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ABTS - Thoracic Surgery Notecards IA > Esophageal Cancer > Flashcards

Esophageal Cancer Flashcards

1
Q

MC histologic type of esophageal cancer worldwide

A

SCC

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2
Q

RF for esophageal SCC

A
  • EtOH
  • Tobacco (100-fold increased risk when combined with EtOH)
  • Dietary factors:
    • nitrosamines
    • high-cholesterol consumption
  • Achalsia
  • Plummer-Vinson syndrome
  • HIV
  • EBV
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3
Q

Esophageal SCC more common in men or women

A

Men (2:1 - 3:1 M:F ratio)

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4
Q

MC esophageal location for SCC

A

MIddle 1/3 of esophagus

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5
Q

Most common histologic type of esophageal cancer in United States

A

Adenocarcinoma

(fastest growing solid malignancy in US)

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6
Q

Etiologic hypothesis for deveopment of esophageal adenocarcinoma

A

Metaplasia-Dysplasia-Carcinoma sequence in Barrett’s epithelium related to GERD (especially long-segment disease)

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7
Q

RF for esophageal adenocarcinoma

A
  • Barrett’s esophagus (GERD)
  • Nitrates
  • Obesity
  • Smoking
  • LES relaxing drugs
  • Mixed bile-acid reflux
  • TP53 gene mutations
  • Chronic esophageal inflammation
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8
Q

MC esophageal location of adenocarcinoma

A

Distal esophagus

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9
Q

Classic presentation of esophageal cancer

A

Dysphagia to solids

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10
Q

Typical patient with esophageal adenocarcionoma

A
  • Middle aged male
  • Middle-High SES
  • Long history of GERD with known hital hernia
  • No weight loss
  • No palpable LN
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11
Q

Typical patient with esophageal SCC

A
  • Heavy EtOH and cigarette use
  • Low SES
  • Few months of dysphagia and weight loss
  • Odynophagia, hemoptysis and horseness (may be present)
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12
Q

Diagnostic modalities used for esophageal cancer

A
  • Barium swallow esophagography
  • Flexible endoscopy with brushings and multiple bx
  • EUS/FNA (staging with LN biopsy)
  • PET (staging and eval for metastatic disease)
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13
Q

T-stage for esophageal cancer determined by what modality

A

EUS

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14
Q

Five EUS esophageal layers used in T-staging for carcinoma

A
  • First layer: mucosa (hyperechoic)
  • Second layer: deep mucosa (hypoechoic)
  • Third layer: submucosa (hyperechoic)
  • Fourth layer: muscularis propria (hypoechoic)
  • Fifth layer: adventitia (hyperechoic)
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15
Q

Esophageal carcinoma T-stages

A
  • T1: layers 1-3 (up to submucosa)
    • T1a: Tumor invades the lamina propria or muscularis mucosa
    • T1b: Tumor invades the submucosa
  • T2: layer 4 (muscularis propria)
  • T3: layer 5 (beyond muscularis propria into adventitia)
  • T4: beyond layer 5 with obliteration of fat planes surrounding esophagus
    *
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16
Q

Features of LN used to define TNM (N stage) for esophageal cancer

A
  • Intrathoracic or intraabdominal LN > 1cm
  • Supraclavicular LN > 0.5 cm
  • Cervical or celiac LN: M disease
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17
Q

Anatomic sites of esophageal carcinoma metastasis

A
  • Liver (35%)
  • Lung (20%)
  • Bone (9%)
  • Adrenals (2%)
  • Brain (2%)
  • Pericardium
  • Pleura
  • Soft tissues
  • Stomach
  • Pancreas
  • Spleen
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18
Q

Two MC sites of esophageal carcinoma metastasis

A

Liver (35%)

Lung (20%)

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19
Q

Non-surgical treatment options for early stage I esophageal carcinoma

A
  • Endoscopic mucosal resection (EMR)
  • Photodynamic therapy (PDT)
  • Laser ablation
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20
Q

Rate of LN positivity for T1a (mucosal) esophagel cancer

A

0-12%

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21
Q

Rate of LN positivity for T1b esophageal cancer

A

25-40%

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22
Q

Histopathologic features important in determining prognosis for esophageal cancer

A
  • LN status
  • Multifocal neoplasia
  • Skip lesions
  • Lymphovascular invasion
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23
Q

Indicatations for esophagectomy

A

Absence of regional (N) or distant (M) disease (single modality therapy)

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24
Q

Indications for multimodality therapy for esophageal cancer

A

Advanced stage (N or M disease)

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25
Esophagectomy that avoids the pulmonary morbidity of thoracotomy
Transhiatal esophagectomy
26
Risks associated with transhiatal esophagectomy
* Recurrent LN injury (11%) * Esophageal anastomotic leak (12-16%) * easier to control than thoracic anastomotic leak * Esophageal stricture (28%)
27
Transhital hernia indicated for which populations
* Poor pulmonary reserve * Mid to low tumors (non-bulky, early stage)
28
Survival and perioperative mortality for transhiatal esophagectomy
5-yr survival: 20-25% Perioperative mortality: 5%
29
Oncolgoic concern related to performane of transhital esophagectomy
Compromises LN tissue removal
30
Ivor-Lewis Esophagectomy Description
* Right posterolateral thoracotomy + midline laparotomy/laparoscopy * thoracic esophageal anastomosis * Allows for 2-field LN dissection
31
Morbidity and Mortality estimates for ILE
* Esophageal anastomotic leak (10%) * Esophageal stricture (16%) * Recurrent LN injury (5%)
32
3-Incision Esophagectomy Components
* Right posterolateal thoracotomy * Midline laparotomy/laparoscopy * Left lateral neck incision with cervical esophageal anastomosis
33
Advantages and Risks of 3-Incision Esophagectomy
* Direct visualization of dissection in chest and abdomen * Leak rates and risk of RLN injury similar to trans-hital esophagectomy
34
Conduit choices for esophageal reconstruction
* Stomach: * Advantages: _robust blood supply_ and _isoperistaltic arrangement_ * Disadvantages: * delayed gastric emptying (pyloromyotomy/plasty to improve drainage) * GERD * Risk of Barrett's in esophagel remnant * Colon: * Preferred in youg patients with benign disease or gastric compromise (lye disease) * Left colon preferred (longer length, smaller caliber) * Requires colonscopy, preop blood supply studies, 3 anastomoses, long operative time, more blood loss * Jejunum: * preferred for Roux-n-Y when gastrectomy required for distal tumors * Merendino interposition: * interposition of jejunal loop between esophagus and proximal stomach * Long jejunal loop: * requires pedicle preparation * Free graft: used for cervical reconstruction
35
Advantages and Disadvantages of Stomach conduit for esophageal reconstruction
* Advantages: * robust blood supply and isoperistaltic arrangement * Disadvantages: * delayed gastric emptying (pyloromyotomy/plasty to improve drainage) * GERD * Risk of Barrett's in esophagel remnant
36
Characteristics of Colon conduit for esophageal reconstruction
* Preferred in youg patients with benign disease or gastric compromise (lye disease) * Left colon preferred (longer length, smaller caliber) * Requires: * colonscopy * preop blood supply studies * 3 anastomoses * long operative time * more blood loss
37
Characteristics of jejunal conduit for esophageal reconstruction
* Preferred for Roux-n-Y when gastrectomy required for distal tumors * Interposition strategies: * Merendino interposition: * Interposition of jejunal loop between esophagus and proximal stomach * Long jejunal loop: * Requires pedicle preparation * Free graft: used for cervical reconstruction
38
MC location for esophageal conduit
Orthotopic (anatomic)
39
Indications for retrosternal placement of esophageal conduit
* Fear for tumor invovlement of conduit in posterior mediastinum * Delayed reconstructions or extensive mediastinal scarring/adhesions
40
Indication for neoadjuvant chemoradiation therapy for esophageal cancer
Locoregional disease (T2 or N1 disease) \*Postive LN mets seen in 25-30% of T2 cancers, extending use of induction therapy to patients with T2 disease
41
Benefits of neoadjuvant, induction therapy for esophageal cancer
* Downstage tumors: up to 50% * Complete reponse rate: 10% * Avoids adjuvant radiation of conduit (allows assessment of reponse of tumor to therapy)
42
Most important predictor of improved survival after neoadjuvant therapy
Complete response
43
Treatment strategy more likely to elicit patient compliance with complete chemoradiation therapy (neoadjuvant vs. adjuvant)
Neoadjuvant
44
Role of adjuvant XRT after esophagectomy
Steralize microscopic or gross residual local tumor \*Risk of potential damage to conduit
45
Indications for adjuvant chemotherapy after esophagectomy in absence of metastaic disease
* Highly aggressive histology * Lymphovascular invasion
46
Esophageal Cancer: Chemoradiation regimen used for definitive and adjuvant treatment
* **_Cisplatin + 5-FU_** + Epirubicin/Docetaxel * 40-50 Gy of fractionated RT
47
XRT more efficacious for SCC or adenocarcinoma of esophagus
SCC \*Adenocarcinoma less significant response to chemoradiation therapy (thus, surgery performed more frequently)
48
Palliative options for esophageal cancer
* Endoscopic dilation * Stent placement Goal: improve QOL (controlling dysphagia, odynophagia, blood loss, fistula-related moridity, nutrition)
49
Prevelence of TEF with locally advanced esophageal cancer
~ 15%
50
Treatment options for TEF related to locally advanced esophageal cancer
Gaol: palliation with control of fistula to limit respiratory complications * Options: * Stent coverage (closure rate: 75-100%) * Chemoradiation (small fistulas with minimal spillage) * Bypass and diversion: * good functional status * absence of regional or metastatic disease
51
5-year survival of esophageal cancer without treatment
5-12% (median survival 23%)
52
5-year survival for esophageal cancer stages
* Early stage (80%) * Local stage (24%) * Locoregional stage (12%) * Advanced stage (2%)
53
Poor prognostic factors for esophageal cancer-related survival
* Advanced age * African-American race * Distal esophageal tumors * Increased depth * \> 5 LN involvement * High ratio of positive:negative LNs
54
Favorable prognostic factors for esophageal cancer-related survival
* Complete pathologic reponse to induction therapy * Minimal residual disease * High hospital volume (\> 20 procedure/year)
55
TMN Staging Esohageal Cancer T-stages
* T1: invasion up to submucosa * 1a: up to muscularis mucosa * 1b: invasion of submucosa * T2: ivasion of muscularis propria * T3: invasion of adventitia * T4: invasion of adjacent structures * 4a: invasion of pleura, pericardium, diaphragm * 4b: invasion of aorta, vertebral body, trachea
56
TNM Staging Esophageal Cancer N-stages
* N1: 1-2 regional LN * N2: 3-6 regional LN * N3: \>= 7 regional LN
57
TNM Staging Esophageal Cancer M stages
M0: no distant metastasis M1: distant metastasis
58
Esophageal Cancer Histologic Grading
* G1: well differentiated * G2: moderately differentiated * G3: poorly differentiated * G4: undifferentiated
59
Esophageal tumor location distances
* Upper thoracic: thoracic inlet to tracheal bifurcation (20-25 cm) * Middle thoracic: tracheal bifurcation to GEJ (25-30 cm) * Lower thoracic: distal esophagus/GEJ or within 5 cm of stomach (40-45 cm)
60
Esophageal Cancer Staging Stage I
Stage I * T1-2 only, N0MO, G1-2 * T1 + G3
61
Esophageal Cancer Staging Stage II
Stage II * T1-2 + N1 * T2-3 alone
62
Esophageal Cancer Staging Stage III
Stage III * T1-2 + N2 * T3 + N1-2 * T4 alone * N3 alone
63
Esophageal Cancer Staging Stage IV
Stage IV Any M1 disease
64
Esophageal Cancer: Neoadjuvant chemoXRT regimen

ABTS - Thoracic Surgery Notecards IA (48 decks)

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