RTC Dec Felicitas Koller and Eric Grogan

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1 RTC Dec Felicitas Koller and Eric Grogan

2 Cancer Statistics, United States Number of patients Lung Breast New Cases Deaths Esophageal Colorectal Prostate Histology

3 Squamous Cell Worldwide >>> < Men vs. Women Age Disease Association Location Adenocarcinoma 3:1 (fifth decade) 15:1 (fifth decade) Rarely <30; mortality greatest in men Exposure to environmental factors; smoking, ETOH, pickled/smoked; deficiencies; tylosis, Plummer Vinson syndrome; end stage achalasia Squamous tissue in upper and middle third Rarely < 40, incidence increases with age Barrett s 40 fold increase Submucosal glands of esophagus; heterotopic islands of columnar epithelium; malignant degeneration of metaplastic columnar epithelium Survival 70% with polypoid; 15% advanced Nature Sensitive to chemotherapy Embedded in Barrett's esophagus, less sensitive to chemotherapy

4 Commences at C6 joins stomach at T11, usually cm long. 2.5 cm in diameter Structures: distance from incisors 13 cm cricopharyngeus 22 cm azygous vein 22 27cm carina 40 cm EG junction

5 The Layers at?? The esophagus lacks a serosa: mucosa, submucosa and muscularis propria Two interconnecting lymphatic plexuses arising from the submucosa and muscularis layers.

stomach Externally: The collar of Helvetius (or

6 GE junction at?? Endoscopically: The squamocolumnar epithelial junction (Zline) The transition from the smooth esophageal lining to the rugal folds of the stomach Externally: The collar of Helvetius (or loop of Willis) The gastroesophageal fat pad are consistent identifiers of the GEJ

7 Case Presentation 3/24/09 CC: 73 yo man with a 2 month history of progressive difficulty with swallowing. Solid foods pass the upper esophagus with some difficulty. Has no lodging, but has to drink more water No hx of esophagitis or stricture HTN, HLD, BPH, hx. of arrhythmia PSH: Anterior neck fusion WHAT ADDITIONAL HISTORY? Smoking, drinking, anemia, GERD or GERD sx, foul breath, regurgitation of food, hx of chemical or radiation exposure, medications DIFFERENTIAL DX? Obstructive lesions: tumors, inflammatory masses; Zenker's diverticulum, esophageal webs mediastinal masses,cervical spondylosis, radiation, chemical or medication induced; Schatzki's Ring, vascular compression, enlarged aorta or left atrium, aberrant vessels, lymphadenopathy, substernal thyroid Neuromuscular disorders: achalasia; DES, Hypertensive LES, nutcracker esophagus, scleroderma INITIAL TEST? Barium Swallow Why? both functional and anatomic.

8 A B C D

9 1. A=nutcracker esophagus, B=cancer C=achalasia, D= cancer 2. A=Schatzki s ring, B=cancer, C=normal, D=Barrett s esophagus 3. A=reflux, B=compression from mediastinal mass, C= normal, D=achalasia 4. A=diffuse esophageal spasm, B=Zenker s diverticulum, c=normal, d=cancer

11 EGD with biopsy tissue 1. Location (w/ respect to incisors) 2. Nature of the lesion 3. Proximal and distal extent of the lesion 4. Relationship of the lesion to the cricop., GEJ, cardia 5. Distensibility of the stomach CT scan thorax length of the tumor, thickness of the esophagus and stomach, lymph node status and distant disease to the liver and lungs PET scan primary mass, regional lymph nodes and distant disease Esophageal ultrasound depth of the tumor, the length of the tumor, the degree of luminal compromise, the status of regional lymph nodes, and involvement of adjacent structures

12 EGD: 6 7 mm, 3cm long, 28 cm from the incisors. Patchy antral erythema, normal duodenum Pathology: invasive moderately differentiated squamous cell carcinoma, vascular invasion CT: focal mid esophageal wall thickening, no adenopathy PET: intense focal FDG activity in the mid thoracic esophagus immediately posterior to the left mainstem bronchus. 3 FDG avid nodules: r of midline at the same level, subcarinal and right paratracheal

1 ST hyperechoic (white), represents the superficial mucosa (epithelium and lamina propria). 2 nd hypoechoic (black), represents the deep mucosa (muscularis mucosa).

13 1 ST hyperechoic (white), represents the superficial mucosa (epithelium and lamina propria). 2 nd hypoechoic (black), represents the deep mucosa (muscularis mucosa). 3 rd hyperechoic (white), represents the submucosa. 4 th hypoechoic (black), represents the muscularis propria. 5 th hyperechoic (white) is the periesophageal tissue.

wall pattern; B, a T2 lesion is seen as a hypoechoic

14 A, A T1 lesion is observed as a hypoechoic thickening of the mucosal layer adjacent to the normal appearing wall pattern; B, a T2 lesion is seen as a hypoechoic mass invading into but not through the muscularis propria

16 T2 N1 by EUS What s his stage What are his treatment options

Tumor Nodes Metastasis TX: Primary tumor cannot be assessed NX: Regional lymph nodes cannot be assessed MX: Distant metastasis cannot be assessed T0: No evidence of primary tumor N0: No regional

17 Tumor Nodes Metastasis TX: Primary tumor cannot be assessed NX: Regional lymph nodes cannot be assessed MX: Distant metastasis cannot be assessed T0: No evidence of primary tumor N0: No regional lymph node metastasis M0: No distant metastasis Tis: Carcinoma in situ N1: Regional lymph node metastasis M1: Distant metastasis Tumors of the lower thoracic esophagus: M1a: Metastasis in celiac lymph nodes M1b: Other distant metastasis Tumors of the midthoracic esophagus: M1a: Not applicable M1b: Nonregional lymph nodes and/or other distant metastasis Tumors of the upper thoracic esophagus: M1a: Metastasis in cervical nodes M1b: Other distant metastasis T1: Tumor invades lamina propria or submucosa T2: Tumor invades muscularis propria T3: Tumor invades adventitia T4: Tumor invades adjacent structures

18 Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 Tis, N0, M0 T1, N0, M0 Stage IIA T2, N0, M0 T3, N0, M0 T3, N1, M0 T4, any N, Any T, any N, M1 Stage IIB T1, N1, M0 T2, N1, M0 Stage IVA Any T, any N, M1a Stage IVB Any T, any N, M1b

19 1. Surgery alone 2. Surgery adjuvant chemo 3. Chemoradiation alone 4. Neoadjuvant chemoradiation and then surgery

20 Case Presentation 4/2009 6/2009 Patient receives neoadjuvant chemotherapy (cisplatin and capecitibine) as well as radiotherapy. Repeat PET imaging shows : 1.Decreased LN size with loss of FDG activity. 2.In the middle esophagus right below the carina, moderate FDG activity is seen associated with residual esophageal wall thickness. On previous scan, this was primary site of the cancer with intense FDG uptake and significant esophageal wall thickness. EGD: 1.UES was located at 19 cm from insertion, and the GE junction was located at 41 cm from insertion cm from insertion there was a partially circumferential superficial ulcer with scar tissue. There were proximal esophageal plaques consistent with candidal esophagitis. There was no Barrett's. Stomach: normal Duodenum: normal

21 Transhiatal Transthoracic (Ivor Lewis) Three field (McKeown) Minimally invasive

22 Approach / Incisions Transhiatal Transthoracic Minimally invasive Conduit Stomach Colon Jejunum, supercharged Other Anastamosis Neck Chest Route Posterior mediastinum Retrosternal Subcutaneous

23 Case Presentation JI underwent operation 7/28/09: 1. Bronchoscopy. 2. Esophagogastroduodenoscopy. 3. Laparotomy with transthoracic esophagectomy. 4. Jejunostomy feeding tube. 5. Ligation of thoracic duct. 6. Pyloroplasty Pathology: 1) ESOPHAGUS AND STOMACH, DISTAL ESOPHAGECTOMY: LIMITED RESIDUAL SQUAMOUS CELL CARCINOMA, DISTAL ESOPHAGUS, IN SUBMUCOSA AND MUSCULARIS PROPRIA, 1.8 MM IN GREATEST EXTENT; PRESENT IN A BACKGROUND OF SEVERE MUCOSAL AND SUBMUCOSAL ULCERATION; ALL SURGICAL MARGINS WIDELY FREE OF CARCINOMA; TWO LYMPH NODES NEGATIVE FOR MALIGNANCY (0/2), (SEE COMMENT). 2) LYMPH NODES, LEVEL 7, EXCISION: 3 LYMPH NODES NEGATIVE FOR MALIGNANCY (0/3). COMMENT: These findings correspond to AJCC pathologic stage yiia (ypt2n0m n/a).

24 No difference in operative time, blood loss, morbidity or mortality Survival similar Anastomotic Leak rate Cervical 11% Thoracic 6% Putnam et al., Ann Thor Surg,, 1994

27 Identified endoscopically Resection, mediastinal debridement Diversion, delayed reconstruction 50% mortality

28 Smoking cessation Enteral nutrition in pts undergoing induction tx Epidural anesthesia Bronchopulmonary hygiene Early extubation No difference between TTE and THE

29 Incidence 1 3% (TTE=THE) Suspected with high continued CT output Pleural triglycerides, lymphocytes, chylomicrons Most will not close with conservative management

30 Non operative stratagies NPO, TPN ±octreotide MCT diet ± octreotide IR embolization of thoracic duct Operative ligation VATS vs. open

Quiz Adenocarcinoma of the distal stomach has been increasing in the last 20 years. a. True b. False

Quiz Adenocarcinoma of the distal stomach has been increasing in the last 20 years. a. True b. False Quiz 1 1. Which of the following are risk factors for esophagus cancer. a. Obesity b. Gastroesophageal reflux c. Smoking and Alcohol d. All of the above 2. Adenocarcinoma of the distal stomach has been