carcinoma esophagus

Carcinoma of Esophagus

Dr.B.Selvaraj MS;Mch;FICS;

Neonatal &Pediatric Surgeon

Melaka Manipal Medical College

Melaka Malaysia

Surgical Anatomy :

Arterial Supply :

Venous Drainage :

Lymphatic Drainage :

Epidemiology

►Sixth most common malignancy world-wide.

►Male : Female 4 : 1.

►Most common type SCC. Usually affects the upper

2/3rd.

►Incidence of Adenocarcinoma is increasing. Usually

affects the lower 1/3rd.

Etiology

► Dietary � Nitrates.

� Fungal toxins in pickled vegetables.

� Micronutrient deficiency (Vit. A, B12, C, E).

� Trace Element deficiency (Cobalt, Copper & Selenium).

► Acquired � Cigarette smoking.

� Alcohol.

� Chronic esophagitis.

� Chroinc Dysphagia.

� Barrett esophagus.

� Achalasia

� Lye Corrosive Stricture.

► Hereditary

Classification

►Epithelial:

� Squamous Cell Ca.

� Adeno Ca.

� Adenosquamous Ca.

� Mucoepidermoid Ca.

� Adenoid Cystic Ca.

� Small Cell Ca.

� Undifferentiated Ca.

►Non – Epithelial:

� Leiomyosarcoma.

� Malignant Melanoma.

� Rhabdomyosarcoma.

� Malignant Lymphoma.

Clinical Presentation

►Dysphagia 87-95%.

►Weight Loss 42-71%.

►Vomiting/Regurgitation 29-45%.

►Pain 20-46%.

►Cough/Hoarseness 7-26%.

►Dyspnoea 5%

Patient Evaluation

►Chest X – Ray.

► Barium esophagogram.

► Endoscopy.

►Endoscopic Ultrasound.

►C.T. Chest and upper Abd.

►Bronchoscopy.

►Minimally Invasive Surgical Staging

►Thoracoscopy.

►Laparoscopy.

►MRI / PET Scan.

Chest X - Ray

►Dilated Esophagus.

►Air-Fluid level in esophagus.

►Tracheal Deviation.

►Mediastinal Soft Tissue Mass – Hilar LN.

►May be normal even if disease is advanced.

Barium Swallow

► 74-97% sensitive in detecting growth.

► Determine Location & Length of tumour.

► Identifies TEF.

► Detects other deformities in advanced disease.

►Tortuosity.

►Angulation.

►Deviation.

► Shows irregular stricture with shouldered

margins.

Endoscopy

►Allows direct visualisation of the

tumour and Biopsy.

►Disadvantage : � Miss early mucosal and submucosal lesion.

� No information on radial extension.

►Vital staining on endoscopy

(Lugols Iodine, Toluidine Blue)

facilitates early detection of

tumour.

Endoscopy- In Situ Ca

Bronchoscopy

►To assess invasion of Tracheo- Bronchial tree.

►To assess vocal cord paralysis due to infiltration of Recurrent Laryngeal N.

ENDOSCOPIC USG

►Highly sensitive in determining locoregional disease

►Useful in staging the tumour.

►Accuracy in determining T- Stage is 85% and for N-

Stage 75%.

►Inability to stage advanced stenotic lesions where

scope cannot be negotiated beyond growth.

ENDOSCOPIC USG

TUMOR ESOPHAGUS

ENDOSCOPIC USG

C.T. Scan

►Scans needed for Thorax and Upper Abdomen.

►Stage Loco-regional as well as Metastatic Disease.

►Can stage advanced stenotic lesions where EUS is

not possible.

►Limitation:

� Tissue diagnosis not achieved.

C.T. Scan- Chest

C.T. Scan- Abdomen

PET Scan

Minimal Invasive Staging

►Includes Thoracoscopy and Laparoscopy.

►Highly accurate in evaluating N & M Status.

►Right sided thoracoscopy is usually done.

Accuracy of Staging Techniques

Modality T Accuracy

%

N Accuracy

%

M Accuracy

%

C.T. 49-60 39-74 85-90

E.U.S. 76-92 50-88 66-86

Thoracoscopy /

Laparoscopy

- 90-94 -

TNM Staging :

Stage I T1 N0 M0

Stage II A T2,T3 N0 M0

Stage II B T1,T2 N1 M0

Stage III T3,T4 N1 M0

Stage IV Any T Any N M1

AJCC Staging :

Treatment Modality

�Operative

�Radiotherapy

�Chemotherapy

�Others :

►Intubation

►Laser therapy

►Photodynamic therapy

►Electro – cauterisation

Management of Ca esophagus

Operative Procedures

�Resection: �Pharyngo-laryngo-esophagectomy.

�Three phase esophagectomy.

� Ivor-Lewis operation.

�Transhiatal esophagectomy.

�Esophagectomy (Lt. Thoracotomy).

�Minimally Invasive Surgery.

�Bypass: �Colonic Bypass.

�Jejunal Bypass.

Pharyngo-laryngo-esophagectomy

►Of historical significance only.

►For Ca. Cervical Esophagus.

►Includes partial pharyngectomy, total esophagectomy

and Laryngectomy.

►Needs reconstruction of esophagus.

►Presently Radiotherapy is the preferred mode of

treatment, since it preserve voice.

Transhiatal Esophagectomy

►No thoracotomy

►Blunt esophageal resection through hiatus and left

cervical incision

►Complete thoracic oesophagectomy

►Cervical anastomosis

►Less complete lymph node dissection

►Intra-operative complications may require

thoracotomy

Transhiatal Esophagectomy

Upper Midline Incision

Mobilization of Stomach

Oesophageal Hiatus Enlarged

Blunt Dissection of Thoracic Esophagus

Left Cervical Incision

Blunt Dissection of Cervical &

Sup. Mediastinal Esophagus

Esophagectomy

Prepared Gastric Tube Pulled up

Cervical Esophago-gastric Anastomoses

Secure Haemostasis

Place Chest Drain (if needed)

Transhiatal Esophagectomy

Mobilization of Stomach

Blunt Dissection of Thoracic Esophagus Through Enlarged Hiatus

Preparation of Gastric Tube

Cervical Esophago Gastric Anastomosis

TRANSTHORACIC ESOPHAGECTOMY

(Ivor-Lewis Procedure)

►Standard resection through right posterolateral

thoracotomy & laparotomy

►Good visualization for resection and lymph node

dissection

►Requires repositioning the patient

►Requires thoracotomy & Thoracic anastomosis

►More pulmonary complications

Three hole Esophagectomy (McKeown Esophagectomy)

►Three holes - Laparotomy, Right Posterolateral

Thoracotomy and Cervical resection.

►Cervical anastomosis

►Lengthy procedure

►Pulmonary complications

Left Thoracotomy Approach

►Suitable for tumors around GE junction.

►Incomplete oesophageal resection

►View hampered by arch of aorta and descending

aorta

►Thoracic anastomosis

►Prone to pulmonary complications.

Colonic Reconstruction

Jejunal Reconstruction

Minimal Invasive Surgery

►It involves THORACOSCOPY and

LAPAROSCOPY.

►Right sided THORACOSCOPY (No need of CO2

Insuffalation).

►Disadvantage: 1.Long anaesthesia

2.Inadequate L.N. dissection

3.High learning curve.

Complications

►Pulmonary � Empyema&Sepsis

►Anastomotic Leak.

►Conduit Necrosis

►Anastomotic Stricture.

►Gastro-esophageal reflux.

►Colonic dysmotility.

►Recurrence

Radiotherapy

►As primary therapy: � No long term benefit.

� Initial relief of dysphagia with median duration 3-6 months.

� 5 year survival 4 – 14 %.

►As adjuvant therapy: � Decrease the loco-regional recurrence rate.

� Prevents tracheo-bronchial recurrence in patients with mediastinal

disease after palliative resection.

►Adjuvant chemo-radiotherapy:

Palliative approach

►Aims of therapy:

� To reestablish swallowing.

� To stabilize body weight.

►Laser therapy:

� Improve dysphagia by necrosis of tumour.

� Nd-YAG laser is commonly used.

►Photodynamic therapy:

� Dihematoporphyrin ether followed by argon laser.

Contd….

► Intubation.

� Provides long lasting palliation after single procedure.

� Beneficial in

► infiltrating stenotic or long tumour.

► obstruction is due to external compression.

► Sealing of TEF.

� Tube Types : 1. Atkinson

2. Celestin

3. Souttar

4. Procter Livingstone

5. Expandable Metal Stent

► Electro – cauterisation.

Carcinoma of Esophagus

Laser Vaporisation

Stenting For Carcinoma of Esophagus

Prognosis

5 – year survival

Stage Thoracotomy/

Transhiatal

3 – Field L.N.

Dissection.

Stage I 50% 88%

Stage II 38% 84%

Stage III 10% 54%

Stage IV - 25%