Tumors of the esophagus

1. Benign - most often a leiomyoma.
2. Malignant – squamous cell carcinoma (90%), adenocarcinoma and melanoblastoma (10%).

Benign tumors of the esophagus

1. Intramural (solid or cystic) - leiomyoma, fibroma, lipoma, hemangioma, congenital or retention cysts.
2. Intraluminal (pedunculated or sessile polyps) – adenoma, papilloma, fibrolipoma, myxoma.

• Mostly no problems, rarely bleeding or dysphagia;
• Diagnosis endoscopically or X-ray (contrast passage);
• Indications for removal are clinical difficulties or the impossibility of excluding malignancy - it is performed endoscopically, enucleation of intramural tumors or wedge resection from thoracotomy or thoracoscopically.

Malignant tumors of the esophagus

• Esophageal cancer is most common between the ages of 50 and 70. per year, more in men, the highest incidence is in China;
• Risk factors are exogenous (smoking, alcohol, spicy diet, lack of vitamins) and endogenous (precancers - hiatal hernia, Barrett's esophagus, achalasia, Plummer-Vinson syndrome, post-cautery strictures);
• Five-year survival prognosis is 10%.

Microscopy

File:Spinocel.esophagusJPG.JPG

Esophageal squamous cell carcinoma, endoscope view.

Esophageal squamous cell carcinoma (same patient), endoscope view after the use of Lugol's solution, which better illuminates the extent of the lesion.

Barrett's esophagus

• 90% squamous cell carcinoma;
• 10% adenocarcinoma (mainly distal esophagus and GE junction underlying Barrett's esophagus); currently, adenocarcinoma predominates.
• Melanoblastoma.

Macroscopy

• The tumor can be exophytic (polyp), superficially infiltrating (circular narrowing of the lumen of the esophagus with subsequent longitudinal submucosal spread) or ulcerous;
• The most common tumors are in the middle thoracic esophagus;
• Difficult differentiation of tumors of the terminal esophagus from tumors of the cardia (an adenocarcinoma of the esophagus is considered to be one whose volume is more than 80% located in the esophagus) - tumors of this area are divided into:
• Types:
  • type I – ca in the distal (Barrett's) esophagus;
  • type II – ca cardia;
  • type III – subcardiac (fundus) approx.

TNM classification

• T1 – mucosa or submucosa;
• T2 – muscularis externa infiltration;
• T3 – adventitia infiltration;
• T4 – moving to the surroundings;
• N1 – regional nodes (cervical in the cervical section of the esophagus, mediastinal and perigastric in the thoracic section);
• M1 – distant metastases.

Esophageal cancer spread

• Continuously - per continuitatem to the surroundings (trachea - fistula with aspirations and bronchopneumonia, mediastinum, lungs, pleural and pericardial cavity);
• Lymphogenic - mediastinal and paratracheal nodes, subdiaphragmatic gastric nodes;
• Hematogenously – liver, lung, rarely bone and CNS.

Clinical picture

• Progressive dysphagia and odynophagia (late symptom);
  • dysphagia initially for solid food (as opposed to achalasia, where the passage of liquids is impaired and solid food passes through);
• Retrosternal pain, weight loss, anemia, aspiration pneumonia.

Diagnosis

• Endoscopy with biopsy;
• CT of the chest and abdomen (tumor extent, distant metastases);
• EndoUZ (tumor growth into the surrounding area, involvement of nodes);
• Staging (distant metastases – PET/CT, lung X-ray, liver ultrasound, skeletal scintigraphy);
• Other – X-ray passage of contrast material through the esophagus, NMR, bronchoscopy (tracheobronchial invasion is a contraindication to esophagectomy);
• Laboratory examination: tumor markers CEA, SCC.

Treatment

Surgical and endoscopic

Radical:

• Stage Tis or T1 tumors can be treated with endoscopic mucosectomy;
• For more advanced tumors, different types of esophagectomies (for tumors in the GE junction area with different types of gastrectomy – total gastrectomy or just resection of the cardia) with mediastinal and celiac lymphadenectomy and replacement of the esophagus with a tubularized stomach, colon or small intestine, resections can be performed classically from a thoracotomy and laparotomy or only from a cervical approach and laparotomy with transhiatal stripping of the esophagus (for high-risk patients, where thoracotomy can thus be avoided), possibly also using video-assisted thoracoscopy;
• Contraindications for esophagectomy are distant metastases and tumor growth into the tracheobronchial tree.

Palliative:

• Dilatation of tumor stenoses:
  • laser recanalization (recurrences occur after it);
  • introduction of stents – coated expandable stent (at the same time the best option);
  • Haring's endoprosthesis (no longer used today, many complications including pressure sores of the esophageal wall);
• Palliative bypasss – stomach, intestine;
• Gastrostomy (surgical or endoscopic - PEG).

Radiotherapy

• Low radiosensitivity (more in squamous cell carcinoma);
• Neoadjuvant (improvement of operability) and adjuvant (residue removal) are performed, as well as for inoperable tumors;
• Brachyradiotherapy is also used (palliatively to open stenoses).

Chemotherapy

• Low sensitivity;
• The combination of cisplatin and 5-fluorouracil is most often used;
• It is performed both neoadjuvantly and adjuvantly.

 For more information see Cytostatics.

Photodynamic treatment

• Activated porphyrin is selectively absorbed by tumor tissue, after laser irradiation it forms oxygen radicals causing necrosis of the tumor;
• Also being tested in Barrett's esophagus.

Links

Related Articles

• Esophageal disease
• Esophageal reflux disease

Source

• PASTOR, Jan. Langenbeck's medical web page [online]. [cit. 2009]. <http://langenbeck.webs.com>.