Esophageal Cancer Flashcards
Esophageal Cancer
What is the anatomic landmark for the most superior extent of the esophagus?
cricopharyngeus muscle at the level of the cricoid cartilage
Esophageal Cancer
What is the histology of a normal esophagus?
stratified keratinizing squamous epithelium
Esophageal Cancer
What is the Z-line?
endoscopically visible junction of squamous and glandular epithelium
Esophageal Cancer
This condition is characterized by the replacement of esophageal lining with columnar epithelium.
Barret esophagus
Esophageal Cancer
How many layers are there in esophageal wall?
3.
mucosa (epitelium M1, lamina propria M2, muscularis mucosa M3)
submucosa,
and muscularis propria (inner circular, outer longitudinal OLIC)
Esophageal Cancer
Identify the landmarks and distance from the incisors for the specified division of esophagus.
midthoracic
from the lower of azygos vein/carina to the inferior pulmonary veins.
25-30 cm
Esophageal Cancer
Identify the landmarks and distance from the incisors for the specified division of esophagus.
cervical
from the cricopharyngeus muscle/C7 to the thoracic inlet/T3/suprasternal notch
15-20 cm
Esophageal Cancer
Identify the landmarks and distance from the incisors for the specified division of esophagus.
upper thoracic
from the thoracic inlet/T3/suprasternal notch to the lower border of azygos vein/carina
20-25 cm
Esophageal Cancer
Identify the landmarks and distance from the incisors for the specified division of esophagus.
lower thoracic
from the level of IPVs to the GE junction
30-40 cm
Esophageal Cancer
Differentiate the three Siewert types of esophageal cancers.
Type I: >1 cm to 5 cm above Z-line
Type II: 1 cm cephalad, 2 cm caudad the Z-line
Type III: >2 cm below the Z-line
Esophageal Cancer
Which of the following statement is/are TRUE of esophageal lymphatics?
I. The esophageal lymphatic network is primarily located within the submucosa; however, channels are also present within the lamina propria, facilitating spread of even superficial cancers of the esophagus involving the mucosa.
II. Intramural lymphatics may traverse the muscularis propria, facilitating tumor spread to regional lymphatic channels and paraesophageal nodes.
III. Lymph can travel the entire length of the esophagus before draining into lymph nodes, and thus, the entire esophagus is
at potential risk for lymphatic involvement.
IV. Up to 8 cm or more of “normal” tissue can exist between gross tumor and micrometastases “skip areas” secondary to this extensive lymphatic network.
All.
Esophageal Cancer
The incidence of esophageal cancer is linked with the arid climate and acidic soil as well as the ingestion of nitrosamines, and inversely to the consumption of riboflavin, nicotinic acid, magnesium, and zinc.
TRUE or FALSE.
False.
Gotcha. It’s “alkaline”
yeah i know… not important. pero examiners ask this way.
1 point is 1 point.
Esophageal Cancer
What are the major risk factors for developing esophageal SCCa in the Western world accounting for >80% of cases?
Tobacco and alcohol use
Esophageal Cancer
The relative risk of esophageal adenocarcinoma persists even after three decades following smoking cessation.
TRUE or FALSE?
True.
in contrast to a significant decline in similar patients with squamous cell carcinoma
Esophageal Cancer
Genetic abnormalities in adenocarcinoma include p53 mutations and multiple allelic losses at 3p and 9q, with amplification of cyclin D1 and epidermal growth factor receptor (EGFR).
In contrast, genetic abnormalities in squamous cell carcinoma include overexpression of p53; multiple allelic losses at 17p, 5q, and 13q; and amplification and overexpression of EGFR and human epidermal growth factor receptor 2 (HER-2).
TRUE or FALSE?
False.
It’s the other way around
Esophageal Cancer
What factors are correlated with the incidence of lymph node metastases in SCC?
T stage
tumoral length
and degree of differentiation
Esophageal Cancer
The primary direction for lymphatic flow for the lower esophagus is toward the abdomen.
TRUE or FALSE?
True
Esophageal Cancer
What factor is most consistently correlated with the incidence of lymph node metastases in adenocarcinoma?
depth of invasion
Esophageal Cancer
Local failure is the main mode of failure in esophageal cancer treatment.
Of local failures, 90% were within the gross tumor volume.
TRUE or FALSE?
True
Esophageal Cancer
What is the best tool to diagnose and define the extent of the lesion?
Endoscopy
Esophageal Cancer
What is the best tool to examine the extent of periesophageal and celiac lymph node involvement?
EUS
Esophageal Cancer
What is the most common nonepithelial neoplasm of the esophagus?
leiomyosarcoma
Esophageal Cancer
What are the prognostic factors for patients treated with CRT?
T stage
M stage
gender
(-Nomura t al).
Esophageal Cancer
Tumoral length adversely affected survival in patients undergoing resection, however this is not prognostic for N+ disease.
TRUE or FALSE?
True
Esophageal Cancer
Margins of resection is of significant importance with regard to long-term outcome.
However, only R0 resection had a substantial chance of long-term DFS.
TRUE or FALSE?
True.
Esophageal Cancer
AJCC 8th edition staging.
Identify the T-stage:
confined by the basement membrane
Tis
Esophageal Cancer
AJCC 8th edition staging.
Identify the T-stage:
invades muscularis mucosa
T1a
Esophageal Cancer
AJCC 8th edition staging.
Identify the T-stage:
invades muscularis propria
T2
Esophageal Cancer
AJCC 8th edition staging.
Identify the T-stage:
invades submucosa
T1b
Esophageal Cancer
AJCC 8th edition staging.
Identify the T-stage:
invades adventitia
T3
Esophageal Cancer
AJCC 8th edition staging.
Identify the T-stage:
Identify other organs classified in this T-stage as well
invades aorta
T4b
vertebral body
trachea
Esophageal Cancer
AJCC 8th edition staging.
Identify the T-stage:
Identify other organs classified in this T-stage as well
pericardial invasion
T4a
pleura
azygos vein
diaphragm
peritoneum
Esophageal Cancer
AJCC 8th edition staging.
Identify the N-stage:
5 regional nodes
N2 (3-6)
Esophageal Cancer
AJCC 8th edition staging.
Identify the N-stage:
7 regional nodes
N3 (≥7)
Esophageal Cancer
AJCC 8th edition staging.
Identify the N-stage:
2 regional nodes
N1 (1-2)
Esophageal Cancer
AJCC 8th edition staging.
Identify the grade:
prominent keratinization with pearl formation and a minor
component of nonkeratinizing basal-like cells, tumor cells arranged in sheets
G1 - well differentiated
Esophageal Cancer
AJCC 8th edition staging.
Identify the grade:
> 95% of the tumor composed of well-formed glands
G1 - well differentiated
Esophageal Cancer
What procedure is made through right thoracotomy with laparotomy with intrathoracic anastomosis?
Ivor Lewis esophagogastrectomy
Esophageal Cancer
What procedure is made through right thoracotomy with cervical anastomosis which may be easier management of anastomotic leaks.
McKeown or “three-hole” esophagectomy
Esophageal Cancer
In general, what is the management for proximal esophageal tumors <5 cm from the cricopharyngeus?
definitive CRT.
Esophageal Cancer
What treatment modality is often added to laser ablation in the palliation of esophageal cancers to preven obstruction and improve stenosis-free survival?
intraluminal brachytherapy 7Gyx3
Esophageal Cancer
What margins are usually used for CTV delineation?
primary tumor GTV + 3-5 cm craniocaudally +2 cm circumferentially.
some say 3 cm cranially, 5 cm caudally,
some say 4 cm craniocaudally
generally speaking, margins >3cm
Esophageal Cancer
In GE junction adenocarcinoma, with node negative disease, when are the gastroepiploic, greater curvature, celiac trunk, splenic hilar nodal chains included in the CTV?
+LVI (20% nodal positivity)
+T3/T4
high-grade tumors
Esophageal Cancer
Nodal chains included in the CTV for upper thoracic esophageal SCC (in general)
lower cervical
supraclavicular
subcarinal
upper paraesophageal
Esophageal Cancer
Nodal chains included in the CTV for lower esophageal SCC (in general)
subcarinal
left gastric
common hepatic
celiac
Esophageal Cancer
Periesophageal lymph nodes are generally included in all patients with lower thoracic adenocarcinomas.
TRUE or FALSE?
True.
Esophageal Cancer
Middle and lower paraesophageal nodes should be included in patients with T_-T_ type I and T_-_ type II tumors extending >1.5 cm above the Z line and T_-T_ type II patients.
2-4 type I
2-4 type II +>Z
3-4 type II
Esophageal Cancer
In centers without respiratory motion accounting (during planning and treatment), what margin is added to the CTV to create an ITV?
CTV + 1 cm margin (can be 1.5 distally)
Esophageal Cancer
What is the radial expansion for primary tumor and uninvolved esophagus to create the CTV?
2 cm for primary
1 cm for the uninvolved esophagus (to account for paraesophageal nodes)
+ 1 cm ITV from the CTV
limit of 5mm to the heart including the pericardium
Esophageal Cancer
Standard RT dose
50.4/1.8/28
Esophageal Cancer
Based on the study from Netherlands, a transthoracic approach to esophagectomy with extended lymph node dissection was superior to transhiatal approach in terms of median and overall survival.
TRUE or FALSE?
False.
No significant differences in locoregional recurrences, median-DFS, or median OS even at long term follow-up.
Furthermore, a transthoracic approach causes more treatment-related morbidity.
A trend in improved DFS and OS was seen in the transthoracic approach but not statistically significant weighing with the morbidity from the procedure.
Esophageal Cancer
Based on the study from Japan, a left thoracoabdominal approach to esophagectomy for GE junction tumors was inferior to transhiatal approach in terms of median and overall survival.
TRUE or FALSE?
False. This was not an non-inferiority/superiority trial.
Looking at the data however, survival is better in the transhiatal approach.
Esophageal Cancer
Resection alone is adequate for small, localized tumors that underwent an R0 resection.
TRUE or FALSE?
False.
Locoregional recurrence rate is high.
It should be remembered
that patterns of failure reports often describe the first site of failure only and may
include only patients undergoing R0 resection, potentially underreporting the
true incidence of locoregional recurrence.
Esophageal Cancer
Radiation therapy alone is adequate treatment.
TRUE or FALSE?
Bonus na yan
False.
Esophageal Cancer
Preoperative radiation therapy improves the survival of patients undergoing combined modality treatment compared to those treated with surgery alone.
TRUE or FALSE?
False.
Esophageal Cancer
Which is TRUE regarding the French trial of postoperative RT vs. surgery alone?
I. Survival was improved in patients undergoing postoperative RT.
II. Five-year
survival in node-negative patients treated with was 38% versus 7% with involved nodes.
III. Rates of locoregional recurrence were interestingly higher, albeit non-significant, in patients receiving radiation therapy.
IV. Significant increase in locoregional recurrence are also noted in patients with node-positive disease.
II only.
I. No significant survival difference was seen in patients receiving postoperative
radiation versus surgery alone
II. as is
III. lower
IV. just to confuse you. in
patients without nodal involvement, locoregional recurrence was significantly
improved in patients receiving postoperative therapy
Esophageal Cancer
What large trial evaluated the role of adjuvant CRT after surgery vs. surgery alone?
Patients were R0 resected adenocarcinomas of the stomach and esophagus (20% GE junction)
RT dose: 45 Gy
Chemo: FU+leucovorin
Intergroup (SWOG) 0116
MacDonald
Esophageal Cancer
What intergroup study evaluated the role of preoperative chemotherapy using cis5FU and showed that OS were similar compared to those treated with surgery alone?
RTOG 8911 (Kelsen et al)
A study by MRC conducted a similar trial with contradictory results to the RTOG 8911 in favor of pre-op chemotherapy.
Esophageal Cancer
What trial showed that patients with lower esophageal or gastroesophageal junction tumors showed benefit to the delivery of perioperative chemotherapy with ECF?
MAGIC trial (Medical Research Council Adjuvant Gastric Infusional Chemotherapy)
Esophageal Cancer
What is the standard of care for patients with resectable esophageal or junction cancers?
neoadjuvant chemotherapy (pacli+carbo weekly) \+ concurrent RT 41.4 Gy \+ surgery
Esophageal Cancer
What are the findings of the CROSS trial that established the standard of care for patients with resectable esophageal or junction cancers?
reduced locoregional recurrence, peritoneal carcinomatosis, and hematogenous spread.
increased median OS
Esophageal Cancer
What trial compared preop chemotherapy (cisFU) with preop chemo + 30 Gy CRT (cis-etop) in advanced esophagogastric adenocarcinoma?
Results showed increased N0 rates, increased pCR, and a trend towards improved OS.
POET
Preoperative Chemotherapy, or Radiochemotherapy in Esophagogastric
Adenocarcinoma
German
Esophageal Cancer
What trial compared the MAGIC regimen to FLOT (fu, leucovorin, oxaliplatin and docetaxel) as perioperative chemotherapy in locally advanced esopageal cancer?
ESOPEC (Al Batran)
Esophageal Cancer
What study/trial established the role of chemoradiation (cisFU + 50 Gy) in the definitive setting when compared to radiation alone (64 Gy)?
Although RT dose was less in the CRT arm, it showed decreased in recurrence rate, distant metastasis, and prolonged median OS.
RTOG 85-01 (Herskovic et al)
Esophageal Cancer
Major treatment-related sequelae/complication of brachytherapy
fistula formation / stenosis
Esophageal Cancer
Which can provide long-term dysphagia relief?
endoscopic stenting
intraluminal brachytherapy
brachytherapy
stenting provides short-term relief
Esophageal Cancer
Contraindications for esophageal brachytherapy
Esophageal fistula
Cervical esophageal locations
Stenosis that cannot be bypassed
Esophageal Cancer
Curative brachytherapy dose after EBRT using HDR.
total dose of 10 Gy, 5 Gy/fraction, 1 fraction/wk, starting 2 to 3 wk after
completion of external beam
All doses are specified 1 cm from the midsource or mid-dwell position.
Esophageal Cancer
Curative brachytherapy dose after EBRT using LDR
total dose of 20 Gy, single course, 0.4 to 1.0 Gy/h, starting 2 to 3 wk from
completion of external beam
All doses are specified 1 cm from the midsource or mid-dwell position.
Esophageal Cancer
Palliative brachytherapy dose (for short life expectancy patients)
after EBRT using HDR
How about LDR?
HDR: total dose of 10 to 14 Gy, 1-2 fractions
LDR: total dose of 20 to 40 Gy, one or two fractions, 0.4 to 1.0 Gy/h
All doses are specified 1 cm from the midsource or mid-dwell position.
Esophageal Cancer
Palliative brachytherapy dose EBRT using HDR & LDR, are same for those without EBRT and those recurrent after EBRT (for short life expectancy patients)
What is the dose of EBRT for those not previously treated?
30 to 40 Gy, 2-3Gy/fx
Esophageal Cancer
For patients with expected long life expectancy, what is the palliative EBRT and brachytherapy dose for those not previously treated with EBRT?
EBRT (same as for curative, 45 to 50/1.8-2)
HDR: total dose of 10 Gy, 5 Gy/fraction, 1 fraction/wk, starting 2 to 3 wk after completion of
external beam
LDR: total dose of 20 Gy, single course, 0.4 to 1.0 Gy/h, starting 2 to 3 wk after completion
of external beam
Esophageal Cancer
“Classic” radiation tolerance (TD5/5) of the heart is about ____ when 25% or less of the heart is irradiated and ____ if 65% of the heart is irradiated, assuming 2 Gy/fraction.
60 Gy;
45 Gy
Esophageal Cancer
(from in-service bank)
- The curative treatment of choice for localized limited volume carcinoma of the cervical esophagus in a patient with good performance status is _______.
A. Definitive surgery (pharyngolaryngoesophagectomy)
B. Definitive chemoradiation with platinum agents
C. Definitive chemotherapy followed by surgery
D. Definitive radiotherapy
B
Esophageal Cancer
(from in-service bank)
- In which clinical scenario is initial resection an acceptable option for esophagus CA?
A. Adenocarcinomas that extend no further than the muscularis mucosa
B. Limited segment (<2cm) SCCA that involves the muscularis mucosa that is node negative and poorly differentiated
C. SCCA that involves the lamina propria and is node negative
D. Esophagogastric junction tumors that involve only the lamina propria
C
Esophageal Cancer
(from in-service bank)
- For esophagus CA treated with initial surgical resection, post operative adjuvant therapy is recommended in the following situations, EXCEPT
A. Node negative adenocarcinoma of the EGJ
B. Any pT3N0 adenocarcinoma
C. Completely resected pT2N0 SCCA
D. pT2N0 adenocarcinoma with poorly differentiated histology
C
Esophageal Cancer
(from in-service bank)
- Endoscopic resection alone may be adequate therapy for esophageal tumors with the following features, EXCEPT
A. Invasion limited to the muscularis mucosa
B. Involvement limited to half the circumference of the esophageal wall
C. Tumor diameter < 2cm
D. Invasion limited to the lamina propria
B
Esophageal Cancer
(from in-service bank)
- Which is the least preferred management approach for a patient with good KPS and a T3N(+) Siewert I esophageal adenocarcinoma?
A. Upfront surgical resection via transthoracic esophagectomy
B. Neoadjuvant chemoradiation followed by surgery
C. Pre-operative chemotherapy with 5FU and cisplatin
D. Definitive chemoradiation alone
A
Esophageal Cancer
(from in-service bank)
- A 69-year-old male patient has been diagnosed with squamous cell carcinoma of the cervical (proximal) esophagus clinical Stage III (cT3N1M0) Grade 3. Which statement is FALSE regarding his treatment options?
A. Complete resection involves the surgical removal of the proximal esophagus along with portions of the pharynx, entire larynx, thyroid gland and with radical neck dissection.
B. Definitive chemoradiotherapy may be offered instead of surgery and will result in less functional impairments and morbidities.
C. Surgery results in significant morbidity and loss of organ function but with a higher probability of survival than other treatment modalities.
C
