Thank you for joining me on this
discussion of esophageal cancer
in the section of cardiothoracic surgery.
Unfortunately, esophageal cancer
patients don't typically do very well.
Let's start discussing the esophageal cancer types.
Squamous cell cancer of the esophagus
is associated with smoking and drinking.
But don't forget that chronic reflex
also can lead to esophageal cancer.
Do you remember our discussion
about gastroesophageal reflux disease
and Barrett's esophagus?
In chronic reflux disease,
patients tend to get adenocarcinomas.
What are some physical
findings of esophageal cancer.
In late disease,
patients can have dysphasia.
And this dysphasia may be progressive.
The reason is, as the tumor grows,
the lumen of the esophagus is narrowed.
Additionally, similarly with all other
patients presenting with dysphasia,
inability to tolerate PO may lead to
weight loss, and this can be significant.
Additionally, as you may remember,
any patient with cancer also
secrete tumor necrosis factor,
which can cause anorexia.
Unfortunately, no routine laboratory
studies is indicative of esophageal cancer.
Typically, an EGD is necessary.
An EGD is performed by a GI doctor.
And in this image, on the left,
you notice there is a mass.
Distally, you see the GE junction,
also known as the lower esophageal sphincter.
On the right of the screen,
you note a normal esophagus.
Here, you see a retroflex view of the EGD.
This image actually shows a proximal stomach
or lower esophageal sphincter cancer.
In these situations, although it
may involve the esophagus,
it is treated like a proximal stomach tumor.
Tumor staging is very important for esophageal cancer.
And like all oncologic processes, it's done
according to the AJCC TNM system.
T for tumor,
N for node status or lymph node involvement.
And M for metastasis or distant spread.
For esophageal cancer, especially because
of its invasive nature, the T is very important.
Let’s discuss little bit what the tumor staging involves.
T1 disease are masses that invades the submucosa.
T2 invades the muscularis.
T3 invades the adventitia.
And lastly, T4 invades adjacent structures.
These are more advanced disease.
In this schematic, you notice that there
is a dot in the middle of the esophagus.
That's actually the endoscopic ultrasound probe.
Endoscopic ultrasound probe
has given us incredible images to allow us to
accurately determine the actual depth of invasion.
Now, radiographic imagings,
this is a barium swallow examination.
And although highlighted in the green circle
is a lesion that appears to be apple core in nature,
which is in fact the esophageal cancer.
This finding is rare, though, on normal routine scans
unless it's late in the course of the disease
and the mass is large enough
to show the actual defect.
Vast majority of the time, the patients undergo
EGD and potentially axial images by CAT scan.
In this image, you notice a combined
anatomic CT scan as well as a PET scan.
Remember, cancers are PET-avid.
Now, remember I talked about endoscopic ultrasound.
It's incredibly important to use endoscopic ultrasound
to evaluate for the depth of penetration
as well as endobronchial involvement.
Remember, the esophagus sits very, very
close to the trachea and main airways.
Invasion of these structures is a poor prognostic sign.
Here, you see an endotracheal ultrasound,
showing invasion, highlighted by the green.
Now, before moving to surgery, if you’ve
determined that the patient has advanced cancer,
neoadjuvant chemo radiation therapy
is actually standard protocol as first-line
therapy for higher stage cancers.
Neoadjuvant means you have curative intent surgically,
but the patient receives chemoradiation
before surgery actually occurs.
And when the patient has had neoadjuvant
therapy or if clinically appropriate,
the patient undergoes an esophagectomy.
An esophagectomy is a large, morbid case.
And before surgery,
you will want to make sure that your patient
can tolerate the procedure from a cardiac standpoint.
Esophagectomy involves removing the section
around the tumor and reconstructing the GI system.
This can involve using the stomach
or the colon as a conduit.
The conduit is usually brought into
the chest and a connection is made.
Unfortunately, given the number of
layers of lining in the esophagus,
these anastomoses or connections
are prone to anastomotic leaks.
Anastomotic leaks in these patients
are fraught with complications
and can lead to septic shock.
Now, it's time to visit some important
clinical pearls and high-yield information.
Remember, extensive metastatic workup should
be completed prior to resection of the esophagus,
particularly if the patient may be
a candidate for neoadjuvant therapy.
Additionally, if the patient has metastatic disease,
you should not offer the patient a
morbid procedure such as esophagectomy.
At that point, the patient is likely
a candidate either for clinical trials
or palliative surgery.
And remember, the gastroesophageal junction cancers
are treated like stomach cancers.
Thank you very much for joining me
on this discussion of esophageal cancers.