H&N Evaluation and management of esophageal cancer

Question 1

What are the risk factors for cervical esophageal

squamous cell carcinoma?

Answer 1

● Tobacco
● Alcohol
● Gastroesophageal reflux
● Plummer-Vinson syndrome

Question 2

What is the most common type of cervical

esophageal cancer?

Answer 2

Squamous cell carcinoma (approximately 80%)

Question 3

What is the most common type of distal esophageal cancer?

Answer 3

Adenocarcinoma. Increasing incidence related to gastroesophageal reflux disease

Question 4

What are common initial symptoms in patients

with cervical esophageal cancer?

Answer 4

Progressive dysphagia (solids, then solids and liquids) and
weight loss. Other symptoms include hematemesis, pain,
hoarseness or cough.

Question 5

What are the typical nasopharyngoscopy findings

in patients with cervical esophageal cancer?

Answer 5

Negative findings unless esophagoscopy is performed or

tumor extends to the hypopharynx.

Question 6

According to the AJCC, 7th edition, the cervical
esophagus begins at approximately what distance
from the incisors?

Answer 6

15 cm to less than 20 cm

Question 7

What imaging modality is most accurate at
identifying the extent of cervical esophageal cancer
and its relationship with adjacent soft tissues?

Answer 7

MRI

Question 8

What procedure is generally required for direct
visualization, biopsy, and staging of an esophageal
tumor?

Answer 8

EGD

Question 9

What procedure or diagnostic test is the most
sensitive for T and N staging for esophageal
cancer?

Answer 9

EUS

Question 10

What is the new T staging system for cervical
esophageal squamous cell carcinoma according to
the AJCC 7th edition?

Answer 10

T1a invades lamina propria or muscularis mucosa
T1b invades submucosa
T2 invades muscularis propria
T3 invades adventitia
T4a resectable tumor; invades pleura, pericardium, or diaphragm
T4b invades adjacent structures such as aorta or vertebral body and considered unresectable

Question 11

What is the N staging system for cervical
esophageal squamous cell carcinoma according to
the AJCC 7th edition?

Answer 11

N0 no regional metastasis
N1 1–2 regional lymph nodes
N2 3–6 regional lymph nodes
N3 ≥ 7 lymph node metastasis

Question 12

Describe the staging system used to classify

esophageal cancer based on the TNM stage.

Answer 12

● Stage IA: T1N0
● Stage IA: T2N0
● Stage IIA: T3N0
● Stage IIB: T1-T2N1
● Stage IIIA: T4aN0, T3N1, T1–2N2
● Stage IIIB: T3N2
● Stage IIIC: T4aN1–2, T4bAnyN, AnyTN3
● Stage IV: M1

Question 13

What tumor characteristics have been recently
added to the AJCC, 7th edition, staging of
esophageal cancer?

Answer 13

● Histologic type (squamous cell carcinoma versus adenocarcinoma)
● Histologic grade (1–3)
● Tumor location (upper, middle, or lower esophagus)

Question 14

Although cervical esophageal and hypopharyngeal
squamous cell carcinomas are commonly grouped
together, what is an important difference in
staging at presentation?

Answer 14

Hypopharyngeal squamous cell carcinoma has a higher
incidence of advanced T and N stages at presentation
compared with cervical esophageal squamous cell
carcinoma.

Question 15

True or False. Comparing stages, esophageal
squamous cell carcinoma, and adenocarcinoma
have similar survival rates.

Answer 15

True

Question 16

What imaging modality may play a role in
predicting prognosis in esophageal cancer, and
what is the unit of measurement that is used to
predict prognosis?

Answer 16

PET scans. Standardized uptake values (SUV). This has not
borne out in other head and neck cancer thus far, despite
intense evaluation.

Question 17

What overexpression or gene amplification of
what molecular marker has been associated with
poor outcome in esophageal cancer?

Answer 17

Human epidermal growth factor receptor (HER-2)

Question 18

What treatment modalities are recommended for

esophageal cancer based on stage?

Answer 18

● Stage I: Endoscopic resection vs surgical resection
● Stage II–III: Chemoradiation followed by surgery
● Stage IV: Chemotherapy or best supportive care
Note: Increasing stage is associated with poorer prognosis.

Question 19

What surgical technique is used for primary

cervical esophageal tumors or hypopharyngeal tumors with involvement of the cervical esophagus?

Answer 19

Total pharyngo-laryngo-esophagectomy and total pharyngolaryngectomy with cervical esophagectomy

Question 20

What are the reconstructive options after surgery
for cervical esophageal cancer when resection
includes the esophagus below the thoracic inlet?

Answer 20

● Gastric transposition (gastric “pull-up”)

● Colonic transposition

Question 21

What are some of the disadvantages of the gastric
transposition (gastric “pull-up”) reconstruction for
pharyngeal and esophageal defects?

Answer 21

● High incidence of morbidity and mortality
● Inability to close some defects with oropharyngeal or
nasopharyngeal extension
● Frequent pulmonary complications
● Risk of hypoparathyroidism
● Gastric dumping syndrome
● Gastric outlet obstruction
● Regurgitation

Question 22

What are the reconstructive options after surgery
for cervical esophageal cancer when resection
does not include the esophagus below the
thoracic inlet?

Answer 22

● Gastric transposition (gastric “pull-up”)
● Colonic transposition
● Jejunal vascularized free flap
● Tubed fasciocutaneus vascularized free flap

Question 23

What is the major functional disadvantage for patients undergoing jejunal free flap reconstruction for pharyngeal defects?

Answer 23

Poor speech and swallowing function. See also dysphagia

and donor-site morbidity. Relatively low rate of stenosis.