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THE KURSK STATE MEDICAL UNIVERSITY
DEPARTMENT OF SURGICAL DISEASES № 1
ESOPHAGEAL TUMORS AND CYSTS
Information for self-training of English-speaking students
The chair of surgical diseases N 1 (Chair-head - prof. S.V.Ivanov)
BY ASS. PROFESSOR M.V. YAKOVLEVA
KURSK-2010
I INTRODUCTION
Benign tumors of the esophagus are rare, constituting only 0.5 to 0.8% of all esophageal
neoplasms. Approximately 60% of benign esophageal neoplasms are leiomyomas, 20% are
cysts, and 5% are polyps. Despite advances in surgery, critical care, radiotherapy, and
chemotherapy, esophageal cancer afflicts some 13,000 new patients in the United States each
year.
The disease represents 4% of newly diagnosed cancers. А major shift in the histologic type of
tumors has occurred. Traditionally, esophageal cancer has been squamous cell in patients with
the usual risk factors for other aerodigestive tract carcinomas, specifically smoking (5-fold) and
alcohol (5-fold) abuse. Heavy smoking and heavy drinking combine to increase the risk 25- to
100-fold.
II GENERAL AIM OF THE LESSION
General aim of the lesion includes:
1. Acquiring knowledge about etiology and clinical symptoms of the benign tumors and
esophageal cancer.
2. Acquiring the practical skills of the patients objective examination.
3. Mastering of the main instrumental used in this pathology.
4. Determining the indications for conservative, palliative and surgical curative treatment.
Tasks for self –training:
After individual studying of the material every student have to
A/know: 1) Etiology of the benign tumors and esophageal cancer.
2) Classification of the esophageal benign tumors and cancer.
3) Clinical picture of this pathology.
4) Instrumental methods for diagnostics, such as: X-ray examination,
esophagoscopy, CT-scaning, ultrasonography.
5) Different kinds of the palliative treatment of the esophageal cancer.
6) Surgical curative treatment of the tumors.
7) Indications for different surgical operations in depending on cancer stage.
B/be able: 1) to find out main complains and assess the present state of the patient;
2) to realize objective examination of the patient with these diseases;
3) to estimate received data of instrumental methods of examination;
4) to determine indications for palliative and surgical treatment.
IV
BRIEF OUTLINE OF THE TOPIC ( OBLIGATORY MATERIAL FOR
ACQUISITION )
Benign Esophageal Tumors
Classification of Benign Esophageal Tumors
I. Epithelial tumors
A. Papillomas
B. Polyps
C. Adenomas
D. Cysts
II. Nonepithelial tumors
A. Myomas
1. Leiomyomas
2. Fibromyomas
3. Lipomyomas
4. Fibromas
B. Vascular tumors
1. Hemangiomas
2. Lymphangiomas
C. Mesenchymal and other tumors
1. Reticuloendothelial tumors
2. Lipomas
3. Myxofibromas
4. Giant cell tumors
5. Neurofibromas
6. Osteochondromas
III. Heterotopic tumors
Leiomyomas are the most common benign tumors of the esophagus. These intramural tumors
typically occur between 20 and 50 years of age, and are multiple in 3 to 10% of patients. More
than 80% of these tumors occur in the middle and lower thirds of the esophagus, rarely in the
cervical region. Histologically, the tumors consist of interlacing bundles of smooth muscle cells
with or without calcification. These tumors do not infiltrate surrounding tissue, so the overlying
mucosa is rarely, if ever, invaded. [144]
DIAGNOSIS
Symptoms of dysphagia and vague retrosternal pressure or pain are produced only by large
tumors (larger than 5 cm). Most are found incidentally at autopsy and are asymptomatic.
Esophageal symptoms prompt performance of a barium swallow and/or an endoscopic
examination. The barium swallow appearance is distinctive because the well-localized mass has
a smooth surface and distinct margins, and it is not circumferential. Most frequently, a
leiomyoma is seen on a chest x-ray as a posterior mediastinal mass or is found unexpectedly
during endoscopic examination. During endoscopy, the mucosa is intact, and the extrinsic mass
narrows the lumen but can easily be displaced and passed with the esophagoscope.
TREATMENT.
As a general rule, excision of symptomatic leiomyomas or those larger than 5 cm is advised.
Asymptomatic or smaller tumors discovered incidentally can be observed and followed.
Esophageal resection may be required for eigher giant leiomyomas of the cardia or for
leiomyomatosis.The results of resection of leiomyomas are excellent, and recurrence has not
been reported.
Polyps of the cervical esophagus (20% of benign tumors) are intraluminal lesions that may
cause dysphagia or may even be regurgitated into the larynx with the potential for asphyxiation.
They are composed of a fibroelastic core and usually are covered with normal epithelium. The
preferred approach for resection is through a lateral cervical esophagomyotomy, thereby
delivering the polyp and resecting the mucosal origin of the pedicle under direct vision.
Esophageal polyps have also been removed endoscopically by electrocoagulating the pedicle.
Lipomas, vascular tumors, and neurofibromas are extremely rare, but they must be removed to
control symptoms or to exclude malignancy.
Esophageal Cancer
When resection is indicated, benign tumors of the middle third of the esophagus are approached
through a right thoracotomy; those in the distal third are approached through a left thoracotomy.
Carcinoma of the esophagus now appears to affect younger, healthier patients. Nutritional factors
and potential carcinogens have been incriminated, including alcohol, tobacco, zinc, nitrosamines,
malnutrition, vitamin deficiencies, anemia, poor oral hygiene and dental caries, previous gastric
surgery, and long-term ingestion of hot foods or beverages. Some esophageal lesions are
premalignant, including achalasia, reflux esophagitis, Barrett's (columnar epithelial-lined)
esophagus, [142] radiation esophagitis, [145] caustic burns, Plummer-Vinson syndrome, leukoplakia,
esophageal diverticula, and ectopic gastric mucosa.
The extensive mediastinal lymphatic drainage, which communicates with cervical and abdominal
collateral vessels, is responsible for the finding of mediastinal, supraclavicular, or celiac lymph
node metastasis in at least 75% of patients with esophageal carcinoma. Cervical esophageal
cancers drain to the deep cervical, paraesophageal, posterior mediastinal, and tracheobronchial
lymph nodes. Lower esophageal tumors spread to paraesophageal, celiac, and splenic hilar
lymph nodes. Distant spread to liver and lungs is common.
Histologically, approximately 95% of esophageal cancers worldwide are squamous cell
carcinomas. Early forms of esophageal cancer have been variously termed carcinoma in situ,
superficial spreading carcinoma, and intramucosal carcinoma. Endoscopically, carcinoma in
situ most often presents as a slightly raised, granular, reddish, plaquelike lesion.
Squamous cell carcinoma arises from the mucosa of the esophagus. Located mainly in the
thoracic esophagus, approximately 60% of these tumors are found in the middle third and about
30% in the distal third. Squamous cell neoplasms have four major gross pathologic presentations.
(1) fungating: predominantly intraluminal growth with surface ulceration and extreme friability
that frequently invades mediastinal structures; (2) ulcerating: flat-based ulcer with slightly raised
edges; hemorragic, friable with surrounding induration; (3) infiltrating: a dense, firm, logitudinal
and circumferential intramural growth pattern; and (4) polypoid: intraluminal polypoid growth
with a smooth surface on a narrow stalk (fewer than 5% of cases).
Adenocarcinoma is now the most common cell type of esophageal cancer in the United
States. Adenocarcinoma arises from the superficial and deep glands of the esophagus, mainly in
the lower third of the esophagus, especially near the gastroesophageal junction. Men have an
eightfold higher risk than women. Esophageal adenocarcinoma may have one of three origins:
(1) malignant degeneration of metaplastic columnar epithelium (Barrett's mucosa), (2)
heterotopic islands of columnar epithelium, or (3) the esophageal submucosal glands.
Symptoms of Esophageal Cancer
Symptom
Dysphagia
Weight loss
Vomiting or regurgitation
Symptoms of Esophageal Cancer
Symptom
Pain
Cough or hoarseness
Dyspnea
The tumor may be advanced sufficiently to be identified on a chest x-ray as an abnormal
azygoesophageal recess, widening of the mediastinum, or posterior tracheal indentation. A
barium swallow will show the extent of the tumor and location, if the tumor distorts the
esophageal lumen, and the presence of obstruction or fistulas. The CT or endoscopic ultrasound
examination can determine the anatomic location and enlargement of the mediastinal, perigastric,
or celiac lymph nodes. Esophagoscopy is required to diagnose and determine the extent of
longitudinal intramural tumor spread. The entire esophagus is visualized, and brush cytology
plus biopsy tissue samples may be obtained for histologic analysis.
Once the diagnosis of esophageal carcinoma has been histologically established after
esophagoscopy and biopsy, staging of the tumor is the next critical step in determining which
therapeutic option is appropriate. The stage of a tumor is classified most frequently by a TNMbased system. The "T" (tumor) indicates the progressive degree (1 to 4) of invasion of the tumor
into the esophageal wall. "N" stands for nodal involvement, and "M" represents distant
metastasis.
Lymph node involvement may be assessed by endoscopic ultrasound, CT, positron emission
tomography (PET), or video-assisted thoracoscopy and laparoscopy. Endoscopic ultrasound can
assess the size, shape, border, and internal echo characteristics of the lymph node. CT and
endoscopic ultrasound imaging alone rely on the anatomic size of the node as a predictor of
malignancy, but they cannot differentiate between hyperplastic nodes and nodes enlarged
because of metastasis. Endoscopic ultrasound and CT can then be used for image-directed fineneedle aspiration of mediastinal or celiac nodes.
Stage Grouping of Esophageal Cancer
Stage 0
T0N0
T is N 0 M0
Stage I
T 1 N 0 M0
Stage II
IIA T 2 N0 M 0
T 3 N 0 M0
IIB T 1 N 1 M0
T 2 N 1 M0
Stage III
T 3 N 1 M0
T 4 any N M 0
Stage IV
T: PRIMARY TUMOR
any T any N M 1
T 0 No evidence of a primary tumor
T is Carcinoma in situ (high-grade dysplasia)
T 1 Tumor invading the lamina propria, muscularis mucosae, or submucosa but not breaching the
boundary between submucosa and muscularis propria
T 2 Tumor invading muscularis propria but not breaching the boundary between muscularis
propria and periesophageal tissue
T 3 Tumor invading periesophageal tissue but not adjacent structures
T 4 Tumor invading adjacent structures
N: REGIONAL LYMPH NODES
N 0 No regional lymph node metastasis
N 1 Regional lymph node metastasis
M: DISTANT METASTASIS
M 0 No distant metastasis
M 1 Distant metastasis
DISTANT METASTASIS (M STAGE)
Endoscopic ultrasound is especially suited to visualize lymph nodes around the celiac axis and
the left liver lobe (both considered distant metastases). CT is specific for liver, lung, and pleural
metastases larger than 2 cm in diameter, [165] but evaluation with fine-needle aspiration or
transbronchial biopsy is necessary for the determination of malignancy. Bronchoscopy is
required for patients with tumors of the upper and middle third of the esophagus to view the
pharynx, larynx, and tracheobronchial tree for synchronous and metachronous malignancies. If a
patient complains of bone pain, a bone scan should be performed. [57]
The plain chest x-ray is abnormal in only 50% of patients with esophageal cancer, with findings
such as an air-fluid level in the obstructed esophagus in the posterior mediastinum, a dilated
esophagus, abnormal mediastinal soft tissue representing adenopathy, a pleural effusion, or
pulmonary metastasis being most common. The chest film, however, may be deceivingly normal
even in patients with advanced disease.
Treatment
Curative efforts include surgery, chemotherapy, radiation, or a combination of these techniques;
however, despite multitudes of clinical trials and retrospective reviews, no treatment modality
alone has proved superior. Current trials have focused on radiation and chemotherapy with or
without resection. Therapy for esophageal carcinoma is influenced by the knowledge that in
most of these patients, local tumor invasion or distant metastatic disease precludes cure. In fact,
85 to 95% of patients have lymph node involvement at the time of surgical resection. Fewer than
10% of patients with lymph node involvement survive for 5 years. [146] In the past, palliative
techniques were advocated because of the poor long-term survival rates of patients with
esophageal carcinoma. Palliation affords the patient the ability to swallow (at least saliva) and
perhaps to resume a normal life for 9 to 12 months. After the initial evaluation for staging, the
physician can assess whether palliative or curative approaches are indicated.
PALLIATIVE TREATMENT
Palliation is appropriate when patients are too debilitated to undergo surgery or have a tumor that
is unresectable because of extensive invasion of vital structures, recurrence of resected or
irradiated tumor, and/or metastases. Most of these patients have complete or partial obstruction
of the esophagus resulting from the tumor, and swallowing is painful or impossible. The goal of
palliation is to use the most effective and least invasive means possible to relieve dysphagia and
discomfort, to support nutrition, and to limit hospitalization. Palliation includes dilatation,
intubation, photodynamic therapy, radiotherapy with or without chemotherapy, surgery, and/or
laser therapy.
CURATIVE TREATMENT
At best, only 50% of patients are eligible for a curative resection at presentation. [2] The
lymphatic drainage of the esophagus is extensive, both within the esophageal wall and in the
surrounding mediastinal tissues. As a result, longitudinal extension of the esophageal carcinoma
may be extensive, and tumors may be multicentric. In 10% of patients, tumor recurs at the
resection margin in patients who have had a 6- to 8-cm margin of normal esophagus removed. If
an esophagectomy is indicated, three major technical approaches are available: (1) a
transthoracic esophagectomy, (2) transhiatal esophagectomy without a thoracotomy, and (3) an
en bloc radial esophagectomy. Although no consensus has been formed on the preferred
technique, transthoracic esophagectomy is preferred by most thoracic surgeons.
]
Transthoracic esophagectomy is still preferred by most thoracic surgeons because it allows
complete lymph node dissection under direct vision, complete resection of tumor mass and
adjacent tissue, and complete staging of the tumor. . Great care is taken to avoid any damage to
the recurrent laryngeal nerve, to avoid hoarseness.
The two major complications are similar to transhiatal and transthoracic esophagectomy:
anastomotic leak and respiratory complications.
Because of the risks associated with the more radical transthoracic or en bloc esophagectomies
and the overall low survival rate of patients with esophageal carcinomas, transhiatal
esophagectomy without thoracotomy was proposed.
The advantages of this approach are as follows: (1) a thoracotomy is avoided, thus minimizing
the physiologic insult of the operation; (2) an intrathoracic esophageal anatomosis is avoided,
and if a cervical leak does occur, it is more easily managed and rarely causes mediastinitis or
fatal complications; (3) no intra-abdominal or intrathoracic gastrointestinal suture lines are
present; and (4) clinically significant gastroesophageal reflux seldom occurs after a cervical
esophagogastric anastomosis.
Contraindications to the transhiatal approach include evidence of tumor invasion of the
pericardium, aorta, and/or tracheobronchial tree.
Some early and late complications associated with the transhiatial approach are wound infection,
anastomotic leak, respiratory complications, pneumothorax, recurrent laryngeal nerve injury,
esophageal stricture, and delayed gastric emptying.
Thoracoscopic Esophagectomy.
Several authors have reported the use of video-assisted thoracoscopy or laparoscopy in
performing esophagectomy.Thoracoscopic esophagectomy has three stages. The first is the
thoracoscopic dissection of the thoracic esophagus. The second is the laparoscopic mobilization
of the intended gastric conduit, and the third is the cervical anastomosis.
Preoperative Preparation for Esophagectomy
If the patient is dehydrated or if the esophageal obstruction is tight, endoscopic dilatation of the
malignant stricture and insertion of a nasogastric feeding tube or an intraluminal stent for enteral
nutrition are performed to achieve an intake of approximately 2000 calories per day. Intravenous
hyperalimentation is seldom indicated, because of the associated septic and metabolic
complications. Oral hygiene is often neglected, and abscessed or severely carious teeth should be
removed or repaired preoperatively to minimize the severity of an infection that may result from
anastomotic disruption and swallowed oral bacteria. If the patient has a history of prior gastric
operations that may preclude the use of the entire stomach as an esophageal substitute, a barium
enema examination should be done to assess the suitability of the colon for esophageal
replacement, and the colon should be prepared in the event that a colonic interposition is
required.
V.
LITERATURE
1. Shot Practice of surgery by Charles v. Mann and al.
2. Textbook of surgery by Sabiston.
3. Lections.
VI.
APPROXIMATE ACTIONS BASE
1. Introduction /5 min/. Teacher short characterizes topic actuality, meets students
with main aims of the study and plan.
2. Initial knowledge’s control /15 min/.
3. Individual students work with patients /30 min/. The teacher explains some more
difficult and important parts of problem. The choice is realized by asking of students
and their answers correction.
4. Clinical analyses of topical patients /100 min/. Students observe topical patients
under teaches control. After it finishing, the students report about receiving results.
5. Work in dressing-room and operation theater. Teacher and students change the
dressings of patients after different surgical procedures on esophagus.
6. Study of X-ray pictures.
7. Final knowledge control. Solution of test-questions /25 min/.
8. Conclusion /5 min/. The teacher concludes the session and gives new task for the
next once.
VII. TEST – QUESTIONS
1. What organs the cancer of the lower third of the esophagus may invades?
/diaphragm
/pericardium
/stomach
lungs
hepar
2. For finding of the esophagus tumor the following methods are indicated:
/chest X-ray examination
/barium swallow examination
/esophagoscopy
/endoscopy
/cytology
/biopsy of tissue
3. What methods may assess the lymph node involvement?
/ CT-scanning
/ ultrasound
/ positron emission tomography
/ thoracoscopy
/ laparoscopy
4. Choose the methods of the palliative treatment,
/dilatation
/intubation
/photodynamic therapy
/radiotherapy
/chemotherapy
/palliative surgery
/laser therapy
5. Choose the main technical approaches for esophagectomy performing:
/transhiatal
/transthoracic
/an en bloc radial esophagectomy
transcervical
6. Choose the early complications after transhiatal esophagectomy:
/anastomotic leak
/respiratory complications
/bleeding
esophageal stricture
/pneumothorax
/recurrent laryngeal nerve injury
7. Note the symptoms of the esophageal cancer
/dysphagia
melena
/regurgitation
/pain
/dyspnea
black vomiting
8. Esophageal adenocarcinoma may have such origins as:
/esophageal submucosal glands
mucosal glands of stomach
/Barrett’s mucosa
/islands of columnar epithelium