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Esophageal Cancer

Esophageal Cancer

1. Epidemiology

A. USA - 5 cases per 100,000
B. Iran, China, Russia - 500 cases per 100,000
C. Risk factors for squamous cell cancer:
1) smoking - 5-10x increased risk
2) alcohol abuse
3) older age
4) male gender
5) African-American
6) nitrosamines
D. Risk factors for adenocarcinoma
1) Increased incidence in last 10-15 years, especially in white males
2) Barrett's esophagus found in 50%

2. Precancerous Lesions of the Esophagus

A. Barrett's esophagus
B. Lye stricture
C. Tylosis
D. Plummer-Vinson syndrome
E. Celiac sprue
F. Zenker's diverticulum
G. Achalasia
H. Chagas disease

3. Barrett's Esophagus

A. Change of normal squamous epithelium to columnar epithelium
B. Incidence of cancer associated with Barrett's mucosa is increasing
C. Risk of cancer 50-100x normal
D. Dysplasia precedes malignant transformation
E. Low grade dysplasia often remains stable or regresses
F. High grade dysplasia is equivalent to carcinoma in situ and can predict imminent or existing cancer in 50% of patients
G. 75% of resected cancers are associated with adjacent high grade dysplasia
H. Endoscopic surveillance of patients with Barrett's mucosa detects cancer early and improves survival

4. Evaluation

A. Radiographic Studies
1) Barium swallow and endoscopy are complimentary in early detection
2) CT pathologic correlation has a sensitivity and specificity of 50%, with an overall accuracy of about 40-70%
3) CT is useful in the detection of distant metastasis and as a surveillance tool for postoperative recurrence
4) MRI has an undefined role at this point
B. Endosonography
1) Provides detailed images of the esophageal wall and adjacent structures
2) Well-suited for staging esophageal cancer
3) More accurate than CT in assessing depth of tumor infiltration (T stage) and regional lymphadenopathy
4) May not be safe for patients with malignant strictures
Staging of Esophageal Cancer 
T Primary Tumor 
TisCarcinoma in situ
T1Invades lamina propria or submucosa
T2Invades muscularis propria
T3Invades periesophageal tissue
T4Invades adjacent structures
N Regional lymph nodes
N0Regional can't be assessed
N1Regional node metastasis
N1-4More distant node metastasis
M Distant metastases
M0No distant metastasis
M1Distant metastasis
Stage 0Tis N0 M0
Stage IT1 N0 M0
Stage IIT2-3 N0 M0
Stage IIIT1-2 N1 M0
Stage IVT3 N1 M0, T4 any N M0
Stave VAny T, any N, M1

5. Neoadjuvant Therapy

A. Rationale
1) Reduces bulk and downstages tumor
2) May eradicate tumor in lymph nodes
3) May reduce tumor dissemination during surgery
4) Prevents development of chemoresistance
5) Assesses tumor responsiveness
6) Delivery prior to surgical disruption of blood supply
B. Radiation
1) Can reduce tumor bulk and render some specimens sterile
2) Does not increase postoperative mortality or morbidity
3) Does not improve resection rate or long-term survival
C. Chemotherapy
1) Response rates vary and usually limited in duration
2) Significant toxicity
D. Combined Therapy
1) Increases operability and resectability
2) Several trials have had encouraging complete response rates for combined chemotherapy and radiation
3) Randomized trials ongoing to evaluate long-term survival benefit

6. Operative technique

A. A variety of approaches may be used:
1) right thoracic (Ivor-Lewis)
2) right thoracotomy-abdominal-cervical (3-incision)
3) left thoracotomy
4) left thoracoabdominal
5) left thoracoabdominal cervical
6) transhiatal esophagectomy
7) trans-sternal
8) video-assisted esophagectomy
a) Extent of esophageal resection and dissection varies according to approach
b) Esophageal replacement can be performed using stomach, colon or jejunum

7. Results

A. Most current US series have a 5-year survival of about 20%
B. Asian series have 5-year survival approaching 30%
C. Combined therapy trials are ongoing

8. Palliation

A. Endoscopic placement of prostheses relieves dysphagia in about 75% but carries a significant complication rate
B. Laser therapy is relatively safe but requires repeated procedures
C. Surgical bypass has high mortality