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Esophageal Carcinoma

Esophageal Carcinoma. Anatomy of Esophagus. The esophagus is a hollow tube of muscle 25 to 30 cm long, beginning at C6 and ending at T11. It lies anterior to the vertebral column, posterior to the trachea, and adjacent to the descending aorta.

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Esophageal Carcinoma

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  1. Esophageal Carcinoma

  2. Anatomy of Esophagus The esophagus is a hollow tube of muscle 25 to 30 cm long, beginning at C6 and ending at T11. It lies anterior to the vertebral column, posterior to the trachea, and adjacent to the descending aorta. Four segment: pharyngoesophageal, cervical, thoracic, abdominal.

  3. Anatomy of Esophagus

  4. Anatomy of Esophagus The esophagus has three distinct areas of anatomic narrowing: 1. Cervical constriction (Φ14mm) 2. Bronchoaortic constriction (Φ15-17mm) 3. Diaphragmatic constriction (Φ16-19mm)

  5. Anatomy of Esophagus The esophagus is nourished by numerous segmental arteries:

  6. Anatomy of Esophagus Venous drainage of the esophagus

  7. Anatomy of Esophagus Innervation of the esophagus:

  8. Esophageal Carcinoma Esophageal carcinoma is a common tumor of gastrointestinal tract and China is one of the areas with a high incidence rate of this disease. It is more frequently seen in men than in women and most patients are older than 40 years.

  9. Esophageal Carcinoma The risk factors for Esophageal Carcinoma: alcohol, tobacco, zinc, nitrosamines, malnutrition, vitamin deficiencies, anemia, poor oral hygiene and dental caries, previous gastric surgery, and long-term ingestion of hot foods or beverages, esophageal lesions.

  10. Esophageal Carcinoma Esophageal carcinoma is notorious for its aggressive biologic behavior; it infiltrates locally, involves adjacent lymph node, and metastasizes widely by hematogenous spread. Lack of an esophageal serosal layer tends to favor local tumor extension.

  11. Upper and middle thirds infiltrate the tracheobronchial tree, aorta, and left recurrent laryngeal nerve. Lower-third invade the diaphragm, pericardium, stomach.

  12. Lymphatic Drainage Cervical esophageal cancers drain to the deep cervical, paraesophageal, posterior mediastinal, and tracheobronchial lymph nodes. Lower esophageal cancers spread to paraesophageal, celiac, and splenic hilar lymph nodes. Distant spread to liver and lungs is common.

  13. Lymph node map for esophageal carcinoma

  14. Concept of lymphatic pathways

  15. The prognosis for patients with invasive squamous cell carcinoma is poor: overall 5-yr survival with treated tumors is 5-12%. Extraesophageal tumor extension is present in 70% of cases at diagnosis.

  16. Histology 95% of esophageal cancers worldwide are squamous cell carcinomas.

  17. Squamous cell carcinoma Arises from the mucosa of esophagus. Locates mainly in the thoracic esophagus: 60%--middle third, 30%--distal third. Major gross pathologic presentations: fungating, ulcerating, infiltrating, polypoid.

  18. Adenocarcinoma The most common cell type of esophageal cancer in USA. Arises from the superficial and deep glands of the esophagus, mainly in the lower third of esophagus, especially near the gastroesophageal junction.

  19. Diagnosis Symptoms of esophageal carcinoma are usually insidious, beginning as nonspecific retrosternal discomfort or indigestion, followed by the common symptoms of dysphagia and weight loss.

  20. Clinical Features of Esophageal Cancer

  21. Diagnosis Diagnosis of esophageal cancer is based on esophageal biopsy. Esophagoscopy is required to establish a tissue diagnosis and determine the extent of longitudinal intramural tumor spread. Brush cytologe(accuracy: 85-97%) plus biospy tissue sample(accuracy: 83-90%) are obtained for histologic analysis. The accuracy of the combination of brush cytology and biopsy is more than 97%. If undiagnosed by biopsy or brush cytology because of the depth of the tumor, EUS-guided fine-needle aspiration (FNA) is needed.

  22. Plain chest radiography is abnormal in 50% of patients with esophageal cancer, with findings such as an air-fluid level in the obstructed esophagus, a dilated esophagus, abnormal mediastinal soft tissue representing adenopathy.

  23. Double-contrast barium swallow shows the presence of obstruction or fistulas, as well as the tumor length and location. Advanced cancers manifest as luminal narrowing, ulceration, and strictures with an abrupt shelflike (shouldered) proximal border on barium swallow.

  24. Double-contrast barium swallow of esophageal cancer

  25. CT permits evaluation of the esophageal wall thickness, assessment of direct mediastinal invasion by the tumor and the presence or regional lymphadenopathy and pulmonary, liver, adrenal, and distant nodal metastases.

  26. EUS can determine the anatomic loaction and enlargement of the mediastinal, perigastric, or celiac lymph nodes.

  27. Staging Once the diagnosis of esophageal carcinoma has been histological established, staging of the tumor is next step.

  28. Management algorith for esophageal cancer

  29. Staging (TNM) TMN of AJCC: "T" indicates the progressive degree of invasion of the tumor into the esophageal wall. "N" stands for nodal involvement. "M" represents distant metastasis.

  30. Staging(TNM)

  31. Treatment of Esophageal Cancer Treatment includes surgery, chemotherapy, radiation, or a combination of these techniques.

  32. Curative Treatment At best, only 50% of patients are eligible for a curative resection at presentation. There are 4 types of esophagectomy (transthoracic, en bloc, transhiatal, and video-assisted), with none shown to have a relative survival advantage.

  33. Transthoracic esophagectomy 1. Left-sided thoracoabdominal incision.

  34. Transthoracic esophagectomy 2. Ivor-Lewis pathway: a midline celiotomy for mobilization of stomach and a right thoracotomy for esophageal lesion.

  35. En bloc esophagetomy Involves complete resection of the thoracic esophagus with a two-(chest and abdomen) or three-field (chest, abdomen, and neck) lymph node dissection using a midline celiotomy, right thoracotomy, and a cervical incision for the proximal anastomosis of the stomach tube to the cervical esophageal remnant.

  36. Transhiatal esophagectomy • A cervical incision to mobilize the esophagus and perform the proximal anastomosis then a midline celiotomy to mobilize the esophagus and stomach.

  37. Video-assisted esophagectomy Laparoscopy to mobilize the stomach, VATS to mobilize the esophagus, and a cervical incision for the anastomosis of the stomach tube to the cervical esophageal remnant.

  38. VATS

  39. Laparoscopy

  40. Perioperative complications Anastomotic Leak Anastomotic Stricture Recurrent Laryngeal Nerve Injury Respiratory Complications Bleeding Chyle Leak Postresection Reflux Impaired Conduit Emptying Local Recurrence

  41. Palliative Treatment Dilatation/Stenting. Photodynamic therapy. Radiation therapy. Surgical palliation: palliative surgical bypass with interposed stomach or colon. Chemotherapy.

  42. THANK YOU!

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