CARCINOMA ESOPHAGUS

CLINICAL FEATURES
Presents in mid to late adulthood
Poor survival rate Dysphagia is the most common presenting symptom endemic areas

Disseminate early

EARLY DISEASE
Non-specific dyspeptic symptoms
Vague feeling of abnormal swallowing

ADVANCED MALIGNANCY
Recurrent laryngeal nerve palsy
Horners syndrome Chronic spinal pain Diaphragmatic paralysis

SIGNS OF SURGICAL NON CURE

Weight loss of more than 20%
Loss of appetite Cutaneous tumour metastasis Enlarged supraclavicular lymph nodes

INVESTIGATIONS
Endoscopy
Contrast radiology Cytology/biopsy Assessment of general health

Staging investigations

BARIUM SWALLOW

ACTIVITY
RAISE HANDS

What should be done first: Endoscopy or Barium swallow WHY?

STAGING INVESTIGATIONS
FOR LOCAL RESECTABILITY
FOR DISTANT METASTASIS FOR ADJACENT STRUCTURE INVOLVEMENT

FOR LOCAL RESECTABILITY

Endoscopic ultrasound can determine

the depth of spread through wall Invasion of adjacent organs Metastasis to lymph nodes

Contiguous spread downwards

Distant metastasis to left lobe of liver

FOR DISTANT METASTASIS

Ultrasound

For detection of liver metastasis only

CT scan abdomen

To identify hematogenous metastasis Reliably shows lymphadenopathy Cant distinguish between reactive hyperplasia and nodal mets

MRI scanning

No additional benefits over CT scan

Laparoscopy

To detect peritoneal tumour seedlings Particularly important for tumours arising in abdominal part of the esophagus

FOR ADJACENT STRUCTURES

Bronchoscopy

For local resectability

STAGING

ACTIVITY
MAKE THREE GROUPS AND EACH GROUP ANSWERS ONE OF THE QUESTIONS REGARDING UPPER, MIDDLE AND LOWER THIRD TUMOURS:

Enlist signs and symptoms How will you investigate? What will you expect in results?

MANAGEMENT OPTIONS
Surgery
Neoadjuvant/ adjuvant treatment Chemoradiotherapy alone Palliative treatment

SURGERY
Most important aspect of curative treatment
Surgery alone is best suited to patients with disease confined to esophagus (T1, T2) without nodal metastasis Radical esophagectomy Subtotal esophagectomy

PRINCIPLES OF SURGERY
Adequate local resection of the tumour

Proximal extent of resection is upto 10 cm from macroscopic tumour Distal extent of resection upto 5 cm from macroscopic tumour

Lymphadenectomy according to the site of the tumour

SURGICAL APPROACHES
BASED ON TUMOUR TYPE, LOCATION AND THE EXTENT OF PROPOSED LYMPHADENECTOMY

Left thoracoabdominal Transhiatal Two phase ( Ivor Lewis) Three phase (Mc Keown)

LEFT THORACOABDOMINAL

TRANSHIATAL

IVOR LEWIS

McKEOWN

ACTIVITY
THINK-PAIR-SHARE

What is the best treatment option for a resectable middle and lower third tumour?

COMPLICATIONS OF SURGERY
Respiratory
Anastomotic leakage Chylothorax Recurrent laryngeal nerve injury

Benign anastomotic stricture

GORD

NON SURGICAL TREATMENT

For all patients with lymph node involvement a multimodal approach is required
Combined chemoradiotherapy Better than radiotherapy alone May be used as an alternative to surgery in unfit patients

PALLIATIVE TREATMENT OPTIONS

Surgical resection and radiotheapy

Intubation Expanding metal stents Brachytherapy

Endoscopic palliative treatment options

Endoscopic laser treatment Bipolar diathermy Argon beam plasma coagulation

Alcohol injection