Video Endoscopic Sequence 1 of 5.

 Esophageal Squamous Cell Carcinoma.

Ulcerating Squamous cell carcinoma of the lower end of the esophagus.

This 72 year-old female, presented with progressive dysphagia.

 For more endoscopic details download the video clips by
 clicking on the endoscopic images, wait to be downloaded
 complete then press Alt and Enter that you can appreciate
 the video in full screen.

 This section of esophageal carcinoma displays most
 Squamous cell Carcinoma, you can see several cases of
 adenocarcinoma of the cardias in gastric carcinoma
 chapter.
 All endoscopic images shown in this Atlas contain video
 clips.

Video Endoscopic Sequence 2 of 5.

Esophageal Squamous Cell Carcinoma.

 Squamous cell carcinoma of the esophagus is largely
 associated with a poor prognosis, and the development and
 metastasis of this tumour are complicated. Direct invasion
 of adjacent organs such as the aorta, respiratory tract and
 lungs, and distant metastasis to other organs such as the
 liver, lungs and bone are commonly found in advanced
 esophageal cancer cases. Intramural metastasis (IMM) in
 the esophagus has been found in about 10% of esophageal
 cancer cases. However, IMM to the stomach (IMMS),
 excluding direct invasion and spread to the stomach, is
 relatively rare.

Video Endoscopic Sequence 3 of 5.

 The gastric fundus shows a large fungating and ulcerating
 lesion, retroflexed image.

 A history of smoking and/or alcoholism is often present in
 patients with esophageal squamous carcinoma, while a
 history of Barrett's esophagus precedes development of
 esophageal adenocarcinoma in many cases.

Video Endoscopic Sequence 4 of 5.

Epidemiology

 At least 5X more common is men with the male/female
 ratio varying markedly worldwide, probably representing
 the variable exposure to environmental factors
 At least 4X more common in blacks in the U.S., with the
 incidence in blacks rising while the incidence in whites is
 stable or declining
 A disease of older people with a mean age of onset of
 60 yrs. which probably reflects the slow evolution of the
 dysplasia carcinoma sequence.

Video Endoscopic Sequence 5 of 5.

Etiology

 Examination of geographic areas of high incidence have
 identified a number of environmental factors strongly
 linked to the development of esophageal dysplasia and
 squamous carcinoma
 In the United States and Europe alcohol and smoking
 In China nitrosamine containing foods, fungal
 contamination of foods and vitamin and essential metal
 deficiency
 The only known genetic predisposition occurs in
 hereditary tylosis, an autosomal dominant symmetrical
 keratosis of the palms and soles.

Video Endoscopic Sequence 1 of 2.

 Esophageal Squamous Cell Carcinoma.

 This 73 year old, male presented progressive dysphagia for
 solid and liquid and lost of weight of 20 pounds. Endoscopy
 revealed a large tumor.

Video Endoscopic Sequence 2 of 2

 Esophageal Squamous Cell Carcinoma of the middle third.

 Esophageal cancer is a treatable disease, but it is rarely
 curable. The overall 5-year survival rate in patients
 amenable to definitive treatment ranges from 5% to 30%.
 The occasional patient with very early disease has a better
 chance of survival. Patients with severe dysplasia in distal
 esophageal Barrett’s mucosa often have in situ or even
 invasive cancer within the dysplastic area. Following
 resection, these patients usually have excellent prognoses.

Video Endoscopic Sequence 1 of 4.

 Small cell carcinoma of the lung that invades the upper and
 the middle third of the Esophagus.

Video Endoscopic Sequence 2 of 4.

 Small cell carcinoma: This tumor usually arises close to
 the hilum. Is the most malignant lung cancer and is
 composed of oat cells which are smaller than tumor cells
 found in the squamous cell carcinoma and adenocarcinoma.
 The tumor cells have little cytoplasm, are arranged in
 clusters and nests, show arefactual smearing after
 processing, do not show evidence of squamous or glandular
 differentiation and have neurosecretory granules. The
 neurosecretory granules may be identified at the
 ultrastructural level or by immunohistochemical
 demonstration of chromogranin or synaptophysin. This is
 the type of the tumor that is associated with paraneoplastic
 syndromes.

Video Endoscopic Sequence 3 of 4.

This view is from the upper esophageal sphincter.

Video Endoscopic Sequence 4 of 4.

The middle third of the esophagus.

Video Endoscopic Sequence 1 of 2.

Esophageal Squamous Cell Carcinoma

 This 72 year-old man with progressive dysphagia
 (difficulty swallowing) to solids, who was found to have this
 malign neoplasia.

 Cancer of the esophagus remains a devastating disease
 because it is usually not detected until it has progressed to
 an advanced incurable stage.

Video Endoscopic Sequence 2 of 2.

 The normal esophagus is lined by stratified squamous
 nonkeratinizing epithelium. Squamous cell carcinoma arises
 from this epithelial layer in apparent response to chronic
 toxic irritation. Alcohol, tobacco, and certain nitrogen
 compounds have been identified as carcinogenic irritants.

 Alcohol and tobacco use are the principal modifiable risk
 factors for esophageal squamous cell carcinoma. According
 to the American Cancer Society, the combination of long
 -term alcohol ingestion and tobacco use is the most
 substantial risk factor.

 Infection with human papillomavirus, particularly subtypes
 16 and 18, has been implicated in the pathogenesis of
 esophageal squamous cell carcinoma.

 Esophageal Squamous Cell Carcinoma.

 A 67 year-old female with progressive dysphagia. At the
 level of the middle third, this raised mass lesion can be
 observed. An ulcerated area and another mass nearby
 (left) is seen. (Intramural metastasis). Patient had palpable
 abdominal metastasis.

 Esophageal Squamous Cell Carcinoma.

 A 45 year-old woman, with progressive dysphagia
 (difficulty of swallowing) to solid who was found to have this
 firm, mid esophageal mass. Patient refused surgery and
 died 15 days after diagnosis. 

Video Endoscopic Sequence 1 of 2.

Squamous Cell Carcinoma of the Cardias.

 Risk factors for esophageal squamous carcinoma include
 mainly smoking and alcoholism and in those who have a
 history of chronic heartburn. Chronic heartburn may led to
 a condition called Barrett´s Esophagus which increases the
 risk of cancer until 40-fold (adenocarcinoma).

 THEISEN J , Nigro JJ, DeMeester TR, Peters JH, et al. Chronology of the
 Barrett's metaplasia-dysplasia-carcinoma sequence. Dis Esophagus.
 2004;17(1):67-70.

Video Endoscopic Sequence 2 of 2.

Squamous cell Carcinoma of the Cardias.

 When patients with esophageal cancer are first seen, most have
 dysphagia. Patients adjust their diet as symptoms progress from
 solid to liquid food intolerance, and at presentation they have
 weight loss, anorexia, or both. Odynophagia or back pain may be
 an ominous sign reflecting mediastinal invasion. Hoarseness may
 indicate recurrent laryngeal nerve involvement.

  Squamous Cell Carcinoma of the the upper third of the Esophagus.

 An 82 year-old French male, that had been complaining of
 progressive dysphagia, was found to have a carcinoma of
 the upper third of the esophagus. Six hours after diagnosis
 the patient developed subcutaneous emphysema and
 mediastinitis due to esophageal perforation , as a
 consequence of his necrotizing carcinoma.
 
 Esophageal Carcinoma Etiology and risk factors
 Cigarettes and alcohol Squamous cell carcinomas of the
 esophagus have been associated with cigarette smoking
 and/or excessive alcohol intake. Furthermore, cigarette
 smoking and alcohol appear to act synergistically,
 producing very high relative risks in heavy users of tobacco
 and alcohol.
 Patients with squamous cell carcinoma of the esophagus
 have an increased incidence of second primary tumors of
 the head and neck and/or lung. These second primaries may
 be detected prior to, after, or at the time of diagnosis of the
 esophageal carcinoma. The association of these tumors may
 reflect a cancer "field" defect associated with smoking and
 alcohol use.
 Pathogenesis; a number of predisposing conditions have
 been identified in the pathogenesis of squamous-cell
 carcinoma of the esophagus. These conditions include
 achalasia, caustic injury, and esophageal diverticula and
 webs. Esophageal cancer may also develop as second
 primary tumors in patients with other primary tumors of the
 upper aerodigestive tract that are associated with tobacco
 consumption. In Barrett's esophagus, the normal stratified
 squamous epithelium of the esophagus is replaced by
 metaplastic columnar epithelium. It develops as a result of
 chronic gastroesophageal reflux and can lead to the
 development of adenocarcinoma through a multistep
 process characterized by a progression from metaplasia, to
 indefinite or low-grade dysplasia, to high-grade dysplasia,
 and ultimately to invasive cancer.

Video Endoscopic Sequence 1 of 12.

 Perforation of a Esophageal Carcinoma after the procedure
 with hydrostatic balloon dilation.

 Stenosing Squamous Cell Carcinoma of the upper third of
 the Esophagus.

 This 62 year-old male, previously has been under
 radiotherapy and chemotherapy due to upper third
 neoplasia of the esophagus, in an attempt to perform
 dilation present perforation of 5 cm. of the upper third.
 Due to the presence of clinical signs of perforation such as
 subcutaneous emphysema of the neck and chest, patient
 underwent an emergency surgery.

Video Endoscopic Sequence 2 of 12.

 This endoscopic view shows the neoplasia from the upper
 esophageal sphincter.

Video Endoscopic Sequence 3 of 12.

This view is from the upper esophageal sphincter.

Video Endoscopic Sequence 4 of 12.

 Stenosing carcinoma of the upper third of the Esophagus.

Video Endoscopic Sequence 5 of 12.

 Patient underwent an emergency surgery.

 Surgery of Squamous Cell Carcinoma of the upper third of
 the Esophagus.

 More details download the video clips.

Video Endoscopic Sequence 6 of 12.

Surgery of Squamous Cell Carcinoma of the upper third of the Esophagus.

The are a large mass, a nasogastric tube has been placed.

Video Endoscopic Sequence 7 of 12.

 Surgery of Squamous Cell Carcinoma of the upper third of
 the Esophagus.

 The chest cat scan shows little pleural effusion and nodules
 of 2 cm. compatible with malignant nodules.

Video Endoscopic Sequence 8 of 12.

Surgery of Squamous Cell Carcinoma of the upper third of the Esophagus.

 The triad of vomiting, chest pain, and subcutaneous
 emphysema is known as Mackler's triad. Rarely, a patient
 may have back pain rather than chest pain. Perforations of
 the cervical esophagus may cause neck pain. Rupture at
 the gastroesophageal junction may lead to epigastric pain
 and an acute abdomen. Fever occurs as a later sign for any
 location. When spontaneous rupture occurs, there is
 generally a history of vomiting followed by chest pain. Any
 time chest pain or the other symptoms mentioned above
 occur after instrumentation or vomiting, the diagnosis of
 esophageal perforation must be considered.

Video Endoscopic Sequence 9 of 12.

Surgery of Squamous Cell Carcinoma of the upper third of the Esophagus.

 Surgical, primary closure, broad-spectrum antibiotics
 were administered, due to the early care, the evolution of
 the patient was excellent without mediastinitis.

 In 1724, Dr Hermann Boerhaave described the first, and
 likely most well known, case of esophageal perforation.
 Baron von Wassenaer, the Grand Admiral of Holland,
 followed a large meal with his customary bout of
 emetic -induced vomiting. However, on this occasion, the
 Admiral experienced a sudden and severe pain in his upper
 abdomen after violent but minimally productive retching.
 Dead less than 24 hours later, his autopsy revealed a
 transverse tear of his distal esophagus and gastric contents
 in the pleural spaces. Spontaneous esophageal rupture is a
 rare and dangerous entity, which today is commonly known
 as Boerhaave Syndrome.

Video Endoscopic Sequence 10 of 12.

Histopathology.

 Panoramic view of esophagic carcinoma.

Video Endoscopic Sequence 11 of 12.

Very well differentiated tumor with keratin production.

Video Endoscopic Sequence 12 of 12.

Squamous pattern of the neoplasia at high magnification.

Video Endoscopic Sequence 1 of 3.

  Esophageal Squamous Cell Carcinoma.

 This 60 year-old was referred to our endoscopic unit by
 otorhinolaryngologist, because patient presented
 dysphagia.

Video Endoscopic Sequence 2 of 3.

The tumor is observed between the middle third of the esophagus and the lower one.

Video Endoscopic Sequence 3 of 3.

Obstructing Esophageal Mass.
 

Video Endoscopic Sequence 1 of 3.

 Esophageal Squamous Cell Carcinoma of the the upper third of the Esophagus.

 This 83 year-old male who was referred to our endoscopic
 unit by the same otorhinolaryngologist that send to us the
 patient described in the previous endoscopic sequence,
 both patient were referred in less than a month living in the
 same small city . This patient has a long history of chewing
 tobacco and heavy alcoholism.

Video Endoscopic Sequence 2 of 3.

Large and ulcerated carcinoma is displayed.

 The normal esophagus is lined by stratified squamous
 nonkeratinizing epithelium. Squamous cell carcinoma arises
 from this epithelial layer in apparent response to chronic
 toxic irritation. Alcohol, tobacco, and certain nitrogen
 compounds have been identified as carcinogenic irritants.

Video Endoscopic Sequence 3 of 3.

 Nitrosamines and other nitrosyl compounds are found in
 pickled vegetables, smoked meats, and the water supply of
 certain geographic regions where the incidence of
 esophageal squamous cell carcinoma is high. In regions in
 which the soil is deficient in molybdenum and zinc, plants
 are impaired in their ability to metabolize nitrites to
 ammonia. This impairment permits potentially toxic
 nitrogen compounds to accumulate within plants that enter
 the human food supply.

Video Endoscopic Sequence 1 of 8.

 Esophageal Squamous Cell Carcinoma of the the upper third of the Esophagus that invades the subglotic.

This 75 year-old female, who had 7 sessions of lineal accelerator due to esophagus cancer this treatment with lineal accelerator was suspended due to a pneumonia.

Video Endoscopic Sequence 2 of 8.

 The neoplasia emerge from the esophagus through the
 upper gastroesophageal sphincter.

Video Endoscopic Sequence 3 of 8.

Some biopsies were obtained.

Video Endoscopic Sequence 4 of 8.

Magnetic Resonance of the Neck.

The magnitude of the tumor is observed with this study

 Coronal T1 weighted image without contrast material, that
 shows a hypointense lesion, of partial defined margins, in
 the central part of the neck, that causes compression of the
 left carotid vessel, and stenosis of the esophagus.

Video Endoscopic Sequence 5 of 8.

 Sagital T1 weighted image without contrast in the same
 patient that shows a growing poor defined lesion that
 involves the retroesophagic space which invades the
 esophagi canal, just inferior the epiglottis, surely involving
 the valleculas.

Video Endoscopic Sequence 6 of 8.

Sagital T1 weighted image without contrast

Video Endoscopic Sequence 7 of 8.

Sagital T1 weighted image without contrast

Video Endoscopic Sequence 8 of 8.

 Coronal T1 weighted image without contrast material, that
 shows a hypointense lesion, of partial defined margins, in
 the central part of the neck, that causes compression of the
 left carotid vessel, and stenosis of the esophagus.

Video Endoscopic Sequence 1 of 5.

Adenocarcinoma of the middle third.

 This 47 year-old lady presented with initially for solids
 eventually it progressed to liquids, at endoscopy a large
 and nearly obstructed carcinoma of the middle third of the
 esophagus was detected. Patient referred that almost all
 the life had been suffering of GERD, lately with difficulties
 to swallow that give us the suspected that has been
 suffering of GERD - Barrett to Adenocarcinoma Sequence.

Video Endoscopic Sequence 2 of 5.

 Adenocarcinoma of the middle third. A Close up of the
 tumor, this tumor almost surely it comes from
 Barrett -Adenocarcinoma sequence.

Video Endoscopic Sequence 3 of 5.

 Since the early 1970s, a dramatic change has occurred in
 the epidemiology of esophageal malignancy in both North
 America and Europe: the incidence of adenocarcinomas of
 the lower esophagus and esophagogastric junction is
 increasing. Several lifestyle factors are implicated in this
 change, including gastroesophageal reflux disease (gerd).
 Primary esophageal adenocarcinomas are thought to arise
 from Barrett esophagus, an acquired condition in which the
 normal esophageal squamous epithelium is replaced by a
 specialized metaplastic columnar-cell-lined epithelium.

Video Endoscopic Sequence 4 of 5.

 A small nodule in the upper third of the esophagus is
 displayed at 11 ó clock.

 Peculiar image that shows the differences between two
 epithelium at the middle third is red(columnar from the
 stomach) and the upper third is pink (stratified) from the
 esophagus.

 Barrett’s esophagus, which is the replacement of the
 normal squamous epithelium of the distal esophagus with
 metaplastic columnar epithelium

Video Endoscopic Sequence 5 of 5.

Malignant glandular neoplasia without native esophagic epithelium.

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