Esophageal

Question 1

Epidemiology of esophageal cancer

Answer 1

Represents approximately 1% of all cancer diagnoses.
Men are three to four times more likely to develop esophageal cancer.
Most cancers are diagnosed between 55 to 85 years of age.
Greater frequency in northern china, northern Iran and South Africa has been attributed to nutritional and environmental factors.

Question 2

Etiology of esophageal cancer

Answer 2

Squamous cell carcinoma:
- excessive drinking and smoking
Barret's esophagus
- gastroesophageal reflux
Adenocarcinoma
- long-standing gastroesophageal reflux disease (30% of esophageal cancers are associated with GERD)
Diet
- diets low in fresh fruits and vegetables and high in nitrates (cured meats, pickled veggies)
Other diseases
- Achalasia
- Tylosis

Question 3

Achalasia

Answer 3

The lower two-thirds of the esophagus lose normal peristaltic activity. The esophagus becomes dilated and the esophagogastric junction sphincter fails to relax so food cannot pass to the stomach.

Question 4

Tylosis

Answer 4

A rare inherited disorder that causes excessive skin growth on the palms of the hands and feet. Individuals with this disease see a 40% increased risk of esophageal cancer due to a mutation on the chromosome.

Question 5

Prognostic indicators esophageal cancer

Answer 5

Tumour size is an important tool.
- smaller tumours are typically localized and have a better 2-year survival
- larger tumours typically have metastasized
Other factors:
- weight loss of 10%
- poor performance status
- age greater than 65 years

Question 6

Anatomy of the esophagus

Answer 6

25cm long tube lined with stratified epithelium.
Begins at the level of C6 and traverses the thoracic cage to terminate in the abdomen at the esophageal gastric junction.

Question 7

Three regions of the esophagus

Answer 7

Upper thoracic: SSN to the carina
Middle thoracic: begins at carina and extends to the esophageal gastric junction
Lower thoracic: includes the abdominal esophagus

Question 8

Layers of the esophagus

Answer 8

Mucosa
Submucosa: circular layer
Muscular layer: longitudinal layer
* lacks a serosal layer, the outermost layer is called the adventitia, which consists of thin loss connective tissue. This is another factor that contributes to the early spread to adjacent structures.

Question 9

Barrets Esophagus

Answer 9

Condition in which the distal esophagus is lined with columnar epithelium rather than stratified squamous epithelium.
Mucosal change typically occurs with gastrointestinal reflux.

Question 10

Upper and middle thoracic esophagus lymph drainage

Answer 10

paratracheal lymph nodes
hilar lymph nodes
sub-carinal lymph nodes
paraesophageal lymph nodes
paracardial lymph nodes

Question 11

The lower third of the esophagus lymph drainage

Answer 11

Celiac axis nodes
Left gastric nodes
Nodes of the lesser curvature of the stomach

Question 12

Clinical presentation of the esophagus cancer

Answer 12

Dysphagia and weight loss occur in 90% of patients
Patients may feel the food sticking when swallowing
Regurgitation of undigested food may also occur
Odynophagia (painful swallowing occurs in 50% of patients)
Symptoms of a locally advanced tumour include:
- hematemesis (vomiting blood)
- coughing
- hemoptysis

Question 13

Histologic confirmation of esophageal cancer

Answer 13

Esophagoscopy a rigid or flexible endoscope that can be used to examine the entire esophagus with brushing and biopsies done to suspicious lesions.

Question 14

EUS

Answer 14

Endoscopic ultrasound scan: useful for visualizing the tumour and depth of invasion and lymph node status.

Question 15

Pathology of esophageal cancer

Answer 15

Squamous cell carcinoma: more commonly found in the upper and middle esophagus
Adenocarcinoma: typically occurs in the distal esophagus and GE junction.

Question 16

T1 stage esophagus

Answer 16

T1a: tumour invades lamina propria or muscularis mucosa
T2b: tumour invades submucosa

Question 17

T2 stage esophagus

Answer 17

Tumour invades muscularis propria

Question 18

T3 stage esophagus

Answer 18

Tumour invades adventitia

Question 19

T4 stage esophagus

Answer 19

T4a: resectable tumour invades pleura, pericardium or diaphragm
T4b: unresectable tumour invading other adjacent structures such as the aorta, vertebral body, trachea etc.

Question 20

N1 stage esophagus

Answer 20

regional lymph node metastasis involving 1 or 2 lymph nodes

Question 21

N2 stage esophagus

Answer 21

regional lymph node metastasis involving 3 or 5 lymph nodes

Question 22

N3 stage esophagus

Answer 22

Regional lymph nodes metastasis involving 7 or more lymph nodes

Question 23

Spread of esophagus

Answer 23

Usually longitudinal/
Occasionally skip lesions may be present
Locally advanced disease invasion into adjacent structures and early spread to lymphatics is common.

Question 24

Distant met locations of esophageal cancer

Answer 24

Liver and lung are most common

Question 25

Surgery options for esophageal cancer

Answer 25

Patients who receive either surgery or RT have a high risk of local and distant recurrence.
Surgical resection is typically limited to the middle and lower thirds of the esophagus.
Curative surgery typically involves are esophagectomy, The entire esophagus is removed and the stomach or left colon is placed in the thoracic region.

Question 26

Radiation therapy for esophageal cancer

Answer 26

Radiation + chemotherapy or preoperative chemoradiation is considered the best option to reduce the chance of local and distant recurrence.

Question 27

Clinical treatment volume for esophageal cancer

Answer 27

Planning must take into account the longitudinal spread of esophageal cancers, the chance of skip lesions and the likelihood of lymph node involvement.
The treatment volume includes regional lymph nodes and encompasses the tumour with 3cm to 4cm margins above and below the tumour volume and a 1cm radial margin.

Question 28

Field borders for upper 1/3 of esophagus lesions

Answer 28

The field begins at the thyroid cartilage and ends at the level of the carina to include:

• supraclavicular nodes
• low anterior cervical nodes
• mediastinal lymph nodes

Question 29

field borders for distal 1/3 of esophagus lesion

Answer 29

Must include the celiac-axis nodes which are located at T12-L1. The superior aspect should include the paraesophageal nodes and mediastinal nodes.

Question 30

Field borders for mid-thoracic esophagus lesions

Answer 30

Periesophageal lymph nodes and the mediastinal lymph nodes should be included.

Question 31

Organs at risk esophageal treatment

Answer 31

Lung
Heart
Spinal cord
Kidneys
Liver

Question 32

TDF for esophageal cancer

Answer 32

RT alone: 60 to 65Gy
Pre-operative chemoradiation: 41.4-50.4 Gy
Definitive chemoradiation: 50-50.4Gy

Question 33

Side effects of esophageal cancer

Answer 33

After 2 weeks of RT:

• esophagitis: substernal pain when swallowing and the sensation of food sticking.
• treatment: small meals of soft pureed foods, can supplement with boosts.
• medication: liquid analgesics or viscous lidocaine

Pericarditis and pneumonitis may also occur if the lung or heart is in the field.

Late effects:

• stenosis
• stricture

Question 34

Radiation tolerance of the esophagus

Answer 34

65Gy

With chemotherapy, it is reduced to 50Gy