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Hematology, oncology > Esophageal cancer > Flashcards

Esophageal cancer Flashcards

1
Q

Esophageal SCC risk factors

A

smoking, alcohol
radiation
anatomic abnormalities (esophageal webs, achalasia, Zenkers’s)

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2
Q

Esophageal adenocarcinoma RF’s

A 
Obesity
GERD
Barrett's
High grade dysplasia
Smoking
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3
Q

Percentage of esophageal cancers that are resectable at diagnosis

A

50%

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4
Q

workup of esophageal mass

A

CBC, CMP
EGD w/ biopsy + *EUS
CT chest, abdomen, pelvis
IF mets not detected with CT –> PET/CT for occult mets (more sensitive)
IF thoracic at or above carina + nonmetastatic –> bronchoscopy (preclude from surgery too)
IF cervical SCC + nonmetastatic –> flexible laryngoscopy (to assess location disease spread + exclude synchronous malignancy)

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5
Q

histology

A

adeno (65%)

squamous cell carcinoma (35%)

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6
Q

distinction in where adenos vs. squamous cell carcinomas occur

A

Adeno usually in lower third, squamous cell carcinoma in upper 2/3’s

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7
Q

management of high grade dysplasia

A

Endoscopic mucosal resection (EMR)
Mucosal ablation
Esophagectomy

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8
Q

treatment of locally advanced resectable esophageal adenocarcinoma

A

preoperative or perioperative *concurrent chemoradiation followed by esophagectomy

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9
Q

management of locally advanced, unresectable disease

A

Chemoradiation preferred, radiation alone if not chemo candidate

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10
Q

Life threatening late complication of esophageal cancer

A

Esophageal-airway fistula (tracheobronchial fistulas) (due to direct tumor invasion into the mainstream bronchus)

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11
Q

Epidemiologic shift in histologies

A

adeno becoming more common (as Barrett’s esophagus becomes more prevalent)

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12
Q

meaning of perioperative chemotherapy

A

preoperative, intraoperative, and immediately postoperative chemotherapy.

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13
Q

clinical differences between squamous and adenocarcinoma

A

Squamous is much more radiosensitive

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14
Q

Management of locally advanced squamous esophageal cancer

A

Preoperative chemotherapy and radiation and surgery or definitive chemoradiation (squamous is more radiosensitive)

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15
Q

What somatic tumor testing do you need for metastatic?

A

PD-L1
MSI
HER2
NGS for NTRK

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16
Q

Stage at presentation

A 
Often late
(50-80% of patients present with incurable, locally advanced unresectable or metastatic disease)
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17
Q

CBC abnormalities associated with esophageal cancer

A

IDA common due to chronic GI blood loss (bleed a lot)

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18
Q

Anatomic distinction in where esophageal tumors occur

A

Cervical vs. thoracic

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19
Q

Tracheobronchial fistula presentation

A

Intractable coughing or recurrent pneumonias

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20
Q

Tracheobronchial fistula treatment

A

Stent placement

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21
Q

Most common metastatic sites for esophageal adenocarcinoma

A

Intraabdominal sites (liver, peritoneum)

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22
Q

Why you need to use EUS for loco regional staging

A

Uses a high-frequency US to provide detailed images of esophageal masses and their relationship with the esophageal wall

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23
Q

When an esophageal mass is unresectable

A

Invasion of adjacent structures (aorta, vertebral body, airway)

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24
Q

Use of PET/CT in esophageal cancer

A
  • Detect occult metastatic disease in patients who are otherwise believed to be surgical candidates after CT staging
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25
Q

Role for laparoscopy in staging

A
  • Optional per NCCN
  • Controversial, usually reserved for patients who have potentially resectable T3 or T4 adenocarcinomas of the EGF OR if suspicion for intraperitoneal metastatic disease
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26
Q

Why is diagnostic laparoscopy sometimes performed

A

Detect occult intraperitoneal mets in patients with distal esophageal and EGJ adenocarcinoma (CT and PET have low sensitivity for intraperitoneal mets)

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27
Q

How most esophageal adenocarcinoma forms

A

Chronic GERD leading to metaplasia and then neoplasm

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28
Q

Where esophageal adeno and SCC tends to recur

A

SCCs – locoregionally

Distal esophageal adeno — distant dissemination

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29
Q

Prognosis of adeno vs. SCC

A

Adeno has a better prognosis (less likely to metastasize through lymphatic spread

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30
Q

Is chemoRT with definitive intent for SCC?

A

Controversial (some argue surgery isn’t needed if complete response to chemoRT but there are higher rates of locally persistent, recurrent disease)

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31
Q

Timing of surgery after chemoRT

A

5-7 week interval preferred for most patients (arbitrary, no data)

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32
Q

T2N0 disease management

A

IF adeno –> neoadjuvant concurrent chemoradiotherapy

IF SCC –> resection (assuming <2cm + well differentiated)

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33
Q

Surveillance modalities

A

Tumor markers if previously elevated
CT chest/abdomen (limit the number, particularly in younger individuals given concerns about radiation exposure and risk for second malignancies)

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34
Q

Impact of histology on treatment approach in esophageal cancer

A

Most studies haven’t differentiated but there’s an increasing amount of evidence that they differ significantly in terms of pathogenesis, biology and prognosis so that’s the future.

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35
Q

tumor markers

A

CEA

CA 19-9

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36
Q

Initial therapy in general for metastatic SCC esophageal cancer

A

Chemoimmunotherapy
- Pembro + chemo

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37
Q

Initial therapy for metastatic esophageal adenocarcinoma

A

IF HER2-negative with PD-L1 over expression or deficient mismatch repair –> initial immunotherapy plus chemotherapy

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38
Q

dominant histology of esophageal cancer now

A

adenocarcinoma

39
Q

Difference in management between adeno and SCC

A

adeno – targeted therapies for HER2 and VEGF

SCC – immunotherapies (regardless of PDL1 expression)

40
Q

First line for PDL1 positive advanced esophageal SCC

A

FOLFOX + nivo

41
Q

Typical regimen for advanced adeno

A

IF HER2 –> add trastuzumab
IF dMMR or PDL1 positive –> Nivo or pembro + chemo
Chemo –> no globally accepted first line regimen, typically FOLFOX, CAPOX

42
Q

Targeted therapies for metastatic esophageal adenocarcinoma

A

Her2 – trastuzumab

VEGF

43
Q

Ineligibility criteria for trastuzumab from trials

A
  • Valvular heart disease
  • **Angina requiring antianginals
  • LVH on echo
  • clinically significant pericardial effusion
  • CHF
  • history of MI
  • Cardiomegaly on CXR
44
Q

Tumor testing in esophageal

A

MSI/MMR
PD-L1
HER2
Sequencing

45
Q

Evidence for ACE/ARBs and beta-blockers in HFpEF?

A

None have been shown to reduce morbidity or mortality

46
Q

Indication for bronchoscopy in esophageal cancer workup per NCCN

A

If tumor is at or above the carina with no evidence of M1 disease (typically mid esophageal tumors are high risk for TEF)

47
Q

Management of SCC stage I

A

IF surgical candidate –> Endoscopic resection vs esophagectomy

48
Q

Response assessment following neoadjuvant chemoradiation in esophageal

A

FDG-PET/CT (confirm)

49
Q

management of locally advanced SCC

A

preoperative CRT –> esophagectomy

50
Q

RO margin status means

A

no cancer cells seen microscopically at the primary tumor site

51
Q

R1 margin status means

A

Cancer cells present microscopically at tumor site

52
Q

R2 margin status means

A

Macroscopic residual tumor at primary cancer site

53
Q

MSI interpretation

A

3 categories:
MSI-stable (MSS)
MSI-low (MSI-L) = 1-29% of markers exhibit instability
MSI-high (MSI -H) = 30% or greater of markers exhibit instability

54
Q

What is a liquid biopsy?

A

Sampling of non-solid tissue (primarily blood) for cancer diagnosis and monitoring
- eg., circulating tumor cells (CTCs)

55
Q

When liquid biopsies are useful

A

Patients unable to undergo conventional biopsy

56
Q

First line regimens for esophageal

A

Paclitaxel and carboplatin
Fluorouracil and oxaliplatin

57
Q

CROSS regimen + indication

A
  • carboplatin, paclitaxel

- neoadjuvant chemoradiation of esophageal

58
Q

FLOT regimen is

A

Docetaxel, oxaliplatin, leucovorin, and 5-FU

59
Q

T staging that typically makes esophageal unresectable + anatomy

A

T4b (involving pericardium, pleura, and diaphragm. Do not assume these are unresectable)

60
Q

what is considered Tis disease?

A

CIS or high grade dysplasia

61
Q

Management of Tis disease (high grade dysplasia, CIS)

A
  • endoscopic methods have replaced surgery – endoscopic resection, RFA, endoscopic resection followed by ablation
62
Q

Tumors with high risk of occult peritoneal mets

A
  • gastric and GEJ
63
Q

distinction in management between esophageal thoracic and cervical

A
  • with locally advanced thoracic, neoadjuvant chemoradiation followed by surgery
    ***with cervical chemoradiation is definitive
64
Q

significance of tumor above the carina

A

Need bronchoscopy to rule out a fistula

65
Q

Regimens for chemoradiation

A

CROSS - carbo/taxol
***Cisplatin/5-Fu

66
Q

of lymph nodes that need to be sampled in patient undergoing upfront surgery in esophageal

A

15

67
Q

of lymph nodes that need to be sampled in COLON CANCER

A

12

68
Q

Low grade dysplasia management

A

Antireflux therapy followed by EGD in 6-12 months (low grade dysplasia is not Tis)

69
Q

Surveillance following concurrent chemoRT for esophageal

A
  • *Imaging not needed. ASCO recommends against using PET to monitor for recurrence in individuals with any cancer type treated with curative intent.
  • Just need H&P q3 months.
  • EGD as clinically indicated
70
Q

epidemiology of esophageal cancer

A
  • incidence of adeno is rapidly rising, squamous has been stable
71
Q

T2 disease indicates

A

muscularis propria invasion

72
Q

T3 disease indicates

A

invasion of adventitia

73
Q

T4 disease indicates

A

invasion into adjacent structures

74
Q

CROSS regimen — drugs, duration, drug dosing

A

weekly carbo (AUC=2) + paclitaxel (50 mg/m2) for 5 weeks and radiation 5 days per week

75
Q

Actionable Mutation in esophageal

A

NTRK

76
Q

terminal to describe lymph node involvement beyond regional distribution

A

non-regional

77
Q

Preferred chemo regimen for metastatic esophageal

A

FOLFOX +/- checkpoint inhibitor depending on PD-L1 status

78
Q

Terminology for diffusely metastatic disease in oncology

A

“widely metastatic”

79
Q

N1 disease

A

Mets to 1 or 2 regional lymph nodes

80
Q

T staging indicating

A

T2 or higher (muscle invasive) + high risk

81
Q

Management of locally advanced esophageal adeno s/p neoadjuvant chemoRT and surgery with minimal treatment effect

A

nivo (chemorefractory disease)

82
Q

protective factor against esophageal adenocarcinoma

A

H pylori

83
Q

anatomic point at which distal tumors are considered gastric

A

below cardia

84
Q

T1b management

A

Surgery (unless low risk)

85
Q

SCC vs adeno in terms of behavior

A

SCC more aggressive (more likely for lymphatic spread)

86
Q

Preferred second line for GEJ adeno

A

Ramucirumab + paclitaxel

87
Q

Alternative first line regimen for metastatic esophageal

A

5-fu, cisplatin, and nivo

88
Q

Adjuvant for esophageal adeno after surgery?

A

nivo for 1 year

89
Q

Why TEF is more common in squamous histology

A

More friable and can necrose chemoradiation

90
Q

PDL1 threshold for adding nivo in esophageal

A

CPS greater than 5

91
Q

Management of early stage, node negative esophageal

A

mucosal resection or surgery depending on T1a or T1b

92
Q

What does T1b in esophageal indicate?

A

Submucosal invasion

93
Q

Management of HER2 positive stage IV adeno

A
  • add trastuzumab and pembro (addition of pertuzumab did not show benefit)

Hematology, oncology (218 decks)

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