Esophageal Cancer Flashcards
What are the two predominant histologic types of esophageal cancer?
Adenocarcinoma (most common in the United States)
squamous cell carcinoma (most common worldwide)
Risk factors for esophageal cancer
Gastroesophageal reflux
smoking
alcohol consumption
nutritional deficiencies
environmental carcinogens
long-standing achalasia
caustic injury
commonly reported symptoms at the time of presentation for esophageal cancer?
Regurgitation, odynophagia, weight loss, and hematemesis.
What is the most common presenting symptom
Dysphagia
How do patients typically compensate for symptoms in the early phases of esophageal obstruction?
adjusting their diet and consuming semisolid and liquid nutrition as tolerated
At what point does dysphagia typically present in esophageal cancer patients?
tumor occludes two-thirds of the lumen.
Why are patients typically at an advanced stage at the time of esophageal cancer diagnosis?
Because symptoms often present late.
How might patients with a history of reflux disease be diagnosed earlier with esophageal cancer?
Through surveillance endoscopy.
What is the first study recommended in the diagnostic workup of esophageal cancer?
Barium swallow
What is considered the gold standard for evaluating esophageal cancer and obtaining a tissue diagnosis?
EGD
How many biopsies should be taken during an EGD following the Seattle protocol for esophageal cancer?
Six to eight four-quadrant biopsies should be taken along every centimeter of gross disease
What is the role of endoscopic ultrasound (EUS)
helps with early staging, determining tumor invasion (T stage), assessing suspicious lymph nodes (N stage), and detecting regional metastases (M stage)
What classification does EUS help determine that is important for guiding treatment pathways?
The Siewert classification
How does the addition of fine-needle aspiration (FNA) benefit the diagnostic process in esophageal cancer?
improves the accuracy of the diagnosis
What is Siewert Type I adenocarcinoma?
Adenocarcinoma of the lower esophagus with the epicenter located within 1 to 5 cm above the anatomic gastroesophageal junction (GEJ)
What defines Siewert Type II adenocarcinoma?
True carcinoma of the cardia with the tumor epicenter within 1 cm above and 2 cm below the esophagogastric junction (EGJ).
What is Siewert Type III adenocarcinoma, and how is it managed?
Subcardial carcinoma with the tumor epicenter between 2 and 5 cm below the EGJ, which infiltrates the EGJ and lower esophagus from below. It is considered gastric cancer and follows the gastric cancer algorithm for management.
What stage of esophageal cancer can endoscopic mucosal resection (EMR) be considered therapeutic for?
Early-stage disease (T1a or T1b)
What is the typical size of nodular lesions suitable for EMR in esophageal cancer patients?
Lesions ≤ 2 cm
What should be done with focal nodules during an EMR?
completely excised and sent for pathology
asses Depth of invasion, degree of differentiation, and presence of vascular and/or lymphatic invasion.
factors are associated with a greater risk of lymph node involvement in esophageal cancer?
Poor differentiation
deep submucosal invasion
and/or lymphovascular invasion (LVI)
What imaging modality is indicated to evaluate for metastatic disease and locoregional extent in esophageal cancer patients?
CT) of the chest, abdomen, and pelvis with oral and IV contrast
What is a limitation of CT in the evaluation of esophageal cancer?
It is poorly sensitive for early-stage disease, the type of Siewert location, and distinguishing T3 from T4 lesions
What esophageal thickness on CT is considered abnormal?
Esophageal thickening of more than 5 mm
What imaging modality is used to assess for metastatic disease in esophageal cancer?
FDG-PET)/CT
When should bronchoscopy be performed in esophageal cancer patients?
In patients with tumors at or above the carina and no evidence of M1 disease
What is the treatment for pTis adenocarcinoma of the esophagus?
Endoscopic resection (ER) ± ablation or esophagectomy
What is the treatment for pTis squamous cell carcinoma of the esophagus
ER and/or ablation or esophagectomy.
What is the treatment for pT1a adenocarcinoma of the esophagus?
ER ± ablation or esophagectomy.
What is the treatment for pT1a squamous cell carcinoma of the esophagus?
ER and/or ablation or esophagectomy.
What is the treatment for superficial pT1b adenocarcinoma of the esophagus?
ER ± ablation or esophagectomy
What is the treatment for superficial pT1b squamous cell carcinoma of the esophagus?
Esophagectomy.
What is the recommended treatment for cT1bN0-cT2N0 (low-risk lesions: < 3 cm, well-differentiated) adenocarcinoma?
Esophagectomy.
What is the recommended treatment for cT1bN0-cT2N0 (low-risk lesions: < 3 cm, well-differentiated) squamous cell carcinoma?
Esophagectomy (for non-cervical esophagus).
What is the treatment for high-risk lesions cT2N0 (≥ 3 cm, poorly differentiated) in adenocarcinoma?
Induction chemoradiation therapy or chemotherapy alone.
What is the treatment for cT1b-cT2N+ or cT3-cT4a, any N in adenocarcinoma of the esophagus?
Induction chemoradiation therapy or definitive chemoradiation for those who decline surgery.
What is the treatment for cT1b-cT2N+ or cT3-cT4a, any N in squamous cell carcinoma (noncervical esophagus)?
Induction chemoradiation therapy or definitive chemoradiation therapy
What is the treatment for cT4b adenocarcinoma of the esophagus?
Definitive chemoradiation therapy or chemotherapy alone
What is the treatment for cT4b squamous cell carcinoma of the esophagus?
Definitive chemoradiation therapy or chemotherapy alone
What are the treatment options for T1 tumors involving the mucosa and superficial submucosa in esophageal cancer?
Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection.
How are deeper submucosal lesions (T1) in esophageal cancer treated?
Esophagectomy.
What is the optimal management for T2N0M0 disease in esophageal cancer, and why is it controversial?
due to unreliable clinical staging, leading to under- and overstaging.
Treatment options include esophagectomy with or without induction or adjuvant therapy, or definitive chemoradiation
What do NCCN guidelines suggest for patients with T2N0M0 disease in esophageal cancer
definitive chemoradiation or esophagectomy with or without induction or adjuvant therapy.
What factors differentiate low-risk from high-risk lesions in esophageal cancer?
Low-risk lesions are < 3 cm and well-differentiated,
while high-risk lesions are ≥ 3 cm, poorly differentiated, and may have lymphovascular invasion (LVI) or nodal involvement
How should cT1b-cT2, N0 low-risk lesions in esophageal cancer be treated?
They should be resected with esophagectomy, including for noncervical squamous cell cancer.
What is the recommended treatment for higher-risk esophageal cancer lesions (LVI, ≥ 3 cm, poorly differentiated, cT1b-cT2N +, or cT3-cT4aN+)?
Preoperative chemoradiation for noncervical squamous cell cancer
or definitive chemoradiation for cervical squamous cell cancer
What is preferred for patients with adenocarcinoma in esophageal cancer
Preoperative chemoradiation.
n which cases should definitive chemoradiation be reserved for esophageal cancer patients?
Patients who decline surgery, have poor performance status, or have bulky, multistation nodal involvement.
What is the optimal treatment for patients with T3-4a tumors or nodal disease in esophageal cancer?
Induction chemoradiation followed by surgery.
What did a recent randomized trial demonstrate about the treatment of esophageal or EGJ cancer?
A survival benefit to induction chemoradiation followed by surgery compared with surgery alone
What should be assessed before planning any surgery for esophageal cancer patients?
ability to undergo general anesthesia and major surgery, taking into account their age and performance status.
How many lymph nodes should be resected for adequate staging in esophageal cancer patients who have not received induction chemoradiation, according to NCCN guidelines?
At least 15 lymph nodes
What is the recommended treatment for cervical or cervicothoracic esophageal carcinomas located less than 5 cm from the cricopharyngeus?
Definitive chemoradiation
When should a feeding tube (preferably a jejunostomy tube) be considered before induction therapy in esophageal cancer patients?
When the patient is near totally obstructed and cannot tolerate any oral liquids
What are the conduit options for esophageal cancer resection?
Stomach (preferred), colon, or jejunum
What do NCCN guidelines recommend for patients with cervical esophageal squamous cell carcinoma?
Definitive chemoradiotherapy
For what type of esophageal cancer is Ivor Lewis esophagectomy ideal?
Cancer in the mid- and distal esophagus.
What lymph node dissection is performed during an Ivor Lewis esophagectomy?
A complete D2 lymph node dissection starting at the celiac trunk, hepatic and left gastric artery, the superior margin of the portal vein, and the peripancreatic tissue.
Why is a thorough lymph node dissection particularly important for adenocarcinoma of the cardia?
It has a higher propensity to metastasize to these lymph nodes
What structure is divided during the creation of the gastric conduit in Ivor Lewis esophagectomy?
The gastrocolic ligament, distal to the gastroepiploic arcade.
What methods can be used to facilitate identification of the right gastroepiploic artery during Ivor Lewis esophagectomy?
Fluorescence imaging and Doppler.
What procedure is performed to aid in the emptying of the gastric conduit during Ivor Lewis esophagectomy?
Pyloroplasty or botulinum toxin injection
How wide is the gastric conduit typically created during Ivor Lewis esophagectomy?
3 to 5 cm.
What is the final step in the abdominal phase of Ivor Lewis esophagectomy?
Insertion of a feeding jejunostomy tube in the small bowel.
Where is the posterolateral thoracotomy incision made in the thoracic portion of Ivor Lewis esophagectomy?
In the fifth intercostal space.
How is the azygos vein handled during the thoracic phase of the Ivor Lewis esophagectomy?
It is divided with a vascular stapler to expose the entire esophagus.
What is the required proximal margin distance from the tumor when dissecting the esophagus in Ivor Lewis esophagectomy
A margin of 5 cm from the tumor’s edge
What regions are included in the lymph node dissection during Ivor Lewis esophagectomy?
Paratracheal, subcarinal, and inferior pulmonary ligament regions
What precaution is taken by some surgeons during Ivor Lewis esophagectomy to prevent a chylothorax?
Prophylactic ligation of the thoracic duct at the T9 and/or T10 level.
How is the proximal esophageal margin assessed during Ivor Lewis esophagectomy?
It is sent for frozen section to check for Barrett’s esophagus and tumor
What type of tumors is the McKeown (three-field) esophagectomy utilized for?
Proximal thoracic tumors near the airways
extensive Barrett’s esophagus
or when an adequate tumor-free proximal margin is a concern
What distinguishes the McKeown esophagectomy from the Ivor Lewis esophagectomy?
The McKeown esophagectomy involves a cervical anastomosis and the thoracic portion is performed first
What type of incision is made for the cervical portion of the McKeown esophagectomy?
An oblique incision anterior to the sternocleidomastoid muscle.
For what type of esophageal disease is the transhiatal esophagectomy the procedure of choice?
Lower esophageal early-stage disease
What are the advantages of the transhiatal esophagectomy compared to other esophagectomy procedures?
It is the least invasive, requires less operative time, and has excellent functional outcomes
What is a perceived disadvantage of the transhiatal esophagectomy according to many experts, despite no demonstrated survival differences?
A lower oncologic yield, though this has not been fully analyzed for the minimally invasive approach
What are some common post-esophagectomy complications?
Respiratory events
chyle leak
anastomotic/conduit complications
and atrial fibrillation.
Which patient population is more likely to experience atrial fibrillation after esophageal resection?
Older patients and those who have undergone neoadjuvant therapy
Why should the occurrence of atrial fibrillation after esophagectomy prompt a workup?
It could indicate a possible anastomotic leak.
What are common respiratory complications after esophagectomy, and what increases mortality risk?
Aspiration and subsequent pneumonia increase the risk of worse outcomes, including increased mortality risk
How are low-volume chyle leaks managed after esophagectomy?
By making the patient nil per os (NPO), initiating parenteral nutrition, and conservative management until chest tube output declines
What are the invasive options for managing high-output chyle leaks that do not respond to conservative measures?
Thoracic duct embolization by interventional radiology or surgical ligation.
How is an anastomotic leak typically managed after an Ivor Lewis esophagectomy?
By placement of a metallic or plastic stent (if small and contained) or reoperation
How is an anastomotic leak managed in the setting of a cervical anastomosis (McKeown or transhiatal esophagectomy)?
With bedside neck washout and negative pressure therapy, if needed
What complication is more common in patients with cervical anastomoses and three-field lymph node dissections
Recurrent laryngeal nerve injury.
What is the increased risk associated with recurrent laryngeal nerve injury after esophagectomy?
An increased risk of pulmonary complications in the postoperative period
How is recurrent laryngeal nerve injury evaluated and managed post-esophagectomy?
With a swallow evaluation and, if necessary, vocal cord medialization
