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Esophageal Cancer RTC Dec 11 2009 Felicitas Koller and Eric Grogan New Cases Deaths Cancer Statistics, United States Esophageal 200000 Colorectal 150000 Prostate 100000 Breast 50000 Lung 0 Histology Number of patients of Number http://www.cancer.org/statistics Squamous Cell Adenocarcinoma Worldwide >>> < Men vs. 3:1 (fifth decade) 15:1 (fifth decade) Women Age Rarely <30; mortality greatest in men Rarely < 40, incidence increases with age 60‐70 Disease Exposure to environmental factors; Barrett’s 40 fold increase Association smoking, ETOH, pickled/smoked; deficiencies; tylosis, Plummer‐Vinson syndrome; end‐stage achalasia Location Squamous tissue in upper and middle Submucosal glands of esophagus; third heterotopic islands of columnar epithelium; malignant degeneration of metaplastic columnar epithelium Survival 70% with polypoid; 15% advanced Nature Sensitive to chemotherapy Embedded in Barrett's esophagus, less sensitive to chemotherapy Commences at C6 joins stomach at T11, usually 25‐30 cm long. 2.5 cm in diameter Structures: distance from incisors 13 cm – cricopharyngeus 22 cm azygous vein 22‐27cm carina 40 cm EG junction The Layers at?? The esophagus lacks a serosa: mucosa, submucosa and muscularis propria Two interconnecting lymphatic plexuses arising from the submucosa and muscularis layers. GE junction at?? Endoscopically: The squamocolumnar epithelial junction (Z‐ line) The transition from the smooth esophageal lining to the rugal folds of the stomach Externally: The collar of Helvetius (or loop of Willis) The gastroesophageal fat pad are consistent identifiers of the GEJ Case Presentation 3/24/09 CC: 73 yo man with a 2 month history of progressive difficulty with swallowing. Solid foods pass the upper esophagus with some difficulty. Has no lodging, but has to drink more water No hx of esophagitis or stricture HTN, HLD, BPH, hx. of arrhythmia PSH: Anterior neck fusion WHAT ADDITIONAL HISTORY? Smoking, drinking, anemia, GERD or GERD sx, foul breath, regurgitation of food, hx of chemical or radiation exposure, medications DIFFERENTIAL DX? Obstructive lesions: tumors, inflammatory masses; Zenker's diverticulum, esophageal webs mediastinal masses ,cervical spondylosis, radiation, chemical or medication induced; Schatzki's Ring, vascular compression, enlarged aorta or left atrium, aberrant vessels, lymphadenopathy, substernal thyroid Neuromuscular disorders: achalasia; DES, Hypertensive LES, nutcracker esophagus, scleroderma INITIAL TEST? Barium Swallow‐Why? both functional and anatomic. A B C D 1. A=nutcracker esophagus, B=cancer C=achalasia, D= cancer 2. A=Schatzki’s ring, B=cancer, C=normal, D=Barrett’s esophagus 3. A=reflux, B=compression from mediastinal mass, C= normal, D=achalasia 4. A=diffuse esophageal spasm, B=Zenker’s diverticulum, c=normal, d=cancer EGD with biopsy—tissue 1. Location (w/ respect to incisors) 2. Nature of the lesion 3. Proximal and distal extent of the lesion 4. Relationship of the lesion to the cricop., GEJ, cardia 5. Distensibility of the stomach CT scan thorax—length of the tumor, thickness of the esophagus and stomach, lymph node status and distant disease to the liver and lungs PET scan—primary mass, regional lymph nodes and distant disease Esophageal ultrasound—depth of the tumor, the length of the tumor, the degree of luminal compromise, the status of regional lymph nodes, and involvement of adjacent structures EGD: ‐6‐7 mm, 3cm long, 28 cm from the incisors. Patchy antral erythema, normal duodenum Pathology: invasive moderately differentiated squamous cell carcinoma, vascular invasion CT: focal mid‐esophageal wall thickening, no adenopathy PET: intense focal FDG activity in the mid‐thoracic esophagus immediately posterior to the left mainstem bronchus. 3 FDG avid nodules: r of midline at the same level, subcarinal and right paratracheal 1ST hyperechoic (white), represents the superficial mucosa (epithelium and lamina propria). 2nd hypoechoic (black), represents the deep mucosa (muscularis mucosa). 3rd hyperechoic (white), represents the submucosa. 4thhypoechoic (black), represents the muscularis propria. 5th hyperechoic (white) is the periesophageal tissue. A, A T1 lesion is observed as a hypoechoic thickening of the mucosal layer adjacent to the normal‐appearing wall pattern; B, a T2 lesion is seen as a hypoechoic mass invading into but not through the muscularis propria T2 N1 by EUS What’s his stage What are his treatment options Tumor Nodes Metastasis TX: Primary tumor cannot be NX: Regional lymph MX: Distant metastasis cannot be assessed assessed nodes cannot be assessed T0: No evidence of primary tumor N0: No regional lymph M0: No distant metastasis node metastasis Tis: Carcinoma in situ N1: Regional lymph M1: Distant metastasis Tumors of the lower thoracic esophagus: node metastasis M1a: Metastasis in celiac lymph nodes M1b: Other distant metastasis Tumors of the midthoracic esophagus: M1a: Not applicable M1b: Nonregional lymph nodes and/or other distant metastasis Tumors of the upper thoracic esophagus: M1a: Metastasis in cervical nodes M1b: Other distant metastasis T1: Tumor invades lamina propria or submucosa T2: Tumor invades muscularis propria T3: Tumor invades adventitia T4: Tumor invades adjacent structures Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Tis, N0, M0 T1, N0, M0 Stage IIA T3, N1, M0 Any T, any N, M1 T2, N0, M0 T4, any N, T3, N0, M0 Stage IIB Stage IVA T1, N1, M0 Any T, any N, T2, N1, M0 M1a Stage IVB Any T, any N, M1b 1. Surgery alone 2. Surgery adjuvant chemo 3. Chemoradiation alone 4. Neoadjuvant chemoradiation and then surgery Case Presentation 4/2009‐6/2009 Patient receives neoadjuvant chemotherapy (cisplatin and capecitibine) as well as radiotherapy. Repeat PET imaging shows : 1.Decreased LN size with loss of FDG activity. 2.In the middle esophagus right below the carina, moderate FDG activity is seen associated with residual esophageal wall thickness. On previous scan, this was primary site of the cancer with intense FDG uptake and significant esophageal wall thickness. EGD: 1.UES was located at 19‐cm from insertion, and the GE junction was located at 41‐cm from insertion. 2.31‐cm from insertion there was a partially‐circumferential superficial ulcer with scar tissue. There were proximal esophageal plaques consistent with candidal esophagitis. There was no Barrett's. ‐ Stomach: normal ‐ Duodenum: normal Transhiatal Transthoracic (Ivor –Lewis) Three field (McKeown) Minimally invasive Approach / Incisions Anastamosis Transhiatal Neck Transthoracic Chest Minimally invasive Conduit Route Stomach Posterior mediastinum Colon Jejunum, Retrosternal supercharged Subcutaneous Other Case Presentation JI underwent operation 7/28/09: 1. Bronchoscopy. 2. Esophagogastroduodenoscopy. 3. Laparotomy with transthoracic esophagectomy. 4. Jejunostomy feeding tube. 5. Ligation of thoracic duct. 6. Pyloroplasty Pathology: 1) ESOPHAGUS AND STOMACH, DISTAL ESOPHAGECTOMY: LIMITED RESIDUAL SQUAMOUS CELL CARCINOMA, DISTAL ESOPHAGUS, IN SUBMUCOSA AND MUSCULARIS PROPRIA, 1.8 MM IN GREATEST EXTENT; PRESENT IN A BACKGROUND OF SEVERE MUCOSAL AND SUBMUCOSAL ULCERATION; ALL SURGICAL MARGINS WIDELY FREE OF CARCINOMA; TWO LYMPH NODES NEGATIVE FOR MALIGNANCY (0/2), (SEE COMMENT). 2) LYMPH NODES, LEVEL 7, EXCISION: 3 LYMPH NODES NEGATIVE FOR MALIGNANCY (0/3). COMMENT: These findings correspond to AJCC pathologic stage yIIA (ypT2N0M n/a). No difference in operative time, blood loss, morbidity or mortality Survival similar Anastomotic Leak rate Cervical 11% Thoracic 6% Putnam et al., Ann Thor Surg, 1994 Identified endoscopically Resection, mediastinal debridement Diversion, delayed reconstruction 50% mortality Smoking cessation Enteral nutrition in pts undergoing induction tx Epidural anesthesia Bronchopulmonary hygiene Early extubation No difference between TTE and THE • Incidence 1‐3% (TTE=THE) • Suspected with high continued CT output • Pleural triglycerides, lymphocytes, chylomicrons • Most will not close with conservative management Non‐operative stratagies NPO, TPN ±octreotide MCT diet ± octreotide IR embolization of thoracic duct Operative ligation VATS vs. open.
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