Upper GI cancer

Question 1

What are the two most common types of oesophageal cancer?

Answer 1

squamous cell carcinoma
adenocarcinoma

Question 2

Which type of oesophageal is more common in the UK?

Answer 2

Adenocarcinoma

Question 3

Which type of oesophageal is more common in the developing world?

Answer 3

Squamous cell carcinoma

Question 4

Which part of the oesophagus is typically affected by SCC?

Answer 4

Middle and upper third of the oesophagus

Question 5

Which subtype of oesophageal cancer is more associated with smoking and excessive alcohol consumption?

Answer 5

Squamous cell carcinoma

Question 6

Which part of the oesophagus is typically affected by adenocarcinoma

Answer 6

lower third of the oesophagus

Question 7

Oesophageal SCC risk factors?

Answer 7

SMOKING
EXCESSIVE ALCOHOL CONSUMPTION
Chronic Achlasia
Low vitamin A levels
Iron deficiency (rare)

Question 8

Oesophageal adenocarcinoma risk factors?

Answer 8

long-standing GORD
obesity
high fat intake

Question 9

What does oesophageal adenocarcinoma arise as a consequence of?

Answer 9

This subtype arises as a consequence of metaplastic epithelium (termed Barrett’s oesophagus) which progresses to dysplasia, to eventually become malignant.

Question 10

In which sex is oesophageal cancer more

Answer 10

Men (3x more common)

Question 11

What is a common presenting symptom of oesophageal cancer?

Answer 11

Dysphagia - typically progressive in nature (classically this starts with solids only, before affecting liquids)

Question 12

Signs/symptoms of oesophageal cancer?

Answer 12

Dysphagia is a common presenting symptom of oesophageal cancer*, typically progressive in nature (classically this starts with solids only, before affecting liquids)

Significant weight loss (due to both dysphagia and cancer-related anorexia)

Other less common symptoms:
odynophagia
hoarseness

O/E:
Recent weight loss/cachexia
Signs of dehydration
Supraclavicular lymphadenopathy,
Signs of metastatic disease (such as jaundice, hepatomegaly, or ascites)

Question 13

Oesophageal cancer - signs of metastatic disease

Answer 13

Jaundice
Hepatomegaly
Ascites

Question 14

If lymphadenopathy is present in oesophageal cancer, where might you expect to see it?

Answer 14

Supraclavicular lymph nodes

Question 15

Current NICE guidance states the red-flag symptoms for a suspected oesophageal malignancy requiring urgent endoscopy are what?

Answer 15

Any patient with dysphagia

Any patient >55yrs with weight loss and upper abdominal pain, dyspepsia, or reflux

Question 16

When should a patient >55 be referred urgently for endoscopy to r/o ?oesophageal malignancy?

Answer 16

Any of:
Dysphagia (includes all ages)
Weight loss + upper abdominal pain
Dyspepsia
Reflux

Question 17

Dysphagia - first line investigation and why?

Answer 17

Upper GI endoscopy as first line investigation (also termed oesophago-gastro-duodenoscopy)

Any patient presenting with dysphagia should be assumed to have oesophageal cancer until proven otherwise

Question 18

Investigating oesophageal cancer?

Answer 18

2WW referal for OGD (oesophago-gastro-duodenoscopy)/ upper GI endoscopy +/- biopsy sent for histology

If not suitable for OGD, pts can occasionally have a CT scan (neck and thorax) however this is much less sensitive and specific

Fine Needle Aspiration (FNA) biopsy - to investigate any palpable cervical lymph nodes

bronchoscopy may be warrened if haemoptysis or hoarseness

Staging: CT Chest-Abdomen-Pelvis and PET-CT scan, endoscopic ultrasound, staging laparoscopy

Question 19

What investigations are used to stage oesophageal cancer?

Answer 19

CT Chest-Abdomen-Pelvis and PET-CT scan: to investigate for distant metastases

Endoscopic ultrasound: to measure the penetration into the oesophageal wall (T stage) and assess and biopsy suspicious mediastinal lymph nodes

Staging laparoscopy (for junctional tumours with an intra-abdominal component): to look for intra-peritoneal metastases

If palpable cervical lymph nodes: FNA biopsy

Question 20

How are most (70% of) oesophageal cancers managed and why?

Answer 20

Sadly, the majority of patients present with advanced disease. Approximately 70% of patients are therefore only treated palliatively.

As with all cancers, the management of oesophageal cancer patients should be determined by the multidisciplinary team (MDT), with input from general surgeons, oncologists, specialist nurses, nutritionists, and, if required, the palliative care team.

Question 21

How are oesophageal SCCs managed if there is curative intent?

Answer 21

Definitive chemo-radiotherapy is therefore usually the treatment of choice

(SCCs of the upper oesophagus are technically difficult to operate on)

Question 22

How are oesophageal adenocarcinomas managed if there is curative intent?

Answer 22

the treatment of choice is typically neoadjuvant chemotherapy or chemo-radiotherapy followed by oesophageal resection

Question 23

Why is oesophageal resection considered a major surgery?

Answer 23

Both the abdominal and chest cavities need to be opened.

Patients have one lung deflated for about 2 hours during surgery

30-day mortality rates are around 4%

It takes 6-9 months for patients to recover to their pre-operative quality of life

The main complications are anastomotic leak* (8%), re-operation, pneumonia (30%), and death (4%)

Post-operative nutrition is a major problem for these patients as they lose the reservoir function of the stomach.

Question 24

What are the main complications of oesophageal resection?

Answer 24

Anastomotic leak (8%)
Re-operation
Pneumonia (30%)
Death (4%)
Post operative malnutrition

Question 25

For a small number of patients with very early oesophageal cancers or high grade Barrett’s oesophagus, what less major surgical option may be available?

Answer 25

Endoscopic Mucosal Resection (EMR), which is the removal of just the mucosal layer of the oesophagus

Question 26

What is the main surgical management option for oesophageal cancer and what is involved?

Answer 26

The main surgical management option for oesophageal cancer is an oesophagectomy, with a variety of approaches possible.

They all involve removal of the tumour, top of the stomach, and surrounding lymph nodes.

The stomach is then made into a tube (“the conduit”) and brought up into the chest to replace the oesophagus.

Question 27

What approaches may be taken when an oesophagectomy is performed?

Answer 27

IVOR-LEWIS PROCEDURE - right thoracotomy with laparotomy

MCKEOWN PROCEDURE - right thoracotomy with abdominal and neck incision

Left thoracotomy +/- neck incision

Left thoraco-abdominal incision (one large incision starting above the umbilicus and extending round the back to below the left shoulder blade)

Question 28

What is the Ivor-Lewis procedure?

Answer 28

Surgical approach to oesophogectomy
Right thoractomomy with lapatomoy

Question 29

What is the McKeown procedure?

Answer 29

Surgical approach to oesophogectomy
Right thoracotomy with abdominal and neck incision

Question 30

Post-operative nutrition is a major problem for patients following an oesophagectomy - why is this and how is this managed?

Answer 30

Patient loses the reservoir function of the stomach.

Many centres will routinely insert a feeding tube into the small bowel (a “feeding jejunostomy”) to aid nutrition.

However, most patients will need to eat 5-6 small meals per day to meet their nutritional requirements.

Question 31

Any deterioration, even minor, in an oesophagectomy patient should be considered what until proven otherwise?

Answer 31

An anastomotic leak until proven otherwise

Rates of anastomotic leak are relatively high (8%)

Question 32

Specific palliative management options for oesophogeal cancer?

Answer 32

OESOPHAGEAL STENT - patients with difficulty in swallowing should have an oesophageal stent placed where possible

Radiotherapy and/or chemotherapy can be used for palliation to reduce tumour size and bleeding, temporarily improving the patient’s symptoms.

Nutritional support is essential for this patient group, as progression of the disease can lead to significant dysphagia and cachexia. Thickened fluid and nutritional supplements should be offered (usually via the nutrition team)

If dysphagia becomes too severe to tolerate enteral feeds, a Radiologically-Inserted Gastrostomy (RIG) tube may need to be inserted, to bypass the obstruction.

Question 33

What is the prognosis for oesophageal cancer?

Answer 33

The prognosis for oesophageal cancer is generally poor due to late presentation.

Overall five-year survival is 5-10%.

The outcome of surgically treated patients have survival depending on stage of the disease, with a 5 year survival for stage 1 cancers at around 60%.

Palliative treated patients have a median survival of 4 months.

Question 34

At what vertebral level does the oesophagus originate?

Answer 34

C6

Question 35

Differentials for oesophageal symptoms?

Answer 35

Mallory-Weiss Tear
Usually history of antecedent vomiting. This is then followed by the vomiting of a small amount of blood. There is usually little in the way of systemic disturbance or prior symptoms.

Hiatus hernia of gastric cardia
Often longstanding history of dyspepsia, patients are often overweight. Uncomplicated hiatus hernias should not be associated with dysphagia or haematemesis.

Oesophageal rupture
Complete disruption of the oesophageal wall in absence of per-existing pathology. Left postero-lateral oesophageal is commonest site (2-3cm from OG junction). Suspect in patients with severe chest pain without cardiac diagnosis and signs suggestive of pneumonia without convincing history, where there is history of vomiting. Erect CXR shows infiltrate or effusion in 90% of cases(1).

Squamous cell carcinoma of the oesophagus History of progressive dysphagia. Often signs of weight loss. Usually little or no history of previous GORD type symptoms.

Adenocarcinoma of the oesophagus
Progressive dysphagia, may have previous symptoms of GORD or Barretts oesophagus.
Peptic stricture Longer history of dysphagia, often not progressive. Usually symptoms of GORD. Often lack systemic features seen with malignancy

Dysmotility disorder
May have dysphagia that is episodic and non progressive. Retrosternal pain may accompany the episodes.

Question 36

Potential causes or persistent hoarseness?

Answer 36

Laryngeal cancer

Hoarseness lasting more than 3 weeks must be referred under a 2 week wait to ENT clinic.
Common features of the history would include a significant smoking history.

Chronic Laryngitis

Hoarseness associated with gastroesophageal reflux disease.
It commonly presents as worse in the morning.

Laryngitis

A common cause of hoarseness and is classically viral and self-limiting.
It can be secondary to GORD or auto-immune disease.

Reinke’s Oedema

Caused by enlargement of the vocal cords and is associated with hypothyroidism it leads to prolonged and persistent hoarseness.

Question 37

Current recommendations are that patients with confirmed oesophageal cancer undergoing resection should have a CT scan when?

Answer 37

Current recommendations are that patients with confirmed oesophageal cancer undergoing resection should have a CT scan 6 months after discharge for monitoring