eso + pancreatic + endo

incidence of esophageal cancer

• 1% of all cancers

• 2026 ⇒ estimates 2,800 diagnosed // 2,500 deaths 

mortality of esophageal cancer

HIGH

2026 ⇒ estimates 2,800 diagnosed // 2,500 deaths 

gender affected by esophgeal cancer

men>women (3-4:1)

age affected by esophageal cancer

55-85yo

geography of esophgeal cancer

northern china, northern iran, south africa

race affected of esophageal cancer

Caucasian ⇒ adenocarc

Black person ⇒ SCC

cause/risk factors of adenocarcinoma (esophgaeal cancer)

• Barrett's esophagus 

• Gastroesophageal reflex disease (GERD) 

• Obesity (by ↑ risk of GERD)

cause/risk factors of squamous cell carcinoma

• Smoking 

• Alcohol 

• Dietary and environmental factor that cause chronic irritation and inflammation of esophageal mucosa 

• Tylosis, achalasia, esophageal diverticula and webs, plummer-winson syndrome, HPV infection

barretts esophagus

normal flat, pink lining (squamous epithelium) of the lower esophagus changes into a thicker, red, intestinal-type lining (columnar epithelium with goblet cells) 

• Associated with GERD

GERD

gastroesophageal reflex

chronic digestive condition where stomach acid and contents frequently flow back up into the esophagus (food pipe), irritating its lining

how is GERD related to esophageal cancer

If regular stomach acid and bile splashes up into the lower esophagus, it irritates and injuries the unprotected lining ⇒ may lead to barretts esophagus ⇒ dysplasia

achalasia

disorder when the lower ⅔ of esophagus loses normal peristaltic activities and becomes dilated (“megaesophagus”) and the esophagogastric junction sphincter fails to relax – ∴ prohibits passage of food into stomach 

• Pts w achalasia have a 5-20% risk of developing squamous cell cancer of esophagus

what vertebral does esophagus from/to

• C6 to T11

• begins inferior to the laryngopharynx at the level of the cricoid cartilage (C6) at the upper esophageal sphincter to stomach (T11)

relational anatomy of esophagus

posterior to the trachea, anterior to the vertebral bodies. Lateral and left of esophagus is the aortic arch

which is more ANT/POST: trachea vs esophagus

• trachea = more ANT

• esophagus = more POST

muscle composition of esophagus

deep to superficial  

• Lamina propria, Mucosa, muscularis mucosa, submucosa, circular muscular layer, longitudinal muscle, with interconnecting lymphatics  

  • ⤷ lacks a serosal layer

significance of lacking serosal layer in esophagus

esophagus structurally weaker, more prone to tearing, and lacking a physical barrier to stop the spread of cancer and infection into the chest cavity

regions of esophagus

upper thoracic, middle thoracic, lower thoracic/GE junction

why are esophagus references from upper incisors (front teeth)

fixed and identifiable landmark for endoscopy etc.  

longitudinal or radial growth of cancer in esophagus

longitudinally (up/down)

direct invasion of esophagus

• Longitudinal growth first (up/down) 

• Tumours can grow large before obstruction 

• Esophagus = NO serosal layer ⇒ ∴ less resistance against local spread  

• Fistula with bronchus or trachea possible

lymphatics spread of esophagus

NOT CONTIGUOUS

• early lymphatics invasion + skip lesions distant from primary site

• drainage = unpredictable

  • Upper ⅓ (cervical area) ⇒ drains into… 

    • Internal jugular, cervical, paraesophageal, supraclavicular LNs 

  • Upper/middle thoracic portion drain into… 

    • Paratracheal, hilar, subcarinal, paraesophgeal, paracardial LNs 

  • Distal/lower ⅓ of esophagus drains… 

    • Celiac axis, left gastric nodes, nodes of the lesser curvature of the stomach 

significances of esophagus having a rich lymphatic network

cancer can spread through LN far away from orginal tumour (∴ lymphatic spread if unpredictable)

where do LNs from the upper 1/3 of cervical area drain into

• Internal jugular

• cervical

• paraesophageal

• supraclavicular LNs 

where do LNs from middle thoracic esophagus drain into

• paratracheal

• hilar

• subcarinal

• paraesophageal

• paracardinal

where do LNs from distal/lower 1/3 of esophagus drain

• celiac axis

• left gastric nodes

• nodes of the lesser curvature of the stomach

what is unqiue about esophagus LN

longitudinal flow (bidirectional spread) + skip metastases (able to drain into any adjacent draining nodal bed)

possible mets to esophageal cancer (what are most common)

• *liver, *lung, bone, CNS

• Most patients present with advanced diseases

does esophageal cancer have early or late stage presentation? + why?

• **early-stage = Ū ASYMPTOMATIC/nonspecific

• ∴ esophgeal cancer has late-stage presentation (when symptoms finally show = ū alr advanced)

• Why? Esophagus is used to having food into (allow things to pass/flexible), hard to notice tumour in there

early stage SS clinical presentation of esophageal cancer

• 90%: dysphagia (difficulty swallowing), weight loss

• others

  • coughing and regurgitation

  • 50%: odynophagia (painful swallowing)

  • upper GI bleeding

regional invasion SS esophageal cancer

• respiratory fistula (hole between trachea/esophagus)

• hoarseness from recurrent laryngeal nerve invasion

• pain caused by local spread

advanced distant stage SS for esophageal cancer

• Hypercalcemia (but no brain mets = paraneoplastic syndrome bc of parathyroid production protein) 

• Mets to lungs, liver, central nervous system 

• Hematemesis: vomiting blood 

what paraneoplastic syndrome is related to esophagus cancer

hypercalcemia

are pts w esophageal cancer diagnosed in early or late stage

late stage (ū locally advanced/metastatic) bc early-stage ū asymptomatic/subtle

• esophagus also has no serosal layer… ∴ able to grow/infiltrate deep muscle and lymph nodes before obstruction occur

SS related to esophagus

 dysphagia, odynophagia, regurgitation + mucus, esophagus bleeding, anorexia + weight loss bc of inability to eat

SS related to surrounding anatomy of esophgeal cancer

chest pain, hoarseness, chronic cough, dyspnea (SOB), bone/back pain

tracheoesophageal fistula

abnormal tract connecting the esophagus to the respiratory tract (trachea) 

• ⤷ easily occurs in esophagus bc of no serosal layer

imaging that can be done for esophagus cancer

• barium swallow contrast w xray

• Endosocpic US

• bronchoscopy

• CT chest/upper abdomen

• PET-FDG for mets

which imaging technique is more accurate for staging primary/LNs of esophgeal cancer

endoscopic US — assess depth of tumour, LN assessment, biopsy

barium contrast swallow w xray

drink chalky, liquid barium sulfate mixture that coats the inner lining of your upper digestive tract so tumour shows up bright white on X-rays (highlight)

histopathology for esophagus

• Upper and middle esophagus ⇒ squamous cell carcinoma 

• Lower esophagus/gastroesophageal (GE) junction ⇒ adenocarcinoma 

Other rare histology 

• Adenoid cystic carcinoma 

• Mucoepidermoid carcinoma

• Adenosquamous carcinoma 

• Undifferentiated carcinoma

what histology for upper/middle esophagus

SCC

what histology for lower/GE junction

adenocarcinoma

adverse prognostic factor of esophgeal cancer

• Size of primary tumour >5cm 

• Weight loss 10%

• Poor performance status (impact their ability to tolerate treatment) 

• Age >65yo 

5-year survival of esophgeal cancer

• 5-30% overall (assuming pt is amendable) 

  • Localized (confined to esophagus) – 43% 

  • Regional – 23% 

  • Distant – 5%

goal of treatment for esophageal cancer

Goal of treatment… relieve dysphagia and provide chance for cure 

• ⤷ esophageal cancer is treatable but rarely curable as most patients have locally advanced/metastatic disease at diagnosis

radical intent treatment for esphageal cancer

• 1) Chemoradiation therapy (*standard treatment*) 

• 2) Neoadjuvant pre-op chemo radiation 

  • Chemoradiation = choice of treatment (incl. brachy) 

  • Surgery requires extremely extensive procedure

palliative intent tx for esophageal cancer

• Symptom management = PRIMARY GOAL [pain control, improvement in swallowing, quality of life] 

• Various combinations ⇒ surgery, chemotherapy, radiation therapy, stent, photodynamic therapy, endoscopic laser therapy

total esophagectomy

removes all of esophagus + LN + portion of upper stomach 

• Ū stomach is pulled up into the chest/neck and connected to the remaining upper esophagus/pharynx 

• Depends on location of lesion and extent of disease

Transthoracic resection (TTE) (ivor lewis procedure

• removes all of esophagus, LN, upper portion of stomach 

• Laparotomy + right thoracotomy to remove esophagus and pull stomach up into thoracic cavity

transhiatal approach

esophagus is removed through abdomen and neck… without opening chest (works through esophageal hiatus: opening in diaphragm) 

laparotomy

large abdominal incision

right thoracotomy

surgical incision on right side of the chest (ū bc esophagus is easier to access from right side)

• bc left side has aortic arch

cons of surgery for esophageal cancer

high morbitdity and mortality rate

which part of the esophagus cannot be surgically operated on

Challenging to operate in upper ⅓ near cervicals → ū use chemoradiation in that area

• high surgical risk (high morality/morbitity)

• tight anatomical space with nearby organs (larynx, trachea, thyroid, BV, nerves etc)

chemotherapy as tx for esophagus process

• Three-step approach: 

  • 1) induction chemotherapy – ū to shrink before chemotherapy ? 

  • 2) pre-op chemoradiation 

  • 3) surgery

• continous infusion of 5FU and cisplatin = standard (concurrent w RT) — but a lot of side effects (other regiments are being studied)

3-field approach of RT

• cannot have beam from direct posterior field (hitting spinal cord) 

  • Instead = have 2 oblique posterior fields (avoids spinal cord) + anterior field

compare dose of RT and chemoradiation

• dose of RT alone = higher than chemoradiation

• lower dose bc chemotherapy makes cells more sensitive to radiation… so don’t need that high of a dose to have the same effect

• RT alone = 6000-6500cGy

• Chemoradiation = 5040 cGy

organs at risk/sensitive to radiaiton damage

• lung, heart, spinal cord, (stoamch)

which structures/organs are the most radiosensitive

lung ??

non-surgical tx of choice for esophagus cancer

RT + concurrent chemo

screening for esophgeal cancer

For public/people with GERD ⇒ no regular screening test bc no evidence that show more benefits than risks 

For high-risk people (has Barrett’s esophagus, inherited syndromes) ⇒ carefully monitored for early/precancer + regular upper endoscopies

prevention of esophagus cancer

• Quit smoking 

• limit/avoid alcohol! 

• Maintain healthy weight 

• Eat a diet rich of fruits/veggies

why are long radiation fields used in esophagus cancer

• bc of esophag’s longitudinal spread + extensive lymphatic drainage + skip metastasis

• to ↓ risk of recurrence, margin size is 3-5cm above and below tumour margins to also target more longitudinally and possible skip metastasis

incidence of pancreatic

2% of all cancers all cancers in US

mortality of pancreatic

4th leading cause of cancer in US, one of the deadliest malignancies

age affect of pancreatic

50-80yo, most >70yos

gender affected of pancreatic

males > females

race affected of pancreatic

african american > white

known risk factors

• Tobacco 

• Obesity 

• Diabetes 

• Family history of pancreatic cancer 

• Genetic conditions 

• Occupational exposure to chemicals 

• Chronic pancreatitis

possible risk factors

• Alcohol 

• Helicobacter pylon (bacteria) 

• Hepatitis B virus 

• Exposure to pesticides

lower risk

Diet high in fruits/veggie

location of pancreas

 between aorta and IVC, covered by stomach and liver 

Internal vertebral relation to pancreas – pancreas is located retroperitoneally to T12-L2

what vertebrae is associated with pancreas

T12-L2

3 anatomical portions of pancreas

• Head – surrounded by duodenum

• Body

• Tail – in the hilum of the spleen

function of pancreas

• exocrine ⟹ Make digestive enzymes that are collected in main pancreatic duct and emptied into the duodenum (digest fats, sugar, proteins) 

• endocrine ⟹ make hormones — Islets of langerhans: produce hormones (eg. insulin) that are released into bloodstream 

why is tumour at head of pancreas bad

Head of pancreas has the pancreatic due emptying enzymes into the duodenum + bile duct deliver bile from liver and gallbladder. Tumour ū block both pancreatic and bile duct (∴ also cause jaundice)

bile

yellow-green fluid produced by liver, stored in gallbladder that breaks down dietary fats, absorbs fat-soluble vitamins, neutralizes stomach acids, remove waste

early stage of pancreatic cancer symptoms

asymptomatic in early — “silent disease“ (∴ diagnosed ū at later stage)

direct extension of pancreatic (what structures does it spread to)

• spread to stomach, duodenum, colon, spleen

• IF spread to mesenteric artery, portal vein, celiac axis artery, nerve involvement ⟹ ∴ UNRESECTABLE

local extension, if spread to these structures, will mean unresectable

• IF spread to mesenteric artery, portal vein, celiac axis artery, nerve involvement, ⇒ UNRESECTABLE

lymphatics spread to pancreatic

1. Left side ⇒ drains along tail into splenic hilar nodes 

2. Superior pancreatic LNs and celiac axis 

3. Inferior pancreatic, superior mesenteric, and left paraaortic nodes 

4. Right side ⇒ drains to anterior and posterior pancreaticoduodenal nodes + right para-aortic node

how much % of pancreatic cancer have mets at the time of presentation?

50%

where does metastatsis spread to for pancreatic cancer

spread to liver (via portal vein), lungs, peritoneal seeding into perionteal cavity, bone (less common but possible for advanced stage)

percentage of tumour found in the location segments of pancreas

• Head/neck = 50-60% 

• Body = 25% 

• Tail = 25%

ealry stage clinical presentaiton of pancreatic cancer

• asymptomatic in early stage (“silent disease”)

main S/S of pancreatic cancer

• Jaundice (+itching): yellowing of skin and sclera of eye 

  • tumor blocks the common bile duct, preventing bile and the yellow pigment bilirubin from flowing from the liver into the small intestine 

• Abdominal pain 

• Weight loss

• Anorexia

other S/S of pancreatic cancer

• Jaundice (+itching): yellowing of skin and sclera of eye 

  • tumor blocks the common bile duct, preventing bile and the yellow pigment bilirubin from flowing from the liver into the small intestine 

• Abdominal pain 

• Weight loss

• Anorexia 

• Back pain 

• Digestive problems 

• Diabetes mellitus (type 2 adult onset) 

• Dark urine 

• Light stools

• Enlarged pancreas, gallbladder, or liver possibly

why is pancreatic cancer difficulty to detect and diagnoses

1. No noticeable signs/symptoms in early stages of pancreatic cancer 

2. The signs of pancreatic cancer, when present, are S/S of other illnesses (eg. pancreatitis, ulcer) 

3. The pancreas is obscured by other organs in abdomen and is hard to visualize on imaging 

what lab tests are done for pancreatic cancer

1. Lab testing 

   1. CBC + blood chemistry test 

   2. Liver enzyme test — see liver (bc one of main met sources)

   3. Creatinine — tests how well kidney filter for possible contrast/dye injected in body/ducts

   4. Blood urea nitrogen (BUN): measures waste product formed when liver breaks down protein — liver break down ⟹ relates to liver

   5. glucose — pancreas aids in blood sugar levels (insulin)

what imaging done for pancreatic cancer

1. CT — common!

2. MRI

3. endoscopic retrograde Cholangiopancreatography (ERCP): see bile ducts, gallbladder

   1. ERCP = Using fluoroscopy (live xray) + use contrast to visualize anatomy of pancreatobiliary ductals (whats going on in pancreas and bile duct) 

4. endorectal ultrasound (ERUS) or AKA transrectal US 

diagnostic tests that can be done to test for pancreatic cancer

• lab tests,

• imaging (CT/MRI/ERCP/ERUS)

• FNA (needle to collect sample — biopsy)

• Cholangiography: inject dye into bile duct + branches to see obstruction 

• Visceral angiography to determine vascular invasion

histology of pancreatic

80% adenocarcinoma

types of pancreatic cancer

• Exocrine cancer: 95% of cases, and arise from cells of the pancreatic duct  

  • Functions to produce digestive enzymes

• Endocrine cancer: 5% of cancers 

  • Arise in cells that produce hormones

which type of pancreatic cancer is more common

exocrine (95% of cases) adenocarc

staging of pancreatic cancer

• TNM

• T-stage ⇒ based on tumour diameter size 

  • T1 = <2cm 

  • T2 = 2-4cm 

  • T3 = >4cm 

  • T4 = growing outside of pancreas and into nearby major blood vessels 

• N-stage ⇒ # of nodes affected 

  • N1 = 1-3 LNs

  • N2 = 4+ LNs

good prognostic factors of pancreatic cancer

Good prognostic factors 

• Clear surgical margins 

• Negative lymph nodes 

• Reduced perioperative mortality (death bc of another surgical procedure

5-year survival

• Overall – ~5%

• Local disease = 19%

• Regional disease = 8%

• Distant disease = 2%

radical surgery for pancreatic cancer

surgery = treatment of chocie

• Distal pancreatectomy: remove only body + tail of pancreas + maybe spleen and LNs

• Total pancreatectomy: remove ENTIRE pancreas  + surrounding organs 

• Pancreaticoduodenectomy (whipple procedure): remove head of pancreas + first part of SI + gallbladder + bile duct ⇒ and reconnect to allow for flow between 

  • Ū for tumours that have NOT spread beyond pancreas (still resectable) 

  • Anatomy anastomosed (reconnected) ⇒ remaining pancreatic tail to jejunum//remaining common bile duct to jejunum//remaining stomach to jejunum 

  • ⤷ surgery may be done laparoscopically

distal pancreatectomy

• remove only body + tail of pancreas + maybe spleen and LNs