neoplasms of oesophagus
TRANSCRIPT
CARCINOMA OESOPHAGUSCARCINOMA OESOPHAGUS
Common in China,S.africa &Asian Common in China,S.africa &Asian countries.countries.
66 thth most common cancer. most common cancer.
Less than 1% of all cancers.7% of all GI Less than 1% of all cancers.7% of all GI malignancies.malignancies.
Karnataka & Orissa.Karnataka & Orissa.
Advanced stages – Dysphagia – palliation.Advanced stages – Dysphagia – palliation.
Surgery – Rx of choice for early growthsSurgery – Rx of choice for early growths
AETIOLOGYAETIOLOGY
Diet- deficencies(vit A, C & Riboflavin)Diet- deficencies(vit A, C & Riboflavin)Mycotoxin - common aftr 45 yrsMycotoxin - common aftr 45 yrsAlcohol & tobacco –common in menAlcohol & tobacco –common in menFungal contamination of foodFungal contamination of foodAchalasia cardiaAchalasia cardiaOesophageal websOesophageal websBarret”s oesophagusBarret”s oesophagusPlummmer vinson”s sydromePlummmer vinson”s sydromeCorrosive stricturesCorrosive stricturesTylosisTylosisNitrosaminesNitrosamines
PATHOLOGYPATHOLOGY
Common in - Middle 3Common in - Middle 3 rdrd(50%)(50%)
Lower 3Lower 3rdrd(33%)(33%)
Upper 3Upper 3 rdrd(17%)(17%)
Lower 3 cm- Adenoca common(Barrett”s Lower 3 cm- Adenoca common(Barrett”s columnar metaplasia)columnar metaplasia)
SCC – Commonest in india & AsiaSCC – Commonest in india & Asia
GROSS TYPESGROSS TYPES
Annular –(15%)Annular –(15%)
Ulcerative –(20%)Ulcerative –(20%)
Fungating-cauliflower like –(60%)Fungating-cauliflower like –(60%)
Polypoid Polypoid
Varicoid –diffuse submucosal typeVaricoid –diffuse submucosal type
CF CF
Recent onset of dysphagia(2/3Recent onset of dysphagia(2/3 rdrd lumen lumen occlusion)occlusion)
RegurgitationRegurgitation
Anorexia , loss of weight & cachexiaAnorexia , loss of weight & cachexia
Pain – Substernal or in the abdomenPain – Substernal or in the abdomen
Liver secondaries, ascitisLiver secondaries, ascitis
Bronchopneomonia, melaenaBronchopneomonia, melaena
Features of broncho-oesophageal fistula in CA Features of broncho-oesophageal fistula in CA upper 3upper 3rdrd oesophagus oesophagus
Left supraclavicular lymphnodes may be palpable
Hoarseness of voice
Hiccough
Backpain due to nodal (paraoesophageal or coeliac) spread
M:f- 3:1
INVESTIGATIONSINVESTIGATIONS
Ba swallow-shouldering sign n irregular Ba swallow-shouldering sign n irregular filling defectsfilling defectsOesophagoscopyOesophagoscopyBiopsy (confirmation)Biopsy (confirmation)Chest X-ray(aspiration pneumonia)Chest X-ray(aspiration pneumonia)BronchoscopyBronchoscopyOesophageal endosonographyOesophageal endosonographyCT scanCT scan
u/s abdomen
Endoscopic oesophageeal staining
Blood test
Laproscopy
PET scan
Video assisted thoracoscopic approach
TreatmentTreatment
Gastrostomy shud not b done as a Gastrostomy shud not b done as a palliative procedurepalliative procedure
For early growth without nodal spread-For early growth without nodal spread-radical oesophagectomyradical oesophagectomy
If nodes+ -multimodal aproach If nodes+ -multimodal aproach used(curative resection,radiotherapy n used(curative resection,radiotherapy n chemotherapy)chemotherapy)
Neoadjuvant therapy prior to surgNeoadjuvant therapy prior to surg
Advanced cases-palliation
Indications 4 curative treatment
1.early growth when patient is fit
2.when no involvemnt adj perioesophageal structres or distant organs
Indications for palliative therapy
1.Relieves pain
2.Relieve dysphagia
3.prevent bleeding
4.prevent aspiration
STAGING OF CA OESOPHAGUSSTAGING OF CA OESOPHAGUS
T0: no primary trT0: no primary tr
Tis:CA insituTis:CA insitu
T1: Tr involving mucosaT1: Tr involving mucosa
T2: Tr involving muscularis propriaT2: Tr involving muscularis propria
T3: Tr with paraoesophageal spreadT3: Tr with paraoesophageal spread
T4: involvement of recurrent laryngeal T4: involvement of recurrent laryngeal nerve, phrenic nerve, sympathetic nerve, phrenic nerve, sympathetic chain,azygos vein ; malignant effusionchain,azygos vein ; malignant effusion
No :No lymph nodes
N1: Mobile regional lymph nodes
M0: No distant metastasis
M1a: Upper thoracic oesophageal CA with spread to necknodes or lower oesophageal CA with spread to coeliac nodes
M1b: Upper TE CA with spread to other non regional nodes or distant spread.Middle TE CA with spread to necknodes or coeliac nodes or other npn regional nodes.Lower TE CA with spread to other nonregional nodes or distant spread.
Approaches for different level tumoursApproaches for different level tumours
Post cricoid tr(SCC) Post cricoid tr(SCC) radiotherapy radiotherapy pharynolaryngectomypharynolaryngectomyUpper 3Upper 3 rdrd growth(SCC) growth(SCC) radiotherapy radiotherapy Mc Keown three phased oesophagectomyMc Keown three phased oesophagectomyMiddle 3Middle 3 rdrd growth(SCC) Ivor growth(SCC) Ivor lewis operation palliative lewis operation palliative radiotherayradiotheray
Lower 3rd growth(SCC +Adenoca)
Partial oesophagogastrectomy
Transhiatal blind total oesophagectomy
Other approaches
Thoracoscopic – lap oesophagectomy
Radical oesophagectomy
POST OP MGMTPOST OP MGMT
Fluid & electrolyte mgmtFluid & electrolyte mgmt
Antibiotics& proper analgesiaAntibiotics& proper analgesia
Resp careResp care
Prevention of DVTPrevention of DVT
TPN only during initial postop period TPN only during initial postop period &early jejunostomy feeding for nutrition&early jejunostomy feeding for nutrition
PALLIATIVE PROCEDURESPALLIATIVE PROCEDURES
External or intraluminal RTExternal or intraluminal RT
Traction tubes like celestinTraction tubes like celestin
Pulsion tubes like selfexpandable metal Pulsion tubes like selfexpandable metal stentsstents
Endoscopic laserEndoscopic laser
ChemotherapyChemotherapy
Transhiatal oesophagectomy- orringerTranshiatal oesophagectomy- orringer
COMPLICATIONS OF COMPLICATIONS OF OESOPHAGECTOMYOESOPHAGECTOMY
5 – 10% Mortality5 – 10% MortalityHgeHgeResp infectionResp infectionSepticaemiaSepticaemiaChylothoraxChylothoraxAnastomotic leakAnastomotic leakHoarseness Hoarseness Stricture frmnStricture frmn
Terminal events in CA oesophagusTerminal events in CA oesophagus
Cancer cachexiaCancer cachexia
Sepsis , mediastinitisSepsis , mediastinitis
ImmunosupressionImmunosupression
Malignant tracheo oesophageal fistulaMalignant tracheo oesophageal fistula
Erosion into major bld vessel - bleedingErosion into major bld vessel - bleeding
PROGNOSISPROGNOSIS
NOT GOOD –early spread , longitudinal NOT GOOD –early spread , longitudinal lymphatics , aggresiveness , diff lymphatics , aggresiveness , diff approach ,late presentationapproach ,late presentation
Nodal involvement – bad prognosisNodal involvement – bad prognosis
5 yr survival rate- 10%5 yr survival rate- 10%
BENIGN TUMOURSBENIGN TUMOURS
RareRare
Grows by exapnsion .Never infiltrates or Grows by exapnsion .Never infiltrates or spreads.spreads.
Usually in submucous planeUsually in submucous plane
Obstuction, regurgitation, aspiration, Obstuction, regurgitation, aspiration, mediastinal compressionmediastinal compression
LEIOMYOMA COMMONEST (65%)LEIOMYOMA COMMONEST (65%)
Smooth , sessile , lobulated , firm ,grey white whorled appearance
Multiple localised leiomyomas can occur which can be enucleated independently
90% -in Lower 3rd
INVESTIATIONS
Ba swallow x-ray, oesophagoscopy, endosonography , CTscan