RECOMENDACIONES

• Squamous cell carcinoma- Most common worldwide

• Adenocarcinoma - Most common in most Westernised countries • Oat cell carcinoma

Site;

• 20% - Upper ⅓ - Squamous cell carcinoma • 50% - Middle ⅓ - Squamous cell carcinoma • 30% - Lower ⅓ - Adenocarcinoma

Spread;

• Locoregional - Occurs through submucosal infiltration of the wall of the oesophagus into adjacent structures, along the length of the oesophagus in the submucosal lymphatics & to regional lymph nodes.

This is often discontinuous i.e. distant regional lymph nodes may be invaded even when local nodes are free of tumour, & there may be satellite nodules in the oesophagus proximal to the main tumour.

• Systemic (Haematogenous) - Mainly to the liver & lungs, but practically any organ can be involved

S/S

• Progressive Dysphagia • Retrosternal chest pain • Weight loss

• Lymphadenopathy (rare) • S/S of Upper ⅓ of oesophagus;

- Hoarseness - due to recurrent laryngeal nerve palsy - Cough (may be paroxysmal if aspiration pneumonia) • If anaemic, r/o Ca Stomach that has migrated upwards

DDx -

Ix

• Endoscopic U/S with Biopsy/Brushings (Gold standard) - Determines the extent of local regional spread • Bronchoscopy should be done in lesions of the upper or middle ⅓, where there is potential for tracheo-

bronchial invasion.

• CT/MRI of Chest & Abdomen - To assess 1° lesions & to exclude metastatic disease from the lungs &

liver; On CT, tumour oedema may give a false positive indication of the spread of the tumour.

• CXR - to exclude metastatic disease from the lungs; - Pleural effusions

- Fistulas

- Lung destruction

- Diaphragmatic paralysis if lesions involve the phrenic nerve • Abdominal U/S - Indicated for;

- carcinomas from 35cm & lower down - to exclude metastatic disease from the liver

- differentiate tumours from oedematous surroundings seen on CT

• Staging laparoscopy is useful for assessing Adenocarcinoma of the distal oesophagus, particularly if it is likely to extend below the phreno-oesophageal ligament. Also, transperitoneal spread & liver metastasis • Barium swallow - Shows the lesion & extent of adjacent spread (kinking) for radiotherapy purposes

TNM Staging

Tis Carcinoma-in-situ

T1 invading lamina propria/submucosa T2 invading muscularis propria

T3 invading adventitia

T4 invasion of adjacent structures NX, N0, N1

M0 no distant spread

M1 distant metastasis; Spread to the coeliac axis nodes from a lesion in the intrathoracic oesophagus - Regarded as metastatic (M) rather than nodal (N) disease in the TNM classification.

Mx

i) Tis may be cured by endoscopic mucosal resection.

ii) Localised T1/T2;

` Chemo-radiotherapy without surgery for Proximal SCC - may be the definitive treatment but poses technical problems at the lower end of the oesophagus - Curative

` Neo-adjuvant chemotherapy (Cisplatin + 5FU) + Radical Curative Subtotal Oesophagectomy; * an appropriate length of the oesophagus (with generous proximal clearance (at least

5cm) to give the best chance of clearing satellite nodules in the submucosal lymphatics - usually resected just below the thoracic inlet)

* any involved stomach - (the cardia & the upper part of the lesser curvature including the

whole left gastric artery)

* locoregional lymphatics

The oesophagus is anastomosed to the fundus by hand or staple anastomosis (latter reduces hospital stay but has no real benefit).

The viability of the transposed stomach mainly depends on the right gastroepiploic vessels, with a small contribution from the right gastric.

Types of Curative Subtotal Oesophagectomy;

a) Trans-hiatal oesophagectomy is the fastest & is associated with less morbidity. The stomach is mobilised through a midline abdominal incision & the cervical oesophagus is mobilised through an incision in the neck - For Upper & Lower ⅓

Disadv - Blunt blind transection

b) 2 stage Ivor Lewis (or Lewis Tanner) operation - The abdomen is opened first through a midline incision, closed & then the oesophagus is approached from a right thoracotomy (the

left side has the descending aorta) above the 5th _{rib is performed - For lower ⅓}

c) 3 stage McKeown operation - As Ivor Lewis (above) but a third incision on the left side of the neck is made to complete the cervical anastomosis. A neck incision is required if;

* a lymph node dissection is to be done

* there are technical difficulties with an anastomosis at the thoracic inlet - For upper & middle ⅓s

d) Thoracoabdominal - Abandoned Post-op;

• A chest tube is left in place after thoracotomy

• NPO for 5-7days & then perform a contrast swallow (Methylene Blue, Gastrograffin, Dilute Barium) to detect leakage. If present, NPO is maintained until it has healed.

C/I;

• Advanced nutritional debilitation • Inadequate pulmonary reserve • Widespread metastases;

- Malignant effusion or ascites - Recurrent laryngeal nerve palsy - SVC syndrome

- Malignant TEF Complications;

• Strictures (Benign or malignant)

• Anastomotic leak - The Mc Keown operation is preferred as leakage is within the neck & usually closes with time but the Ivor Lewis operation leaks into the pleural cavity → Pleural effusion

• Recurrent laryngeal nerve injury • Chylothorax

• DVT

iii) Advanced disease (T3/4) - Palliative therapy to restore swallowing; a) Chemo/radiotherapy - for upper ⅓ tumours

b) Intubation - For middle & lower ⅓ tumours; Not for upper ⅓ as the tube may become displaced upwards & may block the airway. It is inserted by;

- Oesophagoscopy - Pulsion tubes e.g., Proctar Livingstone, Atkinson, Souttar tubes

- Laparotomy - Traction tubes e.g. Celestin tube (rubber), Mousseau-Barbin tube (Plastic) Unfortunately, the tube has a tendency to become dislodged or blocked with food, thus aggravating pain. Furthermore, concomitant radiotherapy increases the complications of tubes e.g., bleeding,

perforation. Therefore, intubation should be reserved for patients with extensive disease and a life expectancy limited to 1-2 months.

c) Laser therapy - a core of tumour is vaporized, opening the lumen without perforating the

oesophagus.

d) Stenting

Prognosis

* Resectable rate - 30%

* 5YSR - 5-10% (KNH - 25%)