oesophageal malignancies

Question 1

what are the 3 main categories for oesophago-gastric cancers

Answer 1

1. oesophageal malignancy
2. oesophagogoastric junction malignancy
3. gastric malignancy

Question 2

what vertebrae levels does the cervical oesophagus reside at

Answer 2

C6 - T1

Question 3

what vertebrae levels does the thoracic oesophagus reside at

Answer 3

T1-T10

Question 4

what vertebrae levels does the abdominal oesophagus reside at

Answer 4

T11 - T12

Question 5

what narrowings occur at the cervical oesophagus level (2)

Answer 5

1. upper oesophageal sphincter
2. cricoid cartilage

Question 6

what narrowings occur at the thoracic oesophagus level (2)

Answer 6

1. aortic bifurcation
2. tracheal bifurcation

Question 7

what narrowings occur at the abdominal oesophagus level (2)

Answer 7

1. lower oesophageal sphincter
2. diaphragm

Question 8

what are the 4 main layers of the oesophagus (in to out)

Answer 8

1. mucosa (lamina propria, muscularis mucosae)
2. submucosa
3. muscularis externae
4. adventitia

Question 9

what is the appearance of a normal oesophagus on endoscopy

Answer 9

lined by pale pink stratifies squamous epithelium down to the stomach where after the Z line the mucosa is salmon coloured

Question 10

why is the oeophagus lines with stratified squamous cells

Answer 10

these cells are the most resistant to damage from noxious substances that are ingested

Question 11

what are the 2 main histological types of oesophageal carcinoma

Answer 11

1. adenocarcinoma (most common type in western world)
2. squamous cell carcinoma (most common type worldwide)

Question 12

how is the distribution of oesophageal cancer seen across the world

Answer 12

geographically - there is an oeophageal cancer belt that stretches from NE china to iran, even within countries themselves there is geographical distribution

Question 13

invasion of what layer indicates more advanced oesophageal cancer

Answer 13

muscularis propria

Question 14

what derm condition is associated with aggressive oesophageal SCC

Answer 14

palmoplantar keratoderma

Question 15

risk factors for squamous cell carcimoa of the oesophagus (8)

Answer 15

1. cigarette smoking
2. alcohol
3. previous head/neck cancer (usually smokers)
4. low socioeconomic class
5. previous radiotherapy
6. HPV
7. achalasia
8. coeliac disease

Question 16

how does intestinal metaplasia occur (barrett’s oesophagus)

Answer 16

acid reflux causing damage to the oesophagus

Question 17

what is metaplasia

Answer 17

adaptive change in cell type to the local environment -> one fully differentiated cell type changes to another fully differentiated cell type

Question 18

what is the commonest location of oesophageal ACC

Answer 18

oesophagogastric junction

Question 19

risk factors for oesophgeal ACC (5)

Answer 19

1. barrett’s oesophagus
2. being male
3. smoking
4. obesity
5. caucasian

Question 20

what are the stages from squamous epithelium -> oesophageal ACC (5)

Answer 20

1. squamous epithelium
2. non-dysplastic barrett’s oesophagus
3. low grade dysplasia
4. high grade dysplasia (treat as if cancerous)
5. T1 oesophageal ACC

Question 21

what does a nodule in barrett’s oesophagus indicate

Answer 21

either high grade dysplasia or cancer

Question 22

what is the curative treatment for T1a oesophageal ACC

Answer 22

endoscopic mucosal resection (if T1b + then further surgery will be needed)

Question 23

what size ACC is suitable for endoscopic mucosal resection

Answer 23

<2cm, non ulcerated

Question 24

oesophageal cancer presentation (5)

Answer 24

1. progressive dysphagia (if presenting w this assume cancer until proven otherwise!)
2. change to liquid diet
3. weight loss
4. regurgitation
5. presistant reflux not responding to PPI

Question 25

investigations for diagnosis of oesophageal cancer

Answer 25

1. upper GI endoscopy 2. biopsies x8! 3. CT scan (T3 onwards)

Question 26

in whom might a barium swallow still be used in when suspicious of cancer

Answer 26

very frail patients who cannot tolerate OGD

Question 27

what are the 2 pathways for oesophageal cancer treatment

Answer 27

1. curative - chemo + surgery 2. palliative (if metastatic) - chemo + stent

Question 28

components of the curative pathway for oesophageal cancer

Answer 28

1. 4 cycles of chemotherapy -> systemically to prevent risk of recurrence as cancerous cells may be present elsewhere 2. surgery 3. adjuvant chemo

Question 29

examples of benign oesophagea tumours (5)

Answer 29

1. leiomyoma (commonest) 2. duplication cyst 3. fibrovascular polyps 4. squamous cell papillomas 5. granular cell tumours

Question 30

what is a leiomyoma

Answer 30

a smooth muscle tumour (benign) that arises from the muscularis propria and generally occurs in the mid/distal oesophagus -> account for 50% of benign oesophageal tumours

Question 31

risks for gastric cancer (9)

Answer 31

1. male gender 2. age 3. ethnicity (east asian) 4. H.pylori 5. obesity 6. cigarette smoking 7. pernicious anaemia 8. previous gastrectomy 9. gastric polyps

Question 32

gastric cancer presentation (6)

Answer 32

1. iron deficency anaemia 2. early satiety 3. weight loss 4. abdominal pain 5. reflux 6. non-healing gastric ulcer

Question 33

emergency presentation of gastric cancer (4)

Answer 33

1. haematemesis/melaena (i.e. upper GI bleed) 2. gastric outlet obstruction 3. perforated gastric ulcer 4. disseminated disease e.g. ascites

Question 34

what is linitis plastica

Answer 34

morphological variant of diffuse stomach cancer in which the stomach wall becomes thick and rigid

Question 35

investigations for gastric cancer (3)

Answer 35

1. endoscopy 2. biopsies/histology 3. urgent CT (chest, abdo, pelvis)

Question 36

on the curative pathway when is periop chemo forgone in favour of going straight to gastrectomy

Answer 36

aged>80 or many co-morbidities

Question 37

what does achalasia increase the risk of

Answer 37

oesophageal SCC

Question 38

4 characteristics of splenectomy on blood film

Answer 38

1. Howell- Jolly bodies 2. Pappenheimer bodies 3. Target cells 4. Irregular contracted erythrocytes