Esophageal Cancer Flashcards
What is esophageal cancer?
Malignancy of esophagus, mostly SCC or adenocarcinoma
What is the epidemiology of esophageal cancer?
Age >60, males>females 10th most common cause of cancer death SCC - 3.85/100K in males, 0.81/100k in females Adenocarcinoma - 0.5/100k in males, increasing due to GERD and obesity
What are the risk factors for esophageal cancer?
Common risk factors - Age, gender, family history SCC and AC have differing risk factors
What are the risk factors for SCC
Race - African/American, esophageal belt of china/africa Males Alcohol and smoking Hot beverages, nutritional deficiencies, betel nut, nitrosamine ingestion Achalasia, caustic injuries, HPV, radiotherapy, esophageal diverticulum and webs, Plummer Vinson syndrome
What are the risk factors for AC?
White race Males Smoking (Not alcohol) Obesity Chronic GERD/Barrett’s esophagus
What is the pathology of SCC esophagus?
- Can arise anywhere, but typically found in middle third 2. Exophytic fungating growth, 25% ulcerative, 15% infiltrative 3. Development - Dysplasia -> Ca is -> Invasive SCC -> Metastatic disease
What is the pathology of AC esophagus?
- Distal third 2. Malignancy with glandular differentiation that arises in the background of chronic GERD 3. Metaplasia -> dysplasia ->adenocarcinoma
What is the clinical presentation of esophageal cancer?
Most patients with early-stage disease are asymptomatic or may have symptoms of reflux, non-specific i.e. retrosternal discomfort, “indigestion”. However, approximately 50% of patients have unresectable lesions or distant metastasis on presentation. 1. Rapidly progressive dysphagia (first and most common presentation) – fluid and soft food better tolerated than hard/bulky food 2. Odynophagia (20%): pain develops late, usually due to extra-esophageal involvement 3. Weight loss: secondary to reduced appetite, malnutrition and active cancer 4. Regurgitation of saliva or undigested food (without gastric acid): secondary to tumour disrupting normal peristalsis and causing esophageal obstruction (risk of aspiration pneumonia) 5. Anemia (with or without melena/frank hematemesis – bleeding is usually occult): tumour surface may be fragile and bleed
What are the features of complicated esophageal Ca?
Locally advanced 1. Bleeding 2. Obstruction 3. Hoarsness 4. Horner’s syndrome (invasion of brachial plexus) 5. Respiratory symptoms (Trachea-esophageal fistula) Systemic - SCC will spread through thorax, AC spreads through abdomen Nodes - supraclavicular, gastric/celiac Bone - Back/bone pain Liver - RHC pain, ascites, jaundice Lung - Hemoptysis, cough, SOB, pleural effusion Others - adrenals, cutaneous, muscle brain (Rare)
What are the modes of spread of esophageal Ca?
Direct extension into surrounding regions (trachea, pericardium) Lymphatic spread along submucosal lymphatic channels Hematogenous spread to liver, lung adrenal glands and kidney
What lymphatics drain the esophagus?
Superior 1/3 - Deep cervical Middle 1/3 - Mediastinal Inferior 1/3 - Gastric and celiac
What investigations are required for esophageal Ca?
- OGD with biopsy Circumferential, fungating, sloughy, obtsructive, ulcerative lesion Biopsy of specimen to confirm - Diagnosis - Simultaneous lesions in stomach (needed for esophagectomy) - Lumen diameter -Barrett’s -Measurement of tumour location and extent 2. Barium swallow (less invasive) - Can access tumour complications like tracheo-esophageal fistula -Access for proximal dilatation, mucosal irregularities or constrictions -Low diagnostic rate Less commonly performed
What are the staging studies for confirmed esophageal Ca?
- CT TAP +/- Neck 2. Endoscopic ultrasound + FNA 3. PET scan with CT scan 4. Surgical laparascopic staging
What are the findings for CT TAP/Neck?
Modality of choice for staging distant metastasis, If proximal tumour, include CT neck ▪ Can be used for T, N, and M staging - Nodes > 10mm are considered to be metastatic - Nodal involvement outside area of resection (i.e. supraclavicular or paraaortic lymph nodes – M1 disease) – contraindication to esophagectomy ▪ CT Thorax - Presence of any lung metastases - Aspiration pneumonia – pleural effusion, collapse, consolidation - Pleural and/or pericardial effusion - Tracheal deviation or extrinsic compression of tracheobronchial system - Widened superior mediastinum in an upper oesophageal tumour - Raised hemi-diaphragm with phrenic nerve involvement - Any chronic respiratory conditions
What are the findings for EUS?
Endoscopic ultrasound (EUS) +/- FNA ▪ EUS combines endoscopy with high frequency ultrasound within the oesophageal lumen which allows for high resolution image of the tumour, the oesophageal wall and adjacent structures ▪ EUS is good for T staging of small tumours (determine depth of wall invasion), and N staging (identify malignant (>10mm, sharp borders, hypoechoic, homogenous) lymph nodes) ▪ Role in early stage esophageal cancer, if endoscopic resection is feasible
What are the findings of PET Scan in esophageal Ca?
Positron Emission Tomography with integrated CT Scan (PET/CT)* ▪ Essential, most useful test to r/o distant metastatic disease (identified in ~20% if patients who are free of metastases on CT / EUS to prevent unnecessary high morbidity surgery) ▪ Essential staging investigation in identification of distant metastases not evident on CT ▪ Can also be used for assessing recurrence or re-staging after neoadjuvant therapy
What are the surgical laparascopic staging findings in esophageal Ca?
Surgical Laparoscopic Staging (most beneficial for patients with adenocarcinoma) (controversial) ▪ For patients with distal esophageal tumour who appear free of distant metastases on CT scan (T3-T4) ▪ Can r/o occult liver metastasis and peritoneal carcinomatosis not evident on CT scan ▪ Peritoneal lavage also performed at time of laparoscopy
What tests are run to measure complications of the disease?
Blood Tests ▪ FBC: low hemoglobin (anemia from chronic blood loss), raised TW (? aspiration pneumonia) ▪ U/E/Cr: electrolyte derangement for vomiting, poor oral intake ▪ LFTs: low albumin with nutritional deprivation 2. Rigid Bronchoscopy with biopsy and brush cytology ▪ For patients with supracarinal primary tumours and suspicion of airway involvement (trachea-oesophageal fistula) ▪ Patients with tracheo-oesophageal fistula are not for surgery. For palliative care (survival ~6 months) 3. Laryngoscopy: assess vocal cord paralysis
What are the pre operative investigations to be carried out?
- Blood tests - Full blood count - Liver function test - Prothrombin/INR/aPTT - Group cross match 2. Cardiac investigations -ECG, 2D echogram 3. Respiratory investigations - Lung function test to ensure patient can tolerate single lung ventilation during op
What is the TNM Staging for Esophageal Ca?
What is the management of esophageal Ca?
Multimodal approach of
- Surgery
- Chemotherapy
- Radiotherapy
Exceptions are for very early disease which can be managed with endoscopic resection and for metastatic disease which is palliative
What is the approach to selection of treatment modality?
- Staging
- Obstruction
- Localized disease
- Neoadjuvant therapy
How does the stage of esophageal cancer affect managment?
- Very early tumours (Tis, T1a) → endoscopic submucosal dissection (ESD)
Advocated for early cancers such as T1a (mucosa)
▪ T1a tumours have 1-5% chance of LN spread as compared to T1b tumours (involve submucosa) which have 17-20% risk
of LN spread
▪ ESD better than EMR in terms of recurrence rates, curative rates with equivalent rates of complications (perforation, stricture,
bleeding)
- Tumour confined to oesophagus (T1b, T2) → controversial can either do upfront surgery or neoadjuvant chemoRT
(adenocarcinoma) → at present, current staging modalities are not reliable to confidently stage tumours clinically as T2 - Locally advanced tumours (T3-4, N1-3) → multimodal therapy with neoadjuvant chemoRT or neoadjuvant chemotherapy
followed by surgical resection
- Upfront esophagectomy has high rates of recurrence and low 5 year survival, hence multi-modality therapy preferred
- Depending on histology, SCC and Adenocarcinoma have different sensitivities to radiotherapy - Metastatic Disease (M1) → palliative treatment (endoscopic methods to treat malignant dysphagia or fistulous disease)
▪ Malignant dysphagia (M1) → expandable oesophageal stent or RT (for GEJ cancer, as stents leads to severe GERD)
When is feeding done in esophageal Ca?
Feeding via PO route is preferred unless the passage is obstructed (i.e. risk of aspiration)
- If still able to pass NG tube around tumour, then feed via NG (but also consider complications with long-term NG placement e.g.
erosions around nasal area, sinusitis); consider PEG placement* for long-term feeding if able to get scope around tumour
- If unable to pass tube or scope around tumour, consider total parenteral nutrition or open gastrostomy
- Relief of obstruction via endoscopic stenting and/or radiotherapy helps to enable oral feeding, but most techniques are not longlasting
and dysphagia will return with tumour growth
