ESOPHAGUS:

Anatomy:

• Muscular tube (C6 – T12)
• Extends from cricopharyngeous muscle to cardiac sphincter
• 4 Layers: mucosa, submucosa, muscularis, adventita
• Lined with squamous cells to columnar cells
• The esophagus lies directly posterior to the trachea and is anterior to the vertebral column
• Located laterally and to the left of the esophagus is the aortic arch

• LEVELS OF ESOPHAGUS (3):
  • Upper : extends from cricoid to thoracic inlet (C6 – T 2/3)
  • Middle : Suprasternal Notch to carina
  • Lower: carina to GI Junction

View of a Normal Esophagus:

Normal Healthy Esophagus

Non-Malignant Conditions:

Barretts Esophagus:

• Condition in which the distal esophagus is lined with columnar epithelium rather than stratified Squamous epithelium

• Precursor to cancer through metaplasia of the cells
• Occurs frequently in Blacks with GERD

Barretts Esophagus

Candida Esophagus:

• is a fungal or yeast infection of the esophagus.  It is caused by the yeast Candida.

• Occurs frequently in AIDS patients

Candida Esophagus

Hiatal Hernia:

•  In a hiatal hernia, part of the stomach moves through the  diaphragm so that it is positioned outside of the abdomen and in the chest  cavity. The valve (lower esophageal sphincter)  between the esophagus and the stomach often moves above the diaphragm.
• Can be a precusor to cancer because acids from the stomach are now in the esophagus

Hiatal Hernia

Achalasia:

• Is a disorder where the lower 2/3rds of the esophagus has lost its normal peristaltic activity
• Clinical symptoms

• Progressive dysphasia and regurgitation of food
• Patients have a 5-20% chance of developing cancer

Esophageal Varices:

• Hemmorhoids of the esophagus
• Usually occurs in alcoholics

Esophageal Varices

Epidiemiology:

• 7 X more common in males
• usually occurs in peoples 60’s (7th decade of life)
• adenocarcinomas is the most common and more common in White people
• Squamous cell carcinoma is 3 X more prevelant in Blacks
• Overall Cancer of the Esophagus is 20 X higher in China the than in the United States

Etiology:

• Alcohol
• Smoking
• Diet outside the United States it is associated with geography.  Such as soil, regional diets (nitrates in soil)
• Other pathologies can contribute:
• Tilosis : highly keratinized lining of esophagus would have a higher incidence of developing cancer of the esophagus
• Plummer – Vinsin Syndrome : iron deficient anemia characterized by esophageal webs; atrophic glossitis; and spoon shaped brittle fingernails

Symptoms:

• Most common – Dysphagia
• Cannot feel the blockage in the esophagus until 1/3 – ½ is blocked off
• Weight loss (if it is greater than 10 pounds the prognosis becomes poorer)
• People become cachexic (need to be hyperalimentated)
• Cough
• Odynophagia (1st swallow pain)
• Hoarseness
• Metastasis to Bone

Lymph:

• Lymph fluid can travel the entire length of the esophagus and drain into any adjacent draining nodal bed, placing the entire esophagus at risk for skip metastasis

Diagnostic Studies:

• Dx made on endoscopic biopsy
• Endoscopic ultrasound – good to measure depth of invasion
• Barium X-Rays – can establish the length of the lesion since the tumors usually grow longitudinally
• Bronchoscopy – to determine tracheal invasion if any
• CT / PET / MRI (only done if it will change the treatment options)
• Relapse rate is extremely HIGH

Histophatology:

• ADENOCARCINOMA :
• Incidence is rising relative to Squamous cell
• MOST COMMON
• Occurs mostly in the Distal Third of the esophagus
• SQUAMOUS:
• Most common in African-Americans
• Most common world wide

Prognostic Factors:

• Depth of invasion is #1 prognostic factor
• Age : older people tend to do worse
• Karanofsky Scale ( 0 – 100 ; 0 being dead)
• Weight Loss
• NOT dependent on histology or GRADE

Treatment Options:

• Only ½ of the patients present with apparent local disease
• SURGEY OR CHEMORADIATION have similar outcomes for apparent local disease
• Post-operative CHEMORADIATION does not seem to improve prognosis
• Pre-operative CHEMORADIATION is under investigation and might be an option
• Most Commonly used chemo agent is 5FU usually along with cisplatin

CHEMORADIATION:

• Used for locally advanced disease
• 50 Gy and concurrent 5FU and Cisplatin (60 Gy with IMRT)
• investigation dose escalation with systemic therapy
• investingating BID with CHEMO

Techniques of Radiation Therapy:

• Problems : esophagus is deep in the mediastinum and surrounded by vital structures
• Dangers : patient might form a tracheoesophageal fistula (if this happens we must discontinue radiation)
• Field should extend 5 cm above and below known disease.
• Whole esophagus is usually included in field  (18 X 8)
• Conventional Treatment : (conformal / non-IMRT) : 40 Gy AP / PA with Obliques or Laterals to 60GY
• 60 GY is elevated DOSE
• 50 GY is not elevated DOSE

Palliative Treatment:

• majority of patients present with advanced disease
• Relapse occurs in 80% of those patients who are approached curatively
• Palliative bypass or Radiation Therapy for patients with no know metastesis (to keep the tube open)
• Itralumanar Brachytherapy and/or laser resection
• We must use a curative dose when treating palliativly

Outcomes and Investigations:

• Outcome remains poor for all stages
• New approaches include IMRT based therapy along with systemic therapy, brachytherapy in combination with other modalities