Lecture 41 : Diseases of the esophagus Carcinoma of the Esophagus 95% Squamous cell carcinoma

Clinical Features: Progressive dysphagia (first for solids and then for liquids) and weight loss are typical features. Excessive salivation, aspiration pneumonia, anaemia and lassitude are late effects. may erode into a bronchus to establish an esophago-bronchial fistula, perforate into the mediastinum, or infiltrate the recurrent laryngeal nerves to cause hoarseness. Stimulates recurrent laryngeal nerve vomiting Can also irritate the posterior surface of carina (bifurcation of trachea) Diagnosis: Dysphagia, major presenting complaint complaints of dysphagia (usually progressive) warrants esophagoscopy to rule out carcinoma. Diagnosis based on esophageal biopsy Double-contrast barium swallow: shows irregular filling defect or localized stricture of the esophagus. Endoscopy required to establish a tissue diagnosis and determine the extent of longitudinal intramural tumor spread. entire esophagus is visualized, and brush cytology plus biopsy tissue samples are obtained for histologic analysis. EUS EUS-guided fine-needle aspiration (FNA) further increases diagnostic yield. can determine the anatomic location and enlargement of the mediastinal, perigastric, or celiac lymph nodes.

CT scan can determine anatomic location and enlargement of the mediastinal, perigastric, or celiac lymph nodes. PET(positron emission tomography) Staging: - after esophagoscopy and biopsy, staging of the tumor for determining which therapeutic option TNM staging: T (tumor) indicates the progressive degree (1- 4) of invasion of the into the esophageal wall. N stands for nodal involvement M represents distant metastasis.

Treatment: surgery, chemotherapy, radiation, or combination of these techniques Surgical Treatment: non-metastatic disease, esophagectomy can be performed in patients who are able to tolerate the procedure. Indications and contraindications: general debility, malnutrition, cardiac risk, multisystem dysfunction, liver failure, infection, invasion of a vital structure, or metastatic disease limit the patients health. Reconstruction After Esophagectomy: After partial removal or esophagus or complete esophagectomy, a passage must be established for alimentary continuity. Stomach, colon, and jejunum used as esophageal substitutes most often utilizing the posterior mediastinum or retrosternal routes. Radiation Therapy: goal is to destroy the tumor, its microscopic extensions, and other local sites of metastases has low morbidity,can improve esophageal obstruction in most patients in 4 to 7 days. Relieve of dysphagia Chemotherapy: Chemotherapy is most often used preoperatively alone or in combination with radiation therapy to treat micrometastases and reduce the tumor size to improve resectability. No surgery indication-chemotherapy is combined with radiation therapy for primary treatment to achieve palliation and possibly improve survival. Caustic Injury of the esophagus: rare condition and occurs most commonly in young children accidentally swallowing household caustics, corrosives and bleaches. Clinical features: oral pain, hematemesis, drooling, and inability or refusal to swallow. complication of 2nd or 3rd degree esophageal burns is stricture formation, which develops 3- 8 weeks after initial injury. Treatment: Immediate verification of the etiologic agent, chest and abdominal radiographs and then esophagoscopy. Mild early stricture formation sometimes responds satisfactorily to a single dilatation. requires radiologic and endoscopic evaluation to assess the injury. 1st burns are observed,2nd and 3rd burns without perforation are managed by supportive care, with/without stent placement or gastrostomy, and with surveillance for late strictures. Caustic perforation requires immediate esophageal and/or gastric resection.

Achalasia: most common motility disorder of the esophageal body and lower esophageal sphincter(LES). characterized by dysfunctional or absent esophageal peristaltic waves, impaired relaxation of the LES on receipt of the food bolus, and increased LES resting pressure. Clinical features: symptoms includes dysphagia, regurgitation, and weight loss. In early stages of achalasia, patient notes a sticking sensation, after ingestion of liquids, especially cold liquids, and later after ingestion of solids. Diagnosis: Barium swallow shows uniform esophageal dilatation with a distal tapering (beak) secondary to failure of the LES to relax. Manometric criteria of achalasia are failure of the LES to relax and lack of progressive peristalsis throughout the length of the esophagus. Esophagoscopy is indicated to evaluate the severity of esophagitis and possibility of associated carcinoma. Treatment: Because the derangement in esophageal motor function does not return to normal, treatment is purely palliative. Both nonsurgical/surgical treatments of achalasia are directed toward relieving the obstruction caused by the nonrelaxing LES. Gastroesophageal Reflux Disease Gastro-esophageal reflux refers to the process of reflux of stomach contents into the esophagus. May be physiological, occurring in small amounts in healthy individuals, or pathological, observed in abnormally large quantities in symptomatic patients. major clinical consequences of GERD are esophagitis and its complications ( benign stricture or Barretts esophagus). Clinical features: heartburn and regurgitation. Dysphagia Tumor, Diverticula, and Motor Disorders should be excluded because this determination will affect the operative approach. Diagnosis: Endoscopy is an essential step in the evaluation of GERD. A significant amount of information about the function of the esophageal body and LES may be obtained from stationary esophageal manometry. The gold standard for diagnosing and quantifying acid reflux is the 24-hour pH test. Treatment: antacids, motility agents, H2 blockers, and proton pump inhibitors. The indications for surgical therapy have changed with the advent of proton pump inhibitors.

Lecture 42 : Primary Tumors of Mediastinum Mediastinum -a thoracic cavity between pleural cavities, from sternum to spine, thoracic inlet to diaphragm. - the heart, the great vessels of the heart, esophagus, trachea, phrenic nerve, cardiac nerve, thoracic duct, thymus, and lymph nodes. Categories: Divided into two parts by the plane from the sternal angle to the disc of T4-T5 An upper portion, above the upper level of the pericardium, is named superior mediastinum A lower portion, below the upper level of the pericardium, is subdivided into three parts: Anterior mediastinum, in front of the pericardium; Middle mediastinum, containing the pericardium and its contents; Posterior mediastinum, behind the pericardium. Mediastinal tumors in certain portions of the mediastinum: Superior mediastinum: thymomas, thymic cyst, lymphoma, thyroid lesions, parathyroid adenoma Anterior mediastinum: thymic epithelial tumors and cysts, germ cell neoplasms, lymphoproliferative lesions, retrosternal thyroid glandular proliferations, parathyroid lesions, aorticopulmonary-type paragangliomas, lymphangioma, hemangioma, lipoma Middle mediastinum: pericardial cyst, bronchogenic cyst, lymphoma Posterior mediastinum: neurogenic tumors, gastroenteric cysts

Symptoms: 50% of mediastinal tumors cause no symptoms Due to pressure on local structures, Symptoms include: Chest painchillsCoughCoughing up bloodFeverHoarsenessNight sweatsShortness of breathetc. Local compression from tumor symptom

Techniques for diagnosis: Radiography Chest CT scanning with intravenous contrast MRI Biopsy techniques :CT-guided core needle biopsy ; VATS(video assisted thoracic surgery) ; Endobronchial ultrasound (EBUS) -guided biopsy

- Epithelial tumor generally considered to have an indolent growth pattern but malignant

between the ages of 40-60 years at the time of diagnosis with an equal gender distribution. -common autoimmune diseases associated with thymoma, such as myasthenia gravis Diagnosis of Thynoma: Most common mediastinal neoplasm Epithelial tumor generally considered to have an indolent growth pattern but malignant between the ages of 40-60. -common autoimmune diseases associated with thymoma, such as myasthenia gravis Thymomas are diagnosed with CT or MRI revealing mass in anterior mediastinum. Treatment of Thynoma: Surgical therapy+radiation therapy, has been the mainstay of therapy for early stage thymoma with excellent survival anticipated. Types of surgery include thoracoscopy, mediastinoscopy and the transsternal approach. clearly inoperable disease can be palliated(relieve the symptoms) for prolonged intervals with chemotherapy and/or radiation therapy only. Strategy of treatment: type A and stage I thymoma had no adjuvant therapy after thymectomy Types AB and B1 thymomas had radiotherapy postoperatively; stage II, III were treated with adjuvant mediastinal radiation therapy; Both adjuvant radiation therapy and chemotherapy were administered to stage IV and type C one month after operation. Teratomas: mediastinal germ cell tumors 20-40 years of age 90% occurring in men Mature teratomas =benign , Immature teratomas =malignant Diagnosis: serum tumor markers AFP and human beta-choriogonadotropin HCG CT shows fatty mass with globular calcifications and rarely a tooth or bone in the anterior mediastinum. Fat-fluid level may be seen on CT. Treatment: conservative surgical removal, because of the close proximity to important anatomic structures of the big vessels and heart. Substernal goiters: -PredominanT in women. Most diagnosis by accidental detection on chest radiograph Presence of a substernal goiter, particularly if it is symptomatic, is a clear indication for surgery A large substernal goiters & compression on trachea dyspnea

Bronchogenic cysts:

Most common mediastinal cysts 85%of bronchogenic cysts arise in the mediastinum in close relationship to the trachea, main bronchi, carina lined by columnar ciliated epithelium, and their walls often contain cartilage and bronchial mucous glands. Most of the complications result from compression of adjacent structures. Infection is a common complication , then Pneumothorax.

Diagnosis and treatment: Chest radiographs and CT scans are the most valuable diagnostic studies. definitive diagnosis is established only by surgical excision and tissue biopsy Complete extirpation(to remove by surgery) is necessary. Neurogenic Tumors: found in the posterior mediastinum are treated surgically with thoracotomy or thoracoscopy. most common type of posterior mediastinal tumors 70- 80% are benign and approximately 50% of patients are asymptomatic. Adult neurogenic tumors are usually benign. In children, tend to be malignant and metastasize before symptoms appear. Treatment: complete resection via thoracoscopic surgery or thoracotomy Lymphomas are recommended to be treated with chemotherapy followed by radiation. Apart from Lymphomas treated with chemotherapy followed by radiation, other mediastinal tumors require surgery.