Tumours Of The Oesophagus Flashcards
What is the epidemiology off oesophageal cancer?
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
What are the exogenous and endogenous risk factors for adenocarcinoma? And localisation
Exogenous - smoking and obesity
Endogenous - male sex, older age between 50-60, GERD, Barrett’s oesophagus
Localisation - mostly lower third of oesophagus
What are the exogenous abet endogenous risk factors for squamous cell carcinoma? And localisation
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
What is plummer-Vinson syndrome?
Occurs in people with chronic iron deficiency anemia.
Have problems swallowing due to small thin growths of tissue that partially block the oesophagus
What is tylosis?
Focal thickening of skin of hand and feet
What are the clinical features of oesophageal cancer?
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
What is Horner syndrome?
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
How do you diagnose oesophageal cancer?
Oaesophagogastroduodenoscopy
Barium swallow
What are the characteristics of an EGD?
Best initial and confirmatory test
Direct visualisation of the tumour
Allows biopsy of any suspiciuous loesions
What are the indications of a barium swallow?
Severe stricture that inhibits endoscopic evaluation
Suspected tracheoesophageal fistula
What are the findings for barium swallow?
Asymmetrical and irregulars borders of the oesophagus with characteristic stenosis and proximal dilation
Which diagnostic tests are used to stage oesophageal cancer?
Chest and abdominal CXT
Transoesophageal endoscopic ultrasound
Bronchoscope
Laparoscopy
What is a chest and abdominal ct scan used for?
To identify location and content of the lesion and for to exclude distant metastasis
what is a transesophageal endoscopic ultrasound used for?
To determine the infiltration depth and register regional lymph node disease
What isd a bronchoscopy used for?
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
What is a laparoscopy used for?
To increased accuracy of detection small liver metastasis
What is Ruthie siewert classification of adenocarcinoma of oesophagopgastric junction?
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
What is the Z line?
Represents the normal oesophagogastric junctions where the squamous muscle of the oesophagus and columnar mucosa of the stomach meet
What is the pathology of adenocarcinoma?
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
What is the pathology of squamous cell carcinoma?
Breakdown of uniform tissue structure
Squamous cell carcinoma clusters with circular keratinisation
Lymphocytic infiltration between the carcinoma clusters
What is the curative treatment for oesophageal carcinoma?
Neoadjuvant chemoradiation as a definite treatment in patients with proven cinokete response (eg during endoscopy)
Surgical resection either endoscopy or total esophagectomy
What are the indications for curative treatment?
Locally invasive disease that has not invaded surrounding structures
High grade metaplasia in Barrett oesophagus
What are the methods of palliative treatment for oesophageal cancer?
Chemoradiation
Stent placement
Other endoscopic treatment eg laser therapy
What are the indications for palliative treatment?
Patients with advanced disease (majority of patients)
What are the cancer related complications of oesophageal cancer?
Oesophageal stenosis
Tracheoesophageal fistula -> passage of food and fluid into the respiratory tract -> increased risk of aspiration pneumonia
What are the treatments associated complications?
Surgical complications - anastamotic leak or stricture
Recurrent laryngeal nerve inury
Functional GI disorders - reflux, dumping syndrome
What is the prognosis staging system for oesophageal cancer?
STEER staging
What are the stages of STEER? and5 year survival rate chances
Localised - 47%
Regional - 25%
Distant - 5%
Combined - 25%
What will the physical examination show for squamous cell carcinoma?
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
Which lab tests should be done for squamous cell carcinoma?
CA19-9 (serum carbohydrate antigen) - not a sufficiently sensitive test for ther carcinoma though
Which radiographic tests should be done fort squamous cell carcinoma?
Standard chest radiograph
Barium contrast radiography
Double contrast technique
What will a standard chest radiograph reveal?
Evidence of pulmonary complications, such ass pneumonia and metastasis into mediastinum or lung parenchyma
Subtle changes such as mediastinal widening, posterior tracheal indentation
What will a barium contrast radiography reveal?
Provides strong evidence for diagnosis in nearly all patients
What will a double contrast technique reveal?
Best study for mucosal detail
What is the diagnosis tic tests for adenocarcinoma?
Proper history suggests distal malignant oesophageal obstruction
Barium contrast radiography
Endoscopy
CT scan
EUS (oesophageal ultrasound)
What will a barium contrast radiography reveal?
Nearly always confirms or suggests the diagnosis
What will endoscopy with biopsy and cytology reveal?
Provides histological diagnosis in virtually all cases
What will a ct scan reveal?
Evidence of mucosal thickening or periesophageal metastasis
What will EUS reveal?
More precisely evaluates involvement of the oesophageal wall and periesophageal region
