SlideShare uma empresa Scribd logo
1 de 59
Baixar para ler offline
Carcinoma Esophagus




Presented By:
Dr. Vandana
Dept. of Radiation Oncology
CSMMU, Lucknow
Clinical Anatomy
„ Hollow muscular tube 25 cm in
  length which spans from the
  cricopharyngeus at the cricoid
  cartilage to gastroesophageal
  junction (Extends from C7-T10).

„ Has 4 constrictions-
   ƒ At         starting(cricophyrangeal
     junction)
   ƒ crossed by aortic arch(9’inch)
   ƒ crossed by left bronchus(11’inch)
   ƒ Pierces the diaphragm(15’inch)

„ Histologically 4 layers:
  mucosa, submucosa, muscular &
  fibrous layer.
                                           FIGURE Anatomy of the esophagus
Contd…
Four regions of the esophagus:
„    Cervical = cricoid cartilage to
    thoracic inlet (15–18 cm from
    the incisor).
„    Upper thoracic = thoracic inlet
    to tracheal bifurcation (18–24
    cm).
„    Midthoracic = tracheal
    bifurcation to just above the GE
    junction (24–32 cm).
„    Lower thoracic = GE junction
    (32–40 cm).
                                       Figure Anatomy of the esophagus with
                                       landmarks and recorded distance from the
                                       incisors used to divide the esophagus into
                                       topographic       compartments.       GE,
                                       gastroesophageal.
Lymphatic Drainage
„   Rich mucosal and submucosal
    lymphatic system.

„   The submucosal lymphatics may
    extend long distances (proximal and
    distal margins used for RTP have
    traditionally been a minimum of 5
    cm).

„   The submucosal plexus drains into the
    regional lymph nodes in the cervical,
    mediastinal, paraesophageal, left
    gastric, and celiac axis regions




                                            Figure Lymphatic drainage of the esophagus
                                            with anatomically defined lymph node basins
Epidemiology
„   Esophageal cancer is the 7th leading cause of cancer deaths.

„   accounts for 1% of all malignancy & 6% of all GI malignancy.

„   Most common in China, Iran, South Africa, India and the former Soviet
    Union.

„   The incidence rises steadily with age, reaching a peak in the 6th to 7th
    decade of life.

„   Male : Female = 3.5 : 1

„   African-American males : White males = 5:1
Contd…

„ Worldwide SCC responsible for most of the cases.

„    Adenocarcinoma now accounts for over 50% of esophageal cancer
    in the USA, due to association with GERD , Barretts’s esophagus &
    obesity.

„ SCC usually occurs in the middle 3rd of the esophagus (the ratio of
  upper : middle : lower is 15 : 50 : 35).

„ Adenocarcinoma is most common in the lower 3rd of the esophagus,
  accounting for over 65% of cases.
Risk Factors : Squamous Cell Carcinoma

„   Smoking and alcohol (80% - 90%)
„   Dietary factors
     ƒ   N-nitroso compounds (animal carcinogens)
     ƒ   Pickled vegetables and other food-products
     ƒ   Toxin-producing fungi
     ƒ   Betel nut chewing
     ƒ   Ingestion of very hot foods and beverages (such as tea)


„   Underlying esophageal disease (such as achalasia and
    caustic strictures, Tylosis)


„ Genetic abnormalities:
     ƒ p53 mutation, loss of 3p and 9q alleli, amp. Cyclin D1 & amp.
       EGFR
Risk Factors: Adenocarcinoma

„ Associated with Barretts’s esophagus, GERD
  & hiatal hernia.
„ Obesity (3 to 4 fold risk)
„ Smoking (2 to 3 fold risk)
„ Increased esophageal acid exposure such as
  Zollinger-Ellison syndrome.



         Barrett’s esophagus is a
metaplasia of the esophageal epithelial lining. The
squamous epithelium is replaced by columnar
epithelium,with 0.5% annual rate of neoplastic
transformation.

                                    Fig. Barretts’s esophagus
Pattern of spread
„    No serosal covering, direct invasion of contiguous structures occurs early.

„    Commonly spread by lymphatics (70%)

„    Lymph node involvement increases with T stage.
      ƒ   T1 – 14 to 21%
      ƒ   T2 – 38 to 60%

„    25% - 30% hematogenous metastases at time of presentation.

„    Most common site of metastases are
      ƒ   lung, liver, pleura, bone, kidney & adrenal gland

„    Median survival with distant metastases – 6 to 12 months
Site-wise nodal involvement
Pathological Classification




                        95%
Clinical Features
„ It is commonly associated with the
  symptoms of dysphagia, wt. loss, pain,
  anorexia, and vomiting

„ Symptoms often start 3 to 4 months
  before diagnosis

„ Dysphagia - in more than 90% pt.
  Odynophagia - in 50% of pt.

„ Wt. loss – more than 5 % of total body
  wt. in 40 – 70% pt. associated with
  worst prognosis.
Contd…
Complications:
„ Cachexia, Malnutrition, dehydration, anaemia,.
„ Aspiration pneumonia.
„ Distant metastasis.
„ Invasion of near by structures: e.g.
   ƒ Recurrent laryngeal nerve → Hoarseness of voice
   ƒ Trachea → Stridor & TOF→ cough, choking &
     cyanosis
   ƒ Perforation into the pleural cavity → Empyema
   ƒ back pain in celiac axis node involvement
AJCC TNM classification




                          „   a:     Includes     nodes
                              previously   labeled     as
                              “M1a”
                          „   b : “M1a” designation is
                              no longer recognized in
                              the 7th edn. of the AJCC
                              system
Staging : Squamous cell carcinoma
Staging : Adenocarcinoma
Group       T         N     M    Grade
 0       Tis (HGD)                1, X
 IA         T1                   1-2, X
 IB         T1                     3
                     N0
            T2                   1-2, X
 IIA        T2                     3
 IIB        T3
           T1-2      N1
                            M0
IIIA       T1-2      N2
            T3       N1
           T4a       N0
                                  Any
IIIB        T3       N2
IIIC       T4a       N1-2
           T4b       Any
           Any       N3
 IV        Any       Any    M1
Diagnostic Workup
„        Detailed history & Physical examination: Dysphagia,
    odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines,
    history of GERD. Examine for cervical or supraclavicular adenopathy.
„   Confirmation of diagnosis:
    ƒ     EGD: allow direct visualization and biopsy, measure proximal & distal distance of
          tumor from incisor, presence of Barrett’s esophagus.




        Early, superficial     Circumferential ulceration          Malignant stricture
        cancer                 esophageal cancer                   of esophagus
„ Staging:
    ƒ    CT chest and abdomen: Essential for staging because it can identify extension
        beyond the esophageal wall, enlarged lymph nodes and visceral metastases.




Figure Esophageal cancer with aortic invasion. An   Figure Esophageal cancer with tracheal invasion. CT
arc (bent arrow) of the contact between the         scan shows circumferential wall thickening of the
esophageal cancer (arrows) and the aorta            proximal esophagus (arrowheads), which shows
(arrowheads) is more than 90 degrees, indicating    irregular interface with the posterior wall of the trachea
aortic invasion.                                    (arrows), indicating direct extension into the lumen
Endoscopic Ultrasonography
„   EUS:
    ƒ   assess the depth of penetration and LN involvement. Limited by the degree of
        obstruction.
    ƒ    Compared with EUS, CT is not a reliable tool for evaluation of the extent of
        tumor in the esophageal wall.




                                     Fig. —55-year-old man with T2 esophageal tumor (m)
                                     shown on endoscopic sonogram. Note alternating
                                     hyperechoic and hypoechoic layers (arrowheads) of normal
                                     esophageal wall as seen on sonography. Innermost layer is
                                     hyperechoic and corresponds to superficial mucosa. Second
                                     layer is hypoechoic and corresponds to deep mucosa and
                                     muscularis mucosae. Third layer is again hyperechoic and
                                     corresponds to submucosa and its interface with muscularis
                                     propria. Fourth layer is hypoechoic and corresponds to
                                     muscularis propria, and outer fifth layer is hyperechoic and
                                     corresponds to adventitia.
PET Scan
  „   most recently, proven to be valuable staging tool
  „   can detect up to 15–20% of metastases not seen on CT and EUS
  „   low accuracy in detecting local nodal disease compared to CT / EUS
  „   Value in evaluating response to Chemo Therapy & Radio Therapy
  „   addition of PET to CT can improve specificity and accuracy of non-
      invasive staging




Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A, Integrated CT
PET demonstrates para-aortic lymph node metastases showing increased FDG uptake (arrowheads). B,
Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in diameter. Based on size
criteria, these lymph nodes may be considered benign on CT scan
„ Barium swallow:
   ƒ can delineate proximal and distal margins as well as TEF
   ƒ Helpful for correlation with simulation film.
„ Bronchoscopy: rule-out fistula in midesophageal lesions.
„ Routine Investigations: CBC, chemistries, LFTs.




                                  Cancer lower 1/3                   Apple core appearance
    Rat tail appearance           Filling defect (ulcerative type)
Treatment
Management depends upon:

„   Site of disease
„   Extent of disease involvement
„   Co-morbid conditions
„   Patient preference.
Surgery
„ Prerequisite for surgery
    ƒ disease should be 5 cm beyond cricophyrangeus.

„ Surgery indications
    ƒ Lower 1/3 rd oesophageal ds involving GE junction.
    ƒ Tumor size <5 cm .
    ƒ palliative surgery

„ 5-Year OS for surgery alone is 20–25% (no significant difference
  between surgical techniques according to results of 2 meta-analyses)
„  Local failure rate around 19–57% when used alone

„   surgical morbidity/mortality related to experience of the surgeons.
Types of Surgery
„   Transhiatal esophagectomy: for tumors anywhere in esophagus or
    gastric cardia. No thoracotomy. Blunt dissection of the thoracic esophagus.
    Left with cervical anastomosis. Limitations are lack of exposure of
    midesophagus and direct visualization and dissection of the subcarinal LN
    cannot be performed.

„   Right thoracotomy (Ivor-Lewis procedure): good for exposure of mid
    to upper esophageal lesions. Left with thoracic or cervical anastomosis.

„   Left thoracotomy: appropriate for lower third of esophagus and gastric
    cardia. Left with low-to-midthoracic anastomosis.

„   Radical (en block) resection: for tumor anywhere in esophagus or
    gastric cardia. Left with cervical or thoracic anastomosis. Benefit is more
    extensive lymphadenectomy and potentially better survival, but increased
    operative risk.
Chemotherapy
„ No data proving that chemotherapy alone provides improved
  survival or palliation. Partial response, not long-term remission, is
  the rule


„ Indication
    ƒ   Used in combination with radiation for locally advanced cancers
    ƒ   Used as single treatment modality in stage IV disease
    ƒ   Combination chemotherapy has been used preoperatively in a combined
        modality approach to esophageal Ca in hopes of controlling occult metastatic
        disease and improving the resectability rate.
„ Platinum doublet is preferred over single agents
„ Cisplatin plus 5-FU or docetaxel are commonly used combinations

Regimens:
„ Paclitaxel and carboplatin
„ Cisplatin and 5-FU or capecitabine
„ Oxaliplatin and 5-FU or capecitabine
„ Paclitaxel or docetaxel and cisplatin
„ Carboplatin and 5-FU
„ Irinotecan and cisplatin
„ Oxaliplatin, docetaxel and capecitabine
„ Epirubicin, cisplatin and 5-FU (Only for adenocarcinoma)
Radiotherapy
„ Curative
  ƒ   Radical RT
  ƒ   Pre-Op RT
  ƒ   Post Op RT
  ƒ   Concurrent chemo-radiation
„ Palliative
„ EBRT
„ Brachytherapy
EBRT Techniques
„   Patient Positioning:
    ƒ CERVICAL ESOPHAGUS: Supine with arms by the side
    ƒ   MID AND LOWER THIRD:
        ‚   SUPINE With arms above their head if AP – PA portals are being planned
        ‚   PRONE if posterior obliques are being included.
             • Esophagus is pulled anteriorly and spinal cord can be spared.

„   IMMOBILISATION :
    ƒ   Perspex cast
    ƒ   Vertebral column should be as parallel to couch as possible.
„    Barium swallow contrast to delineate the esophageal lumen and
    stomach.
EBRT – Cervical Esophagus
Field Portals:
„ AP – PA foll. by opposed oblique pair.
„ 2 anterior obliques and 1 posterior field.
„ 2 posterior obliques and 1 anterior field
„ 4 field box with soft tissue compensators foll by obliques ( Univ of
   Florida tech )


„   SUPERIOR BORDER: At C 7
„   INFERIOR BORDER : At T 4 ( carina )
„    2 cm lateral margins.
„   SC nodes irradiated electively.
„   SC nodes will be underdosed if oblique portals are used to treat
    primary; can be boosted by a separate field if required.
EBRT – Mid & Lower1/3rd

 AP – PA followed by 1 Ant and 2 Post oblique pair
 4 FIELD : AP-PA & opposed laterals – for mid 1/3rd lesions with
  patient in prone position.
 AP-PA upto 43 Gy foll by 2 Post obliques upto 50 Gy ( gross disease
  boosted to 60 Gy )



„   SUPERIOR BORDER: 5 cm proximal to superior extent of disease.
„   INFERIOR BORDER:
    ƒ MID 1/3RD – AT GE jn. As visualised by Barium swallow
    ƒ LOWER 1/3RD - Coeliac plexus ( L 1 ) to be included.
Radiotherapy for
 CA esophagus
EBRT - DOSES
„ Energy
    ƒ   6 – 10 MV linac or Co60


„ Chemoradiation:
    ƒ 50.4 Gy in 28 # at 1.8 Gy per #
    ƒ Boost to 60 – 66 Gy for residual disease


„   Radical RT:
    ƒ   45 Gy / 25 # / 1.8 Gy per #
    ƒ   boost with 2 cm margin to total dose of 60Gy

„ Dose limitations
    ƒ Spinal cord Dmax:45 Gy at 1.8 Gy/fx
    ƒ Lung: Limit 70% of both lungs <20 Gy
    ƒ Heart: Limit 50% of ventricles <25 Gy
Brachytherapy (Intraluminal)

„ As a boost after EBRT or as a palliative measure
„ Local control of 25% - 35 in palliative setting
„ In curative setting, addition of brachytherapy does not improve
  results compared to Chemoradiation.
„ Limit dose to critical structure
„ Dose escalation to primary
„ Relief bleeding, pain and improves swallowing status in palliative
  setting.
American Brachytherapy Society Guidelines

Patient selection:
   ƒ    Primary tumor length ≤ 10 cm length
   ƒ    Tumor confined to esophageal wall
   ƒ    Thoracic esophagus location
   ƒ    No nodal / systemic metastasis.

Contraindications:
   ƒ    T E fistula
   ƒ    Cervical esophagous location
   ƒ    Stenosis which cannot be bypassed
Contd…


„   EBRT 45 – 50 Gy in 1.8-2.0Gy /#,5#/wk
         ‚   HDR – 5 Gy x two # one week apart , 2 – 3weeks after EBRT.
         ‚   LDR – single 20 Gy # @ 0.4 – 1.0 Gy per hr, 2 -3 weeks after EBRT.
„   Never concurrently with chemotherapy
„   Ext diameter of applicator must be 6 – 10 mm.
„    Active length : visible tumor by UGI scopy plus 1 – 2 cm proximal &
    distal margin.
„ Dose is prescribed 1 cm from mid source or mid dwell position.
APPLICATORS
Carcinoma oesophagus
Trials – RT alone
„   No randomized trials of RT Vs Sx
„   5 yr survival with conventional RT : < 10%
„   Tumors < 5 cm , 5 yr survival : 20%
„   Stage wise 5 yr survival:
    ƒ   Stage   I – 20%
    ƒ   Stage   II – 10%
    ƒ   Stage   III – 3 %
    ƒ   Stage   IV – 0%
Contd…

„ For cervical esophagus, cure rates were similar with Radical RT or
  Sx alone.

„ RT or Sx alone DOES NOT alter the natural history of the disease.

„ RTOG 8501: RT Vs Chemo RT
    ƒ Better LRC and improved OS with ChemoRT

 RT alone should be used for palliation or in medically unfit patients.
Trials– PreOP RT
„ Principle:

    ƒ  ↑ resectability, ↓ likelihood of tumor dissemination during Sx ,
      ↑ radioresponsiveness due to unaltered blood supply
    ƒ 5 randomised trials ,shows no apparent clinical benefit to use
      of preop rt alone except,
    ƒ Only one trial ( Huang et al ) showed survival advantage of
      46% Vs 25% with 40 Gy RT
    ƒ Recent meta analysis Oesophageal Cancer Collaborative Group
      study showed no clear survival advantage.

 No difference in resectability rates, LRC or survival with pre-op RT
Trials– PostOP RT
„ Advantages:
  ƒ  Treat areas at risk for recurrences while minimizing
    dose to OAR.
  ƒ Patients with node negative , completely resected T1
    / T2 tumors can be excluded.


„ Disadvantage:
  ƒ Tolerance of stomach        or   bowel    used    for
    interpositioning.
Contd…

„    2 randomised trials:
     ƒ Peniere et al :-
         ‚   221 pts, mid / low 1/3rd growth
         ‚   RT : 45- 55 Gy @ 1.8 Gy per #
         ‚   3 yrs -  local failure rate ( from 35% to 10%)
                     - no significant disease free survival.
     ƒ Fok et al :-
         ‚   130 pts , RT – 49 Gy @ 3.5 Gy per #
         ‚   Local failure rate  in patients who had palliative resection
             ( from 46% to 20% )
         ‚   No difference for completely resected patients

 Post op RT improves local control, but does not confer any survival
    advantage.
Trials– Chemoradiation

                      ChemoRT Vs RT Alone
„ RTOG 8501 INTERGROUP TRIAL:
   ƒ 121 pts: 60 pts RT alone – 64 Gy @ 2 Gy per #
         61 pts chemoRT – 50 Gy RT +
         5 FU + CDDP – on 1 , 5 , 8 & 11 weeks
   ƒ   Median survival : 8.9 Vs 12.5 months
   ƒ   5 yr survival : 0% Vs 30 %
   ƒ   Distant mets @ 5 yrs: 40% Vs 12 %
   ƒ   Acute toxicity : 25% Vs 44 %
„  Median & overall survival, LRR and Acute toxicity in Chemo RT
  arm.

 Chemoradiation is a standard Non-surgical Tx.
Contd…


             RT dose escalation in Chemo RT
„   Intergroup 0123 TRIAL – 218 pts
    ƒ Chemoradiation - either 50.4 Gy or 64.8 Gy
    ƒ No significant difference in median survival, 2 yr survival or loco-
      regional failure.


 Intensification of RT dose beyond 50.4 Gy(in combination with
    chemotherapy ) does not improve results.
Contd…

               PRE OP CHEMO RT Vs Sx ALONE
„ 44 Randomised trials
„ 2 studies showed  in local recurrence
   ƒ Urba et al – 19 % Vs 42 %
   ƒ Bosset et al ( EORTC ) – 28% Vs 40%

„ One study showed significant survival benefit at 3 yrs (in pts who had
  a pathologic CR )
   ƒ Urba et al – 64% Vs 19%

„ One study (Walsh et al) showed benefit in median (16 Vs 11 months )
  and overall survival at 3 yrs ( 32 Vs 6%)

 Results support TRIMODALITY approach.
Pre-operative Chemotherapy


                     The role of preoperative
                     chemotherapy      alone     is
                     controversial, according to
                     mixed results from clinical
                     trials.
Stage                                Recommended treatment
Stage I–III and IVA      definitive chemo-RT (preferred for cervical esophagus)
resectable
medically-fit
                         Or, Pre-op chemo-RT → surgery. Surgery preferred for adenocarcinoma
                         regardless of response to chemo-RT.
                         Or, surgery. (noncervical T1N0 and young T2N0 patients with primaries
                         of lower esophagus or gastroesophageal junction.
                         Indications for post-op chemo-RT include: unfavorable T2N0, T3/4,
                         LN+, and/or close/+ margin.
Stage I–III inoperable   Definitive chemo-RT
Stage IV palliative      Concurrent chemo-RT (5-FU + cisplatin, 50 Gy) or RT alone (e.g., 2.5
                         Gy × 14 fx) or chemo alone or best supportive care.
                         Pain: medications ± RT
                         Bleeding: endoscopic therapy, surgery, or RT
Current approach

„   EBRT using 3D-CRT to a total dose of 50.4 Gy (1.8 Gy per daily fraction) is
    standard.
„   IMRT is often utilized to minimize exposure to adjacent structures.
„   Proton beam in combination with chemotherapy is being explored.
„   Targeted biologic agents added to standard cytotoxic chemotherapy is
    being explored
Conclusion
„    Esophageal cancer is the 7th leading cause of cancer deaths.

„    Adenocarcinoma now accounts for over 50% of esophageal cancer in the
     USA, due to association with GERD & obesity.

„    Dysphagia and weight loss are the two most common presentations in
     patients with esophageal cancer.

„     Endoscopic ultrasound (EUS) is necessary to accompany a complete workup
     for proper staging and diagnosis of esophageal cancer.

„    Surgery is the standard of care for early-stage esophageal cancer.

„    Preoperative chemotherapy and radiation is the standard option for locally
     advanced esophageal cancer in surgically eligible patients.
Thank You
Carcinoma oesophagus
Carcinoma oesophagus
Carcinoma oesophagus
Carcinoma oesophagus
Carcinoma oesophagus
Carcinoma oesophagus
ChemoRT followed Sx Vs.ChemoRT

                      „   Patient undergoing surgery
                          have worse quality of life.

                      „   Surgery following combined
                          CRT appears to improve
                          local control, its impact on
                          ultimate survival remains
                          controversial.
Figure:    A     proposed    treatment
algorithm for esophageal cancer.

Mais conteúdo relacionado

Mais procurados (20)

Ca rectum
Ca rectumCa rectum
Ca rectum
 
Carcinoma gall bladder
Carcinoma gall bladderCarcinoma gall bladder
Carcinoma gall bladder
 
testicular tumors
testicular tumorstesticular tumors
testicular tumors
 
Colorectal cancer
Colorectal  cancerColorectal  cancer
Colorectal cancer
 
Management of Rectal Cancer
Management of Rectal CancerManagement of Rectal Cancer
Management of Rectal Cancer
 
Liver abscess
Liver abscessLiver abscess
Liver abscess
 
Colorectal cancer
Colorectal cancerColorectal cancer
Colorectal cancer
 
Bladder carcinoma
Bladder carcinomaBladder carcinoma
Bladder carcinoma
 
carcinoma of stomach
 carcinoma of  stomach carcinoma of  stomach
carcinoma of stomach
 
Colorectal carcinoma anatomy to management
Colorectal carcinoma  anatomy to managementColorectal carcinoma  anatomy to management
Colorectal carcinoma anatomy to management
 
Pancreatic carcinoma
Pancreatic carcinomaPancreatic carcinoma
Pancreatic carcinoma
 
Prostate cancer
Prostate cancerProstate cancer
Prostate cancer
 
Carcinoma Of Thyroid Gland
Carcinoma Of Thyroid GlandCarcinoma Of Thyroid Gland
Carcinoma Of Thyroid Gland
 
Cholangiocarcinoma
CholangiocarcinomaCholangiocarcinoma
Cholangiocarcinoma
 
Gastric Cancer PPT
Gastric Cancer PPTGastric Cancer PPT
Gastric Cancer PPT
 
Anal cancer ppt
Anal cancer pptAnal cancer ppt
Anal cancer ppt
 
CARCINOMA PENIS
CARCINOMA PENISCARCINOMA PENIS
CARCINOMA PENIS
 
Acute appendicitis
Acute appendicitisAcute appendicitis
Acute appendicitis
 
Gastrointestinal stromal tumours
Gastrointestinal stromal tumoursGastrointestinal stromal tumours
Gastrointestinal stromal tumours
 
Colorectal Cancer
Colorectal CancerColorectal Cancer
Colorectal Cancer
 

Semelhante a Carcinoma oesophagus

esophageal cancer staging.pptx
esophageal cancer staging.pptxesophageal cancer staging.pptx
esophageal cancer staging.pptxDrRohan NU
 
Carcinoma Esophagus new.pptx
Carcinoma Esophagus new.pptxCarcinoma Esophagus new.pptx
Carcinoma Esophagus new.pptxAdithi Rao
 
Presentation1, radiological imaging of anal carcinoma.
Presentation1, radiological imaging of anal carcinoma.Presentation1, radiological imaging of anal carcinoma.
Presentation1, radiological imaging of anal carcinoma.Abdellah Nazeer
 
Cancer of the esophagus
Cancer of the esophagusCancer of the esophagus
Cancer of the esophaguskrisshk1989
 
Carcinoma oesophagus
Carcinoma oesophagus Carcinoma oesophagus
Carcinoma oesophagus Silah Aysha
 
Gall Bladder Carcinoma
Gall Bladder CarcinomaGall Bladder Carcinoma
Gall Bladder CarcinomaDr.Mohsin Khan
 
Carcinoma stomach seminar
Carcinoma stomach seminarCarcinoma stomach seminar
Carcinoma stomach seminarRushabh Shah
 
Carcinoma rectum-radiotherapy perspective
 Carcinoma rectum-radiotherapy perspective Carcinoma rectum-radiotherapy perspective
Carcinoma rectum-radiotherapy perspectiveParneet Singh
 
gastriccancer-160428190410.pptx
gastriccancer-160428190410.pptxgastriccancer-160428190410.pptx
gastriccancer-160428190410.pptxPranaviShewale
 
Surgical persrective in lung cancer
Surgical persrective in lung cancerSurgical persrective in lung cancer
Surgical persrective in lung cancerHarilal Nambiar
 
Cancer of the anal canal
Cancer of the anal canalCancer of the anal canal
Cancer of the anal canalNilesh Kucha
 
Carcinomarectum 111113085726-phpapp01
Carcinomarectum 111113085726-phpapp01Carcinomarectum 111113085726-phpapp01
Carcinomarectum 111113085726-phpapp01Drrajan Paliwal
 
Management of anal canal tumors with emphasis on treatment(1)
Management of  anal canal tumors with emphasis on treatment(1)Management of  anal canal tumors with emphasis on treatment(1)
Management of anal canal tumors with emphasis on treatment(1)SabaMajid5
 

Semelhante a Carcinoma oesophagus (20)

Oesophageal carcinoma
Oesophageal carcinomaOesophageal carcinoma
Oesophageal carcinoma
 
esophageal cancer staging.pptx
esophageal cancer staging.pptxesophageal cancer staging.pptx
esophageal cancer staging.pptx
 
Carcinoma Esophagus new.pptx
Carcinoma Esophagus new.pptxCarcinoma Esophagus new.pptx
Carcinoma Esophagus new.pptx
 
Esophageal cancer
Esophageal cancerEsophageal cancer
Esophageal cancer
 
Esopageal cancer ,
Esopageal cancer ,Esopageal cancer ,
Esopageal cancer ,
 
Presentation1, radiological imaging of anal carcinoma.
Presentation1, radiological imaging of anal carcinoma.Presentation1, radiological imaging of anal carcinoma.
Presentation1, radiological imaging of anal carcinoma.
 
Cancer of the esophagus
Cancer of the esophagusCancer of the esophagus
Cancer of the esophagus
 
Carcinoma oesophagus
Carcinoma oesophagus Carcinoma oesophagus
Carcinoma oesophagus
 
Ca esophagus 12th
Ca esophagus 12thCa esophagus 12th
Ca esophagus 12th
 
Cancergastritis200810
Cancergastritis200810Cancergastritis200810
Cancergastritis200810
 
Gall Bladder Carcinoma
Gall Bladder CarcinomaGall Bladder Carcinoma
Gall Bladder Carcinoma
 
Carcinoma stomach seminar
Carcinoma stomach seminarCarcinoma stomach seminar
Carcinoma stomach seminar
 
Carcinoma rectum-radiotherapy perspective
 Carcinoma rectum-radiotherapy perspective Carcinoma rectum-radiotherapy perspective
Carcinoma rectum-radiotherapy perspective
 
gastriccancer-160428190410.pptx
gastriccancer-160428190410.pptxgastriccancer-160428190410.pptx
gastriccancer-160428190410.pptx
 
Surgical persrective in lung cancer
Surgical persrective in lung cancerSurgical persrective in lung cancer
Surgical persrective in lung cancer
 
Cancer of the anal canal
Cancer of the anal canalCancer of the anal canal
Cancer of the anal canal
 
Rectal cancer
Rectal cancerRectal cancer
Rectal cancer
 
Carcinomarectum 111113085726-phpapp01
Carcinomarectum 111113085726-phpapp01Carcinomarectum 111113085726-phpapp01
Carcinomarectum 111113085726-phpapp01
 
Management of anal canal tumors with emphasis on treatment(1)
Management of  anal canal tumors with emphasis on treatment(1)Management of  anal canal tumors with emphasis on treatment(1)
Management of anal canal tumors with emphasis on treatment(1)
 
CT Imaging of CA Esophagus
CT Imaging of CA EsophagusCT Imaging of CA Esophagus
CT Imaging of CA Esophagus
 

Mais de Dr Vandana Singh Kushwaha

Mais de Dr Vandana Singh Kushwaha (9)

Cell survival curve
Cell survival curveCell survival curve
Cell survival curve
 
Ewings sarcoma - Dr. Vandana
Ewings sarcoma - Dr. VandanaEwings sarcoma - Dr. Vandana
Ewings sarcoma - Dr. Vandana
 
Part ii management of testicular carcinoma - dr vandana
Part ii   management of testicular carcinoma - dr vandanaPart ii   management of testicular carcinoma - dr vandana
Part ii management of testicular carcinoma - dr vandana
 
Part 1 management of testicular carcinoma - dr vandana
Part 1  management of testicular carcinoma - dr vandanaPart 1  management of testicular carcinoma - dr vandana
Part 1 management of testicular carcinoma - dr vandana
 
Retinoblastoma dr vandana
Retinoblastoma dr vandanaRetinoblastoma dr vandana
Retinoblastoma dr vandana
 
Diagnosis, Treatment & Management of Medulloblastoma
Diagnosis, Treatment & Management of Medulloblastoma Diagnosis, Treatment & Management of Medulloblastoma
Diagnosis, Treatment & Management of Medulloblastoma
 
Renal Tumors, Renal Cell Carcinoma- Dr. Vandana
Renal Tumors, Renal Cell Carcinoma-  Dr. VandanaRenal Tumors, Renal Cell Carcinoma-  Dr. Vandana
Renal Tumors, Renal Cell Carcinoma- Dr. Vandana
 
LET, RBE & OER - dr vandana
LET, RBE & OER - dr vandanaLET, RBE & OER - dr vandana
LET, RBE & OER - dr vandana
 
Interaction of radiation with Matter - Dr. Vandana
Interaction of radiation with Matter -  Dr. VandanaInteraction of radiation with Matter -  Dr. Vandana
Interaction of radiation with Matter - Dr. Vandana
 

Último

Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...bkling
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)Mohamed Rizk Khodair
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingAnonymous
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
World-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxWorld-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxsumanchaulagain3
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 

Último (20)

Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_Wellbeing
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
World-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxWorld-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptx
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 

Carcinoma oesophagus

  • 1. Carcinoma Esophagus Presented By: Dr. Vandana Dept. of Radiation Oncology CSMMU, Lucknow
  • 2. Clinical Anatomy „ Hollow muscular tube 25 cm in length which spans from the cricopharyngeus at the cricoid cartilage to gastroesophageal junction (Extends from C7-T10). „ Has 4 constrictions- ƒ At starting(cricophyrangeal junction) ƒ crossed by aortic arch(9’inch) ƒ crossed by left bronchus(11’inch) ƒ Pierces the diaphragm(15’inch) „ Histologically 4 layers: mucosa, submucosa, muscular & fibrous layer. FIGURE Anatomy of the esophagus
  • 3. Contd… Four regions of the esophagus: „ Cervical = cricoid cartilage to thoracic inlet (15–18 cm from the incisor). „ Upper thoracic = thoracic inlet to tracheal bifurcation (18–24 cm). „ Midthoracic = tracheal bifurcation to just above the GE junction (24–32 cm). „ Lower thoracic = GE junction (32–40 cm). Figure Anatomy of the esophagus with landmarks and recorded distance from the incisors used to divide the esophagus into topographic compartments. GE, gastroesophageal.
  • 4. Lymphatic Drainage „ Rich mucosal and submucosal lymphatic system. „ The submucosal lymphatics may extend long distances (proximal and distal margins used for RTP have traditionally been a minimum of 5 cm). „ The submucosal plexus drains into the regional lymph nodes in the cervical, mediastinal, paraesophageal, left gastric, and celiac axis regions Figure Lymphatic drainage of the esophagus with anatomically defined lymph node basins
  • 5. Epidemiology „ Esophageal cancer is the 7th leading cause of cancer deaths. „ accounts for 1% of all malignancy & 6% of all GI malignancy. „ Most common in China, Iran, South Africa, India and the former Soviet Union. „ The incidence rises steadily with age, reaching a peak in the 6th to 7th decade of life. „ Male : Female = 3.5 : 1 „ African-American males : White males = 5:1
  • 6. Contd… „ Worldwide SCC responsible for most of the cases. „ Adenocarcinoma now accounts for over 50% of esophageal cancer in the USA, due to association with GERD , Barretts’s esophagus & obesity. „ SCC usually occurs in the middle 3rd of the esophagus (the ratio of upper : middle : lower is 15 : 50 : 35). „ Adenocarcinoma is most common in the lower 3rd of the esophagus, accounting for over 65% of cases.
  • 7. Risk Factors : Squamous Cell Carcinoma „ Smoking and alcohol (80% - 90%) „ Dietary factors ƒ N-nitroso compounds (animal carcinogens) ƒ Pickled vegetables and other food-products ƒ Toxin-producing fungi ƒ Betel nut chewing ƒ Ingestion of very hot foods and beverages (such as tea) „ Underlying esophageal disease (such as achalasia and caustic strictures, Tylosis) „ Genetic abnormalities: ƒ p53 mutation, loss of 3p and 9q alleli, amp. Cyclin D1 & amp. EGFR
  • 8. Risk Factors: Adenocarcinoma „ Associated with Barretts’s esophagus, GERD & hiatal hernia. „ Obesity (3 to 4 fold risk) „ Smoking (2 to 3 fold risk) „ Increased esophageal acid exposure such as Zollinger-Ellison syndrome. Barrett’s esophagus is a metaplasia of the esophageal epithelial lining. The squamous epithelium is replaced by columnar epithelium,with 0.5% annual rate of neoplastic transformation. Fig. Barretts’s esophagus
  • 9. Pattern of spread „ No serosal covering, direct invasion of contiguous structures occurs early. „ Commonly spread by lymphatics (70%) „ Lymph node involvement increases with T stage. ƒ T1 – 14 to 21% ƒ T2 – 38 to 60% „ 25% - 30% hematogenous metastases at time of presentation. „ Most common site of metastases are ƒ lung, liver, pleura, bone, kidney & adrenal gland „ Median survival with distant metastases – 6 to 12 months
  • 12. Clinical Features „ It is commonly associated with the symptoms of dysphagia, wt. loss, pain, anorexia, and vomiting „ Symptoms often start 3 to 4 months before diagnosis „ Dysphagia - in more than 90% pt. Odynophagia - in 50% of pt. „ Wt. loss – more than 5 % of total body wt. in 40 – 70% pt. associated with worst prognosis.
  • 13. Contd… Complications: „ Cachexia, Malnutrition, dehydration, anaemia,. „ Aspiration pneumonia. „ Distant metastasis. „ Invasion of near by structures: e.g. ƒ Recurrent laryngeal nerve → Hoarseness of voice ƒ Trachea → Stridor & TOF→ cough, choking & cyanosis ƒ Perforation into the pleural cavity → Empyema ƒ back pain in celiac axis node involvement
  • 14. AJCC TNM classification „ a: Includes nodes previously labeled as “M1a” „ b : “M1a” designation is no longer recognized in the 7th edn. of the AJCC system
  • 15. Staging : Squamous cell carcinoma
  • 16. Staging : Adenocarcinoma Group T N M Grade 0 Tis (HGD) 1, X IA T1 1-2, X IB T1 3 N0 T2 1-2, X IIA T2 3 IIB T3 T1-2 N1 M0 IIIA T1-2 N2 T3 N1 T4a N0 Any IIIB T3 N2 IIIC T4a N1-2 T4b Any Any N3 IV Any Any M1
  • 17. Diagnostic Workup „ Detailed history & Physical examination: Dysphagia, odynophagia, hoarseness, wt. loss, use of tobacco, nitrosamines, history of GERD. Examine for cervical or supraclavicular adenopathy. „ Confirmation of diagnosis: ƒ EGD: allow direct visualization and biopsy, measure proximal & distal distance of tumor from incisor, presence of Barrett’s esophagus. Early, superficial Circumferential ulceration Malignant stricture cancer esophageal cancer of esophagus
  • 18. „ Staging: ƒ CT chest and abdomen: Essential for staging because it can identify extension beyond the esophageal wall, enlarged lymph nodes and visceral metastases. Figure Esophageal cancer with aortic invasion. An Figure Esophageal cancer with tracheal invasion. CT arc (bent arrow) of the contact between the scan shows circumferential wall thickening of the esophageal cancer (arrows) and the aorta proximal esophagus (arrowheads), which shows (arrowheads) is more than 90 degrees, indicating irregular interface with the posterior wall of the trachea aortic invasion. (arrows), indicating direct extension into the lumen
  • 19. Endoscopic Ultrasonography „ EUS: ƒ assess the depth of penetration and LN involvement. Limited by the degree of obstruction. ƒ Compared with EUS, CT is not a reliable tool for evaluation of the extent of tumor in the esophageal wall. Fig. —55-year-old man with T2 esophageal tumor (m) shown on endoscopic sonogram. Note alternating hyperechoic and hypoechoic layers (arrowheads) of normal esophageal wall as seen on sonography. Innermost layer is hyperechoic and corresponds to superficial mucosa. Second layer is hypoechoic and corresponds to deep mucosa and muscularis mucosae. Third layer is again hyperechoic and corresponds to submucosa and its interface with muscularis propria. Fourth layer is hypoechoic and corresponds to muscularis propria, and outer fifth layer is hyperechoic and corresponds to adventitia.
  • 20. PET Scan „ most recently, proven to be valuable staging tool „ can detect up to 15–20% of metastases not seen on CT and EUS „ low accuracy in detecting local nodal disease compared to CT / EUS „ Value in evaluating response to Chemo Therapy & Radio Therapy „ addition of PET to CT can improve specificity and accuracy of non- invasive staging Figure Distant lymph node metastases of esophageal cancer detected by integrated CT PET. A, Integrated CT PET demonstrates para-aortic lymph node metastases showing increased FDG uptake (arrowheads). B, Corresponding CT image shows lymph nodes (arrowheads) measuring 5 to 8 mm in diameter. Based on size criteria, these lymph nodes may be considered benign on CT scan
  • 21. „ Barium swallow: ƒ can delineate proximal and distal margins as well as TEF ƒ Helpful for correlation with simulation film. „ Bronchoscopy: rule-out fistula in midesophageal lesions. „ Routine Investigations: CBC, chemistries, LFTs. Cancer lower 1/3 Apple core appearance Rat tail appearance Filling defect (ulcerative type)
  • 23. Management depends upon: „ Site of disease „ Extent of disease involvement „ Co-morbid conditions „ Patient preference.
  • 24. Surgery „ Prerequisite for surgery ƒ disease should be 5 cm beyond cricophyrangeus. „ Surgery indications ƒ Lower 1/3 rd oesophageal ds involving GE junction. ƒ Tumor size <5 cm . ƒ palliative surgery „ 5-Year OS for surgery alone is 20–25% (no significant difference between surgical techniques according to results of 2 meta-analyses) „ Local failure rate around 19–57% when used alone „ surgical morbidity/mortality related to experience of the surgeons.
  • 25. Types of Surgery „ Transhiatal esophagectomy: for tumors anywhere in esophagus or gastric cardia. No thoracotomy. Blunt dissection of the thoracic esophagus. Left with cervical anastomosis. Limitations are lack of exposure of midesophagus and direct visualization and dissection of the subcarinal LN cannot be performed. „ Right thoracotomy (Ivor-Lewis procedure): good for exposure of mid to upper esophageal lesions. Left with thoracic or cervical anastomosis. „ Left thoracotomy: appropriate for lower third of esophagus and gastric cardia. Left with low-to-midthoracic anastomosis. „ Radical (en block) resection: for tumor anywhere in esophagus or gastric cardia. Left with cervical or thoracic anastomosis. Benefit is more extensive lymphadenectomy and potentially better survival, but increased operative risk.
  • 26. Chemotherapy „ No data proving that chemotherapy alone provides improved survival or palliation. Partial response, not long-term remission, is the rule „ Indication ƒ Used in combination with radiation for locally advanced cancers ƒ Used as single treatment modality in stage IV disease ƒ Combination chemotherapy has been used preoperatively in a combined modality approach to esophageal Ca in hopes of controlling occult metastatic disease and improving the resectability rate.
  • 27. „ Platinum doublet is preferred over single agents „ Cisplatin plus 5-FU or docetaxel are commonly used combinations Regimens: „ Paclitaxel and carboplatin „ Cisplatin and 5-FU or capecitabine „ Oxaliplatin and 5-FU or capecitabine „ Paclitaxel or docetaxel and cisplatin „ Carboplatin and 5-FU „ Irinotecan and cisplatin „ Oxaliplatin, docetaxel and capecitabine „ Epirubicin, cisplatin and 5-FU (Only for adenocarcinoma)
  • 28. Radiotherapy „ Curative ƒ Radical RT ƒ Pre-Op RT ƒ Post Op RT ƒ Concurrent chemo-radiation „ Palliative „ EBRT „ Brachytherapy
  • 29. EBRT Techniques „ Patient Positioning: ƒ CERVICAL ESOPHAGUS: Supine with arms by the side ƒ MID AND LOWER THIRD: ‚ SUPINE With arms above their head if AP – PA portals are being planned ‚ PRONE if posterior obliques are being included. • Esophagus is pulled anteriorly and spinal cord can be spared. „ IMMOBILISATION : ƒ Perspex cast ƒ Vertebral column should be as parallel to couch as possible. „ Barium swallow contrast to delineate the esophageal lumen and stomach.
  • 30. EBRT – Cervical Esophagus Field Portals: „ AP – PA foll. by opposed oblique pair. „ 2 anterior obliques and 1 posterior field. „ 2 posterior obliques and 1 anterior field „ 4 field box with soft tissue compensators foll by obliques ( Univ of Florida tech ) „ SUPERIOR BORDER: At C 7 „ INFERIOR BORDER : At T 4 ( carina ) „ 2 cm lateral margins. „ SC nodes irradiated electively. „ SC nodes will be underdosed if oblique portals are used to treat primary; can be boosted by a separate field if required.
  • 31. EBRT – Mid & Lower1/3rd  AP – PA followed by 1 Ant and 2 Post oblique pair  4 FIELD : AP-PA & opposed laterals – for mid 1/3rd lesions with patient in prone position.  AP-PA upto 43 Gy foll by 2 Post obliques upto 50 Gy ( gross disease boosted to 60 Gy ) „ SUPERIOR BORDER: 5 cm proximal to superior extent of disease. „ INFERIOR BORDER: ƒ MID 1/3RD – AT GE jn. As visualised by Barium swallow ƒ LOWER 1/3RD - Coeliac plexus ( L 1 ) to be included.
  • 32. Radiotherapy for CA esophagus
  • 33. EBRT - DOSES „ Energy ƒ 6 – 10 MV linac or Co60 „ Chemoradiation: ƒ 50.4 Gy in 28 # at 1.8 Gy per # ƒ Boost to 60 – 66 Gy for residual disease „ Radical RT: ƒ 45 Gy / 25 # / 1.8 Gy per # ƒ boost with 2 cm margin to total dose of 60Gy „ Dose limitations ƒ Spinal cord Dmax:45 Gy at 1.8 Gy/fx ƒ Lung: Limit 70% of both lungs <20 Gy ƒ Heart: Limit 50% of ventricles <25 Gy
  • 34. Brachytherapy (Intraluminal) „ As a boost after EBRT or as a palliative measure „ Local control of 25% - 35 in palliative setting „ In curative setting, addition of brachytherapy does not improve results compared to Chemoradiation. „ Limit dose to critical structure „ Dose escalation to primary „ Relief bleeding, pain and improves swallowing status in palliative setting.
  • 35. American Brachytherapy Society Guidelines Patient selection: ƒ Primary tumor length ≤ 10 cm length ƒ Tumor confined to esophageal wall ƒ Thoracic esophagus location ƒ No nodal / systemic metastasis. Contraindications: ƒ T E fistula ƒ Cervical esophagous location ƒ Stenosis which cannot be bypassed
  • 36. Contd… „ EBRT 45 – 50 Gy in 1.8-2.0Gy /#,5#/wk ‚ HDR – 5 Gy x two # one week apart , 2 – 3weeks after EBRT. ‚ LDR – single 20 Gy # @ 0.4 – 1.0 Gy per hr, 2 -3 weeks after EBRT. „ Never concurrently with chemotherapy „ Ext diameter of applicator must be 6 – 10 mm. „ Active length : visible tumor by UGI scopy plus 1 – 2 cm proximal & distal margin. „ Dose is prescribed 1 cm from mid source or mid dwell position.
  • 39. Trials – RT alone „ No randomized trials of RT Vs Sx „ 5 yr survival with conventional RT : < 10% „ Tumors < 5 cm , 5 yr survival : 20% „ Stage wise 5 yr survival: ƒ Stage I – 20% ƒ Stage II – 10% ƒ Stage III – 3 % ƒ Stage IV – 0%
  • 40. Contd… „ For cervical esophagus, cure rates were similar with Radical RT or Sx alone. „ RT or Sx alone DOES NOT alter the natural history of the disease. „ RTOG 8501: RT Vs Chemo RT ƒ Better LRC and improved OS with ChemoRT  RT alone should be used for palliation or in medically unfit patients.
  • 41. Trials– PreOP RT „ Principle: ƒ ↑ resectability, ↓ likelihood of tumor dissemination during Sx , ↑ radioresponsiveness due to unaltered blood supply ƒ 5 randomised trials ,shows no apparent clinical benefit to use of preop rt alone except, ƒ Only one trial ( Huang et al ) showed survival advantage of 46% Vs 25% with 40 Gy RT ƒ Recent meta analysis Oesophageal Cancer Collaborative Group study showed no clear survival advantage.  No difference in resectability rates, LRC or survival with pre-op RT
  • 42. Trials– PostOP RT „ Advantages: ƒ Treat areas at risk for recurrences while minimizing dose to OAR. ƒ Patients with node negative , completely resected T1 / T2 tumors can be excluded. „ Disadvantage: ƒ Tolerance of stomach or bowel used for interpositioning.
  • 43. Contd… „ 2 randomised trials: ƒ Peniere et al :- ‚ 221 pts, mid / low 1/3rd growth ‚ RT : 45- 55 Gy @ 1.8 Gy per # ‚ 3 yrs -  local failure rate ( from 35% to 10%) - no significant disease free survival. ƒ Fok et al :- ‚ 130 pts , RT – 49 Gy @ 3.5 Gy per # ‚ Local failure rate  in patients who had palliative resection ( from 46% to 20% ) ‚ No difference for completely resected patients  Post op RT improves local control, but does not confer any survival advantage.
  • 44. Trials– Chemoradiation ChemoRT Vs RT Alone „ RTOG 8501 INTERGROUP TRIAL: ƒ 121 pts: 60 pts RT alone – 64 Gy @ 2 Gy per # 61 pts chemoRT – 50 Gy RT + 5 FU + CDDP – on 1 , 5 , 8 & 11 weeks ƒ Median survival : 8.9 Vs 12.5 months ƒ 5 yr survival : 0% Vs 30 % ƒ Distant mets @ 5 yrs: 40% Vs 12 % ƒ Acute toxicity : 25% Vs 44 % „  Median & overall survival, LRR and Acute toxicity in Chemo RT arm.  Chemoradiation is a standard Non-surgical Tx.
  • 45. Contd… RT dose escalation in Chemo RT „ Intergroup 0123 TRIAL – 218 pts ƒ Chemoradiation - either 50.4 Gy or 64.8 Gy ƒ No significant difference in median survival, 2 yr survival or loco- regional failure.  Intensification of RT dose beyond 50.4 Gy(in combination with chemotherapy ) does not improve results.
  • 46. Contd… PRE OP CHEMO RT Vs Sx ALONE „ 44 Randomised trials „ 2 studies showed  in local recurrence ƒ Urba et al – 19 % Vs 42 % ƒ Bosset et al ( EORTC ) – 28% Vs 40% „ One study showed significant survival benefit at 3 yrs (in pts who had a pathologic CR ) ƒ Urba et al – 64% Vs 19% „ One study (Walsh et al) showed benefit in median (16 Vs 11 months ) and overall survival at 3 yrs ( 32 Vs 6%)  Results support TRIMODALITY approach.
  • 47. Pre-operative Chemotherapy The role of preoperative chemotherapy alone is controversial, according to mixed results from clinical trials.
  • 48. Stage Recommended treatment Stage I–III and IVA definitive chemo-RT (preferred for cervical esophagus) resectable medically-fit Or, Pre-op chemo-RT → surgery. Surgery preferred for adenocarcinoma regardless of response to chemo-RT. Or, surgery. (noncervical T1N0 and young T2N0 patients with primaries of lower esophagus or gastroesophageal junction. Indications for post-op chemo-RT include: unfavorable T2N0, T3/4, LN+, and/or close/+ margin. Stage I–III inoperable Definitive chemo-RT Stage IV palliative Concurrent chemo-RT (5-FU + cisplatin, 50 Gy) or RT alone (e.g., 2.5 Gy × 14 fx) or chemo alone or best supportive care. Pain: medications ± RT Bleeding: endoscopic therapy, surgery, or RT
  • 49. Current approach „ EBRT using 3D-CRT to a total dose of 50.4 Gy (1.8 Gy per daily fraction) is standard. „ IMRT is often utilized to minimize exposure to adjacent structures. „ Proton beam in combination with chemotherapy is being explored. „ Targeted biologic agents added to standard cytotoxic chemotherapy is being explored
  • 50. Conclusion „ Esophageal cancer is the 7th leading cause of cancer deaths. „ Adenocarcinoma now accounts for over 50% of esophageal cancer in the USA, due to association with GERD & obesity. „ Dysphagia and weight loss are the two most common presentations in patients with esophageal cancer. „ Endoscopic ultrasound (EUS) is necessary to accompany a complete workup for proper staging and diagnosis of esophageal cancer. „ Surgery is the standard of care for early-stage esophageal cancer. „ Preoperative chemotherapy and radiation is the standard option for locally advanced esophageal cancer in surgically eligible patients.
  • 58. ChemoRT followed Sx Vs.ChemoRT „ Patient undergoing surgery have worse quality of life. „ Surgery following combined CRT appears to improve local control, its impact on ultimate survival remains controversial.
  • 59. Figure: A proposed treatment algorithm for esophageal cancer.

Notas do Editor

  1. For cervical primaries, patients are placed supine. Various field designs are possible and their choice depends on the geometry of the primary tumor in relation to the spinal cord. The ideal design is a three-field technique (two anterior obliques and a posterior). However, since the primary tumor is rarely limited to the midline, the most common approach is anteroposterior (AP)/posteroanterior (PA) to 39.6 to 41.4 Gy (Fig. 36-3) followed by a left or right opposed oblique pair with photons to 50.4 Gy (Fig. 36-4A-C). Since this technique will exclude the ipsilateral supraclavicular fossa, a separate electron field is added (commonly to a depth of 2 to 3 cm depending on the patient&apos;s anatomy) thereby bringing the total dose to 50.4 Gy. For cervical primaries, patients are placed supine. Various field designs are possible and their choice depends on the geometry of the primary tumor in relation to the spinal cord. The ideal design is a three-field technique (two anterior obliques and a posterior). However, since the primary tumor is rarely limited to the midline, the most common approach is anteroposterior (AP)/posteroanterior (PA) to 39.6 to 41.4 Gy (Fig. 36-3) followed by a left or right opposed oblique pair with photons to 50.4 Gy (Fig. 36-4A-C). Since this technique will exclude the ipsilateral supraclavicular fossa, a separate electron field is added (commonly to a depth of 2 to 3 cm depending on the patient&apos;s anatomy) thereby bringing the total dose to 50.4 Gy.