SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS

GENERAL THORACIC SURGERY

CHAPTER 143

ETIOLOGY

• No specific etiology agent. • Poverty and malnutrition. • High dietary content of nitrosamines,

nitrites. • Tobacco, betel nut, chronic esophageal

irritation.• Lye burn. • Achalasia, peptic reflux esophagitis.

Pathology

• Rare below age 30. • Common located in middle-third （ carina

to inferior pulmonary vein ） .• Microscopic feature— Early-stage esophageal cancer—

intraepitherlial, intramucosal, submucosal carcinoma.

No lymph node metastases.

Molecular biology

• p53 gene mutation in invasive lesion.

• Over expression of HER2/new.

• Amplification of cyclin D gene.

• Frequent mutation p16 multiple suppressor cyclin-dependent kinase 4 inhibitor gene.

Metastases

• Direct extension.

• Lymphatic metastases （ 60% ） .

• Hematogenous metastases （ 50-63% ） .

• Distal metastases — 25-30% at time of diagnosis.

Metastases

• Intraesophageal spread—microscopic spread is greater than macroscopic spread.

• Submucosal lymphatic spread occurs often, may result in tumor emboli producing skip or satellite nodules.

Metastases

• Direct extension—tumor penetrating adventitial layer.

• Upper third invasion to mediastinum, great vessel, trachea, recurrent laryngeal nerve.

• Middle third invasion to pleura, left main bronchus, aorta, pericardium.

• Lower third invasion to diaphragm stomach.

Metastases

• Lymphatic spread—the direction of esophageal lymph flow is longitudinal, cephalad or caudad.

• Upper third tend to be cephalad.

• Lower two third is caudad, incidence 40-60%.

• Related to depth and extent of invasion.

Lymph node station

• 1 — the paraesophageal lymph node.

• 2 — periesophageal, celiac perigastric lymph node.

• 3 — the distal subdiapgragm or supraclavicular, lateral thoracic region.

Clinical manifestation

• s/s — infrequently at early stage. • Retrosternal discomfort, pain sensatin of

frication, burning. • Slow passage of food during swallowing. • Progressive dysphagia — first solid food,

then soft food, then liquid. • Melena, hematemess, anemia, weight loss,

hoarseness, hiccough, cachexia.

Diagnostic studies

• Cytologic screening

• Upper GI series

• CT

• Endoscopy

• Endoscopic ultrasonography

• Bronchoscopy: evaluation the tracheal or bronchial invasion.

Cytologic screening

• Screen asymptomatic people in high-incidence area.

• Obtain smear of esophageal mucosa with abrasive balloon catheter.

Upper GI series

• Diffucult in demonstration the early lesion

• Length of lesion, not correlate with degree of tumor penetration.

• Longer than 10 cm is incurable.

• Esophageal axis, 74% tumor penetrated wall associated with axis abnormalities.

• Demonstration tracheoesophageal fistula.

CT• Four stage — I — intralumonal mass without wall thickening. II — wall thickening. III — tumor spread into adjacent tissue. IV — distal meatastases. • Identified lymph node. • Aortic invasion: loss fat planes and contact less

hen 45 degree — invasion unlikely; exceed 90 degree — invasion real possibility.

• Invasion to pericardium is difficult to detect.

Endoscopy

• Essential in all patients. • Biopsy should be done in all cases. • Positive diagnosis 90%. • If no lesion—mucosal stain— Toluidine blue stain — the tumor cell not

the normal nucosa. Lugol’s solution stain — the normal cell

not the tumor cell.

Endoscopic ultrasonography

• —detailed studies the structure of esophageal wall and periesophageal tissue.

Staging

• —TNM system.

Surgical therapy

• Transthoracic, trandhiatal esophagectomy.

• Reconstruction.

• Respectability rate—45%-56%.

• Morbidity—most respiratory complication.

• Mortality—0.8%-12%.

• Surgical result—long-term survival is poor.

Resection plus adjuvant therapy

• Preoperative radiation therapy

• Postoperative irradiation

Preoperative radiation therapy

• Tumor became smaller and softer.

• Less infiltrating tissue plane develop.

• Increase respectability.

• Long term survival unchanged.

Postoperative irradiation

• No survival advantage.

• Significant reduction in local recurrence.

• High incidence of complication related the transposed intrathoracic stomach.

Chemotherapy

• Response rate — 40-60%.

• Neoadjuvant chemotherapy.

Fate of surgically resected patient

• Survive more than 5 year tend to have the follow prognostic factors—

Small tumor less than 5 cm long.

No invasion to advantia.

No lymph node involvement.

Age younger than 60 year.

Women.

Radiation therapy