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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

SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS

GENERAL THORACIC SURGERY

CHAPTER 143

etiology
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
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
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
Metastases
  • Direct extension.
  • Lymphatic metastases (60%).
  • Hematogenous metastases(50-63%).
  • Distal metastases — 25-30% at time of diagnosis.
metastases7
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.
metastases9
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.
metastases10
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
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
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
Diagnostic studies
  • Cytologic screening
  • Upper GI series
  • CT
  • Endoscopy
  • Endoscopic ultrasonography
  • Bronchoscopy: evaluation the tracheal or bronchial invasion.
cytologic screening
Cytologic screening
  • Screen asymptomatic people in high-incidence area.
  • Obtain smear of esophageal mucosa with abrasive balloon catheter.
upper gi series
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.
slide19
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
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
Endoscopic ultrasonography
  • —detailed studies the structure of esophageal wall and periesophageal tissue.
staging
Staging
  • —TNM system.
surgical therapy
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
Resection plus adjuvant therapy
  • Preoperative radiation therapy
  • Postoperative irradiation
preoperative radiation therapy
Preoperative radiation therapy
  • Tumor became smaller and softer.
  • Less infiltrating tissue plane develop.
  • Increase respectability.
  • Long term survival unchanged.
postoperative irradiation
Postoperative irradiation
  • No survival advantage.
  • Significant reduction in local recurrence.
  • High incidence of complication related the transposed intrathoracic stomach.
chemotherapy
Chemotherapy
  • Response rate — 40-60%.
  • Neoadjuvant chemotherapy.
fate of surgically resected patient
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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