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General Thoracic Surgery > 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)
  • 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
Q

Esophagectomy that avoids the pulmonary morbidity of thoracotomy

A

Transhiatal esophagectomy

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26
Q

Risks associated with transhiatal esophagectomy

A
  • Recurrent LN injury (11%)
  • Esophageal anastomotic leak (12-16%)
    • easier to control than thoracic anastomotic leak
  • Esophageal stricture (28%)
27
Q

Transhital hernia indicated for which populations

A
  • Poor pulmonary reserve
  • Mid to low tumors (non-bulky, early stage)
28
Q

Survival and perioperative mortality for transhiatal esophagectomy

A

5-yr survival: 20-25%

Perioperative mortality: 5%

29
Q

Oncolgoic concern related to performane of transhital esophagectomy

A

Compromises LN tissue removal

30
Q

Ivor-Lewis Esophagectomy Description

A
  • Right posterolateral thoracotomy + midline laparotomy/laparoscopy
    • thoracic esophageal anastomosis
  • Allows for 2-field LN dissection
31
Q

Morbidity and Mortality estimates for ILE

A
  • Esophageal anastomotic leak (10%)
  • Esophageal stricture (16%)
  • Recurrent LN injury (5%)
32
Q

3-Incision Esophagectomy Components

A
  • Right posterolateal thoracotomy
  • Midline laparotomy/laparoscopy
  • Left lateral neck incision with cervical esophageal anastomosis
33
Q

Advantages and Risks of 3-Incision Esophagectomy

A
  • Direct visualization of dissection in chest and abdomen
  • Leak rates and risk of RLN injury similar to trans-hital esophagectomy
34
Q

Conduit choices for esophageal reconstruction

A
  • 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
Q

Advantages and Disadvantages of Stomach conduit for esophageal reconstruction

A
  • 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
Q

Characteristics of Colon conduit for esophageal reconstruction

A
  • 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
Q

Characteristics of jejunal conduit for esophageal reconstruction

A
  • 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
Q

MC location for esophageal conduit

A

Orthotopic (anatomic)

39
Q

Indications for retrosternal placement of esophageal conduit

A
  • Fear for tumor invovlement of conduit in posterior mediastinum
  • Delayed reconstructions or extensive mediastinal scarring/adhesions
40
Q

Indication for neoadjuvant chemoradiation therapy for esophageal cancer

A

Locoregional disease (T3 or N1 disease)

*Postive LN mets seen in 25-30% of T2 cancers, extending use of induction therapy to patients with T2 disease

41
Q

Benefits of neoadjuvant, induction therapy for esophageal cancer

A
  • Downstage tumors: up to 50%
  • Complete reponse rate: 10%
  • Avoids adjuvant radiation of conduit (allows assessment of reponse of tumor to therapy)
42
Q

Most important predictor of improved survival after neoadjuvant therapy

A

Complete response

43
Q

Treatment strategy more likely to elicit patient compliance with complete chemoradiation therapy (neoadjuvant vs. adjuvant)

A

Neoadjuvant

44
Q

Role of adjuvant XRT after esophagectomy

A

Steralize microscopic or gross residual local tumor

*Risk of potential damage to conduit

45
Q

Indications for adjuvant chemotherapy after esophagectomy in absence of metastaic disease

A
  • Highly aggressive histology
  • Lymphovascular invasion
46
Q

Chemoradiatoin regimen used for definitive and adjuvant treatment

A
  • Cisplatin + 5-FU + Epirubicin/Docetaxel
  • 40-50 Gy of fractionated RT
47
Q

XRT more efficacious for SCC or adenocarcinoma of esophagus

A

SCC

*Adenocarcinoma less significant response to chemoradiation therapy (thus, surgery performed more frequently)

48
Q

Palliative options for esophageal cancer

A
  • Endoscopic dilation
  • Stent placement

Goal: improve QOL (controlling dysphagia, odynophagia, blood loss, fistula-related moridity, nutrition)

49
Q

Prevelence of TEF with locally advanced esophageal cancer

A

~ 15%

50
Q

Treatment options for TEF related to locally advanced esophageal cancer

A

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
Q

5-year survival of esophageal cancer without treatment

A

5-12% (median survival 23%)

52
Q

5-year survival for esophageal cancer stages

A
  • Early stage (80%)
  • Local stage (24%)
  • Locoregional stage (12%)
  • Advanced stage (2%)
53
Q

Poor prognostic factors for esophageal cancer-related survival

A
  • Advanced age
  • African-American race
  • Distal esophageal tumors
  • Increased depth
  • > 5 LN involvement
  • High ratio of positive:negative LNs
54
Q

Favorable prognostic factors for esophageal cancer-related survival

A
  • Complete pathologic reponse to induction therapy
  • Minimal residual disease
  • High hospital volume (> 20 procedure/year)
55
Q

TMN Staging Esohageal Cancer

T-stages

A
  • 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
Q

TNM Staging Esophageal Cancer

N-stages

A
  • N1: 1-2 regional LN
  • N2: 3-6 regional LN
  • N3: >= 7 regional LN
57
Q

TNM Staging Esophageal Cancer

M stages

A

M0: no distant metastasis

M1: distant metastasis

58
Q

Esophageal Cancer Histologic Grading

A
  • G1: well differentiated
  • G2: moderately differentiated
  • G3: poorly differentiated
  • G4: undifferentiated
59
Q

Esophageal tumor location distances

A
  • 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
Q

Esophageal Cancer Staging

Stage I

A

Stage I

  • T1-2 only, N0MO, G1-2
  • T1 + G3
61
Q

Esophageal Cancer Staging

Stage II

A

Stage II

  • T1-2 + N1
  • T2-3 alone
62
Q

Esophageal Cancer Staging

Stage III

A

Stage III

  • T1-2 + N2
  • T3 + N1-2
  • T4 alone
  • N3 alone
63
Q

Esophageal Cancer Staging

Stage IV

A

Stage IV

Any M1 disease

General Thoracic Surgery (36 decks)

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