Download - Carcinoma esophagus
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Carcinoma of Esophagus
Dr.B.Selvaraj MS;Mch;FICS;
Neonatal &Pediatric Surgeon
Melaka Manipal Medical College
Melaka Malaysia
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Surgical Anatomy :
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Arterial Supply :
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Venous Drainage :
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Lymphatic Drainage :
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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.
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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
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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.
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Clinical Presentation
►Dysphagia 87-95%.
►Weight Loss 42-71%.
►Vomiting/Regurgitation 29-45%.
►Pain 20-46%.
►Cough/Hoarseness 7-26%.
►Dyspnoea 5%
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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.
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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.
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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.
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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.
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Endoscopy- In Situ Ca
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Bronchoscopy
►To assess invasion of Tracheo- Bronchial tree.
►To assess vocal cord paralysis due to infiltration of Recurrent Laryngeal N.
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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.
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ENDOSCOPIC USG
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TUMOR ESOPHAGUS
ENDOSCOPIC USG
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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.
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C.T. Scan- Chest
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C.T. Scan- Abdomen
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PET Scan
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Minimal Invasive Staging
►Includes Thoracoscopy and Laparoscopy.
►Highly accurate in evaluating N & M Status.
►Right sided thoracoscopy is usually done.
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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 -
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TNM Staging :
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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 :
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Treatment Modality
�Operative
�Radiotherapy
�Chemotherapy
�Others :
►Intubation
►Laser therapy
►Photodynamic therapy
►Electro – cauterisation
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Management of Ca esophagus
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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.
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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.
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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
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Transhiatal Esophagectomy
Upper Midline Incision
Mobilization of Stomach
Oesophageal Hiatus Enlarged
Blunt Dissection of Thoracic Esophagus
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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)
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Transhiatal Esophagectomy
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Mobilization of Stomach
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Blunt Dissection of Thoracic Esophagus Through Enlarged Hiatus
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Preparation of Gastric Tube
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Cervical Esophago Gastric Anastomosis
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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
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Three hole Esophagectomy (McKeown Esophagectomy)
►Three holes - Laparotomy, Right Posterolateral
Thoracotomy and Cervical resection.
►Cervical anastomosis
►Lengthy procedure
►Pulmonary complications
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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.
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Colonic Reconstruction
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Jejunal Reconstruction
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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.
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Complications
►Pulmonary � Empyema&Sepsis
►Anastomotic Leak.
►Conduit Necrosis
►Anastomotic Stricture.
►Gastro-esophageal reflux.
►Colonic dysmotility.
►Recurrence
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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:
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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.
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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.
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Carcinoma of Esophagus
Laser Vaporisation
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Stenting For Carcinoma of Esophagus
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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%
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