11-7 (3,4) Esophagus Neoplastic

Front 1

Esophageal CA types

Back 1

-Squamous Cell Carcinoma
-Adenocarcinoma
Adeno>SCCA (but roughly 50/50)
-both: avg. age of onset=70

Front 2

Esophageal SCCA

Back 2

Squamous Cell Carcinoma:
-from squamous epithelium.
-Composed of solid nests/cords of squamous cells +/- keratin pearls

Front 3

Esophageal Adeno CA

Back 3

Composed of glands
Arises from either:
a.normal simple columnar glandular epithelium
b.exocrine glands-mucus glands
c.metaplastic glandular epithelium

Front 4

Esophageal Cancer presentation

Back 4

Almost always: dysphagia
Sometimes: weight loss(bad)->mets disease
Less common:
Chest pain
GI bleeding
Shortness of breath
Occasionally: with distant metastatic disease

Front 5

gross morphology type for malignancies

Back 5

Fungating=Polypoid=Exophytic:
-grows into lumen
Infiltrating:
-grow into wall then spreads laterally
Ulcerating:
-grow deeply into wall w/ necrosis

Front 6

Basic esophageal cancer epidemiology

Back 6

-uncommon in US
-Avg. age of onset=70

Front 7

SCCA Epidemiology

Back 7

More common in African-Americans
More common in lower SES(poor)
smoking
EtOH
toxic ingestions

Front 8

Esophageal Adenocarcinoma Epidemiology

Back 8

More common in Caucasians(like berretts)
Strongly associated with reflux symptoms(GERD) and the development of Barrett’s esophagus

Front 9

Esophageal cancer DDx

Back 9

-Esophageal strictures
-Extrinsic compression of the esophagus (other cancers, aneurysms, etc)
-Viral infection of the esophagus
-Benign esophageal growths
-Erosive esophagitis

Front 10

Esophageal Adenocarcinoma Basics

Back 10

-almost all from Barrett's epith
-few from esoph mucus glands

Front 11

Esophageal Adenocarcinoma Natural history

Back 11

10% of patients with Barrett metaplasia → adenocarcinoma
Risk related to:
-length of the metaplastic segment
-presence and degree of dysplasia

Front 12

Esophageal Adenocarcinoma Pathogenisis

Back 12

Continued reflux of gastric contents
->Continued injury of metaplastic epithelium
->↑ mitosis as epithelium regenerates
->↑opportunities for genetic alterations
->Dysplastic changes
-can → AdenoCA

Front 13

Esophageal dysplasia Histopathology

Back 13

Dysplasia-typified by nuclear changes:
-large(↑N/C ratio
-pleomorphic(diff shape/size)
-hyperchromatic
-prominent nucleoli
at multiple levels in the cell(normally all basal)
-↑mitotic figures

Front 14

Esophageal Adenocarcinoma Gross Pathology

Back 14

-in distal esophagus(site of Barretts)
-any pattern:(fungating, ulcerating, infiltrating)

Front 15

Esophageal Adenocarcinoma Histopathology

Back 15

Invasive atypical glands

Front 16

Esophageal SCCA causes/RF's

Back 16

Dietary factors (ETOH, others)
Environmental factors(tobacco use, others)
Esophageal diseases (chronic esophagitis, others)
Genetics (blacks > other races)

Front 17

Esophageal SCCA Gross

Back 17

Any where in esophagus
Any pattern(fungating, ulcerating, infiltrating)

Front 18

Esophageal SCCA Histopathology

Back 18

Nests/cords of atypical squamous epithelial cells in desmoplastic (fibrotic) stroma
-secrete growth factors(cause fibrosis)

Front 19

Growth of Esophageal malignancies

Back 19

1.Circumferential growth can lead to stenosis and obstruction of lumen → dysphagia
2.Invasion into neighboring structures is common.

Front 20

Esophageal cancer testing

Back 20

-Diagnosis almost always made by endoscopy(need biopsy to say what type)
-May be preceded by barium esophagram
-CT scan, MRI and EUS(ultrasound on endoscope)->extent of the tumor

Front 21

Esophageal cancer Therapy

Back 21

Resection = best hope for cure
-Tough surgery(back of chest)
-30-40% morbidity, 2-5% mortality
Rads/Chemo usually palliative, occasionally curative
May use rads/chemo pre-op to shrink tumor
Can use lasers endoscopically to cut away tumor for palliation
Can place stents inside esophagus to open it

Front 22

Esophageal Cancer Outcomes

Back 22

Most cancers present at a stage too advanced for a cure
Overall, survival is dismal:
-1 year survival = 18%
-5 year survival = 5%
Even those considered “resectable” have 5 yr survival <50%

Front 23

Benign Esophageal Tumors

Back 23

1.leiomyomas(from smooth muscle=leiomyoma, don't do anything)
2.esophageal cysts
3.fibrovascular polyps
4.papillomas
5.granular cell tumors
6.Lipomas
Most occur submucosally
Endoscopic ultrasound helps determine histology

Front 24

Shotzky’s Ring

Back 24

stricture at the junction b/w esophagus and stomach

Front 25

Complications of esophageal malignancy

Back 25

Nodal Mets
Local infiltration
visceral mets

Front 26

Esophageal malignancy Nodal mets

Back 26

Upper 1/3 → cervical & supraclavicular nodes
Mid 1/3 → hilar & tracheal nodes
Lower 1/3 → gastric & celiac nodes

Front 27

Esophageal malignancy Local infiltration

Back 27

No serosa(around esoph) → infiltrates neighboring structures:
-Recurrent laryngeal n. → hoarseness
-Trachea → cough
-Aorta → hemorrhage

Front 28

Esophageal malignancy Visceral mets

Back 28

-Skin
-Liver
-Lungs
-etc.