Esophageal Cancer Flashcards
What is the most common esophageal cancer?
Adenocarcinoma (formerly the most common type was squamous cell carcinoma)
What are the most important risk factors for the development of squamous cell carcinoma of the esophagus?
Smoking and alcohol
What are the predominant risk factors associated with the development of adenocarcinoma of the esophagus?
Barrett’s esophagus and long standing GERD
What is the most common presenting symptom of esophageal cancer?
Dysphagia
What is included in the preoperative evaluation for esophageal cancer?
Determining extent of disease and patients clinical status. Upper endoscopy, CT scan, PET and EUS.
What is the role of CT scan in esophageal cancer?
For detection of metastatic disease.
Is transhiatal approach to esophageal cancer the only effective option?
No, Ivor-Lewis is a combined thoracic and abdominal dissection with complete lymphadenectomy, and eliminates risk of a blind thoracic dissection.
True or False: Small intestine interposition is the simplest method for esophageal reconstruction in esophageal cancer.
False. Small bowel interposition is the most complex method of reconstruction, requiring microvascular and intestinal anastomoses.
Which interposition grafts are preferred for benign disease?
Colonic
True or False: A gastric pullup is the most popular method of esophageal reconstruction.
True. It requires only a single anastomosis, has enough length to reach the neck, and serves as an effective alimentary conduit.
True or False: The detection of high grade dysplasia (HGD) in BE is an indication for esophagectomy.
True. HGD is a marker of occult adenocarcinoma. Presence of occult adenocarcinoma in resected specimen approaches 50%.
How does treatment differ in patients with small, visible mucosal lesions of high grade dysplasia in Barrett’s?
Endoscopic mucosal resection (EMR) is an option, and adequate therapy if area is less than 20mm in diameter and cancer is confined to the lamina propria.
Treatment for disease that invades the muscularis mucosa or extends into submucosa.
En bloc esophagectomy, because are locally advanced disease.
What is the risk of nodal metastasis in esophageal cancers limited to mucosa?
3-6%
What is the risk of nodal metastasis in esophageal cancers penetrating the submucosa?
30%
What are the recommendations for resection in patients with esophageal cancers penetrating the muscularis mucosa?
Esophagectomy, lymphadenectomy.
Do esophageal tumors invading the lamina propria require lymphadenectomy?
No. Recommendations include sparing vagal esophagectomy.
In nonmetastatic locally advanced esophageal cancer, which surgical approach has less incidence of local recurrence?
En bloc
True or False: Transhiatal esophagectomy has a better overall survival than en bloc resection for esophageal cancer.
False, transhiatal resection has survival of 25% for all stages compared to en bloc survival of 40-50% at 5 years.
What are the two most important prognostic factors for survival in esophageal cancer?
tumor depth and nodal involvement
Does number of nodes removed provide a survival benefit in patients with esophageal cancer?
Yes.
Indications for surgery in metastatic esophageal cancer.
Palliation: esophageal perforation, bleeding and unsuccessful stent placement
Followup after esophagectomy.
During first 3 years, every three months, then every 4-6 months.
When is adjuvant chemotherapy employed in patients with esophageal cancer?
When there are four or more positive lymph nodes on histology of surgical specimen.
Which procedure is utilized in palliative resection of esophageal cancer and why?
Transhiatal, because of less extensive dissection and fewer complications.
Can esophageal stents be used in benign disease?
Yes
Which patients are candidates for esophageal stent placements?
- Perforation of benign disease but unable to undergo surgery, 2. Late perforations 3. Perforation of malignant disease but unable to undergo surgery 4. Anastomotic leak after esophagogastrectomy, 5 Immediate recognition of iatrogenic perforation during endoscopy
When stenting for benign disease, how long are most stents left in place?
2 months
Name the early complications of stent placement
Early complications appear <30 days after stent placement and include chest pain, bleeding, aspiration, perforations, fistula and stent migration, stent obstruction.
Name the common late complications of stent placement
Late complications appear >30 days after stent placement and are usually related to tumor progression. Tumor ingrowth or overgrowth leading to dysphagia, bleeding, ulceration, perforation, fistula, stent fracture and migration.
What percentage of patients diagnosed with esophageal carcinoma present with metastatic disease?
50%
What is overall survival for esophageal cancer?
About 20%
Has neoadjuvant therapy shown a survival benefit in esophageal cancer?
Yes, neoadjuvant chemoradiotherapy provides a survival benefit for locally advanced esophageal carcinoma.
What is the main blood supply to the gastric conduit?
Right gastroepiploic artery
