Professor of general and oncology surgery Mansoura Faculty of Medicine Oncology center - Masoura university OCMU O ! M e d i c a l L e c t u r e M e d i c a l L e c t u r e M e d i c a l L e c t u r e Cancer Esophagus M e d i c a l L e c t u r e ! Professor. Nazem Shams ! ! Cancer Esophagus O ! ! M e d i c a l L e c t u r e ! ! ! ! Professor Nazem Shams Professor of general and oncology surgery OCMU Mansoura Faculty of Medicine ! ! M e d i c a l L e c t u r e M e d i c a l L e c t u r e M e d i c a l L e c t u r e M e d i c a l L e c t u r e

8 6 Oncology center - Cancer Esophagus Masoura university Incidence th OCMU Cancer Esophagus Professor. Nazem Shams Worldwide, esophageal cancer is the most common malignancy most common cause of cancer-related death. 8 th Incidence 6 th

Sepsis, Syphilis, Spirits, Spices, Smoking. (5 S) Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams 3- Precancerous conditions: 1. Reflux disease and Barrett’s esophagus (the most important) 2. Achalasia 3. Ectopic gastric epithelium 4. Previous irradiation 5. Corrosive strictures. 2. Dietary: a. Ingestion of exogenous carcinogens and promoting factors as: - Polyhydrophenols - Nitrates and nitrosamines - Aflatoxine. b. Absence of protective substances in fruits and green vegetables: As vitamin A, B2, C, E, and iron, zinc 1. Chronic irritation: Sepsis, Syphilis, Spirits, Spices, Smoking. (5 S) Etiology

Oncology center - Cancer Esophagus Masoura university Site: Pathology OCMU Cancer Esophagus Professor. Nazem Shams Site: a. Upper third: 20% b. Middle third: 30% c. Lower third: 50% Pathology

Oncology center - Cancer Esophagus Masoura university N/E: Pathology OCMU Cancer Esophagus Professor. Nazem Shams N/E: A- Annular type: more common in lower 1/3. B- Ulcerative type: raised everted edge- necrotic floor- indurated base C- Cauliflower type (60%): fungating mass. Pathology A B C

Oncology center - Cancer Esophagus Masoura university M/E: Pathology OCMU Cancer Esophagus Professor. Nazem Shams M/E: (a) Squamous cell carcinoma (60%) (b) Adenocarcinoma (40 %) in the lower end of the oesophagus from: 1- Barrett’s esophagus (commonest) 2- Heterotropic gastric mucosa 3- Adenocarcinoma of the stomach spreading upwards. 4- Adenocarcinoma arising from esophageal submucosal glands. (c) Rare types: adenoid cystic, and mucoepidermoid carcinoma, melanoma, carcinoid, small cell carcinoma Pathology

Oncology center - Cancer Esophagus Masoura university Spread: OCMU Cancer Esophagus Professor. Nazem Shams Spread: (1) Direct: (main method): to the surrounding (2) Lymphatic: mainly in a downward direction. ** Cervical esophagus → lower deep cervical L.N. ** Thoracic esophagus → para-oesophageal & tracheo-bronchial lymph nodes ** Abdominal esophagus → lymph nodes along the lesser curvature of the stomach → coeliac axis L.N. (3) Blood (rare): Liver, lung, bone, brain Pathology

Regional lymph nodes (N) Distant metastasis (M) Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams TNM staging Primary tumor (T) Tx → Primary tumor cannot be assessed TO→ No evidence of primary tumor Tis→ Carcinoma in situ T1 → Tumor invades mucosa or submucosa T2→ Tumor invades musculosa T3→ Tumor invades adventitia. T4→ Tumor invades adjacent structures. Regional lymph nodes (N) Nx→ Regional nodes cannot be assessed NO→ No regional node metastasis N1 → Regional node metastasis Distant metastasis (M) Mx→ Presence of distant metastasis cannot be assessed MO→ No distant metastases M1 → Distant metastasis Pathology

Cancer Esophagus Pathology Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams Pathology

Cancer Esophagus Pathology Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams Pathology

More common in Old male than female Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams More common in Old male than female (> 45 years) Presentation

(difficult in swallowing) Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams (1) Dysphagia (the cardinal symptom): (difficult in swallowing) Dysphagia in male > 50 years > 2 wks considered cancer esophagus until proved otherwise. characterized by a- Onset: Late onset b- Course: Continuous and progressive course c- Duration: Short duration (few months). d- First to: solid but not to fluids, later to both fluids & solids e- Associated with: very bad general condition Presentation

(characterized by pointing pain) Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams (4) Complications. (1) Cachexia, Malnutrition, dehydration, anaemia,. (2) Aspiration pneumonia. (3) Distant metastasis. (4) Invasion of near by structures: e.g. 1. Recurrent laryngeal nerve → Hoarseness of voice 2. Trachea → Stridor & TOF→ cough, choking & cyanosis 3. Perforation into the pleural cavity → Empyema (3) Pain: usually a late manifestation. (characterized by pointing pain) (2) Regurgitation (Regurgitation is effortless while vomiting is forcible) Presentation

Cancer Esophagus Investigations Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams Apple core appearance Rate tail appearance Cancer lower 1/3 Filling defect (ulcerative type) A- For diagnosis: (1) Barium swallow: Fungating and ulcerative mass: narrowed irregular filling defect. Annular mass: - If middle stricture: Apple core appearance with evident shouldering - If lower stricture: Rat tail appearance. Investigations

Cancer Esophagus Investigations Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams A- For diagnosis: (2) Esophagoscopy + Biopsy and cytology (the most important) Investigations

Cancer Esophagus Investigations Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams B- For evaluation of resectability: (1) Endoluminal endoscopic US: to detect wall penetration and regional LN status. T4 esophageal cancer (2) CT and MRI. (3) Thoracoscopy or laparoscopy: to detect Intrathoracic and intrabdominal disease. Investigations

Cancer Esophagus Investigations Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams C- For staging: Lung: chest x-ray & C.T Liver: US Bone: Bone scan & Bone survey Brain: C.T. Investigations

Cancer Esophagus Investigations Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams D- Laboratory: 1- Complete blood picture: iron deficiency anemia. 2- Occult blood in stool 3- Tumor markers: CEA - CA15-3 Investigations

Cancer Esophagus Investigations Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams E- Positron emission tomography (PET): - Non invasive method of detecting primary, nodal, distant metastases & locally recurrent tumor - The technique estimates area of high glucose metabolism (the tumor) by measurement of the uptake of radiotracer (Flurodeoxyglucose FDG). Investigations

Cancer Esophagus Treatment Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams Treatment of cancer esophagus Treatment Operable Inoperable Radical surgery followed by chemoradiotherapy Palliative procedure

Criteria of inoperability Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams Unfit patient Presence of distant metastases Criteria of inoperability Treatment Unresectable tumor Infiltration of important structure as trachea, aorta

+ appropriate LN dissection Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams Operable cancer esophagus Upper 1/3 Middle 1/3 Lower 1/3 Treatment Total esophagectomy Partial esophago-gastrectomy Subtotal esophago-gastrectomy + appropriate LN dissection

The esophagus is replaced by Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams After esophagectomy The esophagus is replaced by Gastric pull up Colon interposition 1. Gastric pull up in the neck: the best 2. Colon interposition: 3. Free jejunal replacement: Treatment

Palliative chemo-radiotherapy Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams Inoperable cancer esophagus Non-obstructed Obstructed Treatment Palliative chemo-radiotherapy 1. LASER tunneling with endoluminal stenting 2. Photodynamic therapy 3. Intubation 4. Jejunostomy or Gastrostomy for feeding

Very bad (5 year survival rate 5%) due to: Oncology center - Masoura university OCMU Cancer Esophagus Professor. Nazem Shams Very bad (5 year survival rate 5%) due to: 1- Old age 2- Bad general condition before operation 3- Early local spread 4- High morbidity after operation e.g. empyema, leakage from anastomosis Prognosis

Cancer Esophagus By Professor Nazem Shams Professor of General and Oncology surgery Oncology Center - Mansoura University (OCMU) 2009© www.nazemshams.com هذه النسخة مهداه من أ.د.ناظم شمس لطلبة الفرقة الثالثة(مانشستر)وليست للبيع