Esophageal Cancer

1
Esophageal Cancer

• Victor Ghobrial, MD
• Hira Koul, MD
• Temple University
• Conemaugh Memorial Hospital

2
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

3
PMH

• GERD since 1992
• Had hiatal hernia w required Nissen
  Funduplication (1992)
• Intermittent heartburn, indigestion.
• Spontaneous retinal detachment.
• No CAD, HTN, DM or cancer

4
ROS

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

5
Physical Exam

• Appears cachectic in distress cause of epigastric
  pain.
• Vital WNL
• Ht Lungs clinically free
• Abdomen soft no organomegally, epigastric
  tenderness.

6
EGD

• Barrettes mucosa in the distal esophagus.
• Large ulcerating GE junctional area with active
  bleeding from a Mallory-Weiss tear
• Bleeding was stopped by BICAP electro-coagulation.
  
• No other pathology was revealed in gastric mucosa.

7
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

8
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 Caucasians

9
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.

10
Difficulties of Dx

• Different identifications of GE junction by
  anatomists, radilogists, physiologists and
  endoscopists.
• Associated hiatal hernia hides Barrettes.
• Columnar epithelium, reddish and velvet-like
  texture, distinguished from the pale, glossy
  squamous epithelium of the esophagus.

11
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
12
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
(?). (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.)
13
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.

14
The 2nd EGD

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

15
Ulcerating malignant esophageal mass in distal
esophagus seen on endoscopy. Courtesy of William
Brugge, MD.
16
Pathology

• Moderate to poorly differentiated adenocarcinoma

17
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

18
Epidemiology of Esophageal Cancer in the United
States

• Squamous Adeno
• New cases per year 6000 6000
• Male-to-female ratio 31 71
• Black-to-white ratio 61 14
• Most common locations middle distal
• Major risk factors smoking Barretts
• alcohol esophagus

19
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.

20
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)

21
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

22
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

23
Risk Factors

• Increased esophageal acid exposure (such as
  Zollinger-Ellison syndrome)
• Helicobacter pylori infection Probable
  protective role from chronic infection.

24
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.

25
Early, superficial esophageal cancer on
endoscopy. Courtesy of William Brugge, MD
26
Circumferential ulceration esophageal cancerseen
on endoscopy. Courtesy of William Brugge, MD
27
Malignant stricture of esophagus The tumor mass
is not readily evident because it is
predominantly infiltrating the esophageal wall.
Courtesy of William Brugge, MD.
28
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

29
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.

30
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.

31
study...

• 158 patients at high risk of SCC12 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.

32
Take home message

• Surgical repair for symptoms of GERD did not
  prevent development of AC on top of Barrettes
  esophageous in this pt.
• Periodic endoscopy in Barrettes is needed
• No single modality is known to reverse the
  mucosal dysplasia in Barrettes as of yet. (Argon
  LASER Rx still under trial)