CA Eso Flashcards by Julie Ng

Risk factors for SCC

Smoking
Alcohol
Caustic injury
Low socioeconomic status
Poor oral hygiene
Achalasia
Hx of thoracic radiation
Nutritional deficiencies
Non-epidermolytic palmoplatnar

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Risk factors for adenocarcinoma

BE
Symptomatic GERD
Obesity
Tobacco
Male
Increased Age
Low diet of vegetables and fruit
History of thoracic radiation

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Field change/ cancerization

1) Definition
2) Clinical implication

1) the process whereby cells in a particular tissue/organ are transformed due to prolonged exposure to carcinogens such that genetically altered but histologically normal appearing cells predate the development of neoplasia or coexist with malignant cells
2) synchronous tumor up to 17%, mainly in SCC

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Tis

high grade dysplasia

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T1a

invades lamina propria or muscularis mucosae

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T1b

invades submucosa

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invades muscular propria

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invades adventitia

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T4a

resectable tumor
invades pleura/pericardium/diaphragm

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T4b

unresectable tumor
invades other adjacent structures

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Regional lymph nodes

1) N1
2) N2
3) N3

1) 1-2 LNs
2) 3-6 LNs
3) 7 or more regional LNs

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Definitions of

1) cervical esophagus
2) upper thoracic
3) middle thoracic
4) lower thoracic

1) UES to sternal notch (15-20cm from incisor)
2) sternal notch to azygos vein (20-25)
3) azygos vein to inferior pulmonary vein (25-30)
4) inferior pulmonary vein to EGJ (30-40cm)

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Risk of nodal metastasis for

a) T1a
b) T1b

a) 5%
b) 16%

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T stage subclassification

a) mucosa
b) submucosa

a) invades
M1- epithelial layer = Ts
M2-lamina propria = T1a
M3- invades muscularis mucosae = T1b
b) penetrates
SM1: shallowest 1/3 submucosa
SM2: 2/3 submucosa
SM3: deepest 1/3 submucosa

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Tumor features affecting risk of LN metastasis

macroscopic appearance of lesion (flat/depressed/ulceration)
tumor size (>2cm)
lymphovascular invasion
histologic differentiation

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Argument of esophagectomy over ER in early superficial eso cancer

1) ADV
2) DISDV

1)Precise pathological staging
Permanent removal of all Barrett’s mucosa
2)
Risk of major complication
Long hospital stay
Risk of preoperative death
Long recovery
LT problems of swallowing

Treatment options of superficial oesophageal cancer (M1,M2, M3 w/o LN invasion)

Endoscopic resection (EMR, ESD
Endoscopic ablation (RFA, PDT, cryotherapy)
Esophagectomy
EBRT

Staging for ca esophagus. Five year survival

1) I
2) IIa
3) IIb
4) III
5) IV

1) 50-80%
2) 30-40%
3) 10-30%
4) 10-15%
5) < 5%

Criteria for resection

T1-T2N0M0
T3N0M0 after neoadj chemoRT
Selected T4a

Surgical approaches for esophagectomy

1) transhiatal vs transthoracic
2) thoracoabdominal, 2 phase, 3 phase

McKeown procedure

1) Defn
2) Indication

1) Tri-incisional oesophagectomy, 3 phase
1) Tri-incisional oesophagectomy, 3 phase
- Right thoracotomy: mobilise esophagus and tumor
- Laparoscopy (abdominal): creation of gastric conduit

Left neck incision: anastomosis of stomach to cervical oesophagus
2) Middle or distal esophageal cancer

Ivor Lewis procedure

1) Defn
2) Indication

1)2 phase oesophagectomy

Laparotomy: stomach mobilisation + creation of gastric conduit

Right thoracotomy: resection of tumour and anastomosis to proximal oesophagus

2)Low thoracic or EGJ cancers

1FLND

“1 field lymph node dissection”
dissection of only abdominal field

2FLND

abdominal + thoracic field

3FLND

cervical + thoracic + abdominal fields

Methods of oesophageal reconstruction

1) Presternal 2) Retrosternal 3) Posterior mediastinal (most preferred)

Possible organs for reconstruction

Stomach Colon Jejunum

Methods of stomach lengthening

Kocher maneuver Excision of lesser curve of stomach Incision of serosa on the gastric wall

Two possibilities for effective isoperistaltic colon

1) transverse colon based on left colic vessels 2) right colon based on middle colic vessels

Indications for colonic reconstruction

Previous gastric resection Tumors with extensive gastric involvement Failed gastric transposition

Indications for jejunal reconstruction

after pharyno-laryngectomy performed for carcinoma of hypopharyx, postcricoid region and cervical oesophagus

PLO 1) Defn 2) Indication

1) removal of larynx, lower pharynx, cervical trachea, one or both thyroid lobes and cervical oesophagus 2) ca eso or hypopharynx

Grey Turner

Transhiatal oesophagectomy for early stage tumours with low risk of LN metastasis

Complications

Respiratory cx Cardiac cx Anastomotic leak (5%) Chyle leak (3-4%) Ischemic conduit Wound problem (3%) Reoperation (\<10%) GERD Anastomotic stricture

Palliative aims

Pain control Symptomatic control Nutrition Luminal control of dysphagia (stent/RT/ndYAGlaser) Control of distant disease (chemo, monoclonal antiB)

Early complications of esophageal stenting

Chest pain Bleeding Perforation/fistulation Aspiration Malposition Incomplete expansion

Late complications of esophageal stenting

Food bolus obstruction Migration Overgrowth Ulceration Perforation Fistula Stent fracture

LN involved in abdominal field dissection

1- right cardia 2-left cardia 3-lesser curvature 7- left gastric 8- common hepatic artery 9- celiac artery 11- splenic artery 19- infradiaphragmatic 20- paraesophageal

LN involved in thoracic field dissection

* R + L recurrent nerve * pretracheal * R + L tracheobronchial * R+ L main bronchus * subcarinal * upper + middle + lower thoracic paraesophageal * supradiaphragmatic * posterior mediastinal (include thoracic duct nodes)