esophagus

Question 1

The esophagus can be divided anatomically into:

Answer 1

Cervical (C7-T3):
15-20cm from incisor, or to thoracic inlet

Thoracic (T3-T11): 20-40cm from incisor, upper (to the tracheal bifurcation) (5cm), middle (5cm), lower (10cm)

Abdominal (GOJ)
Siewert classification – determines extent of esophagectomy/ gastrectomy required

Question 2

Broadly outline the surgical approach to esophageal cancer:

Answer 2

Most guidelines consider surgery where possible (up to and not including T4b) a key part of management.

Except!!! Cervical tumour: treated non-operatively because laryngo-pharyngectomy with permanent stoma sucks!

For tumours limited to the submucosa (T1b): Endoscopic mucosal resection (EMR)/ endoscopic submucosa dissection (ESD). EMR ok for lesions < 2cm en-bloc, larger lesions need piecemeal resection which limit
assessment of margin status
- ESD allow dissection of larger tumour (regardless of size), labour intensive, and high risk
of perforation
- High risk of oesophageal stenosis/ stricture after extensive EMR/ ESD

Upper and middle thoracic tumour (>5cm from crico-pharyngeus): total
esophagectomy with gastric pull-through is standard
o Options: Ivor Lewis, McKeown (tri-incisional), trans-hiatal
- Distal/ GOJ tumour: distal oesphagogastrectomy

Question 3

What classification may surgeons use for more distal esophageal cancers? Why

Answer 3

Siewert classification.Higher tumours (class 1 = 1-5cm above GOJ) are treated with distal esophagectomy or transthoracic esophagectomy.

Class II (1cm above and 2cm below GOJ) Extended gastrectomy oesophagus and Class III 1-5cm below total gastrectomy.

Note: all pretty much get a mediastinallymphadectomy

Question 4

What is the surgical approach to esophagectomy, broadly when can it be done?

Answer 4

Upper and middle thoracic tumour (>5cm from crico-pharyngeus, >3cm from GOJ): total esophagectomy with gastric pull-through is standard this can be:
Ivor Lewis, McKeown (tri-incisional), trans-hiatal

• Distal/ GOJ tumour: distal oesphagogastrectomy

Lymphadenectomy: generally performed for distal lesions, controversial regarding minimum LN, generally recommends 6-23 LN

Question 5

Contraindications to esophagectomy

Answer 5

Contraindications for surgery
- Distant metastases
- T4b lesions (involving heart, great vessels, trachea, surrounding organs)
- Bulky multi-station lymphadenopathy

Question 6

Comment on esophagectomy mortality, what intervention can worsen this (and by how much?):

Answer 6

Post-operative mortality ~ 5%, can be 10% of higher after neoadjuvant CRT

Question 7

For Barrett’s oesophagus, describe:
Macroscopic and microscopic appearance

Answer 7

Macroscopic:
Red velvety appearance, “Salmon eophagus”

Micro:
- Metaplasia: Replacement of non-keratinized stratified squamous epithelium with ‘intestinal- type’ columnar epithelium with goblet cells
- Dysplasia: nuclear polychromasia, irregular nuclear size and shape, prominent nucleoli, high N: C ratio, increased mitotic activity

Question 8

For Barrett’s oesophagus, describe:
Pathogenesis and clinical significance

Answer 8

Normal nonkeratinised stratified squarmous epithelium → chronic esophagitis due to gastric acid exposure→ columnar (intestinal-like) metaplasia (columnar epithelial with goblet cells) - Barrett’s oesophagus

Clinical Significance:
- Risk of malignant transformation ~2% per year
- need close endoscopic surveillance
- acid suppression with PPI may halt dysplastic progression

Question 9

For esophagus adeno Ca give
i. Epidemiology
ii. Risk factors

Answer 9

Epidem:
Most common esoophagus cancer in Western countries.

RFs = BOGS
Barretts
Obesity
GORD
Smoking (though to a much lesser extent than SCC)

Question 10

For esophagus SCC give
i. Epidemiology
ii. Risk factors

Answer 10

90% of oesophageal cancer world wide More common in Asia/ East Europe

ABCDEF

Achalasia Bad diet (low fibre, high fat) Ciggies Diverticuli EtOH Familial and Plumer vinson syndrome.

Question 11

Macro and micro appearance of esophagus AdenoCa

Answer 11

Malignant cell with glandular differentiation
* Mucin-producing
* adjacent Barrett’s metaplasia
* WD = more gland; MD = mixed of gland + solid; if PD = solid appearance

Question 12

Macro and micro appearance of esophagus SCC

Answer 12

Polypoid
Fungating
Ulcerative (SCC tends to ulcerate)
Infiltrative (similar to Bormann’s for
gastric)

Micro
large flat atypical squamous cell
* keratinisation pearl formation
* intracellular bridges
* occasional spindle cell morphology
(polypoid)
* adjacent/ coexisting dysplasia

Question 13

IHC for eso SCC

Answer 13

• p53+
• CK5/6+
• p40+

Question 14

IHC for eso AdenoCa

Answer 14

• CK7+
• CK20-
• PAS+ (mucin)
  TTF-1

Question 15

After esophagus neoadjuvant chemoradiotherapy, what are the microscopic changes in the tumour and adjacent tissue?

Answer 15

Post radiation changes are seen in both the tumour, stroma and vessels:

Tumour:
* Necrosis, fibrosis
* if residual tumour, will show giant cells with bizarre (very pronounced) nuclear atypia
TUMOUR RESPONSE GRADING (TRG) – used in CROSS protocol. G1 = CR, G4>50% alive

Stroma: Atypia, fibrosis, inflammatory infiltrate.

Vessels: Hyaline sclerosis

Question 16

List the pathological prognostic factors in esophagectomy specimen:

Answer 16

• Tumour site (upper 1/3 better than lower 1/3)
• Tumour size
• Depth of invasion (lamina propria/ muscularis mucosa/ submucosa/ muscularis propria/ adventitia)
• Tumour grade
• LVI
• Resection margin
• Nodal involvement (most prognostic)
• IHC staining: CEA/ VEGF/ Her2
• Pathological complete response (after neoadjuvant chemoRT)

Question 17

A 64 year old dude presents with dysphagia and weight loss.

Investigation reveals a tumour in the oesophagus from 26 to 31 cm from incisor. Bopsy confirms squamous cell carcinoma.

Key features of Hx:

Answer 17

Symptoms/Emergency:
- Tempo and severity of symptoms, dysphagia/ odynophagia (still able to have any oral intake?), weight loss (how much, over what period of time), hematemesis, melena

Risk factors:
ABCDE And Plummer Vinson

Suitability for surg/chemoRT
- ECOG, comorbidities, which may make him deem high risk surgical candidate
- RT relevant: connective tissue disorders, pacemaker, previous thoracic RT
- Chemotherapy: renal function/ hearing (if considering cisplatin with definitive RT)

Functional and social
Social support to go through treatment; geriatric assessment

Question 18

A 64 year old dude presents with dysphagia and weight loss.

Investigation reveals a tumour in the oesophagus from 26 to 31 cm from incisor. Bopsy confirms squamous cell carcinoma.

Key features of Ex:

Answer 18

Weight/Malnutrition
Lymphadenopathy (esp. SCF) Hepato-splenomegaly (? Mets)

Question 19

A 64 year old dude presents with dysphagia and weight loss.

Investigation reveals a tumour in the oesophagus from 26 to 31 cm from incisor. Bopsy confirms squamous cell carcinoma.

Key features of Ix:

Answer 19

Blood: FBE/ UEC/ CMP/ LFT
Tissue diagnosis:
- More information from biopsy depth of invasion (dictate T stage) Imaging:
- CT chest/ abdomen (contrast) to evaluate extent of local invasion, nodal disease, liver mets
- Complete Staging FDG PET to exclude distant disease

Question 20

A 64 year old dude presents with dysphagia and weight loss.

Investigation reveals a tumour in the oesophagus from 26 to 31 cm from incisor. Bopsy confirms squamous cell carcinoma.

The pt has significant weight loss and has not been able to maintain an adequate oral intake. How you would manage this?

Answer 20

• Dietitian evaluation, extent of dysphagia
• Nutritional supplement with high calorie drinks (e.g. Sustagen/ Resource)
• If still not able to maintain adequate intake, consider nasogastric tube (NGT) insertion
• If recurrent NGT dislodgement, consider percutaneous endoscopic jejunostomy (PEJ) feed (NOT PEG feed)
• Monitor for re-feeding syndrome (regular electrolyte monitoring esp. for hypo-phosphataemia, also hypoMg and hypoK)