esophagus Flashcards
(21 cards)
The esophagus can be divided anatomically into:
Cervical (C7-T3):
15-20cm from incisor, or to thoracic inlet
Thoracic (T3-T11): 20-40cm from incisor, upper (to the tracheal bifurcation) (5cm), middle (5cm), lower (10cm)
Abdominal (GOJ)
Siewert classification – determines extent of esophagectomy/ gastrectomy required
Broadly outline the surgical approach to esophageal cancer:
Most guidelines consider surgery where possible (up to and not including T4b) a key part of management.
Except!!! Cervical tumour: treated non-operatively because laryngo-pharyngectomy with permanent stoma sucks!
For tumours limited to the submucosa (T1b): Endoscopic mucosal resection (EMR)/ endoscopic submucosa dissection (ESD). EMR ok for lesions < 2cm en-bloc, larger lesions need piecemeal resection which limit
assessment of margin status
- ESD allow dissection of larger tumour (regardless of size), labour intensive, and high risk
of perforation
- High risk of oesophageal stenosis/ stricture after extensive EMR/ ESD
Upper and middle thoracic tumour (>5cm from crico-pharyngeus): total
esophagectomy with gastric pull-through is standard
o Options: Ivor Lewis, McKeown (tri-incisional), trans-hiatal
- Distal/ GOJ tumour: distal oesphagogastrectomy
What classification may surgeons use for more distal esophageal cancers? Why
Siewert classification.Higher tumours (class 1 = 1-5cm above GOJ) are treated with distal esophagectomy or transthoracic esophagectomy.
Class II (1cm above and 2cm below GOJ) Extended gastrectomy oesophagus and Class III 1-5cm below total gastrectomy.
Note: all pretty much get a mediastinallymphadectomy
What is the surgical approach to esophagectomy, broadly when can it be done?
Upper and middle thoracic tumour (>5cm from crico-pharyngeus, >3cm from GOJ): total esophagectomy with gastric pull-through is standard this can be:
Ivor Lewis, McKeown (tri-incisional), trans-hiatal
- Distal/ GOJ tumour: distal oesphagogastrectomy
Lymphadenectomy: generally performed for distal lesions, controversial regarding minimum LN, generally recommends 6-23 LN
Contraindications to esophagectomy
Contraindications for surgery
- Distant metastases
- T4b lesions (involving heart, great vessels, trachea, surrounding organs)
- Bulky multi-station lymphadenopathy
Comment on esophagectomy mortality, what intervention can worsen this (and by how much?):
Post-operative mortality ~ 5%, can be 10% of higher after neoadjuvant CRT
For Barrett’s oesophagus, describe:
Macroscopic and microscopic appearance
Macroscopic:
Red velvety appearance, “Salmon eophagus”
Micro:
- Metaplasia: Replacement of non-keratinized stratified squamous epithelium with ‘intestinal- type’ columnar epithelium with goblet cells
- Dysplasia: nuclear polychromasia, irregular nuclear size and shape, prominent nucleoli, high N: C ratio, increased mitotic activity
For Barrett’s oesophagus, describe:
Pathogenesis and clinical significance
Normal nonkeratinised stratified squarmous epithelium → chronic esophagitis due to gastric acid exposure→ columnar (intestinal-like) metaplasia (columnar epithelial with goblet cells) - Barrett’s oesophagus
Clinical Significance:
- Risk of malignant transformation ~2% per year
- need close endoscopic surveillance
- acid suppression with PPI may halt dysplastic progression
For esophagus adeno Ca give
i. Epidemiology
ii. Risk factors
Epidem:
Most common esoophagus cancer in Western countries.
RFs = BOGS
Barretts
Obesity
GORD
Smoking (though to a much lesser extent than SCC)
For esophagus SCC give
i. Epidemiology
ii. Risk factors
90% of oesophageal cancer world wide More common in Asia/ East Europe
ABCDEF
Achalasia Bad diet (low fibre, high fat) Ciggies Diverticuli EtOH Familial and Plumer vinson syndrome.
Macro and micro appearance of esophagus AdenoCa
Malignant cell with glandular differentiation
* Mucin-producing
* adjacent Barrett’s metaplasia
* WD = more gland; MD = mixed of gland + solid; if PD = solid appearance
Macro and micro appearance of esophagus SCC
Polypoid
Fungating
Ulcerative (SCC tends to ulcerate)
Infiltrative (similar to Bormann’s for
gastric)
Micro
large flat atypical squamous cell
* keratinisation pearl formation
* intracellular bridges
* occasional spindle cell morphology
(polypoid)
* adjacent/ coexisting dysplasia
IHC for eso SCC
- p53+
- CK5/6+
- p40+
IHC for eso AdenoCa
- CK7+
- CK20-
- PAS+ (mucin)
TTF-1
After esophagus neoadjuvant chemoradiotherapy, what are the microscopic changes in the tumour and adjacent tissue?
Post radiation changes are seen in both the tumour, stroma and vessels:
Tumour:
* Necrosis, fibrosis
* if residual tumour, will show giant cells with bizarre (very pronounced) nuclear atypia
TUMOUR RESPONSE GRADING (TRG) – used in CROSS protocol. G1 = CR, G4>50% alive
Stroma: Atypia, fibrosis, inflammatory infiltrate.
Vessels: Hyaline sclerosis
List the pathological prognostic factors in esophagectomy specimen:
- Tumour site (upper 1/3 better than lower 1/3)
- Tumour size
- Depth of invasion (lamina propria/ muscularis mucosa/ submucosa/ muscularis propria/ adventitia)
- Tumour grade
- LVI
- Resection margin
- Nodal involvement (most prognostic)
- IHC staining: CEA/ VEGF/ Her2
- Pathological complete response (after neoadjuvant chemoRT)
A 64 year old dude presents with dysphagia and weight loss.
Investigation reveals a tumour in the oesophagus from 26 to 31 cm from incisor. Bopsy confirms squamous cell carcinoma.
Key features of Hx:
Symptoms/Emergency:
- Tempo and severity of symptoms, dysphagia/ odynophagia (still able to have any oral intake?), weight loss (how much, over what period of time), hematemesis, melena
Risk factors:
ABCDE And Plummer Vinson
Suitability for surg/chemoRT
- ECOG, comorbidities, which may make him deem high risk surgical candidate
- RT relevant: connective tissue disorders, pacemaker, previous thoracic RT
- Chemotherapy: renal function/ hearing (if considering cisplatin with definitive RT)
Functional and social
Social support to go through treatment; geriatric assessment
A 64 year old dude presents with dysphagia and weight loss.
Investigation reveals a tumour in the oesophagus from 26 to 31 cm from incisor. Bopsy confirms squamous cell carcinoma.
Key features of Ex:
Weight/Malnutrition
Lymphadenopathy (esp. SCF) Hepato-splenomegaly (? Mets)
A 64 year old dude presents with dysphagia and weight loss.
Investigation reveals a tumour in the oesophagus from 26 to 31 cm from incisor. Bopsy confirms squamous cell carcinoma.
Key features of Ix:
Blood: FBE/ UEC/ CMP/ LFT
Tissue diagnosis:
- More information from biopsy depth of invasion (dictate T stage) Imaging:
- CT chest/ abdomen (contrast) to evaluate extent of local invasion, nodal disease, liver mets
- Complete Staging FDG PET to exclude distant disease
A 64 year old dude presents with dysphagia and weight loss.
Investigation reveals a tumour in the oesophagus from 26 to 31 cm from incisor. Bopsy confirms squamous cell carcinoma.
The pt has significant weight loss and has not been able to maintain an adequate oral intake. How you would manage this?
- Dietitian evaluation, extent of dysphagia
- Nutritional supplement with high calorie drinks (e.g. Sustagen/ Resource)
- If still not able to maintain adequate intake, consider nasogastric tube (NGT) insertion
- If recurrent NGT dislodgement, consider percutaneous endoscopic jejunostomy (PEJ) feed (NOT PEG feed)
- Monitor for re-feeding syndrome (regular electrolyte monitoring esp. for hypo-phosphataemia, also hypoMg and hypoK)
