OESPHAGEAL CANCER

DR KA NAIDU
 PATIENT INFORMATION

• Mr NJ, a 58 yr old male #rvd negative #no known cormobidities. Presented to SOPD
with 3/12 history of progressive dysphagia with associated odynophagia and weight
loss
 HISTORY

• Progressive dysphagia to solids and semi solids food for the past 3/12 with
odynophagia
• Only tolerating liquid diet
• Smoker - 15 pack year
• + History LOW +/- 20kg -3/12
• + Change in voice over the last 3/12
• No other positive risk factors for oesophageal ca
HOW DO YOU GRADE DYSPHAGIA ?
GRADING OF DYSPHAGIA
 EXAMINATION
• Vitals
• Blood pressure 110/70
• Pulse 90
• Temperature 36.8OC

• General examination
• Emaciated with signs of dehydration
• Jo Ao Cyo Clo Oo Lo Do
 SYSTEMIC EXAMINATION
• ENT
• No visible oral candiadias or thrush
• Poor dentition • Central nervous system
• Tonsils not inflamed
• GCS 15/15
• Respiratory
• Trachea central
• No focal neurology
• Good air entry bilateral, • Sensation and motor intact
• lung fields clear, • Muscular skeletal
• Cardiovascular
• No bony tenderness over the spine
• Normal S1 & S2
• no murmurs • Both legs compartments soft and non
tender
• Undisplaced apex beat
• Abdominal
• Soft non tender
• No hepatosplenomegaly noted
INVESTIGATIONS
• CXR
• BILATERAL CANNON BALL LEISIONS
• WIDENENED MEDIASTINUM
• NILL PLEURAL EFFUSIONS NOTED
• ENDOSCOPY
• STRICTURE NOTED AT 33CM
• MACROSCOPIC APPEARENCE NOTED TO BE NON BENIGN CAUSE
• BIOPSY TAKEN
• BIOPSY RESULT IN KEEPING WITH SQUAMOUS CELL CARCINOMA WITH MODERATE DIFFERENTION
• Staging CT
WHAT IS THE ROLE OF FLUOROSCOPY IN INITIAL
WORK UP?
• In a resource limited environment fluoroscopy imaging is challenge to obtain . However , it enables a
clinician to make a better management plan for a patient in terms of respectability and palliation .it also
guides an endoscopes prior to do doing the investigation.
 OESOPHAGEAL CANCER

• Oesophageal cancer is the 8th commonest malignancy worldwide and the 6th most common cause of
death from cancer. In the past this deadly cancer has been predominantly managed by palliative
techniques. However, in the first world, recent advances have improved 5-year survival rates from 6 to
17 percent in the US and to as high as 20 percent in China. This improvement has been attributed to
improved screening, earlier diagnosis, better staging, new surgical techniques and aggressive
neoadjuvant chemotherapy. Unfortunately in South Africa the same improvement has not been made,
possibly due to late presentation and poor resources. Work is needed to bridge this gap in mortality
rates.
 ANATOMY

• Hollow muscular tube 23-25 cm in length which

spans from the cricopharyngeus at the cricoid
cartilage to gastroesophageal junction (Extends
from C7-T10).
• Has 4 constrictions- At starting(cricophyrangeal
junction) crossed by aortic arch crossed by left
bronchus Pierces the diaphragm

• Histologically 4 layers: mucosa, submucosa,

muscular & fibrous layer
DIVISIONS

• Cervical = cricoid cartilage to thoracic inlet (15–

18 cm from the incisor).
• Upper thoracic = thoracic inlet to tracheal
bifurcation (18–24 cm).
• Midthoracic = tracheal bifurcation to just above
the GE junction (24–32 cm).
• Lower thoracic = GE junction (32–40 cm).
CLASSIFIED BASED ON HISTOLOGY

• 85-90% being squamous cell carcinoma

• 5-10% adenocarcinoma
• Other
OTHER
• EPITHELIAL TUMOURS
• Small Cell Carcinoma
• Carcinoid Tumors
• Malignant Melanoma
• Adenoid Cystic Carcinoma

• NON-EPITHELIAL TUMOURS
• Less than 1% of all malignant oesophageal tumors are primary non-epithelial tumors. These are mainly made up of
lymphomas and sarcomas.

• METASTATIC TUMOURS TO THE OESOPHAGUS

• Metastases to the oesophagus are rare and usually arise from a primary in the breast, lung, tongue, stomach, prostate,
uterus or liver. They appear as a stricture on endoscopy due to the fact that they are submucosal lesions. Treatment is
dependent on the primary disease, however the majority of these patients undergo endoscopic palliation.
GASTRO-OESOPHAGEAL JUNCTION TUMORS

• Siewert classification
• Type I: 1-5cm proximal to the anatomical gastro-oesophageal junction.
• Type II: Located in an area extending 1cm proximal to the GO junction to 2cm distal to it.
• Type III: 2-5cm distal to the anatomical gastro-oesophageal junction.
• The new AJCC staging system has simplified the debate by defining all oesophagogastric tumors as
oesophageal cancer. This decision is due to the fact that Siewert III tumors behave like oesophageal
tumors prognostically and therapeutically.
 EPIDEMIOLOGY
• Esophageal 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
• 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 ,
Barret's 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.
 RISK FACTORS
SQUAMOUS CELL CARCINOMA ADENOCARCINOMA
Cigarette smoking Gastro-esophageal reflux disease
Alcohol drinking Barrett’s esophagus
Genetic
• ALDH2 deficiency Reflux symptoms
• P53 mutations
Dietary
• N-nitrosamines containing foods
Obesity
• Beetle nut
• Drinking very hot liquids
Achalasia Cigarette smoking
Diet (high in processed meat, low in fruits,
Caustic injury
vegetables)
History of thoracic radiation History of thoracic radiation
Tylosis Anticholinergic agents
Human papilloma virus infection Family history
Helicobacter pylori infection (decreased risk)
PATTERN OF SPREAD

• No serosal covering, direct invasion of contiguous structures occurs early. Commonly

spread by lymphatics (70%)
• Lymph node involvement increases with T stage. ❙ T1–14to21% ❙ T2–38to60%
• 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
IMAGING MODALITIES
• CXR
• Chest x-ray may be abnormal in up to 50% of patients. Abnormalities include a widened mediastinum, air fluid levels and a raised
hemi diaphragm (indicative of phrenic nerve involvement).
• Barium swallow
• A contrast swallow is a useful initial investigation as it can distinguish oesophageal cancer from other benign causes of dysphagia.
Typical features of malignancy include mucosal irregularity, shouldering, narrowing of the lumen, and proximal dilatation of the
oesophagus. It can also detect features of advanced disease such as tortuosity, angulation, axis deviation, sinus formation, and
tracheoesophageal fistula formation. Axis deviation and a tumor greater than 8cm are independent predictors of incomplete
operative resection and poor long-term survival. A barium swallow also provides a useful guide to the endoscopes, by highlighting
suspicious areas of the oesophagus to be scrutinized. However a barium swallow is not a definitive investigation and endoscopic
biopsy must always be performed.
• Endoscopy
• Endoscopic identification of an advanced malignancy can be straightforward, however early oesophageal lesions may be more subtle.
Early squamous cell carcinoma may be congestive (red), flat, ulcerated or diffusely infiltrative in nature. 17% of lesions thought to be
benign endoscopically were subsequently proven to be malignant. Thus it is important to take multiple biopsies. The diagnostic
accuracy improves as the number of biopsies increase.
• In vivo staining of the oesophagus (chromoendoscopy) may be useful in the identification early malignancy. 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 and remains unstained. Methylene blue is useful for detecting intestinal metaplasia in Barrett’s, and allows for directed
biopsy.
• More advanced cancers can be exophytic, stenotic, ulcerative or a combination of the above. Dilatation of the lesion may be required
to determine its length, and to visualize the stomach for possible reconstructive purposes. Dilatation also facilitates accurate biopsies.
• EUS:
• assess the depth of penetration and LN involvement. Limited by the degree of obstruction.
• Compared with EUS, CT is not a reliable tool for evaluation of the extent of tumor in the esophageal wall.
CLASSIFIED

• Early
• Locally advanced
• Palliative
 STAGING
T N M G

Tis- High Grade dysplasia N0- No nodes M0-No mets G1- Well differentiated

T1a- lamina propria/ muscularis mucosae N1- 1-2 nodes M1-Distant mets G2- Moderately differentiated

T1b- submucosa N2- 3-6 nodes G3- Poorly differentiated

T2- Muscularis propria N3- >7 nodes G4- Undifferentiated

T3- Adventitia

T4a- Pleura, pericardium, diaphragm

(potentially resectable)

T4b-Aorta, vertebral body, trachea

(irresectable)
 EARLY RESECTION
• For many years, the standard treatment for both high-grade dysplasia and
superficial oesophageal cancer has been oesophagectomy. High cure rates Proposed subclassification AJCC
were achieved but at the cost of treatment-related morbidity and stage
mortality. Endoscopic approaches to definitive therapy (e.g. endoscopic M Limited to the epithelial layer Tis
mucosal resection and ablative techniques) are being increasingly used, 1
however, these techniques are only appropriate for patients who have a
very low risk of lymph node metastases or who are poor candidates for M Invades the lamina propria T1a
esophageal surgery. 2
M Invades the (but not through) the
• Early esophageal cancers are those that are classified as Tis (high-grade 3 muscularis mucosa
dysplasia) or T1 tumors. However, a more comprehensive sub
classification for early esophageal cancers has been proposed where S Penetrates the shallowest one-third of T1b
mucosal tumors are divided based upon the depth of invasion. This is M the submucosa
useful for determining prognosis and selecting treatment. 1

• M1 and M2 tumors are not associated with lymph node metastases (in S Penetrates into the intermediate one-
both SCC and AC) and hence are well suited to endoscopic treatment. M third of the submucosa
2
• The risk of nodal metastases with M3 tumors without lymphatic invasion S Penetrates the deepest one-third of
is about 10%. However, this increases to 40% in patients with lymphatic M the submucosa
invasion. The risk of nodal metastases is also higher in patients with non- 3
flat (elevated, depressed, or ulcerated) as compared to flat lesions. All
submucosal tumors however have a substantial risk of lymph node
metastases and EMR should be avoided in these patients.
• Endoscopic Mucosal Resection
• The aims of endoscopic mucosal resection (EMR) are to preserve the integrity
of the oesophagus while providing a potentially curative option for superficial
cancers. The neoplastic epithelium is excised by a variety of techniques thus
allowing for a definitive histologic diagnosis. The largest observational series to
date showed a 96.6% complete response rate at 5 years. Surgery was needed in
3.7% after endoscopic therapy failed. Recurrences were noted in 21.5%, but no
patient died from esophageal cancer.
• Although no randomized trials are available, retrospective comparisons show
long-term outcomes with EMR are comparable to surgery, with fewer
complications, but a higher recurrence rate. Complications of EMR include
bleeding, perforation and strictures. Post-EMR bleeding is reported in 3% to
33% of cases and may be more frequent if saline is not used to lift the lesion
before removal. Lesions larger than 2 cm are more difficult to treat with EMR
and have a higher chance of complications.
• Owing to the lack of level 1 evidence, EMR remains a controversial alternative
to surgery for the treatment of superficial esophageal cancer. Nevertheless,
EMR may be a reasonable option for selected patients with superficial cancers
that are limited to the mucosa. The ideal candidate has a solitary, small (< 2
cm), flat-type mucosal lesion without evidence of lymphatic invasion within a
short segment of Barrett's esophagus. The importance of prolonged follow-up
in patients treated with an endoscopic approach cannot be overemphasized, as
late recurrences may develop.
IRRESECTABILE CRITERIA
• Distant metastases
• Extraregional lymph node spread (eg. Paraaortic/mesenteric) Note: Coeliac nodal metastases are scored as regional nodal
disease in the new 2010 TNM staging system and are no longer regarded as metastatic disease. However prognosis in these
patients is still poor (10% 2 year survival post surgery)
• Thoracic or abdominal esophagus
• T4b Invasion of aorta, trachea, heart, great vessels or presence of a TOF. Invasion of the pleura, pericardium, or diaphragm is
classified as T4a disease, and considered potentially resectable disease.
• Cervical esophageal tumors
• Infiltration of prevertebral fascia or posterior larynx, invasion of the membranous trachea to the level of the carina, or
bilateral encasement of major neurovascular structures.
• Patient criteria
• Age >75yrs
• FEV1 < 1-1.25L
• Ejection Fraction < 40%
• Tumor length - >8cm and abnormal axis on barium swallow make resection unlikely
MANAGEMENT OF LOCALLY ADVANCED DISEASE

• The optimal treatment for patients with localized cancer of the thoracic esophagus is one of the most
controversial areas in oncology. Current treatment of oesophageal cancer is multimodal and therapy is
dependent on site, stage and histology. However, surgery remains the main stay of treatment for local
and locally advanced disease. Patients both AC and SCC of the middle and lower oesophagus require
total oesophagectomy because of the risk of mucosal skip lesions. Three types of oesohagectomy for
locally advanced disease are commonly performed. They have similar overall complications
TYPES OF OESOPHAGECTOMY

• Transthoracic (Ivor-Lewis) oesophagectomy

• Transhiatal oesophagectomy
• Tri-incisional oesophagectomy (McKeown)
ADJUVANT, NEOADJUVANT & NON-OPERATIVE
MANAGEMENT
• Traditionally surgery has been the standard of care for localized thoracic disease, however due to poor long-term survival
rates (15-20% at 5 years), it’s utility as monotherapy has been challenged with neoadjuvent therapy.
• Neoadjuvent therapy
• Chemoradiotherapy is available to all fit patients with locally advanced disease. They are offering a combination of cisplatin,
5 FU and dositaxyl based on results from the CROSS trial. Unfortunately, paklitaxil, the drug used in the original trial is not
available. Patients are then offered radiotherapy with a dose of 50,4G. After 3 cycles of chemoradiotherpy patients undergo
EUS to assess response. Approximately one third will have a complete response and no further treatment is required. The
remained will be offered oesophagectomy.
• Post-operative chemoradiotherapy
• Although the majority of patients at present are offered pre-operative chemoradiotherapy, this approach is not universally
accepted. For patients who are found to have node-positive disease after surgery alone, the addition of postoperative
adjuvant therapy is recommended. It is unclear whether chemoradiotherapy has more benefit than chemotherapy alone.
Patients with positive margins post surgery require post-operative chemoradiotherapy even if neoadjuvant treatment was
given. Locally our oncology unit offers a course of 5FU and cisplatin for all post operative patients with positive margins
PALLIATIVE

• Surgical palliation
• Endoscopic palliation
• Oncologic palliation
SURGICAL PALLIATION

• Palliative resection is usually not considered for patients with locally advanced disease and distant
metastases due to their short life expectancy (<6 months). Palliative resection is also no longer
considered a valid concept for patients with locally advanced non-metastatic oesophageal cancer.
Perioperative morbidity and mortality rates are high, and the opportunity for potentially curative
chemoradiotherapy may be lost. Furthermore, although palliative resection can relieve dysphagia,
restoration of swallowing can now be accomplished with endoluminal stenting.

• Like palliative oesophagectomy, surgical bypass provides limited benefit and is associated with
substantial morbidity in patients with clearly irresectable disease. Although these palliative bypasses
relieve symptoms, complication rates exceed 50%, and mortality rates are between 5 and 10%. As a
result, these procedures are now rarely attempted.
ENDOSCOPIC INTERVENTION

• Endoscopic interventions may be appropriate for palliation of dysphagia in the following settings:
• Patients for whom definitive management is planned, but who have severe dysphagia at presentation, requiring
intervention prior to therapy
• Failure to achieve adequate palliation of dysphagia with initial therapy
• Recurrent dysphagia due to local regional failure
• Recurrent dysphagia due to benign strictures in patients who are successfully treated with RT
• Patients are poor candidates for either chemotherapy or RT
ENDOSCOPIC OPTIONS

• SEMS
• SEPS
• DILATION
• LASER THERAPY
• ARGON PLASMA COAGLUATION
• There are several endoscopic options to providing palliation from malignant dysphagia. The most commonly used is
placement of a prosthetic self-expanding plastic (SEPS) or metal stent (SEMS). This provides immediate relief unlike
chemoradiotherapy. However expandable metal stents are less effective for distal oesophageal malignancies. There are three
varieties of metal stents: uncovered, partially covered, and fully covered.

• The advantage of covered stents is that they resist tumor ingrowth, but they have a higher migration rate, especially when
fully covered. They can also be used in the closure of fistulas and leaks. Partially covered stents are uncovered at their ends,
which allow the stent to embed in the tissue and helps to prevent migration. Fully covered stents offer the advantage of
being removable, but are associated with an increased risk of migration. Uncovered stents are less likely to migrate, but are
subject to tumor ingrowth and resultant obstruction. In addition, some stents have an anti-reflux valve to try to prevent
esophageal reflux in patients with stents placed across the oesophagogastric junction.

• Self-expandable plastic stents are made from polyester and are fully covered with silicone. The advantage is that it causes
less trauma to surrounding tissues (hence less chance of a fistula) and is removable. However one randomized trial showed
no difference in palliation when compared with a partially covered metal stent. However, there were significantly more
complications with the plastic stents, particularly stent migration.

• Endoscopic dilation with wire-guided polyvinyl bougies or a directed balloon dilatation or may provide temporary relief of
dysphagia. However this needs to be repeated every 1-2 weeks. Laser recanalization is alternative palliative technique that
may provide relief for 1 month. The disadvantages include cost, availability, technical difficulty and perforation in 5% of
cases. Other novel ablative techniques include argon plasma coagulation and photodynamic therapy.
ONCOLOGICAL PALLIATION

• External beam radiotherapy with concurrent chemotherapy is a standard approach for patients with
locally advanced irresectable oesophageal cancer who are able to tolerate chemotherapy. Most patients
achieve sustained palliation of dysphagia, and a few will have the opportunity for long-term
progression-free survival.

• Brachytherapy has been shown to be equivalent to stenting but with better quality of life and longer
disease free survival. But as monotherapy, its use should be restricted to patients with a short life
expectancy (less than six months). However, for patients who are expected to live less than three
months, short-term palliation of swallowing may be better achieved with endoscopic stent placement.
Brachytherapy should be used with extreme caution in the setting of a local recurrence after prior
chemoradiotherapy because of the risk of fistula formation.
 Intestinal
Stoma

End Loop

ileostomy colostomy ileostomy colostomy

END ILEOSTOMY
LOOP ILEOSTOMY
LOOP COLOSTOMY
END COLOSTOMY
 HARTMAN'S PROCEDURE

• A proctosigmoidectomy, Hartmann's
operation or Hartmann's procedure is
the surgical resection of
the rectosigmoid colon with closure of
the anorectal stump and formation of
an end colostomy
ABDOMINAL PERINEAL RESECTION

• An abdominoperineal resection is a surgery in

which the anus, rectum, and sigmoid colon are
removed