Tumours Of The Oesophagus

Question 1

What is the epidemiology off oesophageal cancer?

Answer 1

Male 3:1 female
Median age of onset - 60-70 years of age
Adenocarcinoma - most common type of oesophageal cancer in the US
Squamous cell carcinoma - Mostar common typo error of oesophageal cancer worldwide

Question 2

What are the exogenous and endogenous risk factors for adenocarcinoma? And localisation

Answer 2

Exogenous - smoking and obesity
Endogenous - male sex, older age between 50-60, GERD, Barrett’s oesophagus
Localisation - mostly lower third of oesophagus

Question 3

What are the exogenous abet endogenous risk factors for squamous cell carcinoma? And localisation

Answer 3

Exogenous - alcohol consumption
Smoking
Diet low in fruits and vegetables
Hot beverages
Nitrosamine exposure (cured meats, fish, bacon)
Caustic strictures
HPV
Radiotherapy
Brutal or aceca nut chewing
Oesophageal candidiasis (infection of oesophagus caused by Candida albicans infection)

Endogenous - male sex
Age 60-70 years
African American descendent
Plummer-Vinson syndrome
Achalasia
Diverticula
Tylosis

Localisation - mostly in upper 2/3 of oesophagus

Question 4

What is plummer-Vinson syndrome?

Answer 4

Occurs in people with chronic iron deficiency anemia.
Have problems swallowing due to small thin growths of tissue that partially block the oesophagus

Question 5

What is tylosis?

Answer 5

Focal thickening of skin of hand and feet

Question 6

What are the clinical features of oesophageal cancer?

Answer 6

Early stages - often asymptomatic with swallowing difficulties or Retrosternal discomfort
Advanced stages - general signs - weight loss, dyspepsia, signs of anemia
Signs of advances disease - progressive Dysphagia, with possible odynophagia (sensation of painful swallowing), retrosternal chest or back pain, cervical adenopathy, hoarseness or persistent cough, Horner syndrome
Signs of upper GI bleeding - hermatemesis, Melena

Question 7

What is Horner syndrome?

Answer 7

A neurological syndrome caused by a triad of mitosis (abnormally small pupil)”, partial ptosis (drooping of upper eyelid) and facial anhidrosis (absence of sweating). Causes by lesions that interrupt the sympathetic nervous supply

Question 8

How do you diagnose oesophageal cancer?

Answer 8

Oaesophagogastroduodenoscopy
Barium swallow

Question 9

What are the characteristics of an EGD?

Answer 9

Best initial and confirmatory test
Direct visualisation of the tumour
Allows biopsy of any suspiciuous loesions

Question 10

What are the indications of a barium swallow?

Answer 10

Severe stricture that inhibits endoscopic evaluation
Suspected tracheoesophageal fistula

Question 11

What are the findings for barium swallow?

Answer 11

Asymmetrical and irregulars borders of the oesophagus with characteristic stenosis and proximal dilation

Question 12

Which diagnostic tests are used to stage oesophageal cancer?

Answer 12

Chest and abdominal CXT
Transoesophageal endoscopic ultrasound
Bronchoscope
Laparoscopy

Question 13

What is a chest and abdominal ct scan used for?

Answer 13

To identify location and content of the lesion and for to exclude distant metastasis

Question 14

what is a transesophageal endoscopic ultrasound used for?

Answer 14

To determine the infiltration depth and register regional lymph node disease

Question 15

What isd a bronchoscopy used for?

Answer 15

Staging of lesions at or a bog re the carina (a branchpoint in the tracheobronchial tree where the trachea bifurcates into right and left mainstream bronchi) to rule out airway involvement

Question 16

What is a laparoscopy used for?

Answer 16

To increased accuracy of detection small liver metastasis

Question 17

What is Ruthie siewert classification of adenocarcinoma of oesophagopgastric junction?

Answer 17

Type 1 - centre of tumour located 1-5cm above Z line (associated with Barrett mucosa)
Type 2 - centre of tumour located 1cm above or 2cm below Z line
Type 3 - centre of tumour located 2-5cm below the Z line

Question 18

What is the Z line?

Answer 18

Represents the normal oesophagogastric junctions where the squamous muscle of the oesophagus and columnar mucosa of the stomach meet

Question 19

What is the pathology of adenocarcinoma?

Answer 19

Carcinoma arises in context of Barrett oesophagus and high grade dysplasia
Gland forming tumours with different possible growth patterns (tubular, papillary, tubulopapillary)
Mucinous differentiation possible

Question 20

What is the pathology of squamous cell carcinoma?

Answer 20

Breakdown of uniform tissue structure
Squamous cell carcinoma clusters with circular keratinisation
Lymphocytic infiltration between the carcinoma clusters

Question 21

What is the curative treatment for oesophageal carcinoma?

Answer 21

Neoadjuvant chemoradiation as a definite treatment in patients with proven cinokete response (eg during endoscopy)
Surgical resection either endoscopy or total esophagectomy

Question 22

What are the indications for curative treatment?

Answer 22

Locally invasive disease that has not invaded surrounding structures
High grade metaplasia in Barrett oesophagus

Question 23

What are the methods of palliative treatment for oesophageal cancer?

Answer 23

Chemoradiation
Stent placement
Other endoscopic treatment eg laser therapy

Question 24

What are the indications for palliative treatment?

Answer 24

Patients with advanced disease (majority of patients)

Question 25

What are the cancer related complications of oesophageal cancer?

Answer 25

Oesophageal stenosis
Tracheoesophageal fistula -> passage of food and fluid into the respiratory tract -> increased risk of aspiration pneumonia

Question 26

What are the treatments associated complications?

Answer 26

Surgical complications - anastamotic leak or stricture
Recurrent laryngeal nerve inury

Functional GI disorders - reflux, dumping syndrome

Question 27

What is the prognosis staging system for oesophageal cancer?

Answer 27

STEER staging

Question 28

What are the stages of STEER? and5 year survival rate chances

Answer 28

Localised - 47%
Regional - 25%
Distant - 5%
Combined - 25%

Question 29

What will the physical examination show for squamous cell carcinoma?

Answer 29

Some degree of denutrition, from weight loss to classic marasmus (severe form of malnutrition specifically from protein energy under nutrition) over 50% of patients will lose >20kg by time of diagnosis
Carcinoma of cervical oesophagus may present - syndrome that mimics acuity suppurative thyroiditis weigh tenderness and a mass or with hoarseness

Question 30

Which lab tests should be done for squamous cell carcinoma?

Answer 30

CA19-9 (serum carbohydrate antigen) - not a sufficiently sensitive test for ther carcinoma though

Question 31

Which radiographic tests should be done fort squamous cell carcinoma?

Answer 31

Standard chest radiograph
Barium contrast radiography
Double contrast technique

Question 32

What will a standard chest radiograph reveal?

Answer 32

Evidence of pulmonary complications, such ass pneumonia and metastasis into mediastinum or lung parenchyma
Subtle changes such as mediastinal widening, posterior tracheal indentation

Question 33

What will a barium contrast radiography reveal?

Answer 33

Provides strong evidence for diagnosis in nearly all patients

Question 34

What will a double contrast technique reveal?

Answer 34

Best study for mucosal detail

Question 35

What is the diagnosis tic tests for adenocarcinoma?

Answer 35

Proper history suggests distal malignant oesophageal obstruction
Barium contrast radiography
Endoscopy
CT scan
EUS (oesophageal ultrasound)

Question 36

What will a barium contrast radiography reveal?

Answer 36

Nearly always confirms or suggests the diagnosis

Question 37

What will endoscopy with biopsy and cytology reveal?

Answer 37

Provides histological diagnosis in virtually all cases

Question 38

What will a ct scan reveal?

Answer 38

Evidence of mucosal thickening or periesophageal metastasis

Question 39

What will EUS reveal?

Answer 39

More precisely evaluates involvement of the oesophageal wall and periesophageal region