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introductionintroduction

Esophageal cancerEsophageal cancer (or (or oesophageal oesophageal cancercancer) is cancer ) is cancer arising from the arising from the foodpipe known as the foodpipe known as the esophagus that runs esophagus that runs between the throat and between the throat and the stomach. Pnemonia the stomach. Pnemonia can be a complication.can be a complication.

BENIGNBENIGN

Papillary fronds lined by several layers of hyperplastic squamous epithelium around a fibrovascular core

May be associated with HPV

Squamous Papilloma

Demarcated intramural nodule, composed of composed of irregularly oriented bundles of well-differentiated smooth-muscle cellsNormal Squamous epithelium is seen on top

Esophageal leiomyoma

TYPESTYPES

The two main sub-types of the disease are The two main sub-types of the disease are esophageal squamous-cell carcinoma (often esophageal squamous-cell carcinoma (often abbreviated to ESCC), abbreviated to ESCC), which is more common which is more common in the developing world, and in the developing world, and esophageal esophageal adenocarcinoma (EAC), adenocarcinoma (EAC), which is more which is more common in the developed world.common in the developed world.

A general rule of thumb is that a cancer in the A general rule of thumb is that a cancer in the upper two-thirds and middle one 3rd is likely to upper two-thirds and middle one 3rd is likely to be ESCC and one in the lower one-third EAC.be ESCC and one in the lower one-third EAC.

SQUAMOUS CELL CANCERSQUAMOUS CELL CANCER

Arises from epithelial cells of the esophagusArises from epithelial cells of the esophagus RISK FACTORS:RISK FACTORS:The most common causes of the The most common causes of the

squamous-cell type are: tobacco, alcohol, squamous-cell type are: tobacco, alcohol, achalasia,very hot drinks, and a poor diet. High levels achalasia,very hot drinks, and a poor diet. High levels of dietary exposure to nitrosamines.oral hygieneof dietary exposure to nitrosamines.oral hygiene

Chewing betel nut (areca) is an important risk factor Chewing betel nut (areca) is an important risk factor in Asiain Asia

Genetic factors: p16/INK4 tumor suppressor gene Genetic factors: p16/INK4 tumor suppressor gene and EGFR, p53 in 50% of esophageal cancersand EGFR, p53 in 50% of esophageal cancers

Squamous cell carcinoma – morphology

(1) polypoid exophytic masses(2) necrotizing ulcerations(3) diffuse infiltrative neoplasms

Mucosal epithelial dysplasia -> carcinoma in situ -> invasive cancer

ESCC STAGINGESCC STAGING Stage 1A:Cancer has grown through the inner layer and invaded the wall of the

esophagus. The grade is 1. Stage IB Cancer has invaded the wall of the esophagus and is grade 2 or 3. Or, cancer is found

in the lower part of the esophagus, it has invaded the muscle layer or outer layer of the esophagus, and the grade is 1.

Stage IIA Cancer is found in the upper or middle part of the esophagus, it has invaded the

muscle layer or outer layer of the esophagus, and the grade is 1. Or, cancer is found in the lower part of the esophagus, it has invaded the muscle layer or outer layer of the esophagus, and the grade is 2 or 3.

Stage IIB Cancer is found in the upper or middle part of the esophagus, it has invaded the

muscle layer or outer layer of the esophagus, and the grade is 2 or 3. Or, cancer has not invaded the outer layer, and cancer cells are found in one or two nearby lymph nodes.

ADENO CAADENO CA The most common causes of the adenocarcinoma type are The most common causes of the adenocarcinoma type are

GERD smoking tobacco, obesity, and acid refluxGERD smoking tobacco, obesity, and acid reflux RISK FACTORS: RISK FACTORS: male gender, acid reflux, obesity. male gender, acid reflux, obesity.

Adenocarcinoma is the more common type of esophageal Adenocarcinoma is the more common type of esophageal cancer. Having Barrett esophagus increases the risk of this cancer. Having Barrett esophagus increases the risk of this type of cancer. Acid reflux disease (gastroesophageal reflux type of cancer. Acid reflux disease (gastroesophageal reflux disease, or GERD) can develop into Barett esophagus. disease, or GERD) can develop into Barett esophagus. Other risk factors include smoking, being male, or Other risk factors include smoking, being male, or being obese. being obese.

PROTECTIVE EFFECT: PROTECTIVE EFFECT: Female hormone, h pylori, Female hormone, h pylori, prolonged period of breastfeeding declines riskprolonged period of breastfeeding declines risk

Barrett esophagus - sequelae

Ulceration, Bleeding, Stricture

Adenocarcinoma

EAC STAGINGEAC STAGING Stage IA Cancer has grown through the inner layer and invades the wall of the

esophagus. The grade is 1 or 2. Stage IB Cancer has invaded the wall of the esophagus and is grade 3. Or, cancer

has invaded more deeply into the muscle layer of the esophagus, and the grade is 1 or 2.

Stage IIA Cancer has invaded the muscle layer of the esophagus, and the grade is 3. Stage IIB Cancer has invaded the outer layer of the esophagus. Or, cancer has not

invaded the outer layer, but cancer cells are also found in one or two nearby

GERD cont.GERD cont.

The long-term erosive effects of acid reflux (an extremely common The long-term erosive effects of acid reflux (an extremely common condition, also known as gastroesophageal reflux disease or condition, also known as gastroesophageal reflux disease or GERD) have been strongly linked to this type of cancer. GERD) have been strongly linked to this type of cancer. Longstanding GERD can induce a change of cell type in the lower Longstanding GERD can induce a change of cell type in the lower portion of the esophagus in response to erosion of its squamous portion of the esophagus in response to erosion of its squamous lininglining..This phenomenon, known as Barrett's esophagus, seems to This phenomenon, known as Barrett's esophagus, seems to appear about 20 years later in women than in men, maybe due to appear about 20 years later in women than in men, maybe due to hormonal factors. Having symptomatic GERD or bile reflux makes hormonal factors. Having symptomatic GERD or bile reflux makes Barrett's esophagus more likely, which in turn raises the risk of Barrett's esophagus more likely, which in turn raises the risk of further changes that can ultimately lead to adenocarcinoma.further changes that can ultimately lead to adenocarcinoma. The The risk of developing adenocarcinoma in the presence of Barrett's risk of developing adenocarcinoma in the presence of Barrett's esophagus is unclear, and may in the past have been overestimated.esophagus is unclear, and may in the past have been overestimated.

sypmtomssypmtoms Painful or difficult swallowingPainful or difficult swallowing Weight lossWeight loss A hoarse voice or cough that doesn't go awayA hoarse voice or cough that doesn't go away enlarged lymph nodes (glands) around the enlarged lymph nodes (glands) around the

collarbone, a dry cough, and possibly coughing collarbone, a dry cough, and possibly coughing up or vomiting bloodup or vomiting blood

Backwards movement of food through the Backwards movement of food through the esophagus and possibly mouth (regurgitation)esophagus and possibly mouth (regurgitation)

Chest pain and heart burnsChest pain and heart burns Vomiting bloodVomiting blood

EPIDERMIOLOGYEPIDERMIOLOGY Esophageal cancer is the eighth most frequently diagnosed cancer worldwide, and

because of its poor prognosis it is the sixth most common cause of cancer-related death

ESCC comprises 60–70% of all cases of esophageal cancer worldwide, while EAC accounts for a further 20–30% (melanomas, leiomyosarcomas, carcinoids and lymphomas are less common types).

In general, ESCC is more common in the developing world, and EAC is more common in the developed world

In Western countries, EAC has become the dominant form of the disease, following an increase in incidence over recent decades (in contrast to the incidence of ESCC, which has remained largely stable). In 2012, the global incidence rate for EAC was 0.7 per 100,000 with a strong male predominance (1.1 per 100,000 in men vs. 0.3 in women) Areas with particularly high incidence rates include northern and western Europe, north America and Oceania. The countries with highest recorded rates were the UK, Netherlands, Ireland, Iceland and New Zealand

DIAGNOSESDIAGNOSES Doctor uses imaging tests and a biopsy to Doctor uses imaging tests and a biopsy to

diagnose esophageal cancerdiagnose esophageal cancer The disease is diagnosed by biopsy done by an The disease is diagnosed by biopsy done by an

endoscope (a fiberoptic camera)endoscope (a fiberoptic camera) generally tend to be fairly poor, as diagnosis is generally tend to be fairly poor, as diagnosis is

often late. Five-year survival rates are around often late. Five-year survival rates are around 13% to 18%13% to 18%

Staging.Staging. CT scanCT scan Esophagogastroduodenoscopy (EGD) and biopsyEsophagogastroduodenoscopy (EGD) and biopsy PET scan (sometimes useful for determining the PET scan (sometimes useful for determining the

stage of disease, and whether surgery is possiblestage of disease, and whether surgery is possible

PREVENTIONPREVENTION

Do not smokeDo not smoke Limit or do not drink alcoholic beveragesLimit or do not drink alcoholic beverages Get checked by your doctor if you have severe Get checked by your doctor if you have severe

GERDGERD Get regular checkups if you have Barrett Get regular checkups if you have Barrett

esophagusesophagus

TREATMENTTREATMENT

Treatment is based on the cancer's stage Treatment is based on the cancer's stage and location, together with the person's and location, together with the person's general condition and individual general condition and individual preferences. preferences.

ChemotherapyChemotherapy surgerysurgery

A 58-year-old man had dysphagiaA 58-year-old man had dysphagia

Irregular reddish, ulcerated exophytic mid-esophageal mass seen on mucosal Irregular reddish, ulcerated exophytic mid-esophageal mass seen on mucosal surface surface

Diagnosis?Diagnosis?

Risk factors?Risk factors?

A 57 years old man present with cough and weight loss. She A 57 years old man present with cough and weight loss. She has noticed a gradual onset difficulty with swallowing both has noticed a gradual onset difficulty with swallowing both solid and luquid food. She has been soking for the past 20 yrs solid and luquid food. She has been soking for the past 20 yrs and also ingest hard liqueur. He has lost 20lbs in last few and also ingest hard liqueur. He has lost 20lbs in last few months. Esophageal biopsy reveals presence of squamous cells months. Esophageal biopsy reveals presence of squamous cells with keratin. Which is correctwith keratin. Which is correct

A. Barret esophagus is the major risk factorA. Barret esophagus is the major risk factor B. GERD is a common risk factor. B. GERD is a common risk factor. C. The tumour is most likely n the upper one third of the C. The tumour is most likely n the upper one third of the

esophagusesophagus D. Primary ciliary dyskinesiaD. Primary ciliary dyskinesia

A 37 years old male with frequent episodes of gastro-A 37 years old male with frequent episodes of gastro-esophageal reflux disease noticed a dramatic improvement esophageal reflux disease noticed a dramatic improvement in the frequency and severity of her heart burn. She in the frequency and severity of her heart burn. She consulted Dr.Blessing who ordered endoscopy. Esophageal consulted Dr.Blessing who ordered endoscopy. Esophageal biopsy taken reveals the presence of columner type biopsy taken reveals the presence of columner type epithelium with increased Goblet cells in gastro eso epithelium with increased Goblet cells in gastro eso junction. Which is correctjunction. Which is correct

A. risk of squamous cell cancer is increasedA. risk of squamous cell cancer is increased B. it is an example of a dysplasiaB. it is an example of a dysplasia C. It represents malignant transformtionC. It represents malignant transformtion D.Risk of adeno-carcinoma is incresedD.Risk of adeno-carcinoma is incresed

REFERENCESREFERENCES Das A. Tumors of the esophagus. In: Feldman M, Friedman LS, Brandt LJ, Das A. Tumors of the esophagus. In: Feldman M, Friedman LS, Brandt LJ,

eds. eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease.Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 9th ed. 9th ed. Philadelphia, PA: Elsevier Saunders; 2010:chap 46.Philadelphia, PA: Elsevier Saunders; 2010:chap 46.

PATOMAPATOMA https://

www.google.com/search?q=squamous+cell+carcinoma+of+the+esophagus&newwindow=1&source

Robins patholgyRobins patholgy Dr Jeevan’s slidesDr Jeevan’s slides