Oesophageal cancer Flashcards
(124 cards)
1
Q
What is the definition of oesophageal cancer?
A
Malignant neoplasm of oesophagus
Oesophageal cancer can manifest as two primary types: squamous cell carcinoma (SCC) and adenocarcinoma.
2
Q
What is the worldwide incidence of squamous cell carcinoma (SCC) of the oesophagus?
A
5.2/100000
This statistic reflects the overall global incidence of SCC, which varies by region.
3
Q
What is the worldwide incidence of adenocarcinoma of the oesophagus?
A
0.7/100000
This figure represents the global incidence, which is influenced by geographic and lifestyle factors.
4
Q
In which type of countries is SCC more commonly found?
A
Less developed countries
Geographic variation shows that SCC has a much higher incidence in less developed regions.
5
Q
In which type of countries is adenocarcinoma more common?
A
Developed countries
This trend highlights the difference in lifestyle and dietary factors that may influence cancer types.
6
Q
What is the incidence of adenocarcinoma in men in the US?
A
7.2/100000
This statistic indicates a significant prevalence among men compared to women.
7
Q
What is the incidence of adenocarcinoma in women in the US?
A
2.5/1000000
The incidence is notably lower in women, reflecting possible biological or environmental factors.
8
Q
What is the trend in the incidence of SCC worldwide?
A
Declining
This decline can be attributed to various public health measures and lifestyle changes.
9
Q
What is the trend in the incidence of adenocarcinoma worldwide?
A
Increasing
The rise in adenocarcinoma cases may be linked to changes in diet, obesity rates, and other risk factors.
10
Q
What are the two types of oesophageal cancer?
A
SCC and adenocarcinoma
11
Q
What is the primary cause of oesophageal SCC?
A
Chronic irritation and inflammation of oesophageal mucosa
12
Q
What is a major risk factor for oesophageal SCC?
A
Cigarette smoking
13
Q
List three risk factors other than smoking for oesophageal SCC.
A
- Alcohol intake
- Low Socio-economic status
- Drinking hot beverages
14
Q
Which dietary factor is a risk for oesophageal SCC?
A
High intake of barbecued meat
15
Q
What previous medical condition can be a risk factor for oesophageal SCC?
A
Previous caustic injury
16
Q
What viral infection is associated with oesophageal SCC?
A
HPV infection
17
Q
What oesophageal dysmotility condition is a risk factor forSCC?
A
Achalasia
18
Q
What syndrome is a risk factor for oesophageal SCC?
A
Plummer Vinson syndrome
a rare condition characterized by iron deficiency anemia, dysphagia (dif
19
Q
What is the relationship between oesophageal adenocarcinoma and acid exposure?
A
Related to chronic exposure to acid
20
Q
What is the progression pathway leading to oesophageal adenocarcinoma?
A
From oesophagitis, metaplasia to dysplasia to carcinoma
21
Q
What condition is a risk factor for oesophageal adenocarcinoma?
A
GORD
22
Q
What demographic factors increase the risk of oesophageal adenocarcinoma?
A
- Caucasian
- Male
23
Q
How does obesity relate to oesophageal adenocarcinoma?
A
It is a risk factor
24
Q
What is the proposed protective role of H. pylori?
A
Decreasing gastric acid production and increasing pH of refluxed gastric content
25
What is the primary location of oesophageal SCC?
Located primarily in mid oesophagus – upper:mid:lower 1:5:2
26
What are the three macroscopic descriptions of oesophageal SCC according to the Borrmann or Murakami classification?
* Exophytic growth (60%)
* Ulcerative (25%)
* Infiltrative (15%)
27
What percentage of oesophageal SCC cases in Western society have tumours invading beyond muscularis propria at presentation?
60%
28
What percentage of oesophageal SCC cases in Japan are early/superficial at presentation?
40%
29
How are keratinocyte-like cells in oesophageal SCC graded?
Graded well, moderately, or poorly differentiated based on mitotic activity, nuclear atypia, degree of squamous differentiation (including degree of keratinisation)
30
What are the variants of oesophageal SCC?
* Verucous – rare, locally aggressive
* Spindle cell – highly aggressive, polypoid tumour in middle/lower 1/3
* Basaloid – highly aggressive with poor prognosis
31
What are the molecular pathology markers positive in oesophageal SCC?
* CK5/6
* CK14
* p63
* p40
32
What are the molecular pathology markers negative in oesophageal SCC?
* CK7
* CK20
* CDX2
33
What percentage of oesophageal SCC cases have mutations in p53?
80%
34
What gene frequently has mutations in oesophageal SCC?
RB (retinoblastoma) gene and p16
35
What is the primary risk factor for the development of oesophageal adenocarcinoma?
95% of adenocarcinoma associated with Barrett’s oesophagus
36
Where is oesophageal adenocarcinoma almost exclusively found?
Distal 1/3 of oesophagus
37
What classification is used for adenocarcinoma according to its relationship with GOJ?
Siewert classification
38
What is the microscopic description of adenocarcinoma?
Malignant epithelial tumour with glandular differentiation
39
What types of glandular differentiation can adenocarcinoma have?
* Papillary
* Tubular
40
How is adenocarcinoma graded?
Graded high, moderately, or poorly differentiated based on proportion of tumour composed of glands
41
What is a common characteristic of early oesophageal cancers?
Asymptomatic
## Footnote
Early cancers may be detected during surveillance of Barrett's oesophagus.
42
What percentage of patients with advanced oesophageal cancer experience progressive dysphagia?
75%
## Footnote
Dysphagia progresses from liquid to solids.
43
What is a common symptom of advanced oesophageal cancer related to weight?
Weight loss (50%)
## Footnote
This symptom is prevalent among patients with advanced disease.
44
What voice change occurs in advanced oesophageal cancer and why?
Voice change/hoarseness due to RLN involvement
## Footnote
This is considered a late sign of the disease.
45
What complications can arise due to trachea-oesophageal fistula in advanced oesophageal cancer?
Coughing and aspiration
## Footnote
These symptoms occur as a result of the fistula.
46
What is a common symptom of fatigue in relation to oesophageal cancers?
Fatigue
## Footnote
Fatigue is a general symptom that may accompany advanced disease.
47
What is a potential complication of locally regional disease in advanced oesophageal cancer?
Tracheo-oesophageal fistula
## Footnote
This complication can severely affect the patient's condition.
48
What is another serious complication associated with advanced oesophageal cancer?
Aorto-oesophageal fistula
49
What are the three types of Adenocarcinoma at GOJ according to Siewert classification?
* Type I – 1-5cm above GOJ
* Type II – 1cm above to 2cm below GOJ
* Type III – 2-5cm below GOJ (treated as gastric cancer)
## Footnote
The classification is important for understanding the location and treatment of oesophageal cancers at the gastro-oesophageal junction.
50
What is the classification range for GOJ cancers?
Only classify GOJ cancers +5cm above to -5cm below
## Footnote
This range is based on the location of the tumour's epicentre.
51
What is the key characteristic of true junctional Type II cancers?
+1cm above to -2cm below
## Footnote
This specification is crucial for accurate classification.
52
What is the significance of the epicentre of the tumour in GOJ cancer classification?
It determines the classification type and treatment approach
## Footnote
Accurate identification of the epicentre allows for proper categorization into Types I, II, or III.
53
What blood tests are commonly used in the investigation of oesophageal cancers?
FBC, U&Es, LFTs
## Footnote
FBC: Full Blood Count, U&Es: Urea and Electrolytes, LFTs: Liver Function Tests
54
What is the most important investigation for oesophageal cancer?
Endoscopy
## Footnote
Endoscopy provides histologic diagnosis as well as information on location, extent, and relation to anatomic landmarks.
55
What condition can be assessed during an endoscopy for oesophageal cancer?
Evidence of Barrett's
## Footnote
Barrett's esophagus is a precancerous condition that can develop due to chronic gastroesophageal reflux disease (GERD).
56
What is the role of CT Chest/abdo/pelvis in oesophageal cancer assessment?
Good for distant mets, poor for T stage
## Footnote
CT can diagnose T4 disease but is less effective in determining the T stage of the tumor.
57
When is PET FDG indicated in the staging of oesophageal cancer?
For staging of locally advanced oesophageal cancer where radical treatment is considered
## Footnote
PET (Positron Emission Tomography) helps in assessing the metabolic activity of cancer cells.
58
What is the most accurate method of T staging for oesophageal cancer?
EUS (Endoscopic Ultrasound)
## Footnote
EUS allows for fine-needle aspiration (FNA) which enhances the accuracy of N staging.
59
What are the benign/malignant criteria for assessing lymph nodes via EUS?
Benign criteria:
* mm
* Elongated
* Irregular
* Echorich
Malignant criteria:
* mm
* Round
* Smooth
* Echopoor
## Footnote
These criteria help differentiate between benign and malignant lymph nodes.
60
What is the purpose of staging laparoscopy in oesophageal cancer?
Usually used to assess for peritoneal metastases
## Footnote
It is particularly relevant for patients with T3/4 disease or Siewert II or III tumors being considered for surgery.
61
What is included in the pre-operative evaluation for surgical management of oesophageal cancer?
Functional assessment, ASA, ECOG, Formal Cardiopulmonary assessment, Nutritional assessment
## Footnote
ASA: American Society of Anesthesiologists classification, ECOG: Eastern Cooperative Oncology Group performance status.
62
What factors are considered in nutritional assessment before surgery?
Weight loss, degree of dysphagia
## Footnote
Nutritional optimization may include supplementation or enteral feeding.
63
What is the definition of early Oesophageal cancer?
T1, potentially curable with Endoscopic resection
## Footnote
Early-stage cancer is often more treatable and has better outcomes.
64
What does Tis represent in cancer staging?
In situ disease - high grade dysplasia, not invading past basement membrane, N0, M0
## Footnote
Tis indicates a very early stage of cancer where there are no regional lymph node involvement or distant metastases.
65
What does T1 indicate in cancer staging?
Invades lamina propria, muscularis mucosa or submucosa
## Footnote
T1 cancer has begun to invade deeper tissues but is still localized.
66
Differentiate between T1a and T1b.
T1a: invades lamina propria or muscularis mucosa; T1b: invades submucosa
## Footnote
T1a represents a less invasive stage compared to T1b.
67
What does T2 represent in cancer staging?
Invades muscularis propria
## Footnote
T2 indicates further invasion into the muscular layer and involvement of 3-6 regional lymph nodes.
68
What does T3 indicate in oesophageal cancer staging?
Invades adventitia
## Footnote
T3 signifies a more advanced cancer with invasion into surrounding tissues and involvement of 7 or more lymph nodes.
69
What does T4 indicate in oesophageal cancer staging?
Invades adjacent structures
## Footnote
T4 cancers are generally more advanced and have spread to nearby organs or structures.
70
Differentiate between T4a and T4b.
T4a: invades pleura, pericardium, azygous, diaphragm, peritoneum; T4b: invades aorta, vertebral body, trachea
## Footnote
T4a involves less critical structures compared to T4b, which involves more vital organs.
71
What does N0, N1, N2, and N3 represent in oesophageal cancer staging?
N0: No regional LN
N1: 1-2 regional LN
N2: 3-6 regional LN
N3: 7 or more
72
What do M0 and M1 represent in oesophageal cancer staging
M0 no distant mets
M1 distant mets present
73
What is Stage 0 for oesophageal SCC and for oesophageal adenocarcinoma?
Tis
N0
M0
74
What is Stage 1 for oesophageal SCC and for oesophageal adenocarcinoma?
Adenocarcinoma: T1 N0 M0
SCC:
T1, N0-N1, M0
75
What is Stage 2 for oesophageal SCC and for oesophageal adenocarcinoma?
Adenocarcinoma:
Stage IIa:T1 N1 M0
Stage IIb: T2 N0 M0
SCC:
T2 N1 M0
T3 N0 M0
76
What is Stage 3 for oesophageal SCC and for oesophageal adenocarcinoma?
Adenocarcinoma:
T2 N1 M0
T3, T4a N0-1, M0
SCC:
T1-2, N2, M0
T3, N1-2, M0
77
What is Stage 4a for oesophageal SCC and for oesophageal adenocarcinoma?
Adenocarcinoma:
T1-T4a, N2, M0
T4b, N0-2, M0
Any T, N3, M0
SCC
78
What is Stage 4b for oesophageal SCC and for oesophageal adenocarcinoma?
Adenocarcinoma:
Any T, Any N, M1
SCC: Any T, N3, M0
Any T, Any N, M1
79
What is the definition of early oesophageal cancer?
Defined as Tis, T1a or T1b disease
## Footnote
Tis refers to carcinoma in situ, T1a indicates invasion of lamina propria and muscularis mucosa, and T1b indicates invasion of submucosa.
80
What does T1a indicate in oesophageal cancer staging?
Invasion of lamina propria and muscularis mucosa
## Footnote
T1a is further divided into m1 (tumour within epithelium/Tis), m2 (tumour within lamina propria), m3 (tumour within muscularis mucosa).
81
What are the subdivisions of T1a in oesophageal cancer?
* m1 (tumour within epithelium/Tis)
* m2 (tumour within lamina propria)
* m3 (tumour within muscularis mucosa)
## Footnote
These subdivisions help in accurately defining the extent of invasion.
82
What does T1b indicate in oesophageal cancer staging?
Invasion of submucosa
83
What is the similarity between T staging and Kikuchi?
Similar to Kuchoshi ~ sm1 (superficial 1/3), sm2 (superficial 2/3), sm3 (into deepest 1/3)
## Footnote
.
84
What is the risk factor for lymph node involvement in oesophageal cancer?
Higher in SCC than ACC
## Footnote
SCC refers to squamous cell carcinoma, while ACC refers to adenocarcinoma.
85
What are the most important risk factors for lymph node involvement?
* Histology/morphology
* Tumour size
* Depressed vs flat
* Histological grade
* LVI
* Depth of invasion
## Footnote
Depth of invasion is highlighted as the most critical risk factor.
86
What is the risk of lymph node involvement for T1 (M1-M2) lesions?
Nearly 0%
## Footnote
This indicates a very low likelihood of lymph node metastasis in early stage lesions.
87
What is the most important factor for all management decisions?
All management decisions should be discussed at MDM
## Footnote
MDM refers to multidisciplinary meetings that involve various specialists.
88
What sources provide guidelines for management decisions in oesophageal cancer?
ESMO guidelines (and Uptodate)
## Footnote
These resources are key for evidence-based management practices.
89
What are the subdivisions of T1b in oesophageal cancer?
Similar to Kikuchi ~ sm1 (superficial 1/3), sm2 (superficial 2/3), sm3 (into deepest 1/3)
90
What factors influence the treatment of T1 tumours in oesophageal cancer?
Depth of invasion, patient fitness for surgery, risk of lymph node involvement
91
What is the recommended approach for T1a disease without high-risk features?
Consider endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)
## Footnote
T1a disease includes M1 or M2 without features like LVI, high grade, or M3.
92
What treatments should be considered for Barrett's associated with T1a disease?
Radiofrequency ablation (RFA), APC, photodynamic therapy, cryotherapy
## Footnote
RFA is considered the gold standard for Barrett's ablation.
93
In what situation is an esophagus-sparing approach suggested?
For older adults with multiple comorbidities or high surgical risk
## Footnote
This approach is recommended if treated at institutions with expertise in endoscopic techniques.
94
What is the definitive treatment for T1b/T2 disease?
Resection
## Footnote
No neoadjuvant treatment is indicated for T1b/T2 disease.
95
What is the standard treatment for locally advanced oesophageal cancer?
Multimodality treatment
## Footnote
Locally advanced disease is defined as >T2 or N+.
96
What are the treatment options for locally advanced disease based on histological subtype?
Neoadjuvant chemotherapy +/- radiotherapy, definitive chemoradiotherapy
## Footnote
Treatment options depend on whether the cancer is SCC or AC.
97
What is the role of chemoradiotherapy in oesophageal cancer treatment?
Major role in treatment with curative intent
## Footnote
Surgery alone is only suitable for early stage disease.
98
What are the benefits of neoadjuvant treatment?
Improved downstaging, increased R0 rate, higher complete pathological response rate, improved overall survival
## Footnote
R0 resection rate increased from 69% to 92% without increased post-operative complications.
99
What percentage of patients benefit from neoadjuvant treatment?
<20%
## Footnote
This subgroup undergoes a pathological response to treatment.
100
How should cervical SCC be managed?
Definitive chemoradiotherapy
## Footnote
Surgical clearance may involve laryngectomy.
101
True or False: In SCC, surgery offers additional benefits over definitive chemoradiotherapy.
False
## Footnote
Most patients do not benefit from surgery in this context.
102
What is the CROSS protocol for neoadjuvant CRT?
Carboplatin and paclitaxel with concurrent radiotherapy (41.4 Gy)
## Footnote
The protocol includes surgery after a 4-6 week wait.
103
What is the MAGIC trial protocol for neoadjuvant chemotherapy?
6 cycles of ECF (epirubicin, cisplatin, 5-fluorouracil)
## Footnote
MAGIC IS NOW OUTDATED 3 cycles pre-surgery and 3 cycles post-surgery.
104
What recent evidence suggests a treatment may be superior to MAGIC?
FLOT (5-Fluorouracil, Leucovorin, Oxaliplatin, Docetaxel) is superior to magic and cross
## Footnote
This evidence points towards improved outcomes in comparison.
105
What is the FLOT protocol
four cycles of fluorouracil, leucovorin, oxaliplatin, and docetaxel over 8 weeks,
followed by surgery 4 to 6 weeks later.
the same chemotherapy regimen 4 to 6 weeks later.
106
What is the most common surgical approach for esophagectomy?
Two stage resection (Ivor-Lewis)
## Footnote
This approach involves a meticulous selection of patients and requires an experienced surgical team.
107
What are the aims for margins in surgical resection of oesophageal cancer?
10cm proximal and 5cm distal margin, with clear circumferential resection margin
## Footnote
Ensuring clear margins is crucial for reducing the risk of residual disease.
108
What is the purpose of lymphadenectomy in esophagectomy?
Optimal staging and improved locoregional control
## Footnote
There is also some evidence suggesting it may improve overall survival.
109
What are the fields involved in a one-field lymphadenectomy technique?
One-field = upper abdominal lymphadenectomy
* Diaphragmatic
* Right and left paracardial
* Lesser curvature
* Left gastric
* Coeliac
* Common hepatic
* Splenic artery
## Footnote
This approach focuses on the upper abdominal lymph nodes.
110
What additional fields are included in a two-field lymphadenectomy?
One field + paraoesophageal, para-aortic, right and left pulmonary hilar, subcarinal, and right paratracheal
## Footnote
This expands the dissection area to include more lymph nodes.
111
What is the preferred conduit for reconstruction after esophagectomy?
Gastric conduit, preferably using the right gastroepiploic major vessel
## Footnote
This choice aids in vascular supply and mobility.
112
What is the purpose of pyloroplasty in esophagectomy?
To improve pyloric drainage
## Footnote
The downside of pyloroplasty is the risk of dumping syndrome.
113
What are the alternate conduits for reconstruction in esophagectomy?
Jejunum and colon
## Footnote
These alternatives may be considered based on patient-specific factors.
114
What are the surgical approaches to esophagectomy?
Two phase subtotal oesophagectomy (Ivor-Lewis), left thoracoabdominal oesophagectomy, three phase oesophagectomy, transhiatal
## Footnote
Each approach has different indications and potential complications.
115
What are the advantages of transthoracic approaches to esophagectomy?
Direct visualisation, better dissection, and lymph node harvest
## Footnote
However, they also have higher morbidity associated with thoracic procedures.
116
What is a disadvantage of transhiatal approaches?
Possibly inadequate lymph node dissection
## Footnote
This compromises the staging and potentially the outcome.
117
What is a common early general complication of esophagectomy?
Respiratory complications, occurring in up to 25% of patients
## Footnote
This highlights the importance of postoperative respiratory care.
118
What is the incidence of anastomotic leak after esophagectomy?
5%
## Footnote
It is often managed conservatively unless associated with severe complications.
119
What is the management for high-volume chylothorax?
Usually warrants re-exploration
## Footnote
Chylothorax occurs in 2-3% of cases and can be a significant postoperative complication.
120
What are the late specific complications of esophagectomy?
Diaphragmatic hernia, duodeno-gastro-oesophageal reflux, dumping syndrome, anastomotic stricture, metastatic disease
## Footnote
These complications can significantly affect quality of life post-surgery.
121
What is the overall survival rate for patients undergoing palliative chemoradiotherapy?
Less than 1 year
## Footnote
This statistic underscores the aggressive nature of esophageal cancer.
122
What type of stents are useful for obstructing disease?
Endoscopically inserted, nitinol or stainless steel, usually partially covered
## Footnote
These stents help manage obstruction but come with risks.
123
What are the problems associated with stents placed over the gastroesophageal junction?
Reflux and migration
## Footnote
These complications can lead to further patient discomfort and require management.
124
True or False: The cervical esophagus is well tolerated for stent placement.
False
## Footnote
The cervical esophagus is poorly tolerated, increasing the risk of complications.
