Transcript Cancer Esophagus

Medical Lecture
Medical Lecture
Medical Lecture
Medical Lecture
Professor. Nazem Shams
Medical
Lecture
Professor
Nazem Shams
Professor of general and oncology surgery
OCMU
Mansoura Faculty of Medicine
Medical Lecture
Medical Lecture
Medical Lecture
Medical Lecture
Professor. Nazem Shams
Worldwide, esophageal cancer
is
the
most
common
malignancy
most common cause of
cancer-related death.
Professor. Nazem Shams
2. Precancerous
Dietary:
3conditions:
a. Ingestion of exogenous carcinogens and promoting
1. Reflux disease and Barrett’s esophagus (the most •
factors as:
important)
1. Chronic
irritation:
- Polyhydrophenols
2. Achalasia
•
- Nitrates
and nitrosamines
Sepsis,
Syphilis, Spirits,
Aflatoxine.
3. Ectopic -gastric
epithelium•
b.Previous
Absence
of protective
substances in fruits and
4.
irradiation
•
Spices,
Smoking. (5 S)
green vegetables:
5. Corrosive
strictures.
• C, E, and iron, zinc
As vitamin
A, B2,
Professor. Nazem Shams
Site:
a. Upper third: 20%
b. Middle third: 30%
c. Lower third: 50%
Professor. Nazem Shams
N/E:
A- Annular type: more common in lower 1/3.
B- Ulcerative type: raised everted edgenecrotic floor- indurated base
C- Cauliflower type (60%): fungating mass.
A
B
C
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
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 & tracheobronchial lymph nodes
** Abdominal esophagus → lymph nodes along the lesser
curvature of the stomach → coeliac axis L.N.
(3) Blood (rare):
Liver, lung, bone, brain
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
Professor. Nazem Shams
Professor. Nazem Shams
Professor. Nazem Shams
More
common in
Old male
than female
(> 45 years)
Professor. Nazem Shams
(1) Dysphagia (the cardinal symptom):
Dysphagia
in
male
>
characterized
by
(difficult in swallowing)
50 years > 2 wks
considered cancer
esophagus until
proved otherwise.
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
Professor. Nazem Shams
(4)
Complications.
(2)
Regurgitation
(3)
Pain:
usually a late manifestation.
(1) Cachexia, Malnutrition, dehydration, anaemia,.
(Regurgitation
is effortless
while vomiting
(characterized
by pointing
pain) is
(2) Aspiration pneumonia.
forcible)
(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
Professor. Nazem Shams
A- For diagnosis:
(1) Barium swallow:
a. Fungating and ulcerative mass: narrowed irregular
filling defect.
b. Annular mass:
Cancer lower 1/3
- If middle stricture: Apple core appearance with
Filling defect (ulcerative
evident shouldering
type)
- If lower stricture: Rat tail appearance.
Rate tail appearance
Apple core
appearance
Professor. Nazem Shams
A- For diagnosis:
(2) Esophagoscopy + Biopsy and cytology
(the most important)
Professor. Nazem Shams
B- For evaluation of resectability:
(1)
Endoluminal
US:
(2)
and MRI. endoscopic
(3) CT
Thoracoscopy
or laparoscopy:
to detect
wall penetration
and
regional
LN status.
to detect
Intrathoracic
and
intrabdominal
disease.
T4 esophageal cancer
Professor. Nazem Shams
C- For staging:
Lung: chest x-ray & C.T
Liver: US
Bone: Bone scan & Bone survey
Brain: C.T.
Professor. Nazem Shams
D- Laboratory:
1- Complete blood picture:
iron deficiency anemia.
2- Occult blood in stool
3- Tumor markers: CEA - CA15-3
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).
Professor. Nazem Shams
Treatment of cancer esophagus
Operable
Radical surgery followed
by chemoradiotherapy
Inoperable
Palliative procedure
Professor. Nazem Shams
Unfit patient
Presence of distant metastases
Criteria
of
inoperability
Unresectable tumor
Infiltration of important structure as
trachea, aorta
Professor. Nazem Shams
Operable cancer esophagus
Upper 1/3
Total
esophagectomy
Middle 1/3
Lower 1/3
Partial esophagogastrectomy
Subtotal esophagogastrectomy
+ appropriate LN dissection
Professor. Nazem Shams
After esophagectomy
The esophagus is replaced by
1. Gastric pull up in the neck: the best
2. Colon interposition:
3. Free jejunal replacement:
Gastric pull up
Colon interposition
Professor. Nazem Shams
Inoperable cancer esophagus
Non-obstructed
Palliative chemoradiotherapy
Obstructed
1. LASER tunneling with endoluminal
stenting
2. Photodynamic therapy
3. Intubation
4. Jejunostomy or Gastrostomy for feeding
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
‫©‪2009‬‬
‫‪www.nazemshams.com‬‬
‫هذه النسخة مهداه من أ‪.‬د‪.‬ناظم شمس لطلبة الفرقة الثالثة(مانشستر)وليست للبيع‬