Esophageal Cancer

Victor Ghobrial, MD Hira Koul, MD

Temple University Conemaugh Memorial Hospital

HPI
47 yrs W M was seen cause of worsening symptoms of rifting, belching, burping, epigastric distress. Pt has progressive recurrent solid food dysphagia. Also, had rifting up blood
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

PMH
GERD since 1992 Had hiatal hernia w required Nissen Funduplication (1992) Intermittent heartburn, indigestion. Spontaneous retinal detachment. No CAD, HTN, DM or cancer
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

ROS
Pt lost 30 lbs over the past few months. GI symptoms complex of hematemesis, dysphagia, burping and significant weight loss.

Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Physical Exam
Appears cachectic in distress cause of epigastric pain. Vital WNL Ht & Lungs clinically free Abdomen soft no organomegally, epigastric tenderness.
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

EGD
Barrette s mucosa in the distal esophagus. Large ulcerating GE junctional area with active bleeding from a Mallory-Weiss tear Bleeding was stopped by BICAP electrocoagulation. No other pathology was revealed in gastric mucosa.
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Barrett's esophagus
A condition in which an abnormal columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus. It is the most severe histologic consequence of chronic gastroesophageal reflux and predisposes to the development of adenocarcinoma of the esophagus
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

CLINICAL FEATURES
Discovered during endoscopic examinations of middle-aged and older adults 55 years. It rarely occurs before the age of five. Is an acquired condition, not a congenital one. Barrett's esophagus appears to be uncommon in blacks and Asians. The prevalence in Hispanics is similar to CaucasiansTemple University/Conemaugh
Memorial Hospital Esophageal CA VG/2000

Symptomatology
The columnar metaplasia in Barrett's esophagus causes no symptoms. Patients are seen initially for symptoms of the associated GERD such as heartburn, regurgitation, and dysphagia.

Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Difficulties of Dx
Different identifications of GE junction by anatomists, radilogists, physiologists and endoscopists. Associated hiatal hernia hides Barrette s. Columnar epithelium, reddish and velvetlike texture, distinguished from the pale, glossy squamous epithelium of the esophagus.
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Gastroesophageal Junction Schematic representation of the relationship between the

gastroesophageal junction, Z-line and hiatus hernia in patients with Barrettsesophagus. The Barretts mucosa and appear as the confluent area (left picture), as tongues arising from the distal esophagus (middle picture), or as patches containing islands of squamous mucosa or squamous mucosa containing islands of Barretts mucosa (right panel). Armed Forces Institute of Pathology

Barretts Esophagus
Esophagectomy specimen in a patient found to have high grade dysplasia during endoscopic surveillance. Salmon-colored Barretts mucosa has replaced the squamous mucosa circumferentially. Scattered erosions are visible (p). (From Lwein, KJ; Appelman, HD. Tumors of the Esophagus and Stomach. Atlas of Tumor Pathology (electronic fascicle), Third series, fascicle 18, 1996, Washington, DC. Armed Forces Institute of pathology.)
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Back to our pt.

Bleeding from Mallory-Weiss was stopped. Pt admitted to hosp and started on IVFs, antirelux meds. Pt was rescoped 48 h later with Bx of the ulcer.

Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

The 2nd EGD

Fungating mass at GE junction highly suggestive of malignancy. Barrette s mucosa starting 30 cm from upper incisor & border of mass at 35 cm. Bx was done.

Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Ulcerating malignant esophageal mass in distal esophagus seen on endoscopy. Courtesy of William Brugge, MD. Temple University/Conemaugh
Memorial Hospital Esophageal CA VG/2000

Pathology

Moderate to poorly differentiated adenocarcinoma

Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Esophageal Cancer
Sq cell carcinoma and adenocarcinoma account for more than 95 % of tumors. For most of the twentieth century, SCC comprised the vast majority of cancers. In the 1960s, SCC 90%. For the past two decades the two tumors now occur with almost equal prevalence
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Epidemiology of Esophageal Cancer in the United States

Squamous
New cases per year Male-to-female ratio Black-to-white ratio Most common locations Major risk factors 6000 3:1 6:1 middle smoking alcohol

Adeno
6000 7:1 1:4 distal Barrett s esophagus

Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Squamous Cell Carcinoma

The highest rates are found in Asia (particularly in China and Singapore), Africa, and Iran. Lower socioeconomic status was associated with esophageal SCC in a large population-based study.

Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Risk Factors
Smoking and alcohol Dietary factors *N-nitroso compounds (animal carcinogens)
*Pickled vegetables and other food-products *Toxin-producing fungi *Betel nut chewing *Ingestion of very hot foods and beverages (such as tea)

Underlying esophageal disease (such as

achalasia and caustic strictures)
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Risk Factors
Human papilloma virus HPV
serotype 16 was identified in 9 percent of resection specimens from 70 Chinese patients with esophageal SCC.

Tylosis rare disease associated with

hyperkeratosis of the palms of the hands and soles of the feet and a high rate of esophageal SCC
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Adenocarcinoma
AC is largely a disease of Caucasians and males Alcohol is probably not an important risk factor Obesity has been associated with AC but not SCC Smoking probably increases the risk of AC Temple University/Conemaugh
Memorial Hospital Esophageal CA VG/2000

Risk Factors
Increased esophageal acid exposure (such as Zollinger-Ellison syndrome) Helicobacter pylori infection Probable protective role from chronic infection.
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

DIAGNOSTIC TESTING
The diagnosis of esophageal cancer is usually established by endoscopy Early esophageal cancer may appear as a superficial plaque or

ulceration

Advanced lesions may appear as a

stricture an ulcerated mass or

circumferential mass or a large ulceration.
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Early, superficial esophageal cancer on endoscopy. Courtesy of William Brugge, MD Temple University/Conemaugh
Memorial Hospital Esophageal CA VG/2000

Circumferential ulceration esophageal cancer seen on endoscopy. Courtesy of William Brugge, MD

Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Malignant stricture of esophagus The tumor mass is not readily evident because it is predominantly infiltrating the esophageal wall. Courtesy of William Brugge, MD. Temple University/Conemaugh
Memorial Hospital Esophageal CA VG/2000

Biopsy
Confirm the diagnosis in more than 90% In a series of 202 consecutive patients, 47 of whom had gastric or esophageal carcinoma, the percentage of correct diagnoses of esophageal carcinoma were as follows First biopsy 93 percent Four biopsies 95 percent Seven biopsies 98 percent
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Bx...
The addition of brush cytology specimens to seven biopsies increased the accuracy to 100%. Seventeen percent of lesions thought to be benign endoscopically were subsequently proven to be malignant.
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

In vivo staining??!
(chromoendoscopy)

Lugol's iodide reacts with the glycogen components of normal squamous mucosa to produce a greenish brown color, while neoplastic tissue is depleted of glycogen and remains unstained.
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

study...
158 patients at high risk of SCC;12 had cancerous lesions identified before Lugol's staining, while 13 patients had 17 esophageal cancers noted after staining. Staining also found that endoscopy underestimated the extent of tumor.
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000

Take home message

Surgical repair for symptoms of GERD did not prevent development of AC on top of Barrette s esophageous in this pt. Periodic endoscopy in Barrette s is needed No single modality is known to reverse the mucosal dysplasia in Barrette s as of yet. (Argon LASER Rx still under trial)
Temple University/Conemaugh Memorial Hospital Esophageal CA VG/2000