Esophageal carcinoma

Hamad Emad Hamad Dhuhayr 10110067

Contents

Overview of anatomy Esophageal cancerReferences

Anatomy

the esophagus is a fibromuscular tube, approximately 25cm in length that transports food from the pharynx to the stomach. It originates at the inferior border of the cricoid cartilage, C6, extending to the cardiac orifice of the stomach, T11. Anatomically, the oesophagus can be divided into two parts: thoracic and abdominal.

Anatomical Location and Structure

The oesophagus originates in the neck, at the level of the sixth cervical vertebrae. It is continuous with the laryngeal part of the pharynx.

It descends downward into superior mediastinum of the thorax. Here, it is situated between the trachea and the vertebral bodies T1 to T4. It then enters the abdomen by piercing the muscular right crus of the diaphragm, through the oesophageal hiatus (simply, a hole in the diaphragm) at the T10 level.

The phrenicoesophageal ligament connects the oesophagus to the border of the oesophageal hiatus. This permits independent movement of the oesophagus and diaphragm during respiration and swallowing.

The abdominal part of oesophagus is approximately 2cm long – it terminates by joining the cardiac orifice of the stomach at level of T11.

Muscular layers

The oesophagus consists of an internal circular and external longitudinal layer of muscle. Furthermore, the external longitudinal layer is comprised of different muscle types in each third of the oesophagus:

•Superior third – voluntary striated muscle.•Middle third – voluntary striated and smooth muscle.•Inferior third – smooth muscle.

Food is transported through the oesophagus by peristalsis – a rhythmic contractions of the muscles, which propagates down the oesophagus.

Anatomical Relations

Oesophageal Sphincters

Upper Oesophageal Sphincter

The upper sphincter is an anatomical, striated muscle sphincter at the junction between the pharynx and oesophagus. It is produced by the cricopharyngeus muscle.  Normally, it is constricted to prevent the entrance of air into the oesophagus.

Lower Oesophageal Sphincter

The lower oesophageal sphincter is a physiological sphincter located in the gastro-oesophageal junction (junction between the stomach and oesophagus). The gastro-oesophageal junction is situated to the left of the T11 vertebra, and is marked by the change from oesophageal to gastric mucosa.

Vasculature

Thoracic

The thoracic part of the oesophagus receives its arterial supply from the branches of the thoracic aorta and the inferior thyroid artery (a branch of the thyrocervical trunk). Venous drainage into the systemic circulation occurs via branches of the azygous veins and the inferior thyroid vein.

Abdominal

The abdominal oesophagus is supplied by the left gastric artery(a branch of the coeliac trunk) and left inferior phrenic artery. This part of the oesophagus has a mixed venous drainage via two routes: To the portal circulation via left gastric vein To the systemic circulation via the azygous vein. These two routes form a porto-systemic anastomosis, a connection between the portal and systemic venous systems.

Incidence

4% of GIT tumors

Age >>>>> 45-60 years old.

Sex >>>>> Male (5% of all carcinomas) except in cervical esophagus may be more common in females.

It has geographical distribution showing higher incidence in some countries as China and Japan.

Predisposing factor

Chronic lrritation: Spicy food, smoking & spirits.

Food contamination by fungi

Nirosamine used in food preservation.

Barrett's esophaqus which is lined by columnar epithelium in reflux ) adenocarcinoma.

Achalasia of esophagus.

Tylosis type A (A.D, characterized by hyperkeratosis of palm and sole, 100% esophagus carcinoma at age of 40 years).

Decrease beta carotene, selenium, vitamin E in diet.

Plummer-vinson syndrome

postcoroosive

Scleroderma.

Benign tumors: Papilloma or adenoma.

pathology

Site

Upper 1/3: 20% Middle 1/3: 30% Lower1/3 : 50%

Macroscopic

Proliferative. infiltrating. Ulcerative.

Microscopic

• Squamous cell carcinoma (40% upper 2/3 "rare").

• Adenocarcinoma (60% lower 1/3): from;

Lower 3 cm (lined by columnar epithelium)

On top of Barrett's esophagus.

Upward spread from gastric carcinoma

Recently incidence of adenocarcinoma

• Anaplastic: the cells show malignant criteria

Spread

Direct spread

1. Spreads transversely then lonqitudinallv (extensive submucosal lymphatic spread, proximal line of resection should be '10 cm proximal to the upper limit of the tumor).

2. Neighboring structures: .

Cervical esophaqus:

Trachea >> fistula.

Recurrent laryngeal nerve ) vocal cord paralysis.

Thyroid.

Thoracic esophageal:

Trachea >> fistula

Aorta ) fatal hematemesis.

Left recurrent laryngeal nerve.

Lung.

Thoracic vertebrae.

. Abdominal esophaqus:

Liver.

Stomach.

Diaphragm.

Lymphatic Spread (early)

. Cervical esophagus ) deep cervical LNs.

. Thoracic esophagus ) posterior mediastinal, tracheal & tracheobronchial LNs

. Abdominal esophagus ) left gastric & celiac LNs.

Blood Spread

. Rare & late.

. mainly to liver & Iungs.

Tronscoelomic

in abdominal esophagus e.g. krukenburg tumour.

Clinical picture

Symptoms Male > 50 years old with.

Dysphagia : rapidly progressive to solids > fluids, but later the patient cannot swallow his own saliva leading to continuous driplling of saliva.

Regurgitation (blood stained) leads to pulmonary symptoms.

Excessive salivation.

Loss of Appetite.

Symptoms due to infiltration of adjacent structures e.g. change of voice due to infiltration of RLN.

Signs

General>>>> Cachexia, dehydration & chest infection.

Local>>>> Neck: for presence of lymph nodes or mass.

Abdominal for palpable hard nodular liver & ascites.

Complication

Mediastinits: due to esophageal perforation.Fatal hematemesis: due to aortic invasion.Paralysis of diaphragm and vocal cords. Pulmonary complications: (pneumonia, lung abscess

etc.) (cause of death)

Investigation

for-diagnosis:

Esophagoscope "early endoscopy is the key for good result" + biopsy + cytology

Barium swallow:

Rat tail appearance: Narrow lumen at site of Lesion with mild proximal dilatation due to short duration (unlike achalasia)

Shoulderings.

lrregular filling defect in cauliflower mass.

Prestaltic wave may be absent above the lesion due to infiltration of the wall .

for-staging,

- Endoluminal sonar: show extent of tumor(the most important for local staging and assessing operability)

- Chest X-Ray: elevated copula of diaphragm due toaffection of phrenic nerve, pleural effusion.

- U/S ) liver metastasis.

- CT scan.

- Bone Scan.

- Bronchoscope >>> before barium swallow

- indirect Laryngoscope ) invasion of recurrent laryngeal nerve.

For preoperative preparation

CBC. anemia & leucocytosis in chest infection.

LFTs: for metastasis.

Serum electrolytes & serum protein

- KFTs.

Treatment

1. lnoperable Tumors ( 60% of the patients)

Siqns of lnoperabilitv:-

Clinical:

1. Distant secondary's.

2. Enlarged LNs.

3. Voice change )recurrent laryngeal nerve infiltration.

Radiolosical

1. Enlarged mediastinal LN s

2. Diaphragmatic paralysis.

3. Vertebral erosion.

Bronchoscopy>>>> tracheal invasion

Exploratory:

1. Fixed tumor. 2. Aortic invasion. 3. Secondaries in liver.

Treatment:

bypass

Gastric bypass with a cervical esophagogastrostomy.

Colon bypass.

Major operation with high mortality for a patient with short life span

radiotherapy

The dose of X-Ray should be between 4000 and 4500 rads / 4 wks

Patients treated with high doses complicated with; pulmonary fibrosis,

esophageal bleeding or esophageal perforation.

Suitable for upper esophagus

intubationThe idea is to insert a rigid tube through the stenosed segment to keep a patent lumen.The tube is inserted by :o Gastrostomy (e.9. Celestin tube)o Esophagoscopy (e.9. Souttar tube).

Laser photocoagulation Dysphagia can be relieved by endoscopic laser therapy.A core of tumor is vaporized, opening the lumen without perforatingthe esophagus.Treatment needs to be repeated every 6-8 weeks.

gastrotomyObsolete nowadays as the patient remains unable to swallow his saliva\>> aspiration pneumonia

Chemotherapv: s FU.

Preoperative Preparation Surgery:1) Tumors below the carina (tracheal bifurcation):lvor Lewis operation (2 phases) for middle 1/3 tumors. 1st phase: Laparotomy & mobilization of stomach.2nd phase: Rt thoracotomy through the 5th intercostal space,resection of the tumor, LNs and 1Ocm of the esophagus above thetumor & GE anastomosis.

2) Tumors above the carina:Mc Keown operation (3 phases) 1st phase: Laparotomy & mobilization of stomach. 2nd phase: Rt thoracotomy through the 5* intercostal space andoesphageal mobilization. 3rd phase: Neck incision, the esophagus & stomach are deliveredto the neck where resection is done and anastomosis of thestomach & cervical esophagus is carried out.

3) Tumors below the diaphragm (1 phase) for lower 1/3 tumours

• Lt thracoabdominal incision, the stomach & lower esophagus are removed with Roux-en-Y esophagojujenostomy.

4) Nowadays many surgeons prefer to do:

TranshiataI totaI esophagectomy

Chemotherapy Can be effective with surgery especially with squamous cell carcinoma

Barrett’s esophageal

10% of cases of GERD.

Metaplasia of the lower end of the esophageal mucosa into columnar type.

A precursor for ulcers, dysplasia, cancer in situ and adenocarcinoma.

Regular endoscopic monitoring with multiple biopsies is essential

Endoscopic mucosa resection (EMR) using photodynamic therapy or argon beam coagulation may be used before progression to cancer.

The best line of TTT of it is large dose of PPls

Referrences

Baily and love

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