Esophageal Cancer and Barrett's Esophagus

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What are the two most common HPV serotypes associated with esophageal cancer?

HPV 16 and 18

Describe the process of neoplastic transformation of Barrett's Esophagus to adenocarcinoma.

It is a stepwise process that includes non-dysplastic disease, low-grade dysplasia, high-grade dysplasia, and AC. However, some patients with BE under endoscopic surveillance can develop cancer without prior biopsy detection of each of these stages.

What is the main characteristic of intestinal metaplasia in Barrett's Esophagus?

It is characterized by the presence of goblet cells.

What is the definition of Barrett's Esophagus?

It is a change in the distal esophageal epithelium of any length, recognized as columnar type mucosa during endoscopy and confirmed by a biopsy showing intestinal metaplasia. Signup and view all the answers

What is the connection between Gastro-esophageal reflux and Barrett's Esophagus?

Gastro-esophageal reflux leads to an acquired condition where the distal esophagus develops columnar lined epithelium. This is a response to the chronic exposure to stomach acid and is a key factor in the development of Barrett's Esophagus. Signup and view all the answers

Describe the role of telomere length when it comes to esophageal adenocarcinoma (EAC).

Shorter telomere length is associated with an increased risk of progression to EAC. Signup and view all the answers

What are three ways in which tumor suppressor genes can be inactivated?

Tumor suppressor genes can be inactivated by mutation, loss of heterozygosity (LOH), or epigenetic suppression of gene expression through DNA hypermethylation. Signup and view all the answers

How does DNA hypermethylation contribute to inactivation of tumor suppressor genes?

DNA hypermethylation involves the abnormal addition of methyl groups to cytosine bases in gene promoter regions, which silences gene expression. Signup and view all the answers

Explain the potential role of HER2/neu in esophageal cancer development.

HER2/neu is overexpressed in a significant portion of patients with Barrett's esophagus or esophageal adenocarcinoma, potentially playing a role in the transition from dysplasia to adenocarcinoma and correlating with a poor prognosis. Signup and view all the answers

Why is the use of aspirin and NSAIDs potentially linked to a reduced risk of Barrett's esophagus development?

Overexpression of COX-2 is observed in both Barrett's esophagus and esophageal adenocarcinoma, and aspirin and NSAIDs are known to inhibit COX-2 activity. Signup and view all the answers

What are the two main treatment approaches for inoperable esophageal cancer?

The two main approaches for inoperable esophageal cancer are palliative chemoradiotherapy for non-obstructed cases and procedures like LASER tunneling, endoluminal stenting, photodynamic therapy, or feeding tubes in obstructed cases. Signup and view all the answers

Describe the two main options for replacing the esophagus after esophagectomy.

The two main options for replacing the esophagus after esophagectomy are colon interposition and gastric pull-up. Signup and view all the answers

What factors contribute to the poor prognosis for esophageal cancer?

Factors contributing to the poor prognosis of esophageal cancer include old age, bad general condition before operation, early local spread, and high morbidity after operation like empyema or leakage from anastomosis. Signup and view all the answers

Why is surgery not always necessary for treating esophageal cancer?

Studies have shown that combining radiation and chemotherapy can achieve similar cure rates to surgery, making surgery potentially unnecessary in some cases. Signup and view all the answers

Explain the rationale for using chemoradiotherapy as a treatment for operable esophageal cancer.

Following radical surgery, chemoradiotherapy is used to eliminate any remaining cancer cells and reduce the risk of recurrence. Signup and view all the answers

Study Notes

Esophageal Cancer - Overview

Esophageal cancer is the 6th leading cause of cancer deaths globally.
Two main histologic types: squamous cell carcinoma (SCC) and adenocarcinoma (AC).
SCC is more evenly distributed throughout the esophagus, while AC predominantly affects the distal esophagus and gastroesophageal junction.
SCC accounts for over 90% of esophageal malignancies
The location of onset of SCC in descending order is typically: middle third, upper third, and lower third (ratio 50:15:35 approximately).
Adenocarcinoma incidence has increased rapidly since 1970, now accounting for over 70% of esophageal cancers in Caucasian males in the US due to its correlation with obesity, GERD (Gastroesophageal reflux disease), and Barrett's esophagus.

Esophageal Cancer - Risk Factors

Chronic irritation: Alcohol, cigarette smoking, HPV infection, caustic injury, drinking very hot liquids, previous radiation therapy, and gastroesophageal reflux disease.
Dietary: Ingestion of exogenous carcinogens and promoting factors like nitrates, nitrosamines, and aflatoxins (mycotoxins). Lack of protective substances in fruits and green vegetables (vitamin A, B2, C, E and iron, zinc).
Precancerous conditions: Gastroesophageal reflux disease (GERD) and Barrett's esophagus.
Achalasia: A primary esophageal motility disorder characterized by the absence of esophageal peristalsis and impaired relaxation of the lower esophageal sphincter (LES).
Corrosive strictures: Thickening of the skin of the hands and feet (tylosis) associated with a high risk of squamous cell carcinoma.

Epidemiology

High-risk areas include South America and the Asian Esophageal Cancer Belt (Turkey, Iraq, Iran, and parts of the former Soviet Union). High incidence reaches 800 per 100,000 population.
Esophageal Squamous Cell Carcinoma (ESCC) is the prevalent type in Asia, particularly in China, where it accounts for over half of global ESCC cases.
The incidence rises steadily with age, reaching a peak in the 6th-7th decades of life.
Male:Female ratio is approximately 3.5:1.
In the United States, the incidence of esophageal cancer is lower. Black people tend to have a higher incidence of squamous cell carcinoma. White people have a prevalence of adenocarcinoma.

Esophageal Cancer - Clinical Presentation

Dysphagia (difficulty swallowing): Late onset, continuous and progressive course, often with short duration (few months).
Regurgitation: A late symptom.
Pain: Usually a late manifestation, related to swallowing or extension into nearby structures.
Complications: Weight loss, malnutrition, dehydration, anemia, aspiration pneumonia, distant metastasis, invasion of other structures.
- Structures like trachea, nerves (recurrent laryngeal nerve), diaphragm

Esophageal Cancer - Diagnosis

Upper Endoscopy: With biopsy and cytology. Crucial for diagnosis and evaluation of resectability (the possibility of being surgically removed).
Imaging modalities (CT, MRI): Useful for staging the cancer (determining its extent and the spread). This helps assess the local and distant spread of the tumor. Imaging is important to determine whether the tumor is operable.
Laboratory tests (Complete blood count, occult blood in stool, CEA). These assess possible underlying conditions and related complications, such as anemia and identify potential presence of the tumor.

Esophageal Cancer - Staging -TNM

A staging system using Tumor, Node, Metastasis (TNM) classifications. This system provides a standardized way to describe the extent and spread of the cancer. These measurements provide the basis for treatment plan considerations and overall prognosis.
Based on the location, size, and extent of the tumor, which lymph nodes are affected or if there are distant metastases.

Esophageal Cancer - Treatment

Operable cancer: Radical surgery followed by chemoradiotherapy.
Inoperable cancer: Palliative procedure. Chemoradiotherapy or procedures to keep the esophagus open.

Esophageal Cancer - Treatment Options

Operable cancer: Different surgical approaches (total, partial esophagectomy, and subtotal esophago-gastrectomy) depending on the location of the tumor. Procedures that replace the tumor-affected section of the esophagus (with sections of stomach, colon, or other structures).
Inoperable cancer:
- Palliative therapy (chemoradiotherapy, endoscopic options to relieve difficulties in swallowing, and nutrition-related complications).
- Procedures such as esophageal dilation, stent placement, or percutaneous endoscopic gastrostomy (PEG) or jejunostomy to address obstructive symptoms.

Esophageal Cancer - Prognosis

Often has a poor prognosis, particularly in advanced stages diagnosed at an older age with bad overall health conditions before surgery. Early spread after surgery can be a factor influencing poorer survival rates (5-year survival rate less than 5%).

Esophageal Cancer - Early Esophageal Cancer

Endoscopic Eradication Therapy (EET): Recommended for HGD (high-grade dysplasia) and intramucosal cancers (T1a). EET has become the favoured option over esophagectomy.

Molecular Pathways for Esophageal Cancer Development

Genetic and epigenetic changes: Important in neoplastic progression. The changes are induced by acid and/or bile in the gastroesophageal reflux (GER) either directly or indirectly. Multiple genetic changes are present in Barrett's esophagus (BE).
Chronic inflammation: A key player in the development of BE.
Abnormal protein production: Overexpression of certain proteins like COX2 and HER2/neu.
Cellular modifications: Reprogramming and trans-differentiation of stem cells and mesenchymal-to-epithelial transition.
Oxidative stress: A contributor to cellular damage from bile acids.
Tumor suppressor genes in activation: Inactivating or mutating tumor suppressor genes such as TP53, KRAS, and RB.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

This quiz covers critical topics related to esophageal cancer, including HPV serotypes, Barrett's Esophagus, neoplastic transformation, and the role of tumor suppressor genes. Additionally, it explores the relationship between reflux disease and Barrett's, along with potential treatment approaches for esophageal cancer. Test your knowledge on these important aspects of gastrointestinal oncology!