oesophageal cancer

Question 1

where is the location of adenocarcinoma of the oesophagus?

Answer 1

lower 3rd of the oesophagus near gastrooesophageal junction

Question 2

what is the location of oesophageal squamous cell carcinoma?

Answer 2

upper 2/3rds of oesophagus

Question 3

what are the risk factors for oesophageal adenocarcinoma?

Answer 3

Barrett’s oesophagus: metaplasia from squamous epithelium to mucus-secreting columnar epithelium secondary to GORD

Obesity

Smoking

Rare causes: coeliac disease and scleroderma

Question 4

what are the risk factors for oesophageal squamous cell carcinoma?

Answer 4

Smoking: more associated with SCC
Alcohol
Achalasia
Plummer-Vinson syndrome
Hot beverages
Nitrosamines (dietary)

Question 5

which type of oesophageal cancer is most common|?

Answer 5

adenocarcinoma is the commonest type in the Western world, whilst SCC is more common in countries such as Japan

Question 6

when is the peak incidence for oesophageal cancer?

Answer 6

80yrs–> most common in males

Question 7

what are the symptoms of oesophageal cancer?

Answer 7

1. progressive dysphagia to solids and liquids
2. odynophagia
3. weight loss and anorexia
4. hoarseness with recurrent laryngeal involvement
5. vomiting

Question 8

what might you find on examination of someone with oesophageal cancer?

Answer 8

• lymphadenopathy

- melena on PR

Question 9

what is the criteria for a 2WW referral for OGD with suspected oesophageal cancer?

Answer 9

NICE recommends referring patients for an urgent 2-week upper GI endoscopy if they have:
Dysphagia

or
≥ 55 years with weight loss and one of:
Epigastric pain
Reflux
Dyspepsia

Question 10

what is the primary investigation you need to do when suspecting oesophageal cancer?

Answer 10

Upper GI endoscopy (OGD) and biopsy: first-line investigation and allows for visualisation of masses and biopsy

Question 11

what imaging would you do later to stage an oesophageal cancer?

Answer 11

• CT chest abdo pelvis (CAP)
• PET CT
• staging laparoscopy

Question 12

what is the management of adenocarcinoma oesophageal cancer?

Answer 12

localised:
- endoscopic mucosal resection (very early lesions or Barrets)

advanced:
- oesophagectomy- stomach is pulled upwards and acts as an oesophagus

chemo is offered to all surgical patients pre (neoadjuvant) and post (adjuvant) therapy

Question 13

what is the management for a localised SCC oesophageal cancer?

Answer 13

unlike adenocarcinoma can be cured with chemoradiotherapy, but surgical resection can be offered

Question 14

how can advanced metastatic oesophageal cancer be managed?

Answer 14

Palliation: stenting for dysphagia

Chemotherapy or chemoradiotherapy: platinum-based agents

Trastuzumab (Herceptin): for HER2 positive metastatic oesophageal cancer, in combination with chemotherapy

Question 15

what are complications of oesophageal cancer?

Answer 15

Aspiration pneumonia: oesophageal obstruction may result in aspiration

Tracheo-oesophageal or broncho-oesophageal fistula: most likely to occur if the cancer is located in the mid-oesophagus

Metastasis: lymph nodes, liver, lung, bones

Question 16

what are oesophagectomy related complications?

Answer 16

• anastomotic leak-> which can lead to mediastinitis
• recurrent laryngeal nerve injury
• delayed gastric emptying

Question 17

what is Barretts oesophagus?

Answer 17

Barrett’s oesophagus describes metaplasia (transformation of one differentiated cell type to another differentiated cell type) of the lower oesophageal lining

from stratified squamous epithelium to mucous secreting columnar epithelium with goblet cells. It occurs in response to acidic stress

Question 18

what are the risk factors for Barretts oesophagus?

Answer 18

Gastro-oesophageal reflux disease: the single greatest risk factor for developing Barrett’s oesophagus
Middle-age: the average age of diagnosis is approximately 55 years old [6]
Male: 7 times more common in males
Caucasian
Smoking
Obesity

Question 19

what are GORD symptoms?

Answer 19

• burning epigastric retrosternal pain
• worse when lying flat
• worse with spicy meals
• can wake patient up from sleep
• regurgitation-> leading to sour taste in mouth
• reflux induced cough

Question 20

how is barrettes oesophagus diagnosed?

Answer 20

• upper GI endoscopy and biopsy

- biopsies follow Seattle protocol- leads to increase in detection of early lesions

Question 21

what type of surveillance do you do for patients with non dysplastic barrettes oesophagus?

Answer 21

repeat surveillance endoscopy every 3- 5 years

Question 22

what are the principles of managing a Barretts oesophagus?

Answer 22

1. treat underlying reflux= weight loss, smoking cessation, alcohol abstinence, PPI
2. endoscopic surveillance- every 3-5 years for non dysplastic and every 6 months for mild dysplasia
3. management with endoscopic radio frequency ablation and endoscopic mucosal resection.. do this straight away for a high grade dysplasia

Question 23

how do you decide if barrettes oesophagus is treated with endoscopic mucosal resection or radio frequency ablation?

Answer 23

Radiofrequency ablation: typically for flat lesions

Endoscopic mucosal resection: typically for raised lesions