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Ch. 3 - Upper GI Surgery > Oesophageal Cancer > Flashcards

Oesophageal Cancer Flashcards

1
Q

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?

A

SCC upper, 2/3 most common type globally

Adenocarcinoma, lower 1/3, most common in NA and west EU

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2
Q

What is the pathogenesis of oesophageal SCC?

A

Direct mucosal damage by carcinogens

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3
Q

Nitrosamine is a carcinogen known to cause Oesophageal SCC. What is the source of that carcinogen?

A

Processed meats

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4
Q

What are the top 3 carcinogens which increase the risk of oesophageal cancer?

A

Smoking
Alcohol
Poor diet: Nitrosamines (processed meats)

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5
Q

What is the pathogenesis of Adenocarcinoma?

A

Acid and bile reflux causing sqaumo-columnar metaplasia (barret’s)

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6
Q

What are the main RFs for oesophageal SCC?

A

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

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7
Q

What are the RFs for Oesophageal adenocarcinoma

A

RFs of GORD (smoking, alcohol, obesity, hiatus hernia, H.Pylori)
GORD
Barret’s

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8
Q

Which type of oesophageal cancer is more sensitive to radiotherapy

A

SCC: 1/2 have complete response to neoadjuvant therapy
Adenocarcinoma: 1/4 have a complete response to Neoadjuvant therapy

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9
Q

How does oesophageal cancer lead to hoarsness of voice?

A

Local invasion affecting the recurrent laryngeal nerve

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10
Q

A smoking old patient presents with dysphagia and weight loss. You note a neck swelling. What is the likely cause of the swelling?

A

SVC obstruction

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11
Q

With oesophageal cancer, what symptoms does local invasion cause? (other than dysphagia)

A

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)

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12
Q

Oesophageal carcinoma causes horner’s syndrome via local invasion of the………..

A

sympathetic chain C8, T1, T2

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13
Q

Neck swelling is one of the complications of oesophageal Ca. Which side will the swelling be on?

A

Right side as it is SVC obstruction

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14
Q

Oesophageal carcinoma can metastasise to lymph nodes. What are the most common lymph nodes affected?

A

Cervical LN including Virchow’s node
Para-aortic LN
(also paraoesophageal LN but that is via local invasion)

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15
Q

How does para-aortic LA appear on exam?

A

Mass in epigastric region

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16
Q

What findings on examination support oesophageal metastasis?

A

1) Cervical LA including Virchow’s node
2) Epigastric mass (Para-aortic LA)
3) Hepatomegaly

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17
Q

What are the clinical features of oesophageal cancer? (signs and symptoms)

A

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

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18
Q

What is the diagnostic investigation to diagnose oesophageal carcinoma

A

OGD + Biopsy (taken in all 4 quadrants every 1cm)

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19
Q

Local staging in oesophageal Ca is performed via

A

Endoscopic US
It assesses the depth of invasion + paraoesophageal LN

20
Q

Peritoneal disease is a feature of which type of oesophageal Ca?

How would you assess for that?

A

Adenocarcinoma

Laparoscopy

21
Q

Regional staging in oesophageal Ca is performed via

A

CT TAP + If adenocarcinoma also Laparoscopy to assess for peritoneal disease

22
Q

Disseminated Disease in oesophageal Ca is assessed via

A

PET scan
to exclude metastasis

23
Q

How would you stage the oesophageal Ca once confirmed by biopsy?

A

Local staging: Endoluminal US

Regional staging: CT TAP + If adenocarcinoma also Laparoscopy to assess for peritoneal disease

Disseminated Disease: PET Scan

24
Q

Is chemotherapy used in oesophageal Ca?

A

Only for adenocarcinoma

25
Q

Is chemoradiotherapy used in oesophageal Ca?
Is it applicable to both SCC and adeno?
When is neoadjuvant chemoradiotherapy indicated? Who decides?

A

Yes for both SCC and adenocarcinoma
Indicated by the MDT typically for tumours T3-T4 or N1-N3

26
Q

Is adjuvant chemoradiotherapy performed for Oesophageal Ca?

What are the main 3 complications of radiotherapy?

A

No only neoadjuvant chemoradiotherapy is performed

Strictures
Fistulation
Irradiated surgical field for future procedures

27
Q

What chemotherapy regime is used in the treatment of oesophageal adenocarcinoma?

A

MAGIC/CROSS Trials
FLOT chemotherapy

28
Q

For oesophageal Carcinoma, when would surgical treatment be used as a stand-alone treatment?

What is the surgical treatment (including endoscopic) of esophageal Ca?

A

T2N0M0 or below

Same as for the tx of barret’s oesophagus
Endoscopic:
Low grade -> Radiofrequency ablation
High grade -> Endoscopic mucosal resection
Surgical: Oesophagectomy

29
Q

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?

A

Carina => T3

30
Q

What are the 3 most common procedures for an oesophagectomy? include the specific indication for each

A

1) 2-stage oesophagectomy for distal tumours
2) 3-stage oesophagectomy for tumours proximal to the carina (T3)
3) trans-hiatal resection for complicated procedures

31
Q

What is the most likely procedure to be performed as surgical tx of an adenocarcinoma?

A

Adenocarcinoma => typically lower 1/3 so definitely below the Carina (T3) => 2 stage/Ivor Lewis procedure

32
Q

What is an oesophagectomy

What is involved in the Ivor Lewis or 2-stage oesophagectomy for distal tumours.

How does it differ from the 3-stage/McKeown oesophagectomy

How does it differ from the Trans-hiatal resection?

A

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) Abdominal stage: Laparoscopic mobilisation of the stomach and distal oesophagus.
2) Thoracic stage: Thoracotomy, thoracic lymphadenectomy, and intra-thoracic anastomosis

the 3-stage oesophagectomy has an extra stage which is the neck stage

Transhiatal resection is an !open procedure from the abdomen to the neck so its not based on stages.

Image showing 2-stage oesophagectomy

33
Q

When is SEMS indicated? What does it stand for?

Give 2 complications (out of 3)

A

Self-expanding metal stenting used for the palliative care of patients with oesophageal carcinoma

Complications: Perforation, tumour ingrowth, stent migration

34
Q

What are the main indications for palliative care in oesophageal carcinoma?

What is involved in their palliative care?

A

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)

35
Q

Would you do regular monitoring of palliative care patients with OGD or CTTAP to monitor metastatic growth etc…

A

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

36
Q

What nutritional support is provided to patients post-oesophagectomy?

A

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.

37
Q

when can a patient recommence PO feed post-oesophagectomy

A

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)

38
Q

What is the full management of oesophageal Ca? (include for both SCC and adenocarcinoma)

A

1) MDT and staging
2) Neoadjuvant chemoradiotherapy (!CROSS)
3) Endoscopic tx:
Low grade -> Endoscopic Radiofrequency ablation
High grade -> Endoscopic mucosal resection
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)

39
Q

What happens if margins come back as R1?
Include what R1 means

A

R1 means there is microscopic margin positivity
If in surgery, more resection
If not in surgery, Adjuvant chemoradiotherapy
(general rule)

40
Q

What is the most important nearby structure that should be avoided when performing an oesophagectomy?
What would the damage cause?

A

Damage to the thoracic duct causing lymphatic leak AKA Chyle leak

41
Q

What are the specific complications of an oesophagectomy?

A

1) Anastomotic leak
2) Chyle leak
3) Refeeding syndrome

42
Q

How would an anastomotic leak post-oesophagectomy present?

How long after surgery would most cases occur

How will you manage it?

A

Presentation: Typically 3-10 days post-op, Septic (resp distress, tachycardia, fever, hypotension, everything)

Tx: Sepsis 6 + NG tube for suction or Endosponge

43
Q

What is a Chyle leak?
How is it picked up?
How is it treated? (1st and 2nd line)

A

Damage to the thoracic duct causing lymphatic leak

Picked up via high output chest drain with milky/cloudy fluid

Tx:
1st line -> NPO + medium-chain TGs via PEJ/Jejunostomy feed
2nd line -> Duct embolisation

44
Q

Oesophageal carcinoma has a very poor prognosis with a 20% 5-year survival. What are the complications of an oesophagectomy?

A

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

45
Q

How would you classify a tumour at the GOJ? (gastroesophageal junction)

A

Siewert Classification:
Type 1: 5 cm to 1 cm above GOJ (distal oesophagus/barret’s)
Type 2: 1cm above to 2cm below GOJ (at GOJ)
Type 3: 2cm to 5 cm below (Subcardinal Gastric Ca)

Notice how the numbers have a pattern to them

Ch. 3 - Upper GI Surgery (7 decks)

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