Cancer of the Esophagus-kkkkkkkkkkkk1.pdf

Ca esophagus

1. CANCER OF THE
ESOPHAGUS

2. Basic Anatomy and Physiology
of the Esophagus (1)
Anatomy
The esophagus is a muscular tube, approximately 25 cm long, mainly
occupying the post. mediastinum and extending from the upper esophageal
sphinter in the neck to the junction of the cardia of the stomach.
The musculaure of the upper esophagus, including the upper sphincter, is
striated. This is followed by a transitional zone of both striated and smooth
muscle with the proportion of the latter progressively increasing so that, in the
lower half of the esophagus, there is only smooth muscle. It is lined throughout
with squamous epithelium. The PNS nerve supply is mediated by the branches
of the vagus n. that has synaptic connections to the myenteric (Aurebach’s)
plexus.
The upper sphincter consists of powerful striated muscle. The lower sphincter
is more subtle and is created by assymetric arrangment of muscle fibers.
It is helpful to remember the distances 15, 25 and 40 cm for anatomical
locations during ednoscopy.

3. Basic Anatomy and Physiology of the
Esophagus (2)
Physiology
The main function of the esophagus is to transfer food from the mouth to the stomach in a
coordinated fashion. The intial movement from the mouth is voluntary. The Pharyngeal phase of
swallowing involves the sequential contraction of the oropharyngeal musculature, closure of the
nasal and respiratory passages, cessastion of breathing and opening of the upper esophageal
sphinter (UES). Beyond this level, swallowing is involuntary. The body of the esophagus propels
the bolus through a relaxed lower esophageal sphincter (LES) into the stomach.
The UES is normally closed at rest and serves as a protective mechanism againts regurgitation.
The LES is a zone of relatively high pressure that prevents gastric contents from refluxing into the
lower esophagus. The normal LES is 3-4 cm long with a pressure of 10-25 mmHg measured by
manometry.
Manometry is also used to assess the speed anf ampliture of esophageal body contractions.

4. Diagnostics
■Radiography
■Endoscopy
■Endosonography
■Esophageal manometry
■24-hour pH and combined pH-impedance recording

5. Benign Tumors of the Esophagus
Benign tumors of the esophagus are relatively rare. True Papillomas, adenomas and
hyperplastic polyps do occur, but the majority of ”benign” tumors are not epithelial
in origin and arise from other layers of the esophageal. Most benign lesions are
small and asymptomatic.
The most important point in the management of benign esophageal lesions is to
carry out an adequate number of biopsies to prove beyond reasonable doubt that
the lesion is not malignant.

6. Malignant Tumors of the Esophagus
Non-epithelial primary malignancies are also rare, as is malignant melanoma. Secondary
malignancies rarely involve the esophagus except for bronchogenic carcinoma by direct invasion
of either the primary and/or contiguous lymph nodes.
Carcinoma of the esophagus
Cancer of the esophagus is the 6th most common cancer in the world. In general, it is a disease of
mid to late adulthood, with a poor survival rate. Only 5-10% of those diagnosed will survive for 5
years.
■Squamous cell usually affects the upper 2/3; adenocarcinoma usually affects the lower 2/3.
■Common etiological factor are tobacco and alcohol (SCC) and GERD (adenocarcinoma)
■Lymph node involvement is a poor prognostic factor
■Dysphagia is the most common presenting symptom but is a late feature.

7. Squamous Cell Carcinoma of the
Esophagus (1)
SCC of the esophagus is a malignant epithelial tumor with squamous cell
differentiation. Microscopically is is characterized by keratinocyte-like cells with
intercellular bridges and/or keratinization.
Etiology:
■Tobacco and alcohol
■Nutrition: certain pickled foods
■Hot bevarages
■HPV
■Associations with achalasia, Plumer-Vinson syndrome and Celiac disease have
been described

8. Squamous Cell Carcinoma of the
Esophagus (2)
Clinical features
■Dysphagia: most common presenting sign
■Retrosternal or epigastric pain
■Weight loss
■Regurgitation caused by the narrowing of the esophageal lumen.
Superficial SCC has no specific symtoms but sometimes causes a tingling
sensation and is, therefore, often detected during upper GI endoscopy.

9. Squamous Cell Carcinoma of
the Esophagus (3)
Histopathology
Esophageal SCC is defined as the penetration of neoplastic
squamous epithelium through the epithelial basement
membrane and extension into the lamina propria or deeper
tissue layers.
■Verrucous CA: rare variant (a)
■Spindle cell CA: SCC with a variable sarcomatoid spindle
cell component. Also known as carcinosarcoma (b)
■Basaloid SCC: Closely packed cells with hyperchromatic
nuclei and scant basophilic cytoplasm. (c)
a
b
c

10. Squamous Cell Carcinoma of
the Esophagus (4)
Precursor lesions
■Intraepithelial neoplasia: disorganization of the
epithelium and loss of normal cell polarity.
Cytologically the cells exhibit hyperchromatic nuclei,
an increase in nuclear/cytoplamic ratio and
increased mitotic activity.
■Basal cell hyperplasia: this lesion is defined as an
otherwise normal squamous epithelium with a basal
zone thickness greater than 15% of total epithelial
thickness
■Squamous cell papilloma: rare and cause no
specific symptoms (image on the left)

11. Diagnostic Imaging
Examples of SCC
SCC of the esophagus producing an irregular
stricture with shouldered margins
Endoscopic appearance of a mid-esophageal
squamous cell carcinoma.

12. Adenocarcinoma of the Esophagus
(1)
A malignant epithelial tumor of the esophagus with glandular differentiation arising
predominantly from Barret musoca in the lower third of the esophagus.
Etiology
■Barret’s esohagus
■Chronic GERD
■Tobacco
■Obesity
■H. Pylori

13. What is Barrett’s
esophagus?
It is a metaplastic change in the lining mucosa of the
esophagus in response to chronic GERD.
In BE, the junction between squamous esophageal
mucosa and gastric mucosa move proximally.
Patients who are found to have BE may be submitted to
regular surveillance endoscopy with multiple biosies in the
hope of finding dysplasia on in situ cancer rather than
allowing invasive cancer to develop and cause symptoms.
■Classic Barret’s: 3cm of columnar epithelium or more
■Short-segment Barret’s
■Cardiametaplasia
The macroscopic appearance of an

adenocarcinoma 

in Barrett’s esophagus

14. Adenocarcinoma of the Esophagus
(2)
Sings and Symptoms
■Dysphagia is often the first symptom of advanced adenocarcinoma in the esophagus
■Retrosternal or epigastric pain
■Cachexia
Endoscopy: in early stages, theres small polypoid adenomatous-like lesion, but often it is
flat, depressed, elevated or occult. 

Areas with high grade intraepithelial changes are often times multicentric and occult.
Radiologic studes: barium studies are helpful mostly for the analysis of stenotic segments

15. Adenocarcinoma
of the Esophagus
(3)
Histopathology
■Adenocarcinomas arising in
the setting of BE are
typically papillary and/or
tubular(image)
■Signet ring cell
adenocarcinoma is also not
uncommon
■Mucinous adenocarcinoma
is also possible

16. Other Carcinomas
■Adenosquamous
carcinoma: rare
■Mucoepidermoid carcinoma
■Adenoid cystic carcinoma
(image)

17. Other Types of Tumors of the
Esophagus
Endocrine tumors of the esophagus are rare and include carcinoid, small cell carcinoma
and mixed-endocrine and exocrine carcinoma
Lymphoma of the esophagus is defined as an extranodal lymphoma arising in the
esophagus with the bulk of the disease localized to this site.
Mesenchymal tumors of the esophagus
■Leiomaymoa: spindle cells with low or moderate celularity and slight if any mitotic activity
■Leiomyosarcoma: features differentiated smooth muscle cells
■Granular cell tumors : typicaly bening
■Rhabdomyosarcoma: older adult patients, usually in distal esophagus
■Synovial sarcoma: usually in children or older adults
■Kaposi sarcoma seen in HIV-positive patiens. Scattered PAS-positive globules

18. Diagnosis and Treatment of
Esophageal Cancer (1)
Diagnosis
■Blood test: limited value. Abormal LFTs may indicate Liver
metastases
■Endoscopy: main method of diagnosis of esophageal
disorders
■Transcutaneous US: used to asses spread to the liver.
■Bronchoscopy: many middle and upper-third esophageal
carcinomas are sufficiently advanced at the time of diagnosis
that the trachea and the bronchi may already be involve.
■Laparoscopy: for diagnosis of intra-abdominal and hepatic
mets.
■CT/MRI
Endoscopy demonstrating early tumor. 

Note the preservation of the outer dark wall

layer that represents the muscle coat

19. DIAGNOSIS
AND
TREATMENT
OF
ESOPHAGEAL
CANCER (2)

20. Diagnosis and Treatment of
Esophageal Cancer (3)
Treatment
■Radical esophagectomy is the most important aspect of curative treatment
■Neoadjuvent treatments pre-surgery may improve survival outcome
■Chemoradiotherapy alone may cure selected patients particularly those with
SCC.
Surgical Treatment:
■Two-phase esophagectomy( abdomen and right chest, Ivor Lewis)
■Transhiatal esophagectomy without thoractomy

21. THANK YOU
FOR YOUR
ATTENTION