Esophageal Carcinoma, Histological types, signs and symptoms, diagnostic points, Investigation for diagnosis and staging, curative and palliative treatment, Chemotherapeutic Drugs, Common surgical Procedures
Esophageal Carcinoma:
Common Histological types:
- Squamous cell carcinoma (Middle Third of esophagus)
- Adenocarcinoma (Lower Third of esophagus)
- Squamous cell carcinoma:
- Smoking
- Alcohol
- Vitamin A, C, Zinc, Molybdenum deficiency.
- Long standing achalasia
- Celiac disease
- Strictures
- Nitrosamines diet
- Human Papilloma virus
- Adenocarcinoma:
- Long standing GERD
- Barrett’s oesophagus
- Obesity
- High fat intake
- High alcohol intake
Presenting Complaints:
- Dysphasia(Most Common): Initially for solids then progress to Liquid as well.
- Weight loss
- Retrosternal discomfort
- Anemia
- Cervical Lypmphadenopathy
- Hoarseness of voice:Involvement of recurrent laryngeal nerve or direct invasion of the tumour into vocal cord.
- Stridor, Coughing, choking and aspiration pneumonia.(extension of the tumour into Tracheobronchial Tree.
- Tylosis: Hyperkeratosis of Palms and soles.
Diagnostic Points:
- Age > 45 years
- Progressive Dysphagia
- Recent unintentional weight loss.
- Anemia (Pallor)
Investigations:
- For Diagnosis:
- Endoscopy: First line investigation, Provides:
- Direct visualization of the tumour.
- Histological specimen(Biospsy) for accurate diagnosis.
- For Staging:
- CT scan Chest, Abdomen and Pelvis: Gives information about:
- Local extent of the tumour
- Invasion into surrounding structures
- Mediastinal and abdominal lymph nodes involvement
- Disseminated disease (Lungs, Liver and Peritoneum, Which are most common sites)
- Endoscopic Ultrasonography (EUS): Demonstrates:
- Depth of wall penetration by tumour
- Presence of lymph nodes metastasis
- Positron Emission Tomography (PET Scan) in selected cases:
- Agent used is 18F Fluorodeoxyglucose(FDG) >enter this cell> Phosphorylate> Can’t diffuse back out of cell> emits gamma rays> captured by gamma cameras> thus tumour mets identified.
- Bronchoscopy:
- Airway involvement
- Laparoscopy:
- Peritoneal involvement
Staging: TNM Staging system:
- Primary Tumor (T)
- Tx:Primary tumour can’t be assessed
- To: No evidence of tumour
- Tis:Carcinoma in situ
- T1a: Invades lamina propria/Muscularis mucosae
- T1b: Invades Submucosa
- T2: Invades Muscularis propria
- T3: Invades adventitia
- T4a: Invades Resectable structures:
- Pleura
- Pericardium
- Diaphragm
- T4b: Invades non-resectable structures:
- Aorta
- Vertebral body
- Trachea
- Regional Lymph nodes:
- Nx: Lymph node can’t be assessed
- N0: No regional lymph node involvement
- N1: 1 - 2 Positive regional lymph nodes
- N2: 3 - 6 Positive regional lymph nodes
- N3: 7 or more positive regional lymph nodes
- Distant Metastasis:
- M0: No distant metastasis
- M1: distant metastasis
- Stage 0: Tis + N0 + M0
- Stage I: T1 + N0 + M0
- Stage IIa: T2 + N0 + M0 / T3 + N0 + M0
- Stage IIb: T1 + N1 + M0 / T2 + N1 + M0
- Stage III: T3 + N1 + M0 / T4 + Any N + M0
- Stage IV: Any T + Any N + M1
Treatment:
- T1a/T1b: Endoscopic Mucosal Resection + Ablation
- T2/T3:
- Without lymph nodes involvement: Esophagectomy
- With lymph nodes involvement: Esophagectomy + Lymphadenectomy
- T4: Metasatic/Advance cancer > Chemotherapy + Radiotherapy > Restaging > If possible > Esophagectomy.
- Squamous cell carcinoma is radiosensitive while Adenocarcinoma is radio resistant.
- Chemotherapy Drugs:
- Cisplatin
- 5FU
- Surgical Procedures:
- Minimal Invasive Esophagectomy
- Esophagectomy
- Two incisions: Upper midline plus Neck (Without thoracotomy)
- Ivor Lewis/Lewis Tanner or Two phase operation
- Two incisions: Upper midline plus Right thoracotomy
- Mckeown or Three Phase Operation
- Three Incisions: Upper midline plus Right thoracotomy plus Neck
- Salvage Esophagectomy
Palliative Treatment:
- Intubation:
- Expandable stents: Can be passed in collapsed form under radiological or endoscopic guidance.
- Laser therapy: Endoscopic laser to unblock stents encroached tumour.
- Other endoscopic methods:
- Bipolar diathermy
- Argon beam plasma coagulation
- Ethanol injection
- Chemotherapy
- Radiotherapy
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