyvinyl sponge is other option.
It is less expensive, single time, rapid acting . They can be traction or pulsion tubes. Perforation chance is
10%.

84. REFERENCES
• MAINGOT’S ABDOMINAL OPERATION 13TH EDITION
• SHACKELFORD’S SURGERY OF THE ALIMENTARY TRACT 8TH EDITION
• SABISTON TEXT BOOK OF SURGERY 20TH EDITION
• SRB ‘S MANUAL OF SURGERY 6TH EDITION