ESOPHAGEAL NEOPLASMS AND DIAGNOSTIC APPROACHES TO ESOPHAGEAL CANCER

Question 1

What is the most common hisology of esophagus cancer world wide vs USA?

Answer 1

Worldwide, squamous cell carcinoma (SCC)
United States - adenocarcinoma.

During the last 20 years, the incidence of adenocarcinoma
has risen dramatically in Western countries with a
concomitant decline in the incidence of SCC

Question 2

Risk factors for esophagus SCC

Answer 2

Tobacco and alcohol - strong risk factors (synergistic effect)
> X4 in men
Caustic ingestion are at significantly increased

Question 3

which intrinsic disorders are associated with esophageal SCC?

Answer 3

Plummer-Vinson syndrome and achalasia

Question 4

Which hereditary cancer syndromes are associated with esophageal SCC

Answer 4

Tylosis and Fanconi anemia

Question 5

Risk factors for esophageal adenocarcinoma

Answer 5

Barrett esophagus. In addition to GERD, smoking
and obesity are risk factors for adenocarcinoma.
male predominance

Question 6

What is the Plummer–Vinson syndrome

Answer 6

rare disease characterized by difficulty swallowing, iron-deficiency anemia, glossitis, cheilosis and esophageal webs.

Question 7

What is the most common locations of SCC and AC of esophagus?

Answer 7

SCC - majority - proximal and middle esophagus. Adenocarcinomas - distal esophagus or GEJ.

Question 8

Does esophageal cancers are symptomatic at the

time of diagnosis?

Answer 8

Mostly.

Question 9

What is the most common symptom of esophageal cancer at presentation?

Answer 9

Dysphagia - 74% of patients reporting difficulty in swallowing.
Often, patients will report progressive dysphagia, beginning with an initial episode after eating solid food. After the initial episode of dysphagia, many patients will adapt by chewing more thoroughly, avoiding hard foods, or drinking liquids with swallows.
Thus, it is only after the dysphagia has worsened significantly that patients seek medical attention, by which point the majority have weight loss

Question 10

majojr symptom of adenocarcinoma of esophagus

Answer 10

dysphagia and long history of reflux symptoms (heartburn and regurgitation).
Other - fatigue, retrosternal pain, and anemia

Question 11

Locally advanced esophageal tumors

may be manifested with…

Answer 11

Laryngeal nerve involvement causing

hoarseness or tracheoesophageal fistula.

Question 12

What findings are seen in barium esophagram in esophageal cancer?

Answer 12

Irregular narrowing or ulceration. The classic “apple-core” filling defect is seen only if there is symmetrical, circumferential narrowing.
Instead, there is often an asymmetrical bulge seen with an infiltrative appearance.

Question 13

How does the diagnosis of esophageal cancer is made

Answer 13

almost always by endoscopic biopsy.
Single biopsy may not be diagnostic. Therefore,
multiple biopsies should be performed for any suspicious lesions.

Question 14

Which test should always be done for someone with dysphagia? Why?

Answer 14

Endoscopy! to rule out esophageal cancer

even if the barium esophagram is suggestive of a motility disorder

Question 15

How far from the GEJ a tumor is classified as an esophageal tumor?

Answer 15

Tumor epicenter is within 5 cm of the GEJ.

Question 16

esophageal cancer T1?

Answer 16

T1 Tumor invades the muscularis mucosa (T1a) or submucosa (T1b)

Question 17

esophageal cancer T2?

Answer 17

T2 Tumor invades into but not beyond the muscularis propria

Question 18

esophageal cancer T3?

Answer 18

T3 Tumor invades the adventitia

Question 19

esophageal cancer T4?

Answer 19

T4a Tumor invades adjacent structures that are usually resectable
(diaphragm and pericardium)
T4b Tumor invades unresectable structures (trachea and aorta).

Question 20

esophageal cancer N0-3?

Answer 20

N0 No regional lymph node metastasis
N1 Metastasis in 1-2 regional lymph nodes
N2 Metastasis in 3-6 regional lymph nodes
N3 Metastasis in ≥7 regional lymph nodes

Question 21

How can a superficial esophageal lesions can be evaluated and resected?
What are the benefits of this procedure?

Answer 21

endoscopic mucosal resection (EMR)
Adequate staging for depth of penetration
(T stage) and may provide additional information about
the risk of nodal metastasis

Question 22

What is the next stage for T1a esophageal tumors resected by EMR?

Answer 22

the risk of lymph node metastasis is very low, and additional staging studies are not required.

Question 23

What is the next stage for esophageal tumors higher then T1a resected by EMR?

Answer 23

CT (chest and abdomen)
(PET)/CT to evaluate for distant metastatic disease.
If there
is no evidence of distant metastatic disease, EUS should be performed to assess T stage and regional lymph nodes.

Question 24

what are the advantages of obtaining a PETCT before EUS for esophageal cancer?

Answer 24

The scan may demonstrate distant metastatic disease, eliminating the need for the patient to undergo EUS. May also identify a suspicious lymph node that can be specifically examined and sampled during the EUS procedure

Question 25

which is superior to assess T and N for esophageal cancer? EUS? CT? PETCT?

Answer 25

EUS

highly accurate for celiac nodal status with a sensitivity of 85% and specificity of 96%

Question 26

Which test should be performed for esophageal tumors above the carina? why?

Answer 26

bronchoscopy.

assess direct tracheal invasion.

Question 27

Benign Tumors of the Esophagus p 1032

Answer 27

Other Malignant Tumors of the Esophagus p 1032

Question 28

what is the risk of metastasis for T1a esophageal tumor?

Answer 28

from less than 2% to more than 15%

Depending on the size of the lesion, degree of differentiation, and lymphovascular invasion.

Question 29

Why EMR is not adequate for esophageal tumors involving the submucosa?

Answer 29

The risk of lymph node involvement increases with depth of submucosal invasion.

Question 30

which patients with more than T1a esophageal tumor can be treated with EMR? why?

Answer 30

Patients who are poor surgical candidates, with SM1
adenocarcinomas with low-risk features.

SM1 Lesions (involving only the most superficial third of the submucosa) have relatively low rates of nodal metastases, typically reported as less than 30%. On the other hand, lesions involving the deepest
third of the submucosa (SM3) may have nodal involvement in more than 50% of cases.

Likewise, for patients who are good surgical candidates,
esophagectomy is a reasonable option for T1a lesions with high-risk features

Question 31

which esophagus cancer T1b has a higher risk for nodal metastasis?

Answer 31

squamous cell histology 45%

Adenocarcinoma 26%

Question 32

Why does the role of esophagectomy as a singlemodality

treatment for esophageal cancer is diminishing?

Answer 32

Because most tumors are found after symptoms develop, at which point they are usually locally advanced or metastatic.
Locally advanced tumors should be treated with multimodality therapy.
Asymptomatic tumors are usually found during surveillance for Barrett esophagus and can be treated with EMR

Question 33

which tumors should be treated with esophagectomy? why?

Answer 33

T1b tumors - significant risk for nodal metastasis
High-risk T1a lesions (larger tumors or lesions with lymphovascular invasion)
Extensive, multifocal lesions and ulcerated tumors - may be difficult to eradicate endoscopically.

Question 34

What is the controversy with esophagectomy fot T2N0 tumors? which trail has compared surgery with other treatment? which treatment?
what is the suggestions?

Answer 34

T2N0 tumors. Esophagectomy with an adequate lymphadenectomy for T2N0 would be expected to confer an overall 5-year survival of 40% to 65% Unfortunately, the T2N0 is inaccurate in the majority of
cases, and many patients are found to have node-positive disease on final pathology after esophagectomy.
The CROSS trial, compared neoadjuvant chemoradiation followed by surgery versus surgery alone for
esophageal and GEJ cancer. Although the trial demonstrated a survival benefit for the neoadjuvant chemoradiation arm, clinical T2N0 patients represented only a small subset of the study cohort, and it is unclear how much benefit these patients in particular
received. Other retrospective analyses indicate that there may not be a survival advantage for neoadjuvant therapy in this group.
It may be appropriate to offer neoadjuvant therapy to patients with clinical T2N0 disease based
on other high-risk factors. Liberal use of diagnostic EMR is appropriate.
The advent of EMR also influences the type

Question 35

Locally Advanced Esophageal Cancer P 1036

Answer 35

Locally Advanced Esophageal Cancer P 1036