Esophageal Carcinoma, Histological types, signs and symptoms, diagnostic points, Investigation for diagnosis and staging, curative and palliative treatment, Chemotherapeutic Drugs, Common surgical Procedures

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 Esophageal Carcinoma:

Common Histological types:

  • Squamous cell carcinoma (Middle Third of esophagus)
  • Adenocarcinoma (Lower Third of esophagus)
Causative Factors:

  • 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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