18 - Esophageal Gastric Flashcards
Esophageal Cancer - Epi
8th most common cause of cancer
6th leading cause of cancer death
Epithelial: Squamous cell (ESCC) Adenocarcinoma (EAC) Small Cell Other
ESCC (Squamous Cell) - Epi
Worldwide most common cell type
Incidence declining in Western countries
Probably due to decrease in smoking
Incidence of Adenocarcinoma higher now
Male predominance
African American > Caucasian in USA
Esophageal Squamous Cell Carcinoma - Risk Factors
Environmental: Smoking Alcohol History of caustic ingestion Betel nut chewing HPV?!
Associated medical conditions:
Achalasia
Tylosis
Plummer-Vinson Syndrome
Esophageal Adenocarcinoma - Epi
Rise began in 1960s
Reasons unclear
Decreasing rates of H. Pylori infection
Increasing prevalence of GERD
Increasing rates of obesity
Low incidence in developing nations
Esophageal Adenocarcinoma - Risk Factors
Male Sex (>5:1) White GERD (Recurrent sx - 7.7, Long-standing severe - 43) Smoking - 2x Obesity - 1.5 to 2x (BMI > 30) H. Pylori - Lower risk (~0.75)
Barrett’s Esophagus
Primary precursor lesion to EAC
Development of intestinal metaplasia in distal esophagus
Abnormal healing response to erosive esophagitis
Only 8% of patients with EAC were previously diagnosed with BE, though!!
Barrett’s Esophagus - Epi
1 - 2% of general population
5 - 10% of GERD patients
White people get it more than anyone else
Barrett’s Esophagus - Progression to Cancer
No dysplasia (0.1% - 0.3% per year chance of progression) Low grade dysplasia (0.5% - 1.5 - 2% per year chance of progression) High grade dysplasia (5% - 10% per year chance of progression) Cancer
New concept:
Genome doubling & Genomic catastrophes?
Lifetime risk of cancer ~ 5 - 10%
Barrett’s Esophagus - Risk factors for progression
Difficult to study due to low rate of progression Male sex and older age Biomarkers: p53, aneuploidy None yet prospectively validated
Barrett’s Esophagus - Management
Gastric acid suppression via PPIs
Less acid reflux → less esophageal inflammation → decreased risk of cancer
Clinical trial data says efficacy is lacking, though
Endoscopic surveillance Periodic endoscopy with random biopsies Goal: Detect dysplasia or cancer at early stages Effective at "stage shifting" Unclear survival benefit
High grade dysplasia - Endoscopic treatment
Endoscopic mucosal resection
Then they burn your barett’s tissue until you’re down to your submucosa again and it grows back as squamous WHATTTT
Esophageal Cancer - Clinical Features
Frequently no symptoms until advanced disease Dysphagia GI Bleeding: Overt - Hematemesis Occult - Iron deficiency anemia Weight loss
Esophageal Cancer - Staging
TNM Staging
US for T staging
FNA of suspicious nodes
Esophageal Cancer - Prognosis
So poor
17% 5-year survival
Similar in EAC and ESCC
Why?
Rapid lymphatic spread. Esophagus has hella lymph up in thurr
After esophagectomy, you still have a high rate of local and distant recurrence
Esophageal Cancer - Treatment
Early lesions - Endoscopic mucosal resection
Advanced lesions - (>T1b, nodal involvement):
SCC - Surgery or definitive chemo
EAC - Neoadjuvant chemoradiation (Carboplatin + Paclitaxel) then surgery
Metastatic disease: Palliative chemo (HER2 testing in EAC)
Obstruction - stenting, radiation
Bleeding - Radiation
PD-L2+ in ~50% EACs → Pembrolizumab trial underway (PD-1 antibody)
High mortality rate