Oesophageal Cancer Flashcards
What are the 2 most common types of oesophageal cancer?
What parts of the oesophagus are each typically present in?
Which one is more common type globally?
Which one is the most common type in NA and west EU?
SCC upper, 2/3 most common type globally
Adenocarcinoma, lower 1/3, most common in NA and west EU
What is the pathogenesis of oesophageal SCC?
Direct mucosal damage by carcinogens e.g smoking
Or also achalasia
Nitrosamine is a carcinogen known to cause Oesophageal SCC. What is the source of that carcinogen?
Processed meats
What are the top 3 carcinogens which increase the risk of oesophageal cancer?
Smoking
Alcohol
Poor diet: Nitrosamines (processed meats)
What is the pathogenesis of Adenocarcinoma?
Acid and bile reflux causing sqaumo-columnar metaplasia (barret’s)
What are the main RFs for oesophageal SCC?
Carcinogens: Alcohol, smoking (nitrosamine)
Poor diet: Nitrosamine and low fruit and vegetable intake (low Vit. A and C)
Chronic achalasia (middle 1/3)
Chronic Caustic Strictures
Strictures and oesophageal web (Plummer Vinson Syndrome)
Coeliac disease
PUD
What are the RFs for Oesophageal adenocarcinoma
RFs of GORD (smoking, alcohol, obesity, hiatus hernia, H.Pylori)
GORD
Barret’s
Which type of oesophageal cancer is more sensitive to radiotherapy
SCC: 1/2 have complete response to neoadjuvant therapy
Adenocarcinoma: 1/4 have a complete response to Neoadjuvant therapy
How does oesophageal cancer lead to hoarsness of voice?
Local invasion affecting the recurrent laryngeal nerve
A smoking old patient presents with dysphagia, dyspnoea and weight loss. You note a neck swelling. What is the likely cause of the swelling?
SVC obstruction
With oesophageal cancer, what symptoms does local invasion cause? (other than dysphagia)
1) Hoarsness (recurrent laryngeal nerve)
2) Cough w/ haemoptysis (tracheal invasion)
3) Neck swelling due to SVC obstruction
4) Horner’s Syndrome (Affecting sympathetic chain C8, T1, T2)
Oesophageal carcinoma causes horner’s syndrome via local invasion of the………..
sympathetic chain C8, T1, T2
Neck swelling is one of the complications of oesophageal Ca. Which side will the swelling be on?
Right side as it is SVC obstruction
Oesophageal carcinoma can metastasise to lymph nodes. What are the most common lymph nodes affected?
Cervical LN including Virchow’s node
Para-aortic LN
(also paraoesophageal LN but that is via local invasion)
Para/peritracheal LN
How does para-aortic LA appear on exam?
Mass in epigastric region
What findings on examination support oesophageal metastasis?
1) Cervical LA including Virchow’s node
2) Epigastric mass (Para-aortic LA)
3) Hepatomegaly
What are the clinical features of oesophageal cancer? (signs and symptoms)
Dysphagia + weight loss (in a smoking old alcoholic)
Haematemesis
Sx of local invasion:
1) Hoarsness (recurrent laryngeal nerve)
2) Cough w/ haemoptysis (tracheal invasion)
3) Neck swelling due to SVC obstruction
4) Horner’s Syndrome (Affecting sympathetic chain C8, T1, T2)
Signs of Metastasis:
1) Cervical LA including Virchow’s node
2) Epigastric mass (Para-aortic LA)
3) Hepatomegaly
What is the diagnostic investigation to diagnose oesophageal carcinoma
OGD + Biopsy (taken in all 4 quadrants every 1cm)
Local staging in oesophageal Ca is performed via
Endoscopic US
It assesses the depth of invasion + paraoesophageal LN
Peritoneal disease is a feature of which type of oesophageal Ca?
How would you assess for that?
Adenocarcinoma
Laparoscopy
(Note that it can be seen on CT but it would only typically be apparent when it’s already late stage
Regional staging in oesophageal Ca is performed via
CT TAP + If adenocarcinoma also Laparoscopy to assess for peritoneal disease
Disseminated Disease in oesophageal Ca is assessed via
PET scan
to exclude metastasis
How would you stage the oesophageal Ca once confirmed by biopsy?
Local staging: Endoluminal US
Regional staging: CT TAP + If adenocarcinoma also Laparoscopy to assess for peritoneal disease
Disseminated Disease: PET Scan
Is chemotherapy used in oesophageal Ca?
Only for adenocarcinoma (not true, it’s used for both)
Is chemoradiotherapy used in oesophageal Ca?
Is it applicable to both SCC and adeno?
When is neoadjuvant chemoradiotherapy indicated? Who decides?
Yes for both SCC and adenocarcinoma
Indicated by the MDT typically for tumours T3-T4 or N1-N3
Is adjuvant chemoradiotherapy performed for Oesophageal Ca? When?
Are there any other adjuvant therapies?
What are the main 3 complications of radiotherapy?
Yes, neoadjuvant chemoradiotherapy is performed
Adjuvant immunotherapy such as anti-PDL-1 => Pembrilizumab, nivolumab
Strictures
Fistulation
Irradiated surgical field for future procedures
What chemotherapy regime is used in the treatment of oesophageal adenocarcinoma?
MAGIC/CROSS Trials
FLOT chemotherapy
For oesophageal Carcinoma, when would surgical treatment be used as a stand-alone treatment?
What is the surgical treatment (including endoscopic) of esophageal Ca?
T2N0M0 or below
Same as for the tx of barret’s oesophagus
Endoscopic:
Low grade -> Radiofrequency ablation
High grade -> Endoscopic mucosal resection (if up to mucosa), Endoscopic Submucosal dissection (up to submucosa)
Surgical: Oesophagectomy
Typically the oesophagus is divided into 3 parts. When it is divided in half for the purposes of guiding management, where is the cutoff between distal and proximal tumours?
Carina => T3
What are the 3 most common procedures for an oesophagectomy? include the specific indication for each and name of procedure
1) Ivor Lewis: 2-stage oesophagectomy for distal tumours
2) McKeown: oesophagectomy for tumours proximal to the carina (T3)
3) trans-hiatal resection for complicated procedures
What is the most likely procedure to be performed as surgical tx of an adenocarcinoma?
Adenocarcinoma => typically lower 1/3 so definitely below the Carina (T3) => 2 stage/Ivor Lewis procedure
What is an oesophagectomy? What does it involve the removal of?
What are the 3 possible stages of an oesophagectomy? And what do they involve?
For each of the 3 surgical techniques of an oesophagectomy, state which stages are involved and where the anastomosis is
An oesophagectomy is a surgical procedure used to treat oesophageal Carcinoma. It involves the removal of most of the oesophagus as well as the cardia and lesser curve of the stomach. It can be performed laparoscopically or open.
1) Thoracic - Thoracotomy for direct visualisation of the thoracic esophagus and best for LN dissection
1) Abdominal - Laparoscopic mobilisation of the stomach + Preparation for gastric conduit + PEJ tube insertion
2) Neck stage - Esophagogastric anastomosis
Ivor Lewis: T+A - Intrathoracic anastomosis
McKeown: T+A+N - Cervical anastomosis
Transhiatal: A+N - Cervical anastomosis
Image showing 2-stage oesophagectomy
What is meant by gastric conduit in the setting of oesophageal cancer
It is a technique performed in the abdominal stage of an esophagectomy and is the anastomosis between the esophagus and the stomach hence why it is involved in all 3 procedures. This can occur intrathoracically (Ivor lewis/distal tumours) or cervically (McKeown and Transhiatal)
Which oesophagectomy procedure would be best for LN dissection?
Ivor Lewis or Mckeown as they include the thoracic stage which has best access for LN dissection
When is SEMS indicated? What does it stand for?
Give 2 complications (out of 3)
Self-expanding metal stenting used for the palliative care of patients with oesophageal carcinoma
Complications: Perforation, tumour ingrowth, stent migration
What are the main indications for palliative care in oesophageal carcinoma?
What is involved in their palliative care?
Disseminated disease (NM)
Inoperable/multiple comorbidities
Palliative chemoradiotherapy (must weigh SE against quality of life and will of patient)
SEMS to relieve dysphagia (self-expanding metal stent)
Would you do regular monitoring of palliative care patients with OGD or CTTAP to monitor metastatic growth etc…
No palliative care focuses on symptom relief and improved quality of life rather than active disease monitoring.
Always offered as followup for patients post-op up to 5 years tho
What nutritional support is provided to patients post-oesophagectomy?
PEJ, Percutaneous endoscopic jejunostomy, jejunostomy. In severe cases, TPN
Whats the difference between them?
PEJ is endoscopically inserted whereas a jejunostomy is surgically placed via incision into the abdominal wall (laparoscopically or open) - more info in principles of surgery NC not notes.
when can a patient recommence PO feed post-oesophagectomy
Patients are typically NPO for 7-10 days post-op to allow anastomosis to heal and prevent anastomotic leak. Contrast swallow studies are then performed to confirm there is no anastomotic leak before being allowed to commence oral feed again (care refeeding syndrome). I would also assess the patient’s drain for any evidence of complications such as anastomotic or chyle leak
What is the full management of oesophageal Ca? (include for both SCC and adenocarcinoma)
1) MDT and staging
2) Neoadjuvant chemoradiotherapy (!CROSS)
3) Endoscopic tx:
Low grade -> Endoscopic Radiofrequency ablation
High grade -> Endoscopic mucosal resection, endoscopic submucosal dissection
4) Surgical tx: Oesophagectomy (2-stage, 3-stage, trans-hiatal) !! with R0 margins and Chest drain insertion (same MAL but just lower than for pneumothorax)
5) !!! Jejunostomy for nutritional support (for 7-10 days post-op until contrast swallow study ensures no leak)
6) Followup surveillance: OGD/CTTAP at regular intervals for up to 5 years post op
Palliative:
Palliative chemoradiotherapy (must weigh SE against quality of life and will of patient)
SEMS to relieve dysphagia (self-expanding metal stent)
What happens if margins come back as R1?
Include what R1 means
R1 means there is microscopic margin positivity
If in surgery, more resection
If not in surgery, Adjuvant chemoradiotherapy
(general rule)
What is the most important nearby structure that should be avoided when performing an oesophagectomy?
How is it diagnosed?
What would the damage cause?
Damage to the thoracic duct causing lymphatic leak AKA Chyle leak
Diagnosed with chyle in drain. It typically is transparent so may be more serous fluid mixed in with blood. It will first be noticed with a change in color of the drain fluid.
1) give patient fatty meal via PEJ/RIJ, ideally medium chain TGs (as they can travel in lymph), then color will turn into milky white like TPN
2) send fluid to lab testing for chylomicrons and TGs
What 2 nerves are most at risk in an oesophagectomy
Vagus nerve injury (unopposed SNS activity) - Recent studies show a link with parkinsons
Recurrent laryngeal nerve injury (comes off vagus) - Hoarse voice
What are the specific complications of an oesophagectomy?
1) Conduit Complications - Anastomotic leak, anastomotic strictures, conduit ischaemia
2) Chyle leak
3) Functional: Dysphagia, Delayed gastric emptying, Dumping syndrome!!!, Reflux/GORD (most need PPI post-esophagectomy)
4) Others: Refeeding syndrome, Vagus nerve injury, recurrent laryngeal nerve injury
How would an anastomotic leak post-oesophagectomy present?
How long after surgery would most cases occur
How will you manage it?
Presentation: Typically 3-5 days post-op, Septic (resp distress, tachycardia, fever, hypotension, everything)
Tx: Sepsis 6 (including both antibiotics and Antifungals) + NG tube for suction or Endosponge
What is a Chyle leak?
How is it picked up?
How is it treated? (1st and 2nd line)
Damage to the thoracic duct causing lymphatic leak
Picked up via high output chest drain with milky/cloudy fluid (change in contents, giving fatty meal for milky white, labs for chylomicrons and TGs)
Tx:
1st line -> NPO + medium-chain TGs via PEJ/Jejunostomy feed
2nd line -> Duct embolisation or ligation
Oesophageal carcinoma has a very poor prognosis with a 20% 5-year survival. What are the complications of an oesophagectomy?
General: State 10 and move on
Infectious: Wound site infection, sepsis, UTI (catheter use during surgery), pneumonia
Bleeding: Post-op bleeding, haematoma
Thromboembolic: DVT, PE, stroke
Cardiovascular: MI, arrhythmia, A.fib, stroke
Anaesthetics: Atelectasis/barotrauma from intubation, GA intolerance, if spinal, LP (traumatic, incorrect)
Other: Chronic pain, delayed wound healing, Adhesions!!
Specific:
1) Anastomotic leak
2) Chyle leak
3) Refeeding syndrome
How would you classify a tumour at the GOJ? (gastroesophageal junction)
Siewert Classification:
Type 1: 5 cm to 1 cm above GOJ (distal oesophagus/barret’s) - Proximal to GOJ
Type 2: 1cm above to 2cm below GOJ (at GOJ) - At GOJ
Type 3: 2cm to 5 cm below (Subcardinal Gastric Ca) - Distal to GOJ
Notice how the numbers have a pattern to them
What stage(s) of esophageal cancer can be resolved with surgery alone? What surgery?
T1 - Endoscopic mucosal resection
T2 - Endoscopic submucosal dissection
How long after surgery does an anastomotic leak occur?
An early leak indicates?
A later leak indicates?
What makes an anastomotic leak so likely? (3)
What about a chyle leak?
3-5 days after
Early leaks are more likely due to technical issues intraoperatively where late ones often mean ischaemia and tissue breakdown
Anastomotic leaks are common because:
1) Blood supply/ischaemia
2) Peristalsis
3) Diaphragm moves with inspiration
Chyle leaks
They typically occur later (7-10 days) due to the fact that it will be apparent after the patient resumes feeding (via jejunostomy tube)
How would you diagnose a chyle leak? (3)
1) Clinical: We check the drain regularly for change in colour etc..
It will typically be serosanguinous so itll be hard to distinguish,
Once the patient resumes feeding it might change colour to a more milky-white one
2) Drain sample may be sent to microbiolosy to look for chylomicrons and triglycerides
3) Give the patient feed via jejunostomy tube, specifically medium chain fatty acids as it has the best travel in lymph
What is the pH of the stomach pre and post esophagectomy?
What is the reason behind the change?
Pre- 2-3
Post - 4-5
This is because of vagotomy
How would you confirm an anastomotic leak
Test for salivary amylase
Followup surveillance in esophageal cancer can be up to 5 years. What is the regimen you will employ post-esophagectomy?
OGD every 3 months
CT TAP every 6 months (median time of recurrence)
A patient has gastroparesis post-esophagectomy
Why does that occur?
How would you help resolve it?
Gastroparesis occurs post-op anyways but is more significant here due to vagotomy
Erythromycin (same structure as motilin), metoclopramide, domperidone
What chemotherapy regimen would you give to a patient with esophageal Ca if:
Younger:
Older:
How many cycles?
Younger: FLOT
Older: CROSS
4 cycles of chemotherapy typically
You notice a bile leak post-esophagectomy. Why?
How would you then find the leak?
How would you then fix the leak?
Anastomotic leak of refluxed bile
Oral contrast may be used to find leak (may also be done intra-operatively)
1) Watch and wait for it to resolve if not causing symptoms
2) Endoscopy - EndoVac
3) Laparoscopy
4) Esophagostomy!!
5) Future: VAC stent (SEMS + Sponge attached to vacuum
