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SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS . GENERAL THORACIC SURGERY CHAPTER 143. ETIOLOGY. No specific etiology agent. Poverty and malnutrition. High dietary content of nitrosamines, nitrites. Tobacco, betel nut, chronic esophageal irritation. Lye burn.

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SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS

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SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS

GENERAL THORACIC SURGERY

CHAPTER 143


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.


Pathology

  • Rare below age 30.

  • Common located in middle-third(carina to inferior pulmonary vein).

  • Microscopic feature—

    Early-stage esophageal cancer—intraepitherlial, intramucosal, submucosal carcinoma.

    No lymph node metastases.


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.


Metastases

  • Direct extension.

  • Lymphatic metastases (60%).

  • Hematogenous metastases(50-63%).

  • Distal metastases — 25-30% at time of diagnosis.


Metastases

  • Intraesophageal spread—microscopic spread is greater than macroscopic spread.

  • Submucosal lymphatic spread occurs often, may result in tumor emboli producing skip or satellite nodules.


Metastases

  • Direct extension—tumor 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.


Metastases

  • Lymphatic spread—the 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.


Lymph node station

  • 1 — the paraesophageal lymph node.

  • 2 — periesophageal, celiac perigastric lymph node.

  • 3 — the distal subdiapgragm or supraclavicular, lateral thoracic region.


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.


Diagnostic studies

  • Cytologic screening

  • Upper GI series

  • CT

  • Endoscopy

  • Endoscopic ultrasonography

  • Bronchoscopy: evaluation the tracheal or bronchial invasion.


Cytologic screening

  • Screen asymptomatic people in high-incidence area.

  • Obtain smear of esophageal mucosa with abrasive balloon catheter.


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.


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.


Endoscopy

  • Essential in all patients.

  • Biopsy should be done in all cases.

  • Positive diagnosis 90%.

  • If no lesion—mucosal stain—

    Toluidine blue stain — the tumor cell not the normal nucosa.

    Lugol’s solution stain — the normal cell not the tumor cell.


Endoscopic ultrasonography

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


Staging

  • —TNM system.


Surgical therapy

  • Transthoracic, trandhiatal esophagectomy.

  • Reconstruction.

  • Respectability rate—45%-56%.

  • Morbidity—most respiratory complication.

  • Mortality—0.8%-12%.

  • Surgical result—long-term survival is poor.


Resection plus adjuvant therapy

  • Preoperative radiation therapy

  • Postoperative irradiation


Preoperative radiation therapy

  • Tumor became smaller and softer.

  • Less infiltrating tissue plane develop.

  • Increase respectability.

  • Long term survival unchanged.


Postoperative irradiation

  • No survival advantage.

  • Significant reduction in local recurrence.

  • High incidence of complication related the transposed intrathoracic stomach.


Chemotherapy

  • Response rate — 40-60%.

  • Neoadjuvant chemotherapy.


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.


Radiation therapy


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