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    04 Esophageal Tumors

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    Detty Novianty
    This document discusses esophageal tumors, including both malignant and benign types. Malignant tumors are more common than benign ones. Esophageal cancer is often discovered late, resulting in a poor 5-year prognosis of less than 10%. The most common benign tumor is gastrointestinal stromal tumor (GIST). Leiomyoma is another benign tumor that typically occurs in the distal esophagus of young males. Risk factors for esophageal squamous cell carcinoma (SCC) include alcohol, smoking, Achalasia, and radiation exposure. Treatment depends on tumor location, size, and spread, and may include surgery, radiation, chemotherapy, stent placement or endoscopic ablation for palliation. Despite treatment, the overall 5-year

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    04 Esophageal Tumors

    Uploaded by

    Detty Novianty
    148 views36 pages
    This document discusses esophageal tumors, including both malignant and benign types. Malignant tumors are more common than benign ones. Esophageal cancer is often discovered late, resulting in a poor 5-year prognosis of less than 10%. The most common benign tumor is gastrointestinal stromal tumor (GIST). Leiomyoma is another benign tumor that typically occurs in the distal esophagus of young males. Risk factors for esophageal squamous cell carcinoma (SCC) include alcohol, smoking, Achalasia, and radiation exposure. Treatment depends on tumor location, size, and spread, and may include surgery, radiation, chemotherapy, stent placement or endoscopic ablation for palliation. Despite treatment, the overall 5-year

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    This document discusses esophageal tumors, including both malignant and benign types. Malignant tumors are more common than benign ones. Esophageal cancer is often discovered late, resulting in a poor 5-year prognosis of less than 10%. The most common benign tumor is gastrointestinal stromal tumor (GIST). Leiomyoma is another benign tumor that typically occurs in the distal esophagus of young males. Risk factors for esophageal squamous cell carcinoma (SCC) include alcohol, smoking, Achalasia, and radiation exposure. Treatment depends on tumor location, size, and spread, and may include surgery, radiation, chemotherapy, stent placement or endoscopic ablation for palliation. Despite treatment, the overall 5-year

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    148 views36 pages

    04 Esophageal Tumors

    Uploaded by

    Detty Novianty
    This document discusses esophageal tumors, including both malignant and benign types. Malignant tumors are more common than benign ones. Esophageal cancer is often discovered late, resulting in a poor 5-year prognosis of less than 10%. The most common benign tumor is gastrointestinal stromal tumor (GIST). Leiomyoma is another benign tumor that typically occurs in the distal esophagus of young males. Risk factors for esophageal squamous cell carcinoma (SCC) include alcohol, smoking, Achalasia, and radiation exposure. Treatment depends on tumor location, size, and spread, and may include surgery, radiation, chemotherapy, stent placement or endoscopic ablation for palliation. Despite treatment, the overall 5-year

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    ESOPHAGEAL

    TUMORS
    DR (Can). Dr. H. YUSMAIDI, SpB – KBD
    Devisi Bedah Digestif
    Dept Bedah RS. Abdul Moeloek
    Universitas Lampung
    Eso tumors:
     Malignant > common than benign.
     Unfortunately, eso cancer discovered late & overall 5 y ear
    prognosis is bad < 10.
     Even for potentally resectable ca eso, 5 y survival is < 30%
    Benign Neoplasms
     The most common is a gastrointestinal stromal tumour
    (GIST, another name for leimymoma),usually
    asymptomatic but may cause bleeding or dysphagia
     Uncommon, include fibrovascular polyps,
    leiomyomas, papillomas, lipomas,
    neurofibromas, granular cell tumors.
     When large, can cause dysphagia or chest pain
    from obstruction or stretch.
     Usually discovered incidentally.
    LEIOMYOMA OF OESOPHAGUS

     Most common benign tumor of esophagus & small bowel


    but not common in the colon
     Usually asymptomatic
     May produce dysphagia or hematemesis if large.
     Typically occurs in young males
     Found most often in distal third of esophagus.
     Usually solitary, but may be multiple (3%).
     Imaging findings:
     Smooth, sharply-marginated mass.
     Well-defined, intramural (wall) mass &may narrow the
    lumen.
     May have coarse calcifications (only calcifying
    esophageal tumor)
     Rarely ulcerates
    LEIOMYOMA OF OESOPHAGUS: diagnosis

     Barium swallow.
     Endoscopy: smooth submucosal lesion.
    Ca esophagus.
    ETIOLOGY & PATHOGENESIS.

     Almost all are adenocarcinoma or squamous cancers.


     Small-cell cancer is a rare third type.
    SCC.
     In West relatively rare (4 cases /100 000), in Iran, Iraq
    Africa , China,common (200/100 000).
     Can arise in any part of the oesophagus from the post-
    cricoid region to the cardia.
     Almost all tumours above the lower third of the
    oesophagus are squamous cancers.
    Adeno ca.

     Arises in the lower third of the oesophagus from


    Barrett's oesophagus or from the cardia of the stomach.
     The incidence is increasing & now 5:100 000 in UK;
    possibly because of the high prevalence of GERD/
    Barrett's.
    ETIOLOGY & PATHOGENESIS.

     men than women 3-4:1.


     Relatively common in Kurdistan.
     Should be considered in any case presenting with
    dysphagia.
    SCC:Risk factors.

     Alcohol.
     Tobacco smoking.
     SCC of the head & neck.
     Lye or post-caustic strictures
     Achalasia.
     Papilloma virus infection.
     Plummer-Vinson syndrome
     Tylosis (familial hyperkeratosis of palms & soles) .
     Celiac disease.
     Radiation exposure.
     Post-cricoid web
    SYMPTOMS.

     The most common is progressive dysphagia over a


    several-month period until only liquids can be taken.
     The obstruction does not occur until the cancer is far
    advanced.
     The dysphagia may be accompanied by a steady,
    boring pain, which often signals mediastinal
    involvement & inoperability.
    SYMPTOMS.

     Unexplained persistent chest pain should always be


    investigated by a careful double-contrast Barium or
    endoscopy.
     More advanced; halitosis(bau mulut) & weight loss.
     Coughing after drinking fluid may be caused either by
    nearly complete esophageal lumen obstruction, with
    overspill into the larynx, or by the development of a
    tracheoesophageal fistula.
     Hematemesis & Hoarseness from involvement of the
    recurrent laryngeal nerve by tumor are unusual
    symptoms.
    SIGNS:

     Weight loss.
     Nail bed clubbing can be seen with both benign &
    malignant tumors.
     Vricho’s node in left supracalvicular region.
     Early diagnosis affords the only chance for cure.
    DIAGNOSIS.

     The investigation of choice is upper GI endoscopy with


    cytology & biopsy.
     A barium swallow demonstrates the site& length of the
    stricture but adds little useful information.
     Once a diagnosis has been achieved, investigations are
    performed to stage the tumour& define operability.
     Thoracic & abdominal CT are carried out to identify
    metastatic spread & local invasion.
     Invasion of the aorta&other local structures may preclude
    surgery.
     Unfortunately, CT tends to understage tumours &the most
    sensitive modality is EUS to define the TNM stage.
    DIAGNOSIS.

     Dysphagia needs immediately double-contrast Barium.


     Any irregularity, esp if it narrows the lumen, mandates
    further evaluation.
     A bolus of barium-soaked bread may discover any
    possible sites of arrest.
     In the presence of suspicious symptoms & normal
    barium swallow results, endoscopy with biopsy &
    brushing of any suspicious lesion is indicated.
     The endoscopist should always obtain a good
    retroflexed view of the cardia from below, to make
    certain that an adenocarcinoma in GEJ has not been
    overlooked
    DIAGNOSIS.

     If narrowing detected by barium swallow, endoscopy


    with biopsy & cytologic brushings of the involved area
    is required.
     Biopsy of visible tissue may reveal only inflammation;
    so as many as 6-9 deep biopsy specimens should be
    obtained.
    DIAGNOSIS: staging.

     Evaluation for local tumor spread, mediastinal nodal


    & liver metastases is essential for staging before a therapeutic
    decision is reached by:
     Physical examination for lymphadenopathy
     Tests of liver enzymes
     Chest radiography.
     CT scan.
     For upper & mid-esophageal tumors, bronchoscopy is indicated to evaluate
    for asymptomatic invasion of the tracheobronchial tree.
     Endoscopic ultrasound (EUS) is useful to detect the level of invasion &
    presence of mediastinal lymph node abnormalities & is becoming the favored
    test to determine if a lesion is resectable.
    The tumour (T) has extended through oeso wall (stage T3).
    A small peri-tumoral lymph node (LN) is also seen.
    TREATMENT.

     Choice of therapy depends on:


     Location
     Size
     Presence or absence of spread.
     Cell type.
    TREATMENT.

     Surgical resection of SCC & adenocarcinoma of the lower


    1/3 is preferred unless widespread metastases present.
     Surgery offers the benefit of rapidly restoring
    esophagogastric continuity.
     Only 1/4 have a resectable tumor; of these, 10 - 20% do not
    survive the operative period.
     5-year survival is only 5 - 20%, even with extensive
    resection.
     Long-term survival cannot be predicted in the individual
    case by the operative findings.
     There is growing enthusiasm for palliative resection with
    restoration of GI continuity with stomach or colon.
    TREATMENT.

     Radiation therapy +/- surgery or chemotherapy has


    been a mainstay for SCC, but adenocarcinomas are
    relatively radioinsensitive.
     Radiotherapy has little hospital mortality, but some
    short-term & long-term morbidity.
     Patients treated with definitive radiation therapy (50 to
    80 Gy) alone have a 1-year survival of 18-40% & a 5-
    year survival of 6-14% dependent on the initial stage.
    TREATMENT.

     Chemotherapy with cisplatin-containing combinations


    has demonstrated objective tumor response.
     Multimodality treatment with radiation +
    chemotherapy with cisplatin - fluorouracil is superior
    to radiation therapy alone.
     When obvious extraesophageal spread is present,
    palliation may be achieved with bougienage dilation+/-
    Endoscopic metalic stenting to restore & maintain an
    adequate esophageal lumen.
     If performed with a guide wire under fluoroscopic
    guidance, is not hazardous in skilled hands.
    TREATMENT.

     If dilation does not offer lasting relief, then a Silastic


    tube or metal stent can be placed perorally to relieve
    esophageal obstruction&greatly beneficial in treating
    malignant tracheoesophageal fistula.
     Destruction of intraluminal tumor & restoration of an
    adequate lumen may be performed by endoscopic laser
    therapy, intraluminal heat-coagulating probe, or
    photodynamic therapy.
    TREATMENT.

     Despite modern treatment, the overall 5-year survival


    of oesophageal cancer is 6-9%.
     Survival following oesophageal resection depends on
    stage.
     Tumours which have extended beyond the wall,have
    lymph node involvement (T3, N1) are associated with a
    5-year survival of around 10% after surgery.
     Without LNs, Overall survival following 'potentially
    curative' surgery (all macroscopic tumour removed) is
    about 30% at 5 years& can be improved by
    neoadjuvant (pre-operative) chemotherapy with agents
    as cisplatin/ 5-fluorouracil.
    TREATMENT.

     Although SCC are radiosensitive, radiotherapy alone is


    associated with a 5-year survival of only 5%.
     70% have extensive disease at presentation; in these,
    treatment is palliative & based upon relief of dysphagia
    &pain.
     Endoscopically directed tumour ablation using laser
    therapy or insertion of stents is the major method of
    improving swallowing.
     Palliative radiotherapy may induce shrinkage of both
    SCC/ adenocarcinomas but symptomatic response may
    be slow.
     Quality of life can be improved by nutritional support
    /appropriate analgesia.
    ADENOCARCINOMA:
     A rapid rise in adenocarcinoma, particularly in white
    men, has made their current cancer rates about equal.
     Unlike SCC, arise in the distal esophagus because of
    the presence of Barrett’s eso, a complication of GERD.
     Lymphatic spread is common.
     Adenocarcinomas are radio insensitive; although
    chemoradiation &surgery may improve survival, the 5-
    year survival < 10% almost equal to SCC.
     Palliation is the same as for inoperable SCC.
     Barrett’s esophagus, a specialized intestinal-type
    metaplasia in the tubular esophagus
    ADENOCARCINOMA in a
    Barret’s :

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