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A1-G Surg Note Esophagus > Esophageal Cancer > Flashcards

Esophageal Cancer Flashcards

1
Q

What are the two predominant histologic types of esophageal cancer?

A

Adenocarcinoma (most common in the United States)

squamous cell carcinoma (most common worldwide)

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2
Q

Risk factors for esophageal cancer

A

Gastroesophageal reflux
smoking
alcohol consumption
nutritional deficiencies
environmental carcinogens
long-standing achalasia
caustic injury

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3
Q

commonly reported symptoms at the time of presentation for esophageal cancer?

A

Regurgitation, odynophagia, weight loss, and hematemesis.

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4
Q

What is the most common presenting symptom

A

Dysphagia

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5
Q

How do patients typically compensate for symptoms in the early phases of esophageal obstruction?

A

adjusting their diet and consuming semisolid and liquid nutrition as tolerated

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6
Q

At what point does dysphagia typically present in esophageal cancer patients?

A

tumor occludes two-thirds of the lumen.

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7
Q

Why are patients typically at an advanced stage at the time of esophageal cancer diagnosis?

A

Because symptoms often present late.

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8
Q

How might patients with a history of reflux disease be diagnosed earlier with esophageal cancer?

A

Through surveillance endoscopy.

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9
Q

What is the first study recommended in the diagnostic workup of esophageal cancer?

A

Barium swallow

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10
Q

What is considered the gold standard for evaluating esophageal cancer and obtaining a tissue diagnosis?

A

EGD

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11
Q

How many biopsies should be taken during an EGD following the Seattle protocol for esophageal cancer?

A

Six to eight four-quadrant biopsies should be taken along every centimeter of gross disease

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12
Q

What is the role of endoscopic ultrasound (EUS)

A

helps with early staging, determining tumor invasion (T stage), assessing suspicious lymph nodes (N stage), and detecting regional metastases (M stage)

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13
Q

What classification does EUS help determine that is important for guiding treatment pathways?

A

The Siewert classification

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14
Q

How does the addition of fine-needle aspiration (FNA) benefit the diagnostic process in esophageal cancer?

A

improves the accuracy of the diagnosis

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15
Q

What is Siewert Type I adenocarcinoma?

A

Adenocarcinoma of the lower esophagus with the epicenter located within 1 to 5 cm above the anatomic gastroesophageal junction (GEJ)

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16
Q

What defines Siewert Type II adenocarcinoma?

A

True carcinoma of the cardia with the tumor epicenter within 1 cm above and 2 cm below the esophagogastric junction (EGJ).

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17
Q

What is Siewert Type III adenocarcinoma, and how is it managed?

A

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.

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18
Q

What stage of esophageal cancer can endoscopic mucosal resection (EMR) be considered therapeutic for?

A

Early-stage disease (T1a or T1b)

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19
Q

What is the typical size of nodular lesions suitable for EMR in esophageal cancer patients?

A

Lesions ≤ 2 cm

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20
Q

What should be done with focal nodules during an EMR?

A

completely excised and sent for pathology

asses Depth of invasion, degree of differentiation, and presence of vascular and/or lymphatic invasion.

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21
Q

factors are associated with a greater risk of lymph node involvement in esophageal cancer?

A

Poor differentiation
deep submucosal invasion
and/or lymphovascular invasion (LVI)

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22
Q

What imaging modality is indicated to evaluate for metastatic disease and locoregional extent in esophageal cancer patients?

A

CT) of the chest, abdomen, and pelvis with oral and IV contrast

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23
Q

What is a limitation of CT in the evaluation of esophageal cancer?

A

It is poorly sensitive for early-stage disease, the type of Siewert location, and distinguishing T3 from T4 lesions

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24
Q

What esophageal thickness on CT is considered abnormal?

A

Esophageal thickening of more than 5 mm

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25
Q

What imaging modality is used to assess for metastatic disease in esophageal cancer?

A

FDG-PET)/CT

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26
Q

When should bronchoscopy be performed in esophageal cancer patients?

A

In patients with tumors at or above the carina and no evidence of M1 disease

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27
Q

What is the treatment for pTis adenocarcinoma of the esophagus?

A

Endoscopic resection (ER) ± ablation or esophagectomy

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28
Q

What is the treatment for pTis squamous cell carcinoma of the esophagus

A

ER and/or ablation or esophagectomy.

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29
Q

What is the treatment for pT1a adenocarcinoma of the esophagus?

A

ER ± ablation or esophagectomy.

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30
Q

What is the treatment for pT1a squamous cell carcinoma of the esophagus?

A

ER and/or ablation or esophagectomy.

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31
Q

What is the treatment for superficial pT1b adenocarcinoma of the esophagus?

A

ER ± ablation or esophagectomy

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32
Q

What is the treatment for superficial pT1b squamous cell carcinoma of the esophagus?

A

Esophagectomy.

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33
Q

What is the recommended treatment for cT1bN0-cT2N0 (low-risk lesions: < 3 cm, well-differentiated) adenocarcinoma?

A

Esophagectomy.

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34
Q

What is the recommended treatment for cT1bN0-cT2N0 (low-risk lesions: < 3 cm, well-differentiated) squamous cell carcinoma?

A

Esophagectomy (for non-cervical esophagus).

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35
Q

What is the treatment for high-risk lesions cT2N0 (≥ 3 cm, poorly differentiated) in adenocarcinoma?

A

Induction chemoradiation therapy or chemotherapy alone.

36
Q

What is the treatment for cT1b-cT2N+ or cT3-cT4a, any N in adenocarcinoma of the esophagus?

A

Induction chemoradiation therapy or definitive chemoradiation for those who decline surgery.

37
Q

What is the treatment for cT1b-cT2N+ or cT3-cT4a, any N in squamous cell carcinoma (noncervical esophagus)?

A

Induction chemoradiation therapy or definitive chemoradiation therapy

38
Q

What is the treatment for cT4b adenocarcinoma of the esophagus?

A

Definitive chemoradiation therapy or chemotherapy alone

39
Q

What is the treatment for cT4b squamous cell carcinoma of the esophagus?

A

Definitive chemoradiation therapy or chemotherapy alone

40
Q

What are the treatment options for T1 tumors involving the mucosa and superficial submucosa in esophageal cancer?

A

Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection.

41
Q

How are deeper submucosal lesions (T1) in esophageal cancer treated?

A

Esophagectomy.

42
Q

What is the optimal management for T2N0M0 disease in esophageal cancer, and why is it controversial?

A

due to unreliable clinical staging, leading to under- and overstaging.

Treatment options include esophagectomy with or without induction or adjuvant therapy, or definitive chemoradiation

43
Q

What do NCCN guidelines suggest for patients with T2N0M0 disease in esophageal cancer

A

definitive chemoradiation or esophagectomy with or without induction or adjuvant therapy.

44
Q

What factors differentiate low-risk from high-risk lesions in esophageal cancer?

A

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

45
Q

How should cT1b-cT2, N0 low-risk lesions in esophageal cancer be treated?

A

They should be resected with esophagectomy, including for noncervical squamous cell cancer.

46
Q

What is the recommended treatment for higher-risk esophageal cancer lesions (LVI, ≥ 3 cm, poorly differentiated, cT1b-cT2N +, or cT3-cT4aN+)?

A

Preoperative chemoradiation for noncervical squamous cell cancer

or definitive chemoradiation for cervical squamous cell cancer

47
Q

What is preferred for patients with adenocarcinoma in esophageal cancer

A

Preoperative chemoradiation.

48
Q

n which cases should definitive chemoradiation be reserved for esophageal cancer patients?

A

Patients who decline surgery, have poor performance status, or have bulky, multistation nodal involvement.

49
Q

What is the optimal treatment for patients with T3-4a tumors or nodal disease in esophageal cancer?

A

Induction chemoradiation followed by surgery.

50
Q

What did a recent randomized trial demonstrate about the treatment of esophageal or EGJ cancer?

A

A survival benefit to induction chemoradiation followed by surgery compared with surgery alone

51
Q

What should be assessed before planning any surgery for esophageal cancer patients?

A

ability to undergo general anesthesia and major surgery, taking into account their age and performance status.

52
Q

How many lymph nodes should be resected for adequate staging in esophageal cancer patients who have not received induction chemoradiation, according to NCCN guidelines?

A

At least 15 lymph nodes

53
Q

What is the recommended treatment for cervical or cervicothoracic esophageal carcinomas located less than 5 cm from the cricopharyngeus?

A

Definitive chemoradiation

54
Q

When should a feeding tube (preferably a jejunostomy tube) be considered before induction therapy in esophageal cancer patients?

A

When the patient is near totally obstructed and cannot tolerate any oral liquids

55
Q

What are the conduit options for esophageal cancer resection?

A

Stomach (preferred), colon, or jejunum

56
Q

What do NCCN guidelines recommend for patients with cervical esophageal squamous cell carcinoma?

A

Definitive chemoradiotherapy

57
Q

For what type of esophageal cancer is Ivor Lewis esophagectomy ideal?

A

Cancer in the mid- and distal esophagus.

58
Q

What lymph node dissection is performed during an Ivor Lewis esophagectomy?

A

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.

59
Q

Why is a thorough lymph node dissection particularly important for adenocarcinoma of the cardia?

A

It has a higher propensity to metastasize to these lymph nodes

60
Q

What structure is divided during the creation of the gastric conduit in Ivor Lewis esophagectomy?

A

The gastrocolic ligament, distal to the gastroepiploic arcade.

61
Q

What methods can be used to facilitate identification of the right gastroepiploic artery during Ivor Lewis esophagectomy?

A

Fluorescence imaging and Doppler.

62
Q

What procedure is performed to aid in the emptying of the gastric conduit during Ivor Lewis esophagectomy?

A

Pyloroplasty or botulinum toxin injection

63
Q

How wide is the gastric conduit typically created during Ivor Lewis esophagectomy?

A

3 to 5 cm.

64
Q

What is the final step in the abdominal phase of Ivor Lewis esophagectomy?

A

Insertion of a feeding jejunostomy tube in the small bowel.

65
Q

Where is the posterolateral thoracotomy incision made in the thoracic portion of Ivor Lewis esophagectomy?

A

In the fifth intercostal space.

66
Q

How is the azygos vein handled during the thoracic phase of the Ivor Lewis esophagectomy?

A

It is divided with a vascular stapler to expose the entire esophagus.

67
Q

What is the required proximal margin distance from the tumor when dissecting the esophagus in Ivor Lewis esophagectomy

A

A margin of 5 cm from the tumor’s edge

68
Q

What regions are included in the lymph node dissection during Ivor Lewis esophagectomy?

A

Paratracheal, subcarinal, and inferior pulmonary ligament regions

69
Q

What precaution is taken by some surgeons during Ivor Lewis esophagectomy to prevent a chylothorax?

A

Prophylactic ligation of the thoracic duct at the T9 and/or T10 level.

70
Q

How is the proximal esophageal margin assessed during Ivor Lewis esophagectomy?

A

It is sent for frozen section to check for Barrett’s esophagus and tumor

71
Q

What type of tumors is the McKeown (three-field) esophagectomy utilized for?

A

Proximal thoracic tumors near the airways
extensive Barrett’s esophagus
or when an adequate tumor-free proximal margin is a concern

72
Q

What distinguishes the McKeown esophagectomy from the Ivor Lewis esophagectomy?

A

The McKeown esophagectomy involves a cervical anastomosis and the thoracic portion is performed first

73
Q

What type of incision is made for the cervical portion of the McKeown esophagectomy?

A

An oblique incision anterior to the sternocleidomastoid muscle.

74
Q

For what type of esophageal disease is the transhiatal esophagectomy the procedure of choice?

A

Lower esophageal early-stage disease

75
Q

What are the advantages of the transhiatal esophagectomy compared to other esophagectomy procedures?

A

It is the least invasive, requires less operative time, and has excellent functional outcomes

76
Q

What is a perceived disadvantage of the transhiatal esophagectomy according to many experts, despite no demonstrated survival differences?

A

A lower oncologic yield, though this has not been fully analyzed for the minimally invasive approach

77
Q

What are some common post-esophagectomy complications?

A

Respiratory events
chyle leak
anastomotic/conduit complications
and atrial fibrillation.

78
Q

Which patient population is more likely to experience atrial fibrillation after esophageal resection?

A

Older patients and those who have undergone neoadjuvant therapy

79
Q

Why should the occurrence of atrial fibrillation after esophagectomy prompt a workup?

A

It could indicate a possible anastomotic leak.

80
Q

What are common respiratory complications after esophagectomy, and what increases mortality risk?

A

Aspiration and subsequent pneumonia increase the risk of worse outcomes, including increased mortality risk

81
Q

How are low-volume chyle leaks managed after esophagectomy?

A

By making the patient nil per os (NPO), initiating parenteral nutrition, and conservative management until chest tube output declines

82
Q

What are the invasive options for managing high-output chyle leaks that do not respond to conservative measures?

A

Thoracic duct embolization by interventional radiology or surgical ligation.

83
Q

How is an anastomotic leak typically managed after an Ivor Lewis esophagectomy?

A

By placement of a metallic or plastic stent (if small and contained) or reoperation

84
Q

How is an anastomotic leak managed in the setting of a cervical anastomosis (McKeown or transhiatal esophagectomy)?

A

With bedside neck washout and negative pressure therapy, if needed

85
Q

What complication is more common in patients with cervical anastomoses and three-field lymph node dissections

A

Recurrent laryngeal nerve injury.

86
Q

What is the increased risk associated with recurrent laryngeal nerve injury after esophagectomy?

A

An increased risk of pulmonary complications in the postoperative period

87
Q

How is recurrent laryngeal nerve injury evaluated and managed post-esophagectomy?

A

With a swallow evaluation and, if necessary, vocal cord medialization

A1-G Surg Note Esophagus (15 decks)

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