Options For Managemnt Of Malignancies

Question 1

Averagely, how long is the oesophagus?

Answer 1

25cm

Question 2

Where does the oesophagus extend to and from?

Answer 2

C6-T11

Question 3

Divide the lymphatic drainage of the oesophagus:

Answer 3

Upper 1/3rd of the oesophagus
- Supraclavicular and deep cervicle lymph nodes
Middle 1/3rd of the oesophagus
- Superior and posterior mediastinal nodes
Lower 1/3rd of the oesophagus
- Left gastric, splenic and coeliac lymph nodes

Question 4

What is the significance of the oesophagus having no lymph nodes?

Answer 4

Facilitates in extra-oesophageal spread.

Question 5

What are the layers of the oesophagus?

Answer 5

1. Mucosa
2. Submucosa
3. Muscularis Propria
4. Adventitia

Question 6

What are the risk factors for a squamous cell carcinoma?

- (Upper 1/3rd oesophageal carcinoma)

Answer 6

• Drinking hot beverages
  
  • Smoking
  • Betel nut ingestion
  • Alcohol
  • Deficiency of certain micronutrients i.e. sink, selenium, magnesium
  • Plummer Vinson syndrome
  • HPV

Question 7

What are the risk factors for an adenocarcinoma in the oesophagus?
- (Lower 1/3rd oesophageal carcinoma)

Answer 7

• GORD
  
  • Barrett’s oesophagus :- Metaplasia due to GORD
  • Obesity
  • Shmoking

Question 8

What 3 congenital abnormalities influence the propensity of oesophageal carcinoma development?

Answer 8

• Atresia
  
  • Tracheo-oesophageal fistula
  • Mucosal webs

Question 9

Name 3 genetic abnormalities that influence the propensity of oesophageal carcinoma development?

Answer 9

Tylosis
- (Hyperkeratosis of the palms and soles, leukoplakia of the mouth)
Bloom syndrome
- Short stature, rash on the skin, mental retardation, inc leukaemia,
- Lymphomas
Fanconi Anaemi
- Cancers of bone marrow failure

Question 10

What are the symptoms of oesophageal cancer?

Answer 10

Dysphagia
Weight loss
Odynophagia
Pain in the bone :- sign of metastases
Hoarse voice :- Impingement of the recurrent laryngeal nerve
Hemorrhage/empyema :- Infiltrate aorta/mediastinum/pericardium
SVC syndrome
Hornets syndrome
Tracheoseophageal/Bronchoesophageal fistulas

Question 11

What is the grading of dysphagia?

Answer 11

0 :- Eat solid food without too much attention to swallowing
I :- Solid food <18mm, chewed thoroughly
II :- Semisolid food (equivalent to baby food)
III :- Liquids only
IV :- Unable to swallow liquids or saliva

Question 12

Give 4 Diagnostic tests for oesophageal cancer detection:

Answer 12

CT Scan 
Bloods 
  - Albumin, LFT, Renal function
Endoscopy 
  - Visualize extent of tumor 
  - Biopsies 
Endoscopy ultrasonograph 
  - Lymph once metastases 
  - Peri-oesophageal extent
Panendoscopy 
  - Used for cervical tumors
Tracheobronchoscopy
Laparoscopy 
  - For lower oesophageal tumours

Question 13

What factors influence the prognosis of oesophagus carcinoma?

Answer 13

Stage 
Tumor size 
Tumor length page 
OS 
LN Extracapsular extension.
Surgical margins

Question 14

Name 2 roles of radiation therapy :

Answer 14

1. Curative role
   - Definitive role
   - Neo-adjuvant
   - Adjuvant
2. Palliative role

Question 15

What is trimodality treatment?

Answer 15

Chemoradiation therapy

Followed by surgery 5-7 weeks later

Question 16

What is surgeries role after chemoradiation?

Answer 16

Lowers the rate of local tumor recurrence

Question 17

What dose of radiotherapy is usually used?

Answer 17

41,1- 50,4 GY

Question 18

Name a few other oesophageal pathologies:

Answer 18

Adenoid cystic
Mucoepidermoid 
Leiomyosarcoma
Lymphoma
Melanoma 
Karposi sarcoma

Question 19

What is Adjuvant chemotherapy?

Answer 19

In Adjuvant (also called postoperative or secondary) chemotherapy, drug treatment takes place after the surgical extraction of the tumor.

Question 20

What is Neo-adjuvant chemotherapy?

Answer 20

In neoadjuvant (also called preoperative or primary) chemotherapy, drug treatment takes place before surgical extraction of a tumor. This is in contrast with adjuvant chemotherapy, which is drug treatment after surgery.

Question 21

What drugs are used in Neo-adjuvant concurrent chemotherapy?

Answer 21

• Paclitaxel/Carboplatin or
  
  • 5FU/Cisplatin or
  • Capecitabine/Cisplat

Question 22

Indications for adjuvant radiotherapy:

Answer 22

Patients that did not receive Neo-adjuvant treatment

• T3/T4
• Increase in lymph nodes.
• Unfavourable T2 (histological grade, LV invasion, PN invasion, adequacy LND

Question 23

Briefly describe the radiotherapy simulation:

Answer 23

• Patient in Supine position
  
  • Arms above head
  • Knee support
  • For a malignancy in upper oesophagus, use a thermoplastic head mask.
  • Oral contrast
  • Palpable neck disease, Mark with radio opaque marker

Patients with malignancies in distal oesophagus should be nil per os 3-4 hours prior to simulation
With daily treatments to limit variations in gastric bowel movement

Question 24

What 5 organs are at risk during oesophageal radiotherapy?

Answer 24

• Heart
  
  • Liver
  • Lungs
  • Spinal chord
  • Kidneys

Question 25

What are signs of early radiotherapy-induced toxicity?

Answer 25

- Oesophagitis - Weight loss - Fatigue

Question 26

What are signs of late radiotherapy-induced toxicity?

Answer 26

Oesohagel perforation Pneumonitis Oesophageal strictures Pericarditis

Question 27

What are examples of palliative treatment procedures:

Answer 27

Stent placement Dilatation External beam radiotherapy Brachytherapy

Question 28

What is the advantage of using brachytherapy as a palliative treatment procedure?

Answer 28

Longer duration of relief.

Question 29

What is the advantage of using stent placement as a palliative treatment procedure?

Answer 29

Rapid onset of relief

Question 30

What are the absolute contra-indications of using brachytherapy for palliative treatment?

Answer 30

Joesophageal fistulas Cervical oesophageal location Stenosis that can’t be bypassed

Question 31

What is brachytherapy?

Answer 31

Treatment of cancer by inserting radioactive implant in the tissue