Esophageal Cancer

Question 1

What is the most common esophageal cancer?

Answer 1

Adenocarcinoma (formerly the most common type was squamous cell carcinoma)

Question 2

What are the most important risk factors for the development of squamous cell carcinoma of the esophagus?

Answer 2

Smoking and alcohol

Question 3

What are the predominant risk factors associated with the development of adenocarcinoma of the esophagus?

Answer 3

Barrett’s esophagus and long standing GERD

Question 4

What is the most common presenting symptom of esophageal cancer?

Answer 4

Dysphagia

Question 5

What is included in the preoperative evaluation for esophageal cancer?

Answer 5

Determining extent of disease and patients clinical status. Upper endoscopy, CT scan, PET and EUS.

Question 6

What is the role of CT scan in esophageal cancer?

Answer 6

For detection of metastatic disease.

Question 7

Is transhiatal approach to esophageal cancer the only effective option?

Answer 7

No, Ivor-Lewis is a combined thoracic and abdominal dissection with complete lymphadenectomy, and eliminates risk of a blind thoracic dissection.

Question 8

True or False: Small intestine interposition is the simplest method for esophageal reconstruction in esophageal cancer.

Answer 8

False. Small bowel interposition is the most complex method of reconstruction, requiring microvascular and intestinal anastomoses.

Question 9

Which interposition grafts are preferred for benign disease?

Answer 9

Colonic

Question 10

True or False: A gastric pullup is the most popular method of esophageal reconstruction.

Answer 10

True. It requires only a single anastomosis, has enough length to reach the neck, and serves as an effective alimentary conduit.

Question 11

True or False: The detection of high grade dysplasia (HGD) in BE is an indication for esophagectomy.

Answer 11

True. HGD is a marker of occult adenocarcinoma. Presence of occult adenocarcinoma in resected specimen approaches 50%.

Question 12

How does treatment differ in patients with small, visible mucosal lesions of high grade dysplasia in Barrett’s?

Answer 12

Endoscopic mucosal resection (EMR) is an option, and adequate therapy if area is less than 20mm in diameter and cancer is confined to the lamina propria.

Question 13

Treatment for disease that invades the muscularis mucosa or extends into submucosa.

Answer 13

En bloc esophagectomy, because are locally advanced disease.

Question 14

What is the risk of nodal metastasis in esophageal cancers limited to mucosa?

Answer 14

3-6%

Question 15

What is the risk of nodal metastasis in esophageal cancers penetrating the submucosa?

Answer 15

30%

Question 16

What are the recommendations for resection in patients with esophageal cancers penetrating the muscularis mucosa?

Answer 16

Esophagectomy, lymphadenectomy.

Question 17

Do esophageal tumors invading the lamina propria require lymphadenectomy?

Answer 17

No. Recommendations include sparing vagal esophagectomy.

Question 18

In nonmetastatic locally advanced esophageal cancer, which surgical approach has less incidence of local recurrence?

Answer 18

En bloc

Question 19

True or False: Transhiatal esophagectomy has a better overall survival than en bloc resection for esophageal cancer.

Answer 19

False, transhiatal resection has survival of 25% for all stages compared to en bloc survival of 40-50% at 5 years.

Question 20

What are the two most important prognostic factors for survival in esophageal cancer?

Answer 20

tumor depth and nodal involvement

Question 21

Does number of nodes removed provide a survival benefit in patients with esophageal cancer?

Answer 21

Yes.

Question 22

Indications for surgery in metastatic esophageal cancer.

Answer 22

Palliation: esophageal perforation, bleeding and unsuccessful stent placement

Question 23

Followup after esophagectomy.

Answer 23

During first 3 years, every three months, then every 4-6 months.

Question 24

When is adjuvant chemotherapy employed in patients with esophageal cancer?

Answer 24

When there are four or more positive lymph nodes on histology of surgical specimen.

Question 25

Which procedure is utilized in palliative resection of esophageal cancer and why?

Answer 25

Transhiatal, because of less extensive dissection and fewer complications.

Question 26

Can esophageal stents be used in benign disease?

Answer 26

Yes

Question 27

Which patients are candidates for esophageal stent placements?

Answer 27

1. Perforation of benign disease but unable to undergo surgery, 2. Late perforations 3. Perforation of malignant disease but unable to undergo surgery 4. Anastomotic leak after esophagogastrectomy, 5 Immediate recognition of iatrogenic perforation during endoscopy

Question 28

When stenting for benign disease, how long are most stents left in place?

Answer 28

2 months

Question 29

Name the early complications of stent placement

Answer 29

Early complications appear <30 days after stent placement and include chest pain, bleeding, aspiration, perforations, fistula and stent migration, stent obstruction.

Question 30

Name the common late complications of stent placement

Answer 30

Late complications appear >30 days after stent placement and are usually related to tumor progression. Tumor ingrowth or overgrowth leading to dysphagia, bleeding, ulceration, perforation, fistula, stent fracture and migration.

Question 31

What percentage of patients diagnosed with esophageal carcinoma present with metastatic disease?

Answer 31

50%

Question 32

What is overall survival for esophageal cancer?

Answer 32

About 20%

Question 33

Has neoadjuvant therapy shown a survival benefit in esophageal cancer?

Answer 33

Yes, neoadjuvant chemoradiotherapy provides a survival benefit for locally advanced esophageal carcinoma.

Question 34

What is the main blood supply to the gastric conduit?

Answer 34

Right gastroepiploic artery