ESOPHAGEAL

CARCINOMA

Mark Louie M. Lanting, MD

 ESOPHAGEAL CA
• 20-540 per 100,000 population
• 8th most common cancer
• 6th leading cause of cancer death
• Factors:
– Intrathoracic location
– Propensity for invasion to adjacent structures
– Lack of serosal membrane
– Presence of extensive network of lymphatics
– Properties of a distensible tube that mask
symptoms until disease is advanced
 ESOPHAGEAL CA
• Etiologic factors
– Local foodstuffs (nitroso compounds in pickled
vegetables & smoked meats)
– Mineral deficiencies (zinc & molybdenum)
– Smoking & alcohol consumption
– Long standing achalasia
– Lye strictures
– Tylosis (hyperkeratosis of palms & soles)
– HPV
– Barrett’s esophagus
 CLINICAL MANIFESTATIONS
• Dysphagia
– usually presents late  only when >60% of
circumference is involved
• Other signs & symptoms – associated with
distant metastasis
 Functional Grades of Dysphagia
Grade Definition Incidence at Diagnosis

I Eating normally 11

II Requires liquids with 21

meals
III Able to take semisolids 30
but unable to take any
solid food
IV Able to take liquids only 40

V Unable to take liquids but 7

able to swallow saliva

VI Unable to swallow saliva 12

STAGING OF ESOPHAGEAL CA
• TNM
• WNM
 Staging of Cancer of the ESOPHAGUS & Cardia
(AJCC 1988)
Stage Classification Patients % 5 year
survival

0 Tis N0 M0 16 100
I T1 N0 M0 22 78.9
IIA T2 N0 M0 80 37.9
T3 N0 M0
IIB T1 N1 M0 39 27.3
T2 N1 M0
III T3 N1 M0 218 13.7
T4 Any N M0
IV Any T Any N M1 33 0
 Staging of Cancer of the ESOPHAGUS & Cardia
(Modified WNM Criteria)
Stage Classification Patients % 5 year
survival

0 W0 N0 M0 38 88.2
I W0 N1 M0 59 50.3
W1 N1 M0
II W1 N1 M0 95 22.5
W2 N0 M0
III W2 N1 M0 138 10.7
W1 N2 M0
W0 N2 M0
IV Any W Any N M1 33 0
 CLINICAL APPROACH
TO CARCINOMA OF
ESOPHAGUS & CARDIA
• Tumor location
• Age
• Cardiopulmonary Reserve
• Clinical Stage
• Intraoperative Staging
• Cervical –
almost always
squamous cell
CA
• Lower
esophagus &
cardia -
adenoCA
CARDIOPULMONARY RESERVE
• FEV1 should be 2L or more
• FEV1 < 1.25L – poor candidate (40% risk
of dying from respiratory insufficiency
within 4 years)
• Ejection fraction <40% - poor sign
• 2D echo and dipyridamole thallium
imaging – wall motion, EF, myocardial
blood flow
 CLINICAL STAGE
• Factors that indicate advanced stage
– Recurrent nerve paralysis
– Horner’s syndrome
– Persistent spinal pain
– Paralysis of the diaphragm
– Fistula formation
– Malignant pleural effusion
– Tumors > 8 cm in length
– Abnormal axis of esophagus on barium
– Enlarged lymph nodes on CT
– Weight loss > 20 %
– Loss of appetite
 CLINICAL STAGE
• Staging depends on
– Length of tumor – endoscopy
– Degree of wall penetration
– Lymph node metatasis – endoscopic
ultrasound
 INTRAOPERATIVE STAGING
• Palliative resection if:
– Unresectable primary tumor
– Cavitary spread of tumor
– Distant organ metastasis
– Extension of the tumor through the
mediastinal pleura
– Multiple gross lymph node metastasis
– Microscopic evidence of lymph node
involvement at the margins of an en bloc
resection (i. e. Low paratracheal, portal triad,
subpancreatic, or periaortic lymph nodes)
 INTRAOPERATIVE STAGING
• Overall 5-year survival rate after curative
en bloc resection = 40-55%
• If tumor does not penetrate esophageal
wall & there are < 5 lymph nodes, 5-year
survival rate is 75%
 SURGICAL TREATMENT
• CERVICAL & UPPER THORACIC
ESOPHAGEAL CA
– Lesions not fixed to the spine, do not invade
the vessels or trachea, & do not have fixed
cervical lymph node metastasis SHOULD be
resected
– If LN mets are present or if tumor comes in
close proximity to the cricopharyngeus
muscle, preop chemo & radiotherapy should
be given before surgery
• 2-3 cycles chemo
• Not more than 3.5 Gy radiation
 SURGICAL TREATMENT
• CERVICAL & UPPER THORACIC
ESOPHAGEAL CA
– Thoracic esophagus is removed via a right
posterolateral thoracotomy with en bloc
lymphadenectomy
 SURGICAL TREATMENT
• TUMORS OF THE THORACIC
ESOPHAGUS & CARDIA
– For tumors below the carina, en bloc resection
for cure or transhiatal removal for palliation
 SURGICAL TREATMENT
• TUMORS OF THE THORACIC
ESOPHAGUS & CARDIA
– En bloc resection
1. Right posterolateral thoracotomy, en bloc
dissection of distal esophagus, mobilization of
esophagus above the aortic arch, closure of the
thoracotomy, repostitioning of the patient in
recumbent position
2. Upper midline andominal incision, en bloc
dissection of the stomach and associated LNs
3. Left neck incision & proximal division of the
esophagus
 ARGUMENTS TO SUPPORT A MORE
EXTENSIVE ESOPHAGECTOMY

• Injection of submucosal contrast medium

shows that the length of longitudinal lymph
flow is 6x the transverse flow
• At least 10 cm of grossly normal
esophagus proximal to the tumor must be
resected to prevent local recurrence
• Special relation indicates that for an
adequate proximal margin, a cervical
anastomosis is almost always needed
 ARGUMENTS TO SUPPORT A
MORE EXTENSIVE GASTRECTOMY FOR
TUMORS OF THE LOWER 3RD
OF THE ESOPHAGUS OR CARDIA
• No barrier to submucosal lymphatics
between the esophagus & stomach at the
cardia
• Tumor cells in the submucosal lymphatics
can result in intragastric recurrence if too
little of the stomach is resected
• Special relationships of the stomach do
not allow for both adequate distal tumor
margins & sufficient residual stomach to
perform a cervical anastomosis
 ARGUMENTS FOR
LYMPH NODE DISSECTION
• Survival of lung cancer patients with
metastasis to hilar lymph nodes (i.e., a
cancer that also metastasizes to the
mediastinal lymph nodes) is dependent on
the removal of the involved nodes
• Patients with esophageal CA & LN mets
are cured by resections, whereas it is
extremely rare for patients with LN mets to
be cured without surgical removal
 ARGUMENTS FOR
LYMPH NODE DISSECTION
• Patients with esophageal and cardia
cancer, like those with head & nech
cancer, can die with LN mets alone
• Asian surgeons, who are incessant data
keepers, accept unconditionally the benefit
of LN dissection on survival of patients
with CA of esophagus & stomach
 ARGUMENTS FOR
LYMPH NODE DISSECTION
• 43% of patients with esophageal CA who have
histologically node-negative disease have
histochemical node-positive disease.
Furthermore, after a median observation time of
12 months, patients with histologically node-
positive disease had a significantly shorter
disease-free survival. It is believed that when
nodes are reported to be histologically free of
tumor, more disease than is currently
appreciated is removed if left behind, depending
on the extent of resection
 ALTERNATIVE THERAPIES

• RADIATION THERAPY
– Currently restricted to patients who are not
candidates for surgery
– Short term palliation of dysphagia ~ 2-3 mos
• ADJUVANT CHEMOTHERAPY
– Undetected systemic micrometastasis may be
present at the time of diagnosis
 CHEMORADIOTHERAPY

• Preoperatively to reduce tumor size in a

young person with a surgically incurable
squamous cell CA above the carina
• Chemotherapy as salvage therapy for
patients who have not had previous
chemotherapy and develop systemic
recurrent disease after surgical resection
SARCOMA OF THE ESOPHAGUS

• Rare, 0.1-1.5%
• Barium swallow: large polypoid
intraluminal esophageal mass, causing
partial obstruction & dilatation of the
esophagus proximal to the tumor
• Esophagoscopy: intraluminal necrotic
mass
– Biopsy: remove necrotic tissue until bleeding
is seen
SARCOMA OF THE ESOPHAGUS

• Polypoid sarcomas remain superificial to

the muscularis propia and less likely to
metastasize to regional lymph nodes
• Divided into
– Epidermoid carcinomas with spindle cell
features (carcinosarcoma)
– True sarcomas (leiomyosarcoma,
fibrosarcoma, rhabdomyosarcoma)
• Surgical resection – treatment of choice
 BENIGN TUMORS
• Intramural
– Either solid tumors or cysts
– Majority are leiomyomas
– Others: fibroma, myoma, fibromyoma,
lipomyoma, lipoma, neurofibroma,
hemangioma, osteochondroma, granular cell
myoblastoma, glomus tumors
• Intraluminal
 BENIGN TUMORS
• Intraluminal
– Polypoid, pedunculated growths that usually
originate in the submucosa, develop mainly
into the lumen and are covered with normal
stratified squamous epithelium
– Composed of fibrous tissue of varying
degrees of compactness
• Loose & myxoid (myxoma & myxofibroma)
• Collagenous (fibroma)
• Adipose tissue (fibrolipoma)
LEIOMYOMA
ESOPHAGEAL CYST
THANK YOU