Oesophageal Cancer Flashcards
What is the definition of Aetiology
The study of a cause of a disease/ illness
What is the definition of Epidemiology
A branch of medicine that deals with the incidence, control and distribution of diseases
What are two types of oesophageal cancer
Adenocarcinoma and Squamous Cell Carcinoma
Describe the INCIDENCE of oesophageal cancer
2.2% of all cancers 6th cause of cancer death worldwide 5 year survival is less than 25% It is rarely seen in people below 25 It peaks in individuals 60-70
What are risk factors of squamous cell oesophageal cancer?
Tobacco and Alcohol Diet Achalasia Head and Neck Cnacer Tylosis, Coeliac disease and Lye ingestion
What are risk factors of adenocarcinoma oesophageal cancer?
Barrett’s oesophagus
Chronic reflux
Smoking
Obesity
Endemic Oesophageal cancer
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Endemic Oesophageal cancer
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What is some basic anatomy of the oesophagus?
runs from cricoid cartilage to O-G junction
Average length is 25cm
Split into 2 parts: Cervical and Thoracic
Outer layer is longitudinal muscle
Inner layer is circular muscle
OESPHAGEAL LYMPH NODES
see slide 8
What is the natural history (prognosis) of oesophageal cancer
90% dead within 5yrs
30% present with localised disease, 40-50% operable
Local relapse most common problem (SCC)
Systemic spread also a problem
What is the most common route of spread?
Sub-mucosal spread is most common.
Where can CERVICAL oesophageal cancer spread to?
Cervical oesophagus can spread to: carotids, pleura, recurrent laryngeal nerve, treachea
Where can MIDDLE THIRD oesophageal cancer spread to?
bronchi, thoracic duct, aortic arch, azygos vein, right pleura
Where can LOWER THIRD oesophageal cancer spread to?
Pericardium, left pleura, descending aorta
What are symptoms of Oesophageal cancer?
Dysphagia- difficulty swallowing Anorexia Weight loss Pain Vomiting Symptoms dependent on location of tumour
How is Oesophageal cancer diagnosed?
Endoscopy Barium swallow Histology Panendoscopy Laparoscopy PET/CT CT Scan Endoscopic ultrasound
Why is staging important?
To define the extent of the primary lesion
To exclude metastatic disease
To quantify co-morbidity and assess suitability for therapy
Describe Stage 1 of oesophageal cancer?
T0 N0 M0
60% chance of 5 year survival
Describe Stage 2 of oesophageal cancer?
T2-3,N0 M0
31% of 5 year survival
Describe Stage 3 of oesophageal cancer?
T3 N1 M0
20% chance of 5 year survival
Describe Stage 4 of oesophageal cancer?
any T, any N, MI
4% chance of 5 year survival
What is the histology of oesophageal cancer?
50% are squamous cell carcinomas
48% are Adenocarcinomas
The other 2% include: leiomyo-sarcoma, carcinoid, lymphoma, small cell carcinoma
What are curative techniques for oesophageal cancer?
Surgery
Radiation Therapy
Combined therapy
- CT/RT
What is the ideal for of treatment?
surgery - resecting the tumour.
What are some reasons for surgical failures
high frequecny of nodal involvment spread to surronding organs Advanced at presentation (because it asymptomatic) Patient is medically unfit for surgery Patient refuses surgery
What is the survival rate for surgery?
5 year survival rate 15-39%
Surgical mortality 4-10%
How is the CERVICAL oesophagus treated?
The surgery for cervical oesophageal cancer is quite radical and involves removing the pharynx (loss of voice)
thus chemo and radiation are the most common treatments.
Treated like a Head and Neck cancer (shell)
Overall survival @ 10 years 27%
What are the disadvantages SOLE Radiation therapy of oesophageal cancer
Local control limited by normal tissue constraints
Longer duration of treatment leads to more adverse symptoms
9% 2 year Survival rate
6% 5 year Survival rate
Who are the ideal candidates for chemo/radiation therapy
people with localised disease (who arent fit for surgery)
localised SCC - Very small tumours
people with upper third lesions
Is concurrent CT/RT better that just RT
For Ct/RT
the local recurrence is reduced by 12% (when compared to just RT)
However the toxicity is increased by 17%
Is surgery after CT/RT a good idea
The chance of surgical morbidity is increased. However local control (from the CT/RT) is improved.
Their are also fewer interventions required for dysphagia (difficulty swallowing)
Overall the survival chance is equal
What are the goals of palliative treatment in oesophageal cancer?
restore or maintain swallowing
Manage pain
Prevent bleeding
Who are the ideal candidates for palliation
people with local symptoms and distant metastatic disease
People with inadequate respiratory function
Patients with a poor performance status
Patients with very large tumours
What are methods of palliative treatment
Radiation therapy -EBRT, Brachytherapy, Chemotherapy- no evidence of benefit Stenting LASER
Why is the simulation/ CT stage important
important for:
delineation of GTV
lung DVH’s
Spinal cord delineation
What immobilisation devices are used
oesophageal board - arms up
head and neck shell- for cervical oesophagus
Orfit
What are the planning margins for oesophageal cancer?
GTV= gross tumour volume
CTV= GTV plus 2 -2.5 cm margin radially
3-4cm sup&inferior
PTV= CTV plus 0.7cm
What are the usual field arrangements for oesophageal radiation.
ANT, POST, LEFT LAT, RIGHT LAT
ANT, POST and obliques
for palliative- Parallel opposed
What are common dose fractionations
Radical CT/RT
- 50.4 Gy/1.8-2.0 fractions
Radiation (SOLE MODALITY) - 60-66 gy
Palliation
- RT alone 35-45 Gy/15-25#
TROG trial: 45Gy/15#/cisplatin/5FU
What are organs at risk with the oesophagus
Lung - anything that receives more than 20Gy is destroyed
limit the vlume of lung receiving more than 20Gy to 30-35%
Spinal cord limited to more than 46GY @2gy fractions
Cervical oesophagus may allow 50Gy/30# to cord
What are acute side effects of treatment
Lethargy Skin erythema Dysphagia - difficulty swallowing Odynophagia - painful swallowing Risk of neutrpaeni sepsis Percarditis - inflammation of pericardium
What are late side effects of treatment
pulmonary fibrosis
second malignancy
Hypothyroidism- under active thyroid
Increased risk IHD- ischaemic heart disease
Benign stricture- narrowing of oesophagus
