M e d i c a l L e c t u r e Professor. Nazem Shams M e d i c a l L e c t u r e Professor Nazem Shams...

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

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

Professor. Nazem Shams

M e d i c a l L e c t u r e

ProfessorProfessor

Nazem ShamsNazem ShamsProfessor of general and oncology surgeryProfessor of general and oncology surgery

OCMUOCMUMansoura Faculty of MedicineMansoura Faculty of Medicine

ProfessorProfessor

Nazem ShamsNazem ShamsProfessor of general and oncology surgeryProfessor of general and oncology surgery

OCMUOCMUMansoura Faculty of MedicineMansoura Faculty of Medicine


Worldwide, esophageal cancer

is the most common

malignancy

most common cause of

cancer-related death.


2. Dietary2. Dietary::a. a. Ingestion of exogenous carcinogens and Ingestion of exogenous carcinogens and

promoting factors aspromoting factors as::- Polyhydrophenols - Nitrates and nitrosamines - Aflatoxine.

b. Absence of protective substances in fruits b. Absence of protective substances in fruits and green vegetables:and green vegetables:As vitamin A, B2, C, E, and iron, zinc

1. Chronic irritation:1. Chronic irritation:

SSepsis, SSyphilis, SSpirits, SSpices, SSmoking. (5 S)(5 S)

3- Precancerous conditions: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.


Site:

a. Upper third: 20%

b. Middle third: 30%

c. Lower third: 50%


N/E: A-A- Annular typeAnnular type:: more common in lower 1/3.

B- Ulcerative type:B- Ulcerative type: raised everted edge- necrotic floor- indurated base

C- Cauliflower type (60%):C- Cauliflower type (60%): fungating mass.

A B C


M/E:(a) (a) Squamous cell carcinomaSquamous cell carcinoma (60%)(60%)

(b) Adenocarcinoma (40 %)(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:(c) Rare types: adenoid cystic, and mucoepidermoid carcinoma, melanoma, carcinoid, small cell carcinoma


Spread:(1) Direct:(1) Direct: ((main methodmain method):): to the surrounding to the surrounding

(2) Lymphatic:(2) Lymphatic: mainly in a downward direction. mainly in a downward direction.

** ** Cervical esophagusCervical esophagus → → lower deep cervical L.N. lower deep cervical L.N.

** ** Thoracic esophagusThoracic esophagus →→ para-oesophageal & tracheo- para-oesophageal & tracheo-bronchial lymph nodes bronchial lymph nodes

** ** Abdominal esophagusAbdominal esophagus →→ lymph nodes along the lesser lymph nodes along the lesser curvature of the stomach curvature of the stomach →→ coeliac axis L.N. coeliac axis L.N.

(3) Blood (rare): (3) Blood (rare):

Liver, lung, bone, brain


TNM staging

Primary tumor (T)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)Regional lymph nodes (N)

Nx→ Regional nodes cannot be assessed

NO→ No regional node metastasis

N1 → Regional node metastasis

Distant metastasis (M)Distant metastasis (M)

Mx→ Presence of distant metastasis cannot be assessed

MO→ No distant metastases

M1 → Distant metastasis


More common in Old maleOld male than female

(> 45 years) (> 45 years)


Dysphagia in male > 50 years > 2 wks considered cancer esophagus until proved otherwise.

(1) (1) Dysphagia (the cardinal Dysphagia (the cardinal symptom)symptom)::

(difficult in swallowing) characterized bycharacterized by

a- OnsetOnset: Late onset

b- CourseCourse: Continuous and progressive course

c- DurationDuration: Short duration (few months).

d- First toFirst to: solid but not to fluids, later to both fluids & solids

e- Associated withAssociated with: very bad general condition


(2) Regurgitation(2) Regurgitation

(Regurgitation is effortless while vomiting is forcible)

(3) Pain:(3) Pain: usually a late manifestation.

(characterized by pointing pain)(characterized by pointing pain)

(4) Complications. (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


A- For diagnosis:

(1) Barium swallow:(1) Barium swallow:

a.a. Fungating and ulcerative massFungating and ulcerative mass: narrowed irregular filling defect.

b.b. Annular massAnnular mass:

- If middle stricture: Apple core appearanceApple core appearance with evident shouldering

- If lower stricture: Rat tail appearanceRat tail appearance.

Apple core appearance

Cancer lower 1/3 Cancer lower 1/3

Filling defect (ulcerative Filling defect (ulcerative type)type)Rate tail appearance


(2) Esophagoscopy + Biopsy and (2) Esophagoscopy + Biopsy and cytologycytology

(the most important) (the most important)

A- For diagnosis:


B- For evaluation of resectability:

(1) Endoluminal endoscopic US:(1) Endoluminal endoscopic US:

to detect wall penetration and regional LN status.

T4 esophageal cancer

(2) CT and MRI.(2) CT and MRI.(3) Thoracoscopy or laparoscopy:(3) Thoracoscopy or laparoscopy:

to detect Intrathoracic and intrabdominal disease.


LungLung: chest x-ray & C.T

LiverLiver: US

BoneBone: Bone scan & Bone survey

BrainBrain: C.T.

C- For staging:


1-1- Complete blood picture:Complete blood picture:

iron deficiency anemia.

2-2- Occult blood in stoolOccult blood in stool

3-3- Tumor markers:Tumor markers: CEA - CA15-3

D- Laboratory:


- 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).

E- Positron emission tomography (PET):


Treatment of cancer esophagusTreatment of cancer esophagus

Operable Inoperable

Radical surgery followed by chemoradiotherapy

Palliative procedure


Criteria of

inoperability

Unfit patient

Presence of distant metastases

Unresectable tumor

Infiltration of important structure as trachea, aorta


Operable cancer esophagusOperable cancer esophagus

Upper 1/3 Lower 1/3

Total esophagectomy

Subtotal esophago-gastrectomy

Middle 1/3

Partial esophago-gastrectomy

+ appropriate LN dissection


After esophagectomy The esophagus is replaced by

After esophagectomy The esophagus is replaced by

1. Gastric pull up in the neck:1. Gastric pull up in the neck: the best

2. Colon interposition:2. Colon interposition:

3. Free jejunal replacement: 3. Free jejunal replacement:

Gastric pull up Colon interposition


Inoperable cancer esophagusInoperable cancer esophagus

Non-obstructed Obstructed

Palliative chemo-radiotherapy

1. LASER tunneling with endoluminal stenting 2. Photodynamic therapy3. Intubation 4. Jejunostomy or Gastrostomy for feeding


Very bad (5 year survival Very bad (5 year survival rate 5%) due to:rate 5%) due to:

1- Old age 1- Old age

2- Bad general condition before operation 2- Bad general condition before operation

3- Early local spread 3- Early local spread

4- High morbidity after operation e.g. 4- High morbidity after operation e.g. empyema, leakage from anastomosis empyema, leakage from anastomosis

Cancer Esophagus

ByProfessor

Nazem ShamsProfessor of General and

Oncology surgery

Oncology Center - Mansoura University

)OCMU(

2009©

www.nazemshams.com

. . شمس ناظم د أ من مهداه النسخة . هذه . شمس ناظم د أ من مهداه النسخة الفرقة للهذه الفرقة طلبة طلبةللبيع) مانشسترمانشسترالثالثة(الثالثة( للبيع) وليست وليست

M e d i c a l L e c t u r e Professor. Nazem Shams M e d i c a l L e c t u r e Professor Nazem Shams...

Documents

Transcript of M e d i c a l L e c t u r e Professor. Nazem Shams M e d i c a l L e c t u r e Professor Nazem Shams...