Ulcerating Squamous cell carcinoma of the lower end of the esophagus.
This 72 year-old female, presented with progressive dysphagia. In order to determinate the etiology an upper endoscopy was carried out.
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.
Endoscopic appearance of 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.
Endoscopic Picture of Esophageal Carcinoma
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.
Pathophysiology
Esophageal carcinoma arises in the mucosa. Subsequently, it tends to invade the submucosa and the muscular layer and, eventually, contiguous structures such as the tracheobronchial tree, the aorta, or the recurrent laryngeal nerve. The tumor also tends to metastasize to the periesophageal lymph nodes and, eventually, to the liver, lungs, or both.
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 20 pounds of weight. Endoscopy revealed a large tumor.
Esophagus cancer may develop in any part of the esophagus.-- usual distribution is as follows: 20% in upper third, 30% in the middle third and 50% in the lower third.
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 7.
Small cell carcinoma of the lung that invades the upper and the middle third of the Esophagus.
Video Endoscopic Sequence 2 of 7.
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 7.
This view is from the upper esophageal sphincter.
Video Endoscopic Sequence 4 of 7.
The middle third of the esophagus.
Video Endoscopic Sequence 5 of 7.
Video Endoscopic Sequence 6 of 7.
There are malignant small cell neoplasia with round and spindle shaped nuclei. H&E x40.
Video Endoscopic Sequence 7 of 7.
To the left there are small cell tumor, malignant. To the right, the esquamous epithelium of the esophagus that is normal.
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 had 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).
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 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 alcoholSquamous 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 alsodevelop 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 had been under radiotherapy and chemotherapy due to upper third neoplasia of the esophagus, in an attempt to perform dilation presented 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 tubehas 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 effusionand 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 female was referred to our endoscopic unit by otorhinolaryngologist, because the 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.
Endoscopic View of Cancer of the Esophagus
Obstructing Esophageal Mass.
Unfortunately, most patients with esophageal cancer present with advanced, incurable disease.
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 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 dysphagia 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 her life had been suffering of GERD, lately with difficulties to swallowing that made us suspecte that she 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.
Stenosis of the esophagus caused by radiotherapy with cobalt to a carcinoma
This 77 year-old female, who undewent as an paliative treatment to her esophageal squamous cell carcinoma of the middle third.
Video Endoscopic Sequence 2 of 2.
Esophageal Squamous Cell Carcinoma of the middle third.
Radiation therapy can be an integral part of the treatment of esophageal cancer. The objective of radiation therapy to the esophagus is to kill cancer cells that could otherwise persist after therapy and cause the cancer to relapse locally.
Radiation therapy may produce considerable short-term side effects such as mucositis (inflammation of the lining of the throat, mouth and esophagus), perforation of the esophagus with the development of fistulas (connections with other organs such as the trachea), infection, bleeding, xerostomia (dryness in the mouth) and fatigue. Changes to the esophagus and skin usually go away in 6-12 months. Some patients who respond to radiation therapy will develop strictures or narrowing of the esophagus that will require treatment in the future.
Video Endoscopic Sequence 1 of 9.
Synchronous Cancer Gastric and Esophageal
This 60 year-old man, with chronic alcohol abuse presented with progresive dysphagia to solid and liquids, weight lost 30 pounds at the endoscopy two cancer were detected one of the upper and middle third (Squamous Cell Carcinoma, and the second at the stomach adenocarcinoma).
Video Endoscopic Sequence 2 of 9.
Endoscopy of two Cancers Esophagus and Gastric
The Gastric Fundus, that is infiltrated with the adenocarcinoma (second primary neoplasia).
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Extensive Infiltration of the Fundus and Body, upwards the antrum and the pylorus are observed.
Video Endoscopic Sequence 4 of 9.
Gastric body with extensive infiltration by the adenocarcinoma.
Video Endoscopic Sequence 5 of 9.
The lower Third of the Esophagus is observed free of Malignancy.
There are 2 types of cancer - squamous cell carcinoma and adenocarcinoma. In the United States, squamous cell carcinoma is much more common in blacks than whites. Chronic alcohol and tobacco use are strongly associated with an increased risk of squamous cell carcinoma. Adenocarcinoma is more common in whites, and is increasing dramatically in incidence. The vast majority of adenocarcinomas develop as a complication of Barrett's metaplasia ,which is a complication of chronic gastro esophageal reflux. Thus most adenocarcinomas arise in the lower third of the esophagus.
Video Endoscopic Sequence 6 of 9.
Endoscopic Image of Esophageal Carcinoma of the middle third.
History
Dysphagia is the most common presenting symptom.
Dysphagia is initially experienced for solids, but eventually it progresses to include liquids.
A complaint of dysphagia in an adult should always prompt an endoscopy to help rule out the presence of esophageal cancer. A barium swallow study is also indicated.
Weight loss is the second most common symptom and occurs in more than 50% of people with esophageal carcinoma. Patients may experience bleeding.
Pain can be felt in the epigastric or retrosternal area. It can also be felt over bony structures, representing a sign of metastatic disease.
Hoarseness caused by invasion of the recurrent laryngeal nerve is a sign of unresectability. Patients may have a persisting cough.
Respiratory symptoms can be caused by aspiration of undigested food or by direct invasion of the tracheobronchial tree by the tumor. The latter is also a sign of unresectability.
Video Endoscopic Sequence 7 of 9.
Malignant infiltration of the middle third of the Esophagus
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Endoscopic image of the superior esophageal sphincter, immediate to is observed the esophagus cancer.
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Endoscopic Image of Esophageal Cancer of upper third
Video Endoscopic Sequence 1 of 2.
Endoscopy of Esophageal Squamous Cell Carcinoma.
This 75 year-old female, has been sufferring from progresive dysphagia during 2 months
