Esophageal Neoplasms

Question 1

Risk factors for esophageal neoplasm?

Answer 1

Smoking/chew & Alcohol
Barrett’s esophagus
Achalasia
Corrosive-induced esophageal strictures (Lye ingestion)
Other head, neck, chest cancers (Hx of radiation Txfor other conditions in chest)
Poor diet
Obesity

Question 2

Pathophysiology of esophageal neoplasms?

Answer 2

1. Chronic irritation leads to histologic changes in esophageal tissue:
   A. Chronic tobacco, alcohol use, reflux
   B. Inflammation 2° to Barrett’s esophagus, stricture or achalasia

Question 3

What are the two types of esophageal cancer?

Answer 3

1. SCC

Question 4

SCC characteristics

Answer 4

↑ w/tobacco, ETOH, poor diet
Proximal 2/3 of esophagus
Arise from epithelial cells

Question 5

Adenocarcinoma characteristics

Answer 5

↑ w/ Barrett’s esophagus (30-fold risk), tobacco, obesity
Distal 1/3 of esophagus
Arise from glandular cells

Question 6

Signs & Sx’s of esophageal neoplasms?

Answer 6

1. Solid food dysphagia 
A. >90% progression over weeks-months
2. Weight loss
3. Odynophagia
4. Coughing on swallowing
A. Suggests invasion into tracheobronchial tree
5. Chest or back pain
A. Suggests mediastinal invasion
6. Hoarseness
A. Recurrent laryngeal nerve involvement
7. Supraclavicular or cervical lymphadenopathy
A. Indicative of mets

Question 7

Diagnostic Studies for Esophageal Neoplasms

Answer 7

1. Upper Endoscopy
   A. Confirms diagnosis
   B. Biopsy for histologic Dx
2. CT Chest & Abd/Pelvis / PET scan
   A. Used for staging & helps determine Tx
   B. Look for lung or liver mets, lymphadenopathy & local tumor extension
   - Predictors for poor prognosis
   (Mediastinal spread & lymph node involvement)
   - Lab tests are nonspecific
   (+/- anemia, ↑ LFT’s if liver mets, ↑ Alk Phos if bone mets)

Question 8

Stage 0

Answer 8

Abnormal cells in mucosa
High cure rate
Surgery (resection) w/ or w/o chemo-radiation Tx
Chemo + radiation w/o surgery

Question 9

Stage 1

Answer 9

Cancer formed & spread to submucosa
High cure rate
Surgery (resection) w/ or w/o chemo-radiation Tx
Chemo + radiation w/o surgery

Question 10

Stage II (A & B)

Answer 10

Stage II A: Involves esophageal muscle
Stage II B: Involves any of the first 3 layers of esophagus & nearby lymph nodes
Fit patients
Pre-op chemo-radiation Tx , then resection

Question 11

Stage III

Answer 11

1. Involves outer esophageal muscle wall & adventitia
2. May involve tissues or lymph nodes near esophagus
   Fit patients
   Pre-op chemo-radiation Tx , then resection

Question 12

Stage IV (A & B)

Answer 12

1. Stage IV A: Involves nearby or distant lymph nodes

2. Stage IV B: Involves distant lymph nodes &/or other organs

Question 13

Therapy for incurable disease: Stages III & IV

Answer 13

1. Not surgical candidate
2. Palliative care
   A. Radiation Tx, chemotherapy or both
   - 5-FU + Cisplatin
   - Docetaxel (2nd -line)

Question 14

Goals of therapy for incurable disease

Answer 14

1. Relieve dysphagia & pain
A. Wire stent
2. Optimize quality of life 
A. Feeding tube placement
3. Minimize treatment side effects

Question 15

Prognosis

Answer 15

Local spread to mediastinum is common

Overall 5-yr survival rate for esophageal cancer is < 20%