Esophageal Cancer - الأهلية

Anatomical Considerations

• The esophagus is a muscular tube that is 25-40 cm long
• It connects the pharynx to the stomach
• The esophagus extends from the C7 to T11 vertebral levels
• Three anatomic parts make up the esophagus: the cervical, thoracic, and abdominal

Benign Esophageal Tumors

• These tumors are rare, occurring in 0.5-0.8% of the population
• Types of benign esophageal tumors include leiomyoma (most common), neurofibroma, mucosal hemangioma, esophageal polyps, and gastrointestinal stromal tumors (GIST)
• Benign tumors can cause dysphagia or chest pain
• They are usually discovered incidentally

Malignant Tumors: Epidemiology and Incidence

• Malignant tumors account for approximately 1% of all malignancies
• 5% of gastrointestinal tumors are malignant
• Malignant tumors are more common than benign tumors
• The typical age of incidence is between 50-70 years old
• There is a 4:1 male-to-female ratio
• There is a particular geographic distribution of esophageal cancer with higher rates in South Africa, Iran, and China (Asian cancer belt)

Malignant Tumors: Location and Etiology

• Squamous cell carcinoma is more common in the middle third of the esophagus
• Adenocarcinoma is more common in the lower third
• Etiological factors for squamous cell carcinoma include adenocarcinoma, smoking, alcoholism, history of head and neck squamous cell carcinoma or radiotherapy, achalasia, nutritional deficiencies, Plummer-Vinson syndrome, and caustic injury
• Adenocarcinoma risk factors include smoking, GERD, Barrett esophagus, and obesity
• Smoking is a risk factor for both types of esophageal cancer

Premalignant Lesions

• Plummer-Vinson syndrome
• Achalasia after 20 years of age
• Caustic stricture after 30 years
• Barrett’s esophagus increases the risk 40-fold
• Esophageal diverticula
• Tylosis (familial hyperkeratosis of the palm and soles)

Pathology

• Upper third of the esophagus accounts for 20% of locations
• The middle third of the esophagus accounts for 50% of locations
• The lower third of the esophagus accounts for 30% of locations
• Annular type tumors 15% are more common in the lower third
• Ulcerative type tumors accounts for 25% presenting with raised everted edge.
• Cauliflower type tumors accounting for 60% are fungating masses
• Squamous cell carcinoma accounts for 85%
• Adenocarcinoma accounts for 15% and is found in the lower end of the esophagus
• Rare types include adenoid cystic and mucoepidermoid carcinoma

Spread

• Local (direct) spread occurs within the esophagus and may involve the recurrent laryngeal nerve, trachea, aorta, pleura, and lung
• Regional (lymphatic) spread can be cervical (lower deep cervical to supraclavicular lymph nodes)
• Middle is paraesophageal to mediastinal lymph nodes
• Lower is the Lt gastric to celiac lymph nodes
• Systemic (blood) spread to the upper 1/3 of the lung
• Lower 2/3 of the liver gets invaded

Staging and Complications

• Staging of esophageal tumors uses the TNM (Tumor, Node, Metastasis) system
• Complications include aspiration pneumonia
• Malnutrition, dehydration, anemia, and cachexia
• Distant metastasis
• Invasion of nearby structures can lead to hoarseness of voice due to recurrent laryngeal nerve involvement
• Hiccough and diaphragmatic paralysis from phrenic nerve involvement
• Stridor, cough, choking, and cyanosis due to tracheal involvement
• Perforation into the pleural cavity can cause empyema
• Perforation into the pericardium causes purulent pericarditis
• Perforation into the posterior mediastinum causes mediastinitis
• Erosion of the aorta or pulmonary vessels may cause severe bleeding

Clinical Manifestations

• Symptoms may not appear until the cancer has infiltrated over 60% of the circumference of the esophageal tube, indicating an advanced stage
• Dysphagia is often the first symptom, initially presenting with solid foods and later with softer foods and liquids
• The different general manifestations include; Weight loss due to decreased appetite and under nutrition, heartburn, hoarseness of the voice due to tumor affecting the recurrent laryngeal nerve, upper airway obstruction and superior vena cava syndrome, and Metastatic diseases to lymph nodes, the liver, lungs, and bone
• Gastrointestinal manifestations include nausea and vomiting, regurgitation of food, coughing, and increased risk of aspiration, regurgitation and hematemesis

Investigation

• CBC; anemia
• Liver function test-abnormal
• Liver function test; abnormal
• Kidney function test and occult blood in stool
• Tumor markers CEA- CA15-3- CA 19-9
• To investigate chest abnormalities, pneumonia , pleural effusion and lung abscess- use Chest x ray
• For liver and peritoneal metastasis useUltra sound U/S (Abdomen)
• Barium swallow; Rat tail appearance
• To check chest and abdomen use Computed tomography (CT)
• Possible investigations - MRI, Positron – emission tomography (PET), and Endoscopic U/S (EUS)

Upper GIT Endoscopy

• Aid in diagnosis, staging, and surveillance
• It provides value in detection of esophageal tumor, biopsy of any suspicious lesions, location of the tumor, tumor length, and degree of obstruction
• Laparoscopy and Thoracoscopy helps Assessment of occult intraperitoneal & intrathorasic metastasis and avoid unnecessary surgery in advanced patients

Treatment Principles

• Most patients (75%) are not fit for surgery because of advanced disease state or anesthetic cause
• Treatment equals surgery which is resection + reconstruction
• Use Proximal safety margin of 5-10 cm and frozen section is preferred
• SCC is more sensitive to chemo-radiotherapy compared to adenocarcinoma
• Proper Nutritional assessment, Correction of malnutrition, and Electrolyte disturbances

Treatment Options

• Endoscopic therapy which can be Endoscopic mucosal resection (EMR) or Endoscopic submucosal dissection (ESD)
• Radiotherapy
• Chemotherapy
• Surgical Resection
• Palliative treatment

Endoscopic Therapy

• High grade dysplasia (CIS) and T1a tumors ≤ 2cm are indications of ES
• Endoscopic mucosal resection (EMR) can be performed with a snare to capture the target tissue
• Endoscopic submucosal dissection (ESD); is Performed by injecting fluid into the submucosa and creating an incision around the perimeter of the lesion, then carefully dissecting the lesion from the deeper layers.
• Endoscopic phototherapy and radiofrequency.

RadioTherapy (RT)

• It can be Curative, Palliative and forms part of Multimodality treatment
• Apply External beam or brachytherapy

Surgical Resection (Esophagectomy) Indications

• Superficial esophageal cancer
• T1-2,N0,M0 cancer
• Can be used when there is Locally advanced disease after assessment of neoadjuvant chemoradiotherapy
• Fit patient with Cardiopulmonary status

Esophagectomy Contraindications

• Supraclavicular LN metastasis and Distant metastasis or patients with Invasion of adjacent structures such as the recurrent laryngeal, Tracheobronchial tree and Aorta
• Severe comorbid conditions such (cardiac and respiratory)

Types of Esophagectomy

• Total esophagectomy (McKeown or transhiatal)
• Partial esophago-gastrectomy (Ivor lewis)

Approaches to Surgical Resection

• Using McKeown 3 stage operation with Midline laparotomy, Right thoracotomy and Cervical incision to carry out Anastomosis to the cervical
• Using Transhiatal esophagotomy with Right thoracotomy; Abdominal , left neck, applying incisons and then carrying cervical Anastomosis
• Perform radical surgery followed by chemoradiotherapy
• Esophagectomy is replaced by Stomach, Colon and Free jejunal flap

Ivor Lewis Esophagectomy

• Partial esophago-gastrectomy
• Two stage esophagectomy
• Done via Abdominal, right thoracotomy incisions
• Use the Intrathoracic Anastomosis

Palliative Treatment for Advanced Disease

• For malignant tissue use Radiotherapy and Chemotherapy
• For the Palliation of dysphagia use Stenting, Laser ablation, Photodynamic therapy, Electrocoagulation, Ethanol injection, and/or Surgery (feeding gastrostomy and jejunostomy)

Prognosis

• The prognosis is very poor
• 5 y survival rate between 5-10%
• Survival depends on the stage of cancer