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Surgery - Esophageal Carcinoma
Introduction
malignant tumor developing in the mucosa of the oesophagus. Adenocarcinoma and squamous cell carcinoma are the two main histological forms.
Etiology
Alcohol, tobacco, specific vitamin and trace element deficiencies, HPV infection, achalasia, Paterson-Kelly (Plummer-Vinson) syndrome, tylosis (Howel-Evans syndrome), scleroderma, coeliac disease, lye stricture, history of prior thoracic radiation therapy or upper aerodigestive squamous cancer, and dietary nitrosamines are all associated with squamous.
Adenocarcinoma: 0.5–0.7% of cases of adenocarcinoma each year are associated with intestinal metaplasia of the distal oesophageal mucosa, or GORD, Barrett's oesophagus.
Epidemiology
Eighth most frequent cancer (7000–8000 cases annually in the UK). Male to female ratio: 3–4:1.
Squamous carcinoma is more prevalent globally, yet there is significant regional heterogeneity (high prevalence in northern China, Iran and southern Russia). Adenocarcinoma is becoming more prevalent in westernized nations (65% of cases in the UK), growing at a rate of 5–10% year. Peak case frequency: 60–70 years.
History
Early: Reflux symptoms or asymptomatic. Subsequent symptoms include dysphagia, which is initially worse with solid food, regurgitation, coughing or choking after eating, pain (odynophagia), exhaustion, and hoarseness of voice (which may be a sign of recurrent laryngeal nerve palsy).
Examination
There might not be any outward indications of weight loss.Hepatomegaly and supraclavicular lymphadenopathy are possible symptoms of metastatic illness. Indirect tracheobronchial involvement or aspiration may be the cause of respiratory symptoms.
Pathogenesis
The mid-upper oesophagus is more commonly affected by squamous cell carcinomas. Usually, adenocarcinomas originate in the gastro-oesophageal junction (GOJ) or the lower oesophagus. Invasive carcinoma, high-grade dysplasia, and low-grade dysplasia can develop from Barrett's intestinal metaplasia. Since the oesophagus lacks a serosa, spread is usually first direct and then longitudinal, traveling through a vast network of submucosal lymphatics to reach nodes in the tracheobronchial, mediastinal, celiac, stomach, or cervical regions. Leiomyosarcoma, melanoma, and lymphoma are uncommon oesophageal tumors.
Investigational studies
endoscopy: biopsy and localization of tumor. Narrow band imaging, magnification, and chromoendoscopy are examples of endoscopic procedures that improve early identification of high-grade dysplasia and malignancy. T (depth of tumor involvement) and N (perioesophageal node) involvement can be determined by endoscopic ultrasonography.
Imaging: Barium swallow, CT (chest, abdomen, pelvis), and PET can identify distant metastases that were previously undetected.
Other: bone scan if there are signs of skeletal involvement, bronchoscopy (if there is a possibility of tracheo-bronchial invasion). Thoracoscopy, laparoscopy, and peritoneal washings. thorough evaluation of the heart and lungs if surgery is intended.
Management
Most effectively run in specialized facilities with interdisciplinary knowledge. Endoscopic therapy, such as endoscopic submucosal dissection and endoscopic mucosal excision, are becoming more common for early (mucosal) localized illness. Merely thirty percent are appropriate for surgical resection.
Before surgery, neoadjuvant chemoradiotherapy (cisplatin, 5-fluorouracil, etc.) can help downstage tumors.
Surgery: The surgical strategy is determined by the location of the tumor and the desired lymphadenectomy's extent.
Transthoracic approach: laparotomy and Ivor-Lewis right thoracotomy (middle-to lower-third tumors).
Transhiatal approach: oesophagogastric anastomosis (upper third tumors) is performed by laparotomy, blunt dissection of the thoracic oesophagus, and cervical incision.
McKeown tri-incisional technique, involving the abdomen, right chest, and neck.
Reconstruction involves creating a conduit, usually gastric, based on the right gastroepiploic and gastric arteries' vascular pyramid; colon or jejunum are less frequently used (for GOJ tumors with extensive stomach involvement). It is common practice to conduct a feeding jejunostomy for postoperative enteral nutrition and a pyloroplasty for stomach drainage.
Studies have indicated that a more thorough lymphadenectomy (three fields as opposed to two) improves survival.
Increasingly popular minimally invasive techniques include laparoscopic and thoracoscopic dissections.
Squamous cell carcinomas are more radiosensitive than adenocarcinomas when it comes to radiation and chemotherapy. In individuals with localized illness, chemoradiotherapy or radical radiotherapy may be used if surgery is not an option. When tolerated, neoadjuvant and adjuvant chemotherapy with a regimen centered on cisplatin is administered.
Palliation: It is customized based on the tumor and symptoms of each patient. Luminal recannulization can be accomplished using photodynamic therapy, laser ablation, or inflatable stents.
Chemotherapy and/or radiotherapy, such as 5-fluorouracil, epirubicin, and cisplatin, are linked to varying response rates.
Complications
malnourishment, aspiration pneumonia, haematemesis, and oesophago-bronchial fistula related to the tumor; ascites and pleural effusions related to metastatic illness.
Of oesophagectomy: morbidity up to 40%; mortality <5% in specialized centers.
The most frequent consequences are pulmonary in nature, such as pneumonia and atelectasis. Anastomotic leakage (5–15%) and conduit failure are examples of serious consequences; other risks include chylothorax and recurrent laryngeal nerve injury.
Prognosis
Depending on the stage. The 5-year survival rate is 20–25% overall; it is <5% in cases of advanced illness.
Introduction
malignant tumor developing in the mucosa of the oesophagus. Adenocarcinoma and squamous cell carcinoma are the two main histological forms.
Etiology
Alcohol, tobacco, specific vitamin and trace element deficiencies, HPV infection, achalasia, Paterson-Kelly (Plummer-Vinson) syndrome, tylosis (Howel-Evans syndrome), scleroderma, coeliac disease, lye stricture, history of prior thoracic radiation therapy or upper aerodigestive squamous cancer, and dietary nitrosamines are all associated with squamous.
Adenocarcinoma: 0.5–0.7% of cases of adenocarcinoma each year are associated with intestinal metaplasia of the distal oesophageal mucosa, or GORD, Barrett's oesophagus.
Epidemiology
Eighth most frequent cancer (7000–8000 cases annually in the UK). Male to female ratio: 3–4:1.
Squamous carcinoma is more prevalent globally, yet there is significant regional heterogeneity (high prevalence in northern China, Iran and southern Russia). Adenocarcinoma is becoming more prevalent in westernized nations (65% of cases in the UK), growing at a rate of 5–10% year. Peak case frequency: 60–70 years.
History
Early: Reflux symptoms or asymptomatic. Subsequent symptoms include dysphagia, which is initially worse with solid food, regurgitation, coughing or choking after eating, pain (odynophagia), exhaustion, and hoarseness of voice (which may be a sign of recurrent laryngeal nerve palsy).
Examination
There might not be any outward indications of weight loss.Hepatomegaly and supraclavicular lymphadenopathy are possible symptoms of metastatic illness. Indirect tracheobronchial involvement or aspiration may be the cause of respiratory symptoms.
Pathogenesis
The mid-upper oesophagus is more commonly affected by squamous cell carcinomas. Usually, adenocarcinomas originate in the gastro-oesophageal junction (GOJ) or the lower oesophagus. Invasive carcinoma, high-grade dysplasia, and low-grade dysplasia can develop from Barrett's intestinal metaplasia. Since the oesophagus lacks a serosa, spread is usually first direct and then longitudinal, traveling through a vast network of submucosal lymphatics to reach nodes in the tracheobronchial, mediastinal, celiac, stomach, or cervical regions. Leiomyosarcoma, melanoma, and lymphoma are uncommon oesophageal tumors.
Investigational studies
endoscopy: biopsy and localization of tumor. Narrow band imaging, magnification, and chromoendoscopy are examples of endoscopic procedures that improve early identification of high-grade dysplasia and malignancy. T (depth of tumor involvement) and N (perioesophageal node) involvement can be determined by endoscopic ultrasonography.
Imaging: Barium swallow, CT (chest, abdomen, pelvis), and PET can identify distant metastases that were previously undetected.
Other: bone scan if there are signs of skeletal involvement, bronchoscopy (if there is a possibility of tracheo-bronchial invasion). Thoracoscopy, laparoscopy, and peritoneal washings. thorough evaluation of the heart and lungs if surgery is intended.
Management
Most effectively run in specialized facilities with interdisciplinary knowledge. Endoscopic therapy, such as endoscopic submucosal dissection and endoscopic mucosal excision, are becoming more common for early (mucosal) localized illness. Merely thirty percent are appropriate for surgical resection.
Before surgery, neoadjuvant chemoradiotherapy (cisplatin, 5-fluorouracil, etc.) can help downstage tumors.
Surgery: The surgical strategy is determined by the location of the tumor and the desired lymphadenectomy's extent.
Transthoracic approach: laparotomy and Ivor-Lewis right thoracotomy (middle-to lower-third tumors).
Transhiatal approach: oesophagogastric anastomosis (upper third tumors) is performed by laparotomy, blunt dissection of the thoracic oesophagus, and cervical incision.
McKeown tri-incisional technique, involving the abdomen, right chest, and neck.
Reconstruction involves creating a conduit, usually gastric, based on the right gastroepiploic and gastric arteries' vascular pyramid; colon or jejunum are less frequently used (for GOJ tumors with extensive stomach involvement). It is common practice to conduct a feeding jejunostomy for postoperative enteral nutrition and a pyloroplasty for stomach drainage.
Studies have indicated that a more thorough lymphadenectomy (three fields as opposed to two) improves survival.
Increasingly popular minimally invasive techniques include laparoscopic and thoracoscopic dissections.
Squamous cell carcinomas are more radiosensitive than adenocarcinomas when it comes to radiation and chemotherapy. In individuals with localized illness, chemoradiotherapy or radical radiotherapy may be used if surgery is not an option. When tolerated, neoadjuvant and adjuvant chemotherapy with a regimen centered on cisplatin is administered.
Palliation: It is customized based on the tumor and symptoms of each patient. Luminal recannulization can be accomplished using photodynamic therapy, laser ablation, or inflatable stents.
Chemotherapy and/or radiotherapy, such as 5-fluorouracil, epirubicin, and cisplatin, are linked to varying response rates.
Complications
malnourishment, aspiration pneumonia, haematemesis, and oesophago-bronchial fistula related to the tumor; ascites and pleural effusions related to metastatic illness.
Of oesophagectomy: morbidity up to 40%; mortality <5% in specialized centers.
The most frequent consequences are pulmonary in nature, such as pneumonia and atelectasis. Anastomotic leakage (5–15%) and conduit failure are examples of serious consequences; other risks include chylothorax and recurrent laryngeal nerve injury.
Prognosis
Depending on the stage. The 5-year survival rate is 20–25% overall; it is <5% in cases of advanced illness.
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