CTSN -Esophageal Cancer

Esophageal Cancer

Click on hyperlinked text for illustrations

View TSDA Curriculum Online for this topic

1. Epidemiology
· USA - 5 cases per 100,000
· Iran, China, Russia - 500 cases per 100,000
· Risk factors for squamous cell cancer:
a) smoking - 5-10x increased risk
b) alcohol abuse
c) older age
d) male gender
e) African-American
f) nitrosamines
· Risk factors for adenocarcinoma
a) Increased incidence in last 10-15 years, especially in white males
b) Barrett's esophagus found in 50%

2. Precancerous Lesions of the Esophagus
· Barrett's esophagus
· Lye stricture
· Tylosis
· Plummer-Vinson syndrome
· Celiac sprue
· Zenker's diverticulum
· Achalasia
· Chagas disease

3. Barrett's Esophagus
· Change of normal squamous epithelium to columnar epithelium
· Incidence of cancer associated with Barrett's mucosa is increasing
· Risk of cancer 50-100x normal
· Dysplasia precedes malignant transformation
· Low grade dysplasia often remains stable or regresses
· High grade dysplasia is equivalent to carcinoma in situ and can predict imminent or existing cancer in 50% of patients
· 75% of resected cancers are associated with adjacent high grade dysplasia
· Endoscopic surveillance of patients with Barrett's mucosa detects cancer early and improves survival

4. Evaluation
A. Radiographic Studies
· Barium swallow and endoscopy are complimentary in early detection
· CT pathologic correlation has a sensitivity and specificity of 50%, with an overall accuracy of about 40-70%
· CT is useful in the detection of distant metastasis and as a surveillance tool for postoperative recurrence
· MRI has an undefined role at this point

B. Endosonography
· Provides detailed images of the esophageal wall and adjacent structures
· Well-suited for staging esophageal cancer
· More accurate than CT in assessing depth of tumor infiltration (T stage) and regional lymphadenopathy
· May not be safe for patients with malignant strictures

Staging of Esophageal Cancer
T Primary Tumor
Tis	Carcinoma in situ
T1	Invades lamina propria or submucosa
T2	Invades muscularis propria
T3	Invades periesophageal tissue
T4	Invades adjacent structures
N Regional lymph nodes
N0	Regional can't be assessed
N1	Regional node metastasis
N1-4	More distant node metastasis
M Distant metastases
M0	No distant metastasis
M1	Distant metastasis
Stage	TNM
Stage 0	Tis N0 M0
Stage I	T1 N0 M0
Stage IIa	T2-3 N0 M0
Stage IIb	T1-2 N1 M0
Stage III	T3 N1 M0, T4 any N M0
Stage IV	Any T, any N, M1

5. Neoadjuvant Therapy
A. Rationale
· Reduces bulk and downstages tumor
· May eradicate tumor in lymph nodes
· May reduce tumor dissemination during surgery
· Prevents development of chemoresistance
· Assesses tumor responsiveness
· Delivery prior to surgical disruption of blood supply

B. Radiation
· Can reduce tumor bulk and render some specimens sterile
· Does not increase postoperative mortality or morbidity
· Does not improve resection rate or long-term survival

C. Chemotherapy
· Response rates vary and usually limited in duration
· Significant toxicity

D. Combined Therapy
· Increases operability and resectability
· Several trials have had encouraging complete response rates for combined chemotherapy and radiation
· Randomized trials ongoing to evaluate long-term survival benefit

6. Operative technique
· A variety of approaches may be used:
a) right thoracic (Ivor-Lewis)
b) right thoracotomy-abdominal-cervical (3-incision)
c) left thoracotomy
d) left thoracoabdominal
e) left thoracoabdominal cervical
f) transhiatal esophagectomy
g) trans-sternal
h) video-assisted esophagectomy
· Extent of esophageal resection and dissection varies according to approach
· Esophageal replacement can be performed using stomach, colon or jejunum

7. Results
· Most current US series have a 5-year survival of about 20%
· Asian series have 5-year survival approaching 30%
· Combined therapy trials are ongoing

8. Palliation
· Endoscopic placement of prostheses relieves dysphagia in about 75% but carries a significant complication rate
· Laser therapy is relatively safe but requires repeated procedures
· Surgical bypass has high mortality