Esophageal Cancer

Background
Esophageal carcinoma was well described at the
beginning of the 19th century, and the first successful
resection was performed in 1913 by Frank Torek.

In the 1930, Ohsawa in Japan and Marshall in the

United States were the first to perform successful 1-
stage transthoracic esophagectomies With continent
reconstruction.
 Esophageal Cancer
• Pathophysiology
• Esophageal carcinoma arises in the mucosa.

• ►Subsequently, it tends to invade the submucosa

and the muscular layer.

• ► and, eventually, contiguous structures such as:

• the tracheobronchial tree
• the aorta
• or the recurrent laryngeal nerve.
 Esophageal Cancer

• Pathophysiology
• The tumor also tends to metastasize to the
periesophageal lymph nodes and, eventually, to the
liver, lungs, or both.
• Physiopathology: cascades of events to
cancer:
 Esophageal Cancer

• Frequency
• The incidence of esophageal carcinoma is approximately 3-
6 cases per 100,000 persons, although certain endemic
areas appear to have higher per-capita rates.
 Esophageal Cancer

• Sex
• Esophageal cancer is generally more common in men
than in women, with a male-to-female ratio of 7:1.

• Age
• Esophageal cancer occurs most commonly during the
sixth and seventh decades of life.

• History ►
 Esophageal Cancer

• Clinical Presentation
• History
• Dysphagia
• Is the most common presenting symptom.
 Esophageal Cancer

• Clinical Presentation
• History
• Dysphagia
• Is initially experienced for solids, but eventually it
progresses to include liquids.
 Esophageal Cancer

• Clinical Presentation
• History
• A complaint of dysphagia in an adult should always
prompt an ► endoscopy to help rule out the
presence of esophageal cancer.

• A barium swallow study is also indicated.

 Esophageal Cancer

• Clinical Presentation
• History
• Weight loss
• Is the second most common symptom and occurs in
more than 50% of people with esophageal carcinoma.
 Esophageal Cancer

• Clinical Presentation
• History
• ► Pain
• Can be felt in the:
• epigastric
• or retrosternal area.

• ► It can also be felt over bony structures,

representing a sign of metastatic disease.
 Esophageal Cancer

• Clinical Presentation
• History
• Hoarseness
• Caused by invasion of the recurrent laryngeal nerve is
a sign of unresectability.
 Esophageal Cancer

• Clinical Presentation
• History
• Respiratory symptoms
• Can be caused by aspiration of undigested food or by
direct invasion of the tracheobronchial tree by the
tumor.

• ► The latter also is a sign of unresectability.

 Esophageal Cancer

• Clinical Presentation
• Physical Examination
• The goals of the workup are to establish the
diagnosis and to stage the cancer.

• The examination findings are often normal.

 Esophageal Cancer

• Clinical Presentation
• Physical Examination
• Lymphadenopathy in the ►laterocervical or
• ► supraclavicular areas represents ► metastasis
and, if confirmed by needle aspiration or biopsy
findings, is a contraindication to surgery.
 Esophageal Cancer
• Causes
• The etiology of esophageal carcinoma is thought to be
related to exposure of the esophageal mucosa to
noxious or toxic stimuli, ► resulting in a sequence
of dysplasia ► to carcinoma in situ ► to carcinoma.
 Esophageal Cancer
• Causes
• Potential contributing factors for squamous cell
carcinoma include the following:

• Chronic ingestion of hot liquids or foods is a contributing

factor.

• Vitamin or nutritional deficiencies have been recognized

as contributing factors.

• Poor oral hygiene may lead to esophageal cancer.

 Esophageal Cancer
• Causes
• Potential contributing factors for squamous cell
carcinoma include the following:

• Exposure to nitrosamines in the environment or

food has been linked to esophageal cancer.

• In Western cultures, cigarette smoking and

chronic alcohol exposure are the most common
etiological factors for squamous cell carcinoma.
 Esophageal Cancer
• Causes
• Potential contributing factors for squamous cell carcinoma
include the following:

• Certain medical conditions (e.g. Plummer-Vinson

syndrome) and caustic injury to the esophagus are
associated with an increased incidence of esophageal
cancer.

• Human papilloma virus infection has been recognized as a

contributing factor.
• Causes
• GERD is the most common predisposing
factor for adenocarcinoma of the esophagus.

• As a consequence of the irritation caused by the reflux

of acid and bile, 10-15% of patients who undergo
endoscopy for evaluation of GERD symptoms are found
to have Barrett epithelium.

• The risk of adenocarcinoma among patients with Barrett

metaplasia has been estimated to be 30-60 times that of
the general population.
•
 Esophageal Cancer
• Differential Diagnosis
• Achalasia
• Esophageal Stricture
 Esophageal Cancer
• Workup
• Lab examinations
• Complete blood cell count may demonstrate anemia
secondary to iron deficiency or chronic
disease.

• ►Liver function tests

• ► Patients with squamous cell carcinomas may

demonstrate hypercalcemia.
•
 Esophageal Cancer

• Workup
• Lab examinations
• Prothrombin time and activated partial thromboplastin
time coagulation study findings may demonstrate
hepatic insufficiency or nutritional deficiencies.
 Esophageal Cancer
• Workup
• Imaging Studies
• Barium swallow is very sensitive for helping
detect strictures and intraluminal masses.
 Esophageal Cancer
• Workup
• Imaging Studies
• Performing esophagogastroduodenoscopy
allows direct visualization and biopsies of
the tumor.
 Esophageal Cancer

• Workup
• Imaging Studies
• Endoscopic ultrasound is the most sensitive test to
help determine the depth of penetration of the tumor
(T staging) and the presence of enlarged
periesophageal lymph nodes (N staging).
•
 Esophageal Cancer

• Workup
• Imaging Studies
• Abdominal and chest CT scans are useful to help
exclude the presence of metastases (M staging) to
the lungs and liver and may be useful to help
determine if adjacent structures have been invaded
 Esophageal Cancer

• Workup
• Imaging Studies
• Bronchoscopy is indicated for cancers of the middle
and upper third of the thoracic esophagus to help
exclude invasion of the trachea or bronchi.
•
 Esophageal Cancer

• Workup
• Imaging Studies
• Bone scan is indicated in patients with complaints
suggestive of bone metastases.

•
Laparoscopy and thoracoscopy have a greater than 92%
accuracy in staging regional nodes.
•
 Esophageal Cancer

• Workup
• Imaging Studies
• A new modality for staging is positron emission
tomography scanning (PETS).
 Esophageal Cancer

• Treatment
• Medical Care
• Nonoperative therapy is usually reserved for patients who
have esophageal carcinoma and are not candidates for
surgery.
 Esophageal Cancer
• Treatment
• Medical Care
• The goal of therapy for these patients is palliation of
dysphagia, allowing them to eat.

• A single best method of palliation cannot be applied to

every situation.
• Treatment
• Medical Care
• The most appropriate method to control
dysphagia should be tailored for each patient
individually, depending on:

• ► tumor characteristics

• ► patient preference

• ► and the specific expertise of the physician.

• Treatment
• Medical Care
• The following treatment modalities are
available to help achieve this goal:

• Chemotherapy Radiation therapy

• Laser therapy Photodynamic therapy

• Intubations with expandable metallic stents.

 Esophageal Cancer
• Treatment
• Surgical Care
• Esophageal resection (esophagectomy) remains a
crucial part of the treatment of esophageal cancer.

• It is used in patients who are considered candidates

for surgery.
 Esophageal Cancer

• Treatment
• Surgical Care
• Complications occur in approximately 40% of patients.

• Respiratory complications (15-20%) include:

• Atelectasis
• pleural effusion
• and pneumonia.
 Esophageal Cancer
• Treatment
• Surgical Care
• Cardiac complications (15-20%) include:
• cardiac arrhythmias
• and myocardial infarction.

• Septic complications (10%) include:

• wound infection
• anastomotic leak
• and pneumonia.
 Esophageal Cancer
• Treatment
• Surgical Care

• ► Anastomotic stricture may require dilatation

(20%).

• ► The mortality rate depends on the functional

status of the patient and the experience of the
surgeon and the team taking care of the patient.
 Esophageal Cancer

• Prognosis
• Survival depends on the:
• stage of the disease
• Lymph node metastases or solid organ metastases.
• Tumor Stage
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