Esophageal & Gastric Cancer😍

Surgical Anatomy of Esophagus

• It is a 25 cm long tube.

• Extends from 
• C6 (lower border of cricoid cartilage) to 
• T10 (diaphragmatic opening).

3 Main Constrictions

Regions

1. Cervical part: 4 cm

2. Thoracic part: 20 cm

3. Abdominal part: 1-2 cm

Characteristics

1. Pharyngoesophageal junction
• C6
• Distance: 15cm
• Relevance:
• Narrowest portion of GIT
• Foreign bodies can get stuck
• Iatrogenic perforations
• Surrounded by cricopharyngeus muscle

2. Arch of aorta
• T4
• Distance: 25cm

3. Left principal bronchus
• T6
• Distance: 27cm

4. Esophagus pierces diaphragm
• T10
• Distance: 40cm

Foreign Body

• Age: 1–4 years (most common)

• Most common foreign body: Nuts & peanuts

Coin in Esophagus:

• Esophagus: Difficulty swallowing

• Appears CIRCULAR in AP view.

• Appears as a SLIT in lateral view.

Button Battery

• On AP view:
• Double ring appearance.

• On lateral view:
• Sloping/ Bevelled edge.

• Corrosive → Alkali → Liquefactive necrosis

• Has to be removed even if the patient is asymptomatic.

Management

• Beyond C6: Patient observation.

• If coin: Impacted at C6: Endoscopic removal.

• Endoscopic removal (D/T corrosive nature → Perforation)



• 1. Battery in esophagus
• Diagnosis ≤ 12 hours:
• Immediate endoscopic removal.
• Diagnosis > 12 hours:
• Consider surgical consult / CT before endoscopic removal.
• 2. Battery not in esophagus
• Symptomatic or magnet co-ingestion:
• Stomach:
• Immediate endoscopic removal.
• Small intestine:
• Consider surgical consult / CT before endoscopic removal.
• Asymptomatic:
• Repeat X-ray after 7–14 days (or sooner if symptoms develop).

FB Trachea:

• Trachea: Stridor & choking

• Appears as a SLIT in AP view.

• Appears CIRCULAR in lateral view.

Xray

• X-ray on inspiration + expiration should be taken.
• NOTE:
• Pneumothorax → Expiratory X-ray view is taken.

• Normally
• Lungs in inspiration contain air - appears black.
• On expiration, air is expelled out - appears white.

• In FB, if obstruction is on the bronchus:
• On expiration, air is not expelled out.
• Hence remains black.
• Suggests the side of obstruction.

Management (First Aid)

1. No respiratory distress, speaking:
• Encourage coughing
• Back blows

2. Conscious + universal choking sign
• inability to speak, breathe, cough
• Heimlich manoeuvre → Sudden thrust just below sternum → ↑ Intrathoracic pressure

3. Unconscious
• Start CPR

Contraindications of Heimlich Maneuver

• Age < 1 year

• Unconscious → CPR

• Pregnancy & obese → Use chest thrust instead

Other Management

• Visible foreign body → Finger sweep method

Definitive

• If first aid fails →
• Cricothyrotomy (through cricothyroid membrane) / Coniotomy
• Inferior laryngotomy
• Minitracheostomy
• Rigid bronchoscopy (definitive foreign body removal)

Q. A 2-year-old girl is brought with a sudden onset cough and difficulty in breathing. There is no history of fever. On probing, there was a history of choking while feeding. The x-ray is shown below. What is the diagnosis?

• Ans. Foreign body aspiration

• More radiolucent

• Hyperinflated right lung → Air trapping → Expiratory CXR

• M/c obstructs Right bronchus

• Method of choice for foreign body removal:
• Rigid bronchoscopy
• Flexible bronchoscope is used nowadays

Corrosive Injury

Causes

Zargar Classification

Endoscopic Finding	Grading
Normal	0
Superficial edema/erythema	1
Mucosal/Submucosal ulceration	2
Transmural ulceration with necrosis	3
Perforation	4

• Sarkar → put corrosives in our Mouth

Management

• For 1 & 2
• Oral fluid intake

• For others
• IV fluids & NPO.

• NG tube should not be inserted blindly → can cause perforation.

• No role of prophylactic antibiotics.

• No role of steroids.

• Most important intervention: Early skilled endoscopy.

• Definitive management: Mx of stricture.

Esophageal Cancer

Clinical Features

• Progressive dysphagia (solids > liquids.).

• Weight loss.

• Hoarseness: Sign of advanced disease (Left Recurrent laryngeal nerve (RLN) involvement).

• Chronic cough.

Investigations

• Endoscopic biopsy: IOC.

• PET-CT: IOC for staging (FIB-FDG).

• Endoscopic USG: IOC for T-staging.

• Barium swallow:
• Rat tail appearance
• Apple core deformity
• Shouldering effect
• Irregular narrowing

Sievert's classification:

• used for GE junction tumours.

Treatment

Esophagectomy

• Margins: Proximal 10 cm, Distal 5 cm.

• Minimum lymph nodes removed: 15.

Esophageal Replacements

• Gastric tube (Best):
• Based on right gastroepiploic artery >> right gastric artery.

• Jejunum/colon:
• If stomach is affected (Corrosive injury).

• SEMS (Self Expanding Metallic Stents):
• Used in malignant TEF.
• M/C complication: Migration.

Prognosis Note

• Main prognostic factor for esophageal Ca. → T-stage (Depth of invasion).

Esophageal Leiomyoma

Features

• M/C benign tumour of esophagus.

• Site: Mid to distal esophagus.

• M > F.

• Usually asymptomatic (Dysphagia ±).

• Barium swallow: Punched out appearance.

Management

• Enucleation.

• STER (Submucosal Tunnelling Endoscopic Resection).

Gastric Cancer

Risk Factors

• Smoking, Alcohol, Smoked fish/food, hot beverages,

• Preservative rich food, H. Pylori,
• H Pylori Associated Cancers (both of the stomach):
• Adenocarcinoma (most common stomach cancer).
• MALToma.

• Gastric resection, Polyps, Menetriers disease, Gastritis

• Other Associations:
• Mnemonic for "A" in Adenocarcinoma
• Pernicious anemia (B12 deficiency).
• Adenomatous polyp.
• Blood group A.

• Most Common Site:
• Overall: Antrum.
• In pernicious anemia: Fundus.

• Mnemonic : GOLU tumors
• Diffuse Gastric cancer, 
• LU: Invasive Lobular carcinoma of breast

CDH gene (E-cadherin):

• Chromosome 16

• "Glue" for cell-to-cell connection.

Loss/mutation

• Mnemonic: Kadich (CDH) → Breastlum Vyarilum

• "Golu" tumors/Kadicha tumors
1. Diffuse Gastric Cancer

Lauren's Classification	Intestinal Lauren's Classification	Diffuse Lauren's Classification
Epidemiological	Environmental	Familial
Pathology	Gastric atrophy, intestinal metaplasia	Blood Group A
Sex	m > F	F > M
Age	↑ Incidence with ↑Age	Younger age
Morphology	Gland formation Round glands	Poorly differentiated
Cell Type	ㅤ	• Gross: Linitis plastica  ("leather bottle appearance"). • Microscopy: Signet ring cells.
Genetics	APC gene mutations, Microsatellite instability p53, p16 inactivation	Loss of E-cadherin (↓ E-cadherin) p53, p16 inactivation
Invasion	Hematogenous spread	Transmural/Lymphatic spread

2. Lobular Carcinoma Breast
• Indian File/Single File Pattern

• Mnemonic: File (Indian file) of Breast Ca patients
3. Claudin low → EMT positive breast cancer

---

• Krukenberg tumor
• Stomach > Breast/ Colon
• Signet Ring Cells
• Retrograde lymphatic spread

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NOTE: Miscellaneous one liners

Other Classifications

• Japanese classification:
• For early gastric cancers: Above muscle layer.
• Type I: Best prognosis.

• Bormann's classification:
• For advanced gastric Ca: Invading muscle layer.
• Type I: Polypoid tumor with a small ulcerated component
• Type IV (Linitis plastica): Worst prognosis.

Atypical Presentations of Gastric/GI Cancers

Investigations

• Endoscopic biopsy: IOC.

• PET-CT: IOC for overall staging.

• EUS: IOC for T-staging (main prognostic factor).

Surgical Management

Primary tumour

• Margins:
• Proximal margin = 5 cm,
• Distal margin = Pylorus

• Resection:
• Distal/Subtotal (Antral tumor)
• Total gastrectomy (60-70%).

Lymph nodes

• D1 gastrectomy
• 1 - 6 removed

• D2 gastrectomy (Optimal):
• 1 - 11 Stations removed.

• Minimum no. of lymph nodes removed: 16.

Note

• M/C site of mets → Liver.

GIST (Gastrointestinal Stromal Tumor)

• Origin:
• Stromal/mesenchymal tumor from cells of Cajal (GIT pacemaker cells).

• Mutations:
• c-KIT (CD117) → increased tyrosine kinase activity.
• Mnemonic: Kit for game
• PDGFRA beta.
• SDH (succinate dehydrogenase) → in pediatric GIST.

• Most Common Site: Stomach.

• Sporadic > Familial.

Syndromes

• Carney's Triad:
• Sporadic
• Gastric GIST A/W SDH-B mutation (Imatinib resistance)
• Paragangliomas
• Pulmonary chondromas
• Mnemonic: Carnival (Carneys) nu Para () vakkunna gangnu (Paraganglioma) condom (chondroma) GIFT (GIST)

• Carney Stratakis Syndrome:
• Familial
• Gastric GIST
• Paraganglioma
• No pulm. chondroma
• Mnemonic: Carnival nu kiss (Carney stratkis) cheythapo condom () koduthilla

• IOC: CECT (Radiological diagnosis).

• Other carneys
• Carnay complex
• Atrial myxoma
• Carnoy fixative
• Karyotyping

Markers:

• CD117 (cKIT): 
• Most sensitive marker.

• CD34.

• DOG1: 
• Most specific marker.

• Wild type:
• CD117 (-) & PDQFA (-).

• Mnemonic:
• Gist → Just a Kit (C kit) for pedophilic (PDGFRA) Sex (pediatric SDH) between 17 (CD117) year old Choi, 34 (CD34) year old Fletcher () and a dog (DOG1)

Treatment: 

• Surgical resection: 2cm margin.

• Malignant/metastasis (m/c liver):
• Surgery + Imatinib.
• Imatinib (tyrosine kinase inhibitor).

• Imatinib resistant: 
• Sunitinib/Sorafenib.

Note

• Fletcher's classification:
• Differentiate b/w benign & malignant GIST.
• Based on size & mitotic figures.

• CHOI Criteria

Gastric Lymphoma

• DAWSON criteria → Primary GI lymphoma

• M/C extranodal site for lymphoma: Stomach.
• M/c site Antrum

• M/C type: Diffuse large B-cell lymphoma.

• C/F: Lump, upper GI bleed.

• Mx: Chemotherapy (RCHOP) → Radiotherapy.

MALToma (Marginal Zone Lymphoma)

• Mnemonic: Malt → Malli → Elli (Eleven, eighteen) → Palli (Pylori)

• Type: Marginal Zone Lymphoma (MZL).

• Associated Bacteria: H. pylori.

• Genetics: Translocation 11;18.

• Microscopy: 
• Lymphoepithelial lesions 

• Low grade:
• Responds to H. Pylori eradication.

• High grade:
• Treat like lymphoma.