Oephsophagus

Question 1

NZ stats 2013

Answer 1

300 registrations
250 deaths
6th leading cause of cancer death world wide

Question 2

What are the 2 major subtypes of oesophageal cancer?

Answer 2

Squamous Cell Carcinoma (SCC) and Adenocarcinoma (AC)

Question 3

Is there a discrepancy between the sexes and Maori and Non-Maori?

Answer 3

Twice as common in men as women.

Maori incidence and mortality rates are higher than non-Maori

Question 4

SCC epidemiology

Answer 4

• SCC account for about 90% of oesophageal cancers
• Incidence and mortality rates have significantly decreased
• SCC prevalent in E Africa, C Asia, N Iran, N China
• SCC biologically similar for H&N cancers
• Decline possibly due to changes and education: diet, tobacco and alcohol

Question 5

AC epidemiology

Answer 5

• AC incidence rates have significantly increased in the West (Americas, Australia, Europe)
• Linked to obesity
• Often occur in the lower part of the oesophagus and the GOJ
• AC more chomosomally unstable - harder to treat

Question 6

What are the risk factors associated with oesophageal cancer?

Answer 6

Lifestyle:

• smoking and alcohol (SCC)
• obesity (AC)
• though both do apply to both

Dietary:

• Red meats and processed foods
• Hot drinks?

Genetics:

• Male and over the age of 45yrs
• Achalasia (valve at GOJ doesn’t work properly (AC)
• Tylosis (inherited condition - thicker skin on palms of hands and feet) (SCC)

Gastro-oesophageal reflux disease (GORD)
- reflux, heart burn (SCC)

Barrett’s Oesophagus
- Cells lining oesophagus are becoming abnormal. (Acid reflux doesn’t help) (AC)

Environmental:
- Previous RT exposure to mediastinum

Question 7

What is GORD?

Answer 7

Gastro-oesophageal reflux disease

Question 8

What is Barrett’s Oesophagus?

Answer 8

Cells lining oesophagus are becoming abnormal

Question 9

What is Achalasia?

Answer 9

valve at GOJ doesn’t work properly

Question 10

What is Tylosis?

Answer 10

inherited condition - thicker skin on palms of hands and feet

Question 11

Where is SCC more likely to occur?

Answer 11

Upper 2 thirds of the oesophagus

Question 12

Where is AC more likely to occur?

Answer 12

Lower third and at the GOJ

Question 13

What is staging related to?

Answer 13

Related to the destruction of the mucosal layers

Question 14

What physiological characteristics of the oesophagus lend themselves toward spread of disease?

Answer 14

• Adventitia is easy to invade - lack of serosa layer to act as barrier
• It’s smooth and easy to travel along
• Got good lymphatic drainage

Question 15

Where does local extension occur?

Answer 15

Pericardium
Trachea
Vertebral bodies

Question 16

Where does regional lymph node metastasis occur?

Answer 16

Depends where the lesion is.

Cervical: supraclavicular and cervical nodes

Thoracic: Mediastinal nodes - paratracheal and subcarinal nodes

Lower: Left gastric and coeliac nodes

Question 17

Where is it most likely to metastasise to? and which type is more likely to metastasise?

Answer 17

AC is more likely to develop distant mets

Lung, Liver, Bone

Question 18

What are the signs and symptoms of oesophageal cancer?

Answer 18

Common:

• Dysphagia (difficulty)
• Odynophasia (pain)
• Weight loss

Other symptoms related to location and spread:

• Hoarseness
• Cough
• Nausea and vomiting
• Regurgitation/reflux due to pressure in the gastric area
• Coughing up blood
• Fatigue

Question 19

What are the common investigations for oesophageal cancer?

Answer 19

Complete history and physical exam (includes palpation)
EUS (Endoscopic Ultrasonography) +/- biopsy/FNA
Barium swallow
Bronchoscopy
Blood tests
LFT and PFT
CT - abdo, thorax + contrast (LN)
PET-CT
Bone scan

Question 20

What is the common RT prescription used for definitive Chemo RT?

Answer 20

45-50.4Gy in 25-28#, 1.8Gy/#

Question 21

What chemotherapy agents are used for definitive Chemo RT?

Answer 21

5FU and Cisplatin

Question 22

What is the palliative prescription for oesophageal cancer?

Answer 22

40Gy in 15# - high dose palliative (might just use a POP)