oesophageal cancer Flashcards
types of oesophageal cancer include:
-adenocarcinoma = begins in mucous secreting gland cells
-Squamous cell carcinoma= begins in thin cells of the mucosa that line the inside
where does it occur?
-adeno
-SCC
-distal oesogohagus
-upper and middle
Aetiology of SCC
black male
smoking (5x risk than non smokers)
alcohol abuse
diet and nutrition
hereditary (tylosis)
Aetiology - adenocarcinoma
white male
gastroesophageal reflux disease (GORD)
obesity
smoking
diet and nutrition
hereditary
Clinical Presentation
EARLY STAGE GENEREALLY ASYMPTOMATIC
dysphagia(swallowing difficulties)
weightloss
frequent choking while eating
indigestion
coughing/ hoarseness
chest pain
Diagnostic Workup: Ba Swallow
-used widely before endoscopy was available
-distinguish gastroesopageal tumours from gastric tumour
Diagnostic Workup: Endoscopy
used for
function
-diagnosis, staging, treatment and surveillance
-visualization of circumferential involvement, length and location relative to Gastro oesophageal junction (GOJ) and extent into cardia
The cancer may appear as a:
-stricture
-mass
-raised nodule
-ulceration
-irregularity of mucosa
Diagnostic Workup: Biopsy
-when taken
-how
-if biospy is difficult to obtain
-taken at time of endoscopy
-recommended 6-8 sample taken from margin around and centre of lesion
-brush cytology can assist
Staging Workup: Endoscopic Resection
-vital for accurate staging of early stage tumours
-used for tx of T1a disease
-for small tumours its provides more accurate depth of invasion info than EUS
Staging Workup: EUS
function
limitations
«improves clinical staging:
-Locoregionally
-depth of tumour invasion
-nodal status
«
-invasiveness
-reproducibility
-inability to assess distant mets
-high false positive rate 10%
Staging Workup: CT AND PET
-used for staging N and M status
-if nodes are greater than 1cm , treated with sus
-high resolution in CT useful in detecting pulmonary mets
Staging Workup: PET/CT
-used for
-limitation
-staging , assessment of response to neoadjuvant tx , RT planning
-spill over uptake from adjacent primary
Gastrointestinal endoscopic mucosal resection (EMR)
remove precancerous, early-stage cancer or other abnormal tissues (lesions) from the digestive tract.
Esophagogastroduodenoscopy (EGD)
is a procedure to diagnose and treat problems in your upper GI (gastrointestinal) tract
Diagnostic Workup: Summary
EGD w biospy/ EMR and EUS to determind cell type cG cT cN.
followed by FDG-PET/CT for additional cN and cM staging.
staging :T
T1= restricted to supprotive tissue
T2= invades msucular tissue
T3= invades outer membrane
T4= invades nearby structures
Treatment Options depends on
-performance status
-nutritional status
-co-morbidity evaluation
-pulmonary function test
Treatment Options: Endoscopic Therapy
Endoscopic Mucosal Resection (EMR)
Argon plasma coagulation (APC)
Photodynamic therapy
Radiofrequency ablation
Cryotherapy
Endoscopic Therapy: when is it used
barrett oesophagus and very early stage tumours:
Tis, T1a
flat lesion less than 2cm
well differentiated
*this patient group is increasing due to screening of BARRETT Oesophagus and impact of GORD
Endoscopic Therapy side effects
chest pain
stricture
bleeding w APC
ulceration w APC
Treatment option :Surgery (oesophagectomy)
used when
-early stage tumours (T1b -T2N0, less than 3 cm, well. differentiated)
-If local node met is present NOT a contraindictation for surgery. Resected w primary
Treatment Options: Chemoradiation
used for
locally advanced stage disease:
T2 N0 ( greater than 3cm, poorly differentiated) or T1-T3 N1-3 M0
either neoadjuvant or definitive
neoadjuvant treatment
takes place:
stage of cancer:
-4-8 weeks prior surgery
-T1-2 N1M0or T3-4 N0 M0
neo-adjuvant chemoradiation doses
45Gy/25#/1.8
50Gy/25#/2
50.4Gy/28#/1.8
definitive chemoradiation
-patient not surgical candidate
-resectable cancer((T1-3 N0-1) but not surgical candidate due to patient factors
-unresectable middle and lower third carcinoma (T3-4 N0-1 M0)
Treatment Options: Summary by Stage
T1a N0 M0
-Typically discovered during screening for Barrett oesophagus
-very low chance 2-5% chance of nodal involvement when confined to mucosa
-endoscopic mucosal resection EMR
-Well differentiated mucosal lesions <2cm in size
Treatment Options: Summary by Stage
T1B N0 M0
-tumour invades submucosa
-when infiltrated to deep submucosa, chance of LN involvement incease up to 45%
-Oesophagectomy
Treatment Options: Summary by Stage
T1-T3 N1-3 M0 or T2-T3 N0 M0
-depth of tumour invasion ↑ , risk of undetected involved nodes ↑
-neoadjuvant chemoRT followed by surgery (restaging w PET/CT)
-patient ≠. surgical candidate then definitive chemoRT
Treatment Options: More Advanced
Disease
chemo
RT
chemoRT
RT: CT Simulation
supine
knee support
distal oesophagus=arms up and immobilised+indexed wing board/vacbag
upper= neck mask
RT: CT Simulation
-slice thickness
-scan length
-contrast
-prep
- what is used
-2.5mm
-thoracic inlet to mid abdomen (ensure entire lung volume is included for DVH)
-IV contrast may be used to assist in target localisation
-consider empty stomach for distal and GOJ tumours
- 3DCT used as a minimum
CT Simulation: Motion Management
-tumour position varies based on
-pulmonary and cardiac motion
-swallowing and peristalsis
-gastric filling and emptying
Motion observation and management allows for generation of an
Internal Target Volume
-ICRU 62
-ITV accounts for tumour motion and ensures adequate CTV coverage
-helps w prediction of target position and enable asymmetric margins
CT Simulation: Motion Management options
-4DCT w RPM
-inspiration/expiration scans
-DIBH
-ABC
-forced shallow breathing thru abdominal compression
RT Planning: Target Volumes
-recommended
-limitation
fuse PET/CT w planning CT for target delineation
-variability and accuracy of image fusion
-patient position at scanning (arms up or down)
Treatment options:summary by stage
T1a N0 M0
-tumour invades lamina propria or muscularis mucosae
-discovered during screening for Barrett oesophagus
- (2-5%) chance of nodal involvement when confined to the mucosa
-Endoscopic mucosal resection (EMR)
-Well differentiated mucosal lesions <2cm in size
Treatment options:summary by stage
T1b N0 M0
-Tumour invades submucosa
-When infiltrated to the deep submucosa chance of LN involvement increases up to 45%
-Oesophagectomy
T1-T3 N1-3 M0 or T2-T3 N0 M0
-As depth of tumour invasion increases so too does risk of
undetected involved nodes
-Neoadjuvant chemoRT followed by surgical resection
– Restaging with PET/CT is recommended
-If patient not a surgical candidate, then definitive
chemoRT
