dr vivek garg
TRANSCRIPT
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Intr cti n
Classificati n
Epi emi logyand emographics
athology Ris factors
Symptoms and Signs
Investigations Staging
Treatment
References
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When cancer of theWhen cancer of theoesophagusoesophagus becomesbecomes
symptomatic, it is alreadysymptomatic, it is alreadythree minutes untilthree minutes untilmidnightmidnight
Julius L. Stoller
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6th most common cancer in the world.
Black/White: 5/1
Male/Female: 5/1 Men have esophageal cancer 3-5 times
more often than women
The mean age at diagnosis is 60 year
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BENIGNTUMORS MALIGNANT TUMOURS
Epithelial
apillomas
esenchymal Leiomyomas
Hemangiomas
Lymphangiomas
Fi romas Lipomas
yxomas
Ne rofi romas
Epithelial (carcinoma)
Sarcoma
Carcino-sarcoma
Metastatic
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CL SSIFICATIONCLASSIFICATION--
(a)(a) SquamousSquamous cell carcinomacell carcinoma (60%)(60%) (b)(b) AdenocarcinomaAdenocarcinoma (40 %)(40 %)
(c) Rare types(c) Rare types::1.Mucoepidermoid carcinoma,
2.Adenoid cystic carcinoma,3.Small cell carcinoma,
4.undifferentiated carcinoma
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Divides the EJs tumor
1. EJs-1
2. EJs-2
3. EJs-3
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Ris factors- Tabaco smoking Excessive alcohol consumption Nutritionaldeficiency(iron,vit.A) oor dentalhygiene
Long term use of spicy foodandhot drinks Fungal contaminationof food Obesity Fresh fruits andvegetables are protective Occuapational exposure of asbestos,combustion product
re-existing conditions---- Achalasia (3-5%) Barrets esophagus Chronic reflux esophagitis Caustic burns Tylosis
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Human papilloma virus HPV serotype16 was identified in 9 percent of resection specimens
from 70 Chinese patients with esophageal SCC.
Controversial, but HPV has got some protectivevalue in case of adenocarcinoma.
Keratosis palmaris et
plantaris(tylosis) rare disease associatedwith hyperkeratosis of the palms of the hands andsoles of the feet and a high rate of esophageal SCC.
AD
Mapped on ch band 17q25
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NEJM,2003NEJM,2003NEJM,2003
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Upper third: 20%
Middle third- 30%
Lower third: 50%
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Histologically, characterizedby invasive sheetsof cells that run together andare polygonal,oval,or spindle-shaped withadistinct or
ragged stromal-epithelial interface.
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AA-- Cauliflower type(Cauliflower type(fungatingfungating) (60%):) (60%):
BB-- Ulcerative type :Ulcerative type : raised everted edge-
necrotic floor- indurated base
CC--Annular typeAnnular type :: more common in
lower 1/3.
Pattern of GrowthPattern of Growth
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A 5-year survivalof 70% is associated with thepolypoid tumor compared withaless than15%5-year survival for allother types
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Arises from the superficialanddeepglands
of the esophagus, mainly in the lower third
of the esophagus, especiallynear thegastroesophageal junction
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Mayhave one of three origins:
Malignant degenerationof metaplasticcolumnar epithelium (Barrett's mucosa)
Heterotopic islands of columnar
epithelium
The esophageal submucosal glands
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Anaplastic small cell (oat cell) carcinomaarisein the esophagus from same argyrophilic cellsfound in the lung.
Adenoid cystic esophageal carcinoma
Primary malignant melanomaof esophagus
Carcinosarcoma, features of SSCand malignant
spindle cell sarcoma.
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Progressive dysphagia - 87-95 % Weight loss Sialorrhea (Hypersalivation) Regurgitation Pain (Odynophagia) Halitosis Dehydration
RespiratoryProductive coughingHoarsenessDyspnea
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Difficulty in swallowingDifficulty in swallowing
Dysphagia in male > 50 years > 2 wks isconsidered cancer esophagus untill
proved otherwise
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Usuallyno signs
Evidence of weight loss
Cervical LAM
Other signs of dissemination
Hepatomegaly
Jaundice
Cardiac arrhytmias
Ascites
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(1)(1) Direct:Direct: ((main methodmain method):): to the surrounding
(2)(2) LymphaticLymphatic:: mainly inadownwarddirection.
Cervical esophagus lower deep cervical L.N.
Thoracic esophagus para-oesophageal & tracheo-bronchial lymph nodes
Abdominal esophagus lymphnodes along the lessercurvature of the stomach coeliac axis L.N.
(3) Blood (rare):(3) Blood (rare):
Liver,lung,bone,brain
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Obstruction
Perforation
Pulmonary- Pneumonia,lungabscess,
Esophago-tracheal/bronchial fistula
- Cardiovascular- Bleeding, myo-pericardial met,S C syndrome
Neural-Rec. Laryngeal,vagal,phrenic nerveinvolvement,
Claude Bernard Horner syndrome
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HematologicalEx.
Barium swallow
CT Scan
MRI
PET
Endoscopy
Esophagoscopy(biopsy)
EndoscopicUS
Bronchoscopy
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- Non invasive methodof detectingprimary,nodal,distant metastases &locally recurrenttumor
- The technique estimates areaof highglucose
metabolism (the tumor) by measurement of theuptake of radiotracer (Flurodeoxyglucose FDG).
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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 andremains unstained
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Relief fromdysphagia
Long dysphagia free
interval Relief from pain
Improved quality oflife
Improved long-termsurvival
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Surgery
Chemotherapy
Radiotherapy
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SURGERY----
Most effective treatment
Overall resectability50%
Operative mortality5-10% Lymphnode involvement % 80
Routes
Trans-thoracic
Thoraco-abdominal Transhiatal
Lapassistedoesophagectomy
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Mainlydepends onlocationof tumor
CERVICAL Lesion-pharyngogastrostomyanastomosis is preferred.
UPPEROesophagus-Tri Incisional approach
MIDDLEOesophagus-Tri/Ivor Lewis
LOWEROesophagus-Tri/Ivor
Lewis/Transhiatol approach
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Stomach
Lt colon
Rt colon
Jejunum
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Anastomotic leak,
Anastomotic stricture,
Recurrent laryngealnerve palsy,
Respiratory complication,
Bleeding,
Chyle leak,
Impaired conduit emptying
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UnresectabilityCriterias----
Tracheo-esophageal fistula
Hoarseness
Tumor> 10 cm
Malignant pleural effusion
Claude Bernard Horner syndrome
Paralysis of diaphragm Invasionof surrounding structures
Distant metastases
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RT/CT
Dilation withbougie
Atkinson
Souttar Tube
Procter-Livingstone
Self expanding metalstents(SEMS)
Photodynamic therapy (PDT)
Surgery-Bypass procedure(Retro/presternal colonic by-pass)
Feedinggastrostomy orjejunostomy
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Pt withM-1disease have a median survivalof 6to12 months.
Inpt without systemic metastases,a complete R0resection is best.
Pt withanR1(positive microscopic margin) orR2(gross left behind) resectionhave survivalsimilar to those pt havingM1disease.
After surgery: 5-year overall survival
10-20
1-year survival 70%
2-year30%
5-year20%
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Cisplatin 75 mg/m2 bolus givenover 30 min withadequate prehydration,mannitol andantimetics onday1,
5-FU1000 mg/m2/daygivenas continiousinfusiononday1 through4,
Cycle repeated every28days,
Four cycles planned-first 2 withRT,last 2 withoutRT.
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1. Multiple field technique-1.8Gy/day withtarget upto 50.4Gy.
2.Highdose target volume-14.4Gy/day with
target upto 64.8Gy.
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1.Bailey& Loves short practice of surgery,2.Sabiston text bookof surgery,
3.Maingot AbdominalOperation,
4.Devita,Hellman&Rosenbergs cancer principal&practice of oncology,
5.Lee McGregors synopsis of surgicalanatomy,
6.Dx/Rxupper gastrointestinal malignancies:
cancer of the stomach& esophagus-Dr.ManishA.Shah,
7.Schwartz's Principles of Surgery
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