Barrett’s and Oesophageal cancer Flashcards
What is barrettes oesophagus?
When the normal distal oesophageal squamous epithelial is replaced with metaplastic columnar epithelium
What is the cause of barrettes oesophagus?
Consequence of persistent oesophageal injury due GORD
What type of cancer does GORD and barrettes oesophagus predispose cause?
oesophageal adenocarcinoma
Where is the transition zone in the oesophagus?
Lower oesophagus
squamocolumnar junction - Z line lies within 1cm of the
around the lower oesophageal sphincter
lower oesophageal
squamous epithelium meets gastric columnar epithelium
What are the signs and symptoms of GORD?
Heartburn
Regurgitation
Chest discomfort
Dyspepsia
Nausea and/or vomiting
Dysphagia (suggestive of stricture or malignancy in context of BO and reflux)
Does everyone with barrettes oesophagus have a history of troublesome reflux?
No- Approximately 40% of patents with BO will have no history of troublesome reflux.
How is barrettes oesophagus diagnosed?
upper gastrointestinal endoscopy by direct visualisation of the lower oesophagus.
Biopsy should be taken ≥1cm above the GOJ to avoid the natural Z line
What are the 3 main aspects of barrettes oesophagus treatment?
Protein pump inhibitors
Surveillance
Endoscopic therapy
What is the mode of action of Protein pump inhibitors?
Inhibit H+/K+ ATPases in parietal cells
State the 2 main types of barrettes oesophagus?
classical >3cm
short segment < 3cm
What are the 2 main types of cancer which can develop from the oesophagus?
Squamous cell carcinoma - upper or middle oesophagus
Adenocarcinoma - lower oesophagus - near the gastro-oesophageal junction (GOJ)
At what age foes oesophageal cancer usually develop? What is the male to female ratio?
M:F ratio 3-4:1
age > 50 years
What are the risk factors for Squamous cell oesophageal cancer?
- Smoking
- Alcohol consumption
- Previous partial gastrectomy
- Atrophic gastritis
- Human papillomavirus (HPV): mainly genotypes 16 and 18
- oesophageal disorders
- Foods containing N-nitroso compounds
- Chewing of areca nuts
What are the risk factors for Adenocarcinoma oesophageal cancer?
Chronic reflux
Barrett’s oesophagus: 30-fold increase risk of AC
Smoking
Obesity
Zollinger-Ellison syndrome: gastrin-secreting tumour leading to excess hydrochloric acid.
What are the signs and symptoms of oesophageal cancer?
Dysphagia: difficulty swallowing (starts gradually with solid food and progresses to more liquid foods)
Constitutional symptoms: fevers, anorexia, lethargy, weight loss
Weight loss: due to tumour-related anorexia and poor nutrition from swallowing difficulties
Bleeding: haematemesis and melaena
Pain: typically retrosternal pain
Aspiration: cough, shortness of breath, fever
Hoarseness: if there is extension to involve the recurrent laryngeal nerve
Signs
Lymphadenopathy: if local tumour spread
Cachexia
Pallor: due to anaemia
Hepatomegaly: if metastatic spread
When is an Urgent (two week wait) referral for gastroscopy for suspected oesophageal cancer required?
Dysphagia, OR
> 55 years with weight loss and one of the following:
Upper abdominal pain
Reflux
Dyspepsia
When is an NON Urgent referral for gastroscopy for suspected oesophageal pahology required?
Haematemesis, OR
> 55 years with treatment resistant dyspepsia, OR
> 55 years with upper abdominal pain and anaemia, OR
Thrombocytosis with one of the following: Nausea/vomiting Weight loss Reflux Dyspepsia Upper abdominal pain
Nausea/vomiting with one of the following: Weight loss Reflux Dyspepsia Upper abdominal pain
How is Oesophageal cancer diagnosed?
upper GI endoscopy and biopsies of suspected lesions
Which blood tests are conducted when investigating oesophageal cancer?
Full blood count
Serum iron, transferrin saturation, total iron binding capacity (TIBC)
Urea & electrolytes
Liver function tests
Bone profile
Clotting screen
Renal function
Which imaging tests are conducted when investigating oesophageal cancer?
CT chest/abdomen/pelvis: - Help with cancer staging
Abdominal ultrasound - used to assess for liver metastasis
PET-CT - offered to patients with potentially resectable disease (i.e. candidates for surgery) to assess for distant disease not detected by conventional CT.
Which special tests are conducted when investigating oesophageal cancer?
Gastroscopy: principle investigation for diagnosis.
Endoscopic ultrasound (EUS): can be performed at time of endoscopy. Sometimes completed to help more accurately stage oesophageal cancer if it will change management.
Diagnostic laparoscopy: may be used to more accurately stage oesophageal cancer if it will alter management.
Which receptor is tested for on biopsy samples of oesophageal cancer that could help with management?
Human epidermal growth factor receptor 2 (HER2)
Targeted therapy against the HER2 receptor may be offered to patients with HER2 positive metastatic oesophageal cancer.
What is the treatment for Limited and locally advanced tumours (no metastasis)?
Surgical resection,
Squamous cell cancer
Neoadjuvant radiotherapy/chemotherapy the surgical resection
Radical radiotherapy/chemotherapy the, 3 month follow up, then salvage resection
Adenocarcinoma
pre-operative chemotherapy
Restaging
Ressection
Radical radiotherapy/chemotherapy
Restaging
resection
Patients with limited disease may be suitable for endoscopic therapy to remove the oesophageal cancer.
Two options include:
Endoscopic mucosal resection (EMR)
Endoscopic submucosal dissection (ESD)
Which chemotherapy drugs are used for Squamous cell carcinoma and Adenocarcinoma?
cisplatin/5-fluorouracil
How locally advanced/ metastatic oesophageal cancer treated?
Palliative treatment for those who are not operative candidates or fit enough to have surgery
Radiotherapy: if tumour lies within a radiotherapy field that allows high-doses to be applied.
may be used to resolve dysphagia as alternative to stenting
Chemotherapy: regimens depend on fitness of the patient.
Local tumour treatment: endoscopic stenting, palliative radiotherapy.
Best supportive care: focusing on symptom control only.
In patients with HER2 positive cancers, which chemotherapy drug is used?
trastuzumab
What are the macroscopic features associated with oesophageal cancer?
polypoid fungating
ulcerating
annular constricting
diffuse infiltrating
What are the 2 main ways oesophageal cancer spreads?
direct
via lymphatics
