SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS

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SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS

• GENERAL THORACIC SURGERY
• CHAPTER 143

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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.

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Pathology

• Rare below age 30.
• Common located in middle-third(carina to inferior
  pulmonary vein).
• Microscopic feature
• Early-stage esophageal cancerintraepitherlial,
  intramucosal, submucosal carcinoma.
• No lymph node metastases.

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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.

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Metastases

• Direct extension.
• Lymphatic metastases (60).
• Hematogenous metastases(50-63).
• Distal metastases 25-30 at time of diagnosis.

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Metastases

• Intraesophageal spreadmicroscopic spread is
  greater than macroscopic spread.
• Submucosal lymphatic spread occurs often, may
  result in tumor emboli producing skip or
  satellite nodules.

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Metastases

• Direct extensiontumor 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.

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Metastases

• Lymphatic spreadthe 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.

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Lymph node station

• 1 the paraesophageal lymph node.
• 2 periesophageal, celiac perigastric lymph
  node.
• 3 the distal subdiapgragm or supraclavicular,
  lateral thoracic region.

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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.

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Diagnostic studies

• Cytologic screening
• Upper GI series
• CT
• Endoscopy
• Endoscopic ultrasonography
• Bronchoscopy evaluation the tracheal or
  bronchial invasion.

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Cytologic screening

• Screen asymptomatic people in high-incidence
  area.
• Obtain smear of esophageal mucosa with abrasive
  balloon catheter.

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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.

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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.

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Endoscopy

• Essential in all patients.
• Biopsy should be done in all cases.
• Positive diagnosis 90.
• If no lesionmucosal stain
• Toluidine blue stain the tumor cell not the
  normal nucosa.
• Lugols solution stain the normal cell not
  the tumor cell.

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Endoscopic ultrasonography

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

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Staging

• TNM system.

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Surgical therapy

• Transthoracic, trandhiatal esophagectomy.
• Reconstruction.
• Respectability rate45-56.
• Morbiditymost respiratory complication.
• Mortality0.8-12.
• Surgical resultlong-term survival is poor.

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Resection plus adjuvant therapy

• Preoperative radiation therapy
• Postoperative irradiation

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Preoperative radiation therapy

• Tumor became smaller and softer.
• Less infiltrating tissue plane develop.
• Increase respectability.
• Long term survival unchanged.

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Postoperative irradiation

• No survival advantage.
• Significant reduction in local recurrence.
• High incidence of complication related the
  transposed intrathoracic stomach.

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Chemotherapy

• Response rate 40-60.
• Neoadjuvant chemotherapy.

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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.

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Radiation therapy