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Questions and Answers
What is the 6th most common cause of death worldwide?
Esophageal cancer
What is the 5-year survival rate for people diagnosed with esophageal cancer?
18.8%
Which type of esophageal cancer constitutes 60-80% of cases?
What is the leading cause of cancer in Western countries?
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Adenocarcinoma is more common in developed countries than squamous cell carcinoma.
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Which factor is NOT associated with the etiology of Squamous Cancer?
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What is the most common symptom of esophageal cancer?
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Esophageal cancer typically has a serosa present.
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What factors are linked to the development of Barrett's esophagus?
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Which of the following is the most common benign tumor of the esophagus?
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What is the definitive diagnosis for esophageal cancer?
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What is a common complication of esophageal cancer surgery?
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What kind of treatments are considered palliative for esophageal cancer?
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What stage of esophageal cancer is indicated by suspicious full-thickness wall involvement and less than 8 lymph nodes involved?
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What is the main symptom of esophageal sarcoma?
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Which imaging technique is used for early diagnosis of esophageal cancer?
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List two common symptoms of esophageal leiomyoma.
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Esophageal sarcomas usually metastasize to lymph nodes.
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Which of the following is the most common benign tumor of the esophagus?
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What is the primary method for the definitive diagnosis of esophageal cancer?
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Anastomotic leakage is the least common complication after esophageal surgery.
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Which imaging technique is used for early diagnosis of esophageal cancer?
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What are the two main types of treatment for esophageal cancer?
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The presence of _____ in esophageal cancer significantly impacts operability.
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What is a common symptom of esophageal tumors?
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Which staging technique uses imaging to assess lymph node status in esophageal cancer?
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What is the average 5-year life expectancy after resection for esophageal cancer?
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What is the 5-year survival rate for esophageal cancer?
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Which type of esophageal tumor constitutes 60-80% of cases?
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Adenocarcinoma is more common in underdeveloped countries than squamous cell carcinoma.
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What are the two main types of esophageal cancer mentioned?
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The most common symptom of esophageal cancer is _____
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What is the relationship between Barrett's esophagus and adenocarcinoma?
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Which factors contribute to the etiology of squamous cell carcinoma?
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Esophageal tumors are only found in the lower third of the esophagus.
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List one symptom of esophageal cancer.
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Which type of esophageal tumor is indicated as more common in Western countries?
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What syndrome is mentioned as a risk factor for adenocarcinoma development?
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Study Notes
Esophageal Cancer
- Esophageal cancer is the 6th most common worldwide cause of death, with a 5-year survival rate of 18.8%.
- The main symptoms include dysphagia (difficulty swallowing), odynophagia (painful swallowing), and aspiration pneumonia.
- Dysphagia usually progresses over time, with difficulty swallowing solid foods first, followed by difficulty swallowing warm foods.
- Pain can be a late symptom, indicating tumor metastasis or invasion.
- Weight loss, weakness, and pyrosis are also common symptoms.
- Jaundice and bone pain can indicate systemic organ metastasis.
- Late findings occur due to the lack of serosa in the esophagus, resulting in 60% infiltration of surrounding tissue before symptoms appear.
- The most common histological type of esophageal cancer is squamous cell carcinoma (SCC), accounting for 60-80% of cases.
- Adenocarcinoma is the leading cause of esophageal cancer in Western countries, accounting for more than 50% of cases.
- Mesenchymal sarcoma is a rarer type of esophageal cancer, representing 0.5-1.5% of all esophageal tumors.
- Squamous cell carcinoma is most commonly located in the mid-thoracic esophagus, while adenocarcinoma is often found in the lower third.
- Lower esophageal adenocarcinoma often originates from Barrett's mucosa, which can be caused by GERD.
Esophageal Cancer: Risk Factors
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Contributing factors to squamous cell carcinoma include:
- Alcohol and cigarette consumption
- Environmental factors like contaminated water, lead/heavy metals, and food additives
- Nitrous compounds found in burnt meats and pickled vegetables
- Vitamin deficiencies, particularly Riboflavin (B2) and Vitamin A
- Mineral deficiencies, including zinc and molybdenum
- Achalasia
- Corrosive esophagitis
- Plummer-Vinson syndrome
-
Contributing factors to adenocarcinoma include:
- GERD and Barrett's esophagus
- Cigarette smoking
- Obesity
- Metabolic syndrome
- Achalasia
-
Adenocarcinomas developing in patients with achalasia are often seen in the middle esophagus, while adenocarcinomas developing in patients with Barrett's esophagus are commonly found in the lower esophagus.
Esophageal Cancer: Spread and Metastasis
-
Spread can occur through:
- Direct invasion
- Lymphatic invasion – most frequent occurrence
- Vascular invasion
- Most common metastatic sites are the liver (2), lungs, and bones.
Esophageal Cancer: Siewert Classification
- The Siewert classification system categorizes esophagogastric junction (EGJ) adenocarcinomas.
- Types 1 and 2 are considered esophageal tumors, while Type 3 is considered a gastric tumor.
- Type 1 tumors are located 2-5 cm distal to the EGJ.
- Type 3 tumors are located within the stomach.
Esophageal Cancer: Histological Type and Localization
- The most common histological type is squamous cell carcinoma.
- Localization is typically in the thoracic region.
Esophageal Cancer
- Barium Esophagus X-ray: Irregular narrowing of the lumen, finger-print sign
- Esophagoscopy: Biopsy is the best way to make a diagnosis
- Chromoendoscopy (using Lugol's solution and toludine blue) is used for early diagnosis
- Endomicroscopy detects flat lesions, termed SCL.
- Endoscopic Ultrasound: Used for T staging and lymph node status.
- PET Scan: Used for locoregional disease staging
- Bronchoscopy: Determines if there is any bronchial infiltration.
- Treatment:
-
Palliative:
- Endoscopic treatments such as bougie, intubation, stenting, electrocoagulation and laser.
- Radiotherapy.
-
Curative:
- Endoscopic treatment
- Neoadjuvant radiotherapy
- Surgery
-
Palliative:
Early Stage Esophageal Cancer
- Full thickness wall involvement of the tumor OR less than 8 lymph nodes involved
Endoscopic Treatments
- EMR (Endoscopic Mucosal Resection): Less than 2 cm diameter, well or moderately differentiated, no muscularis mucosa invasion, no lymphovascular invasion, clean edges.
- ESR (Endoscopic Submucosal Resection): Used for larger lesions.
Operability
- Low possibility of resection if tumor size is greater than 8 cm.
- N2 or 5 or more lymph nodes metastases - curative resection can be attempted
- Presence of metastasis - curative resection should NOT be attempted
- General situation:
- Advanced age (above 75)
- Cachexia
- Pulmonary insufficiency, cardiac, renal, hepatic insufficiency
- EF below 40
Cervical Esophageal Cancer
- Radiation and surgery provide equal survival rates.
- Pharyngolaryngoesophagectomy + pharyngogastrostomy
Thoracic Inlet (Supraaortic Region)
- Resection is difficult due to surrounding structures.
- Neoadjuvant chemo-radiotherapy to reduce tumor size
- Esophagectomy + esophagogastrostomy
Lower Esophageal and Cardia Tumors
- Mostly adenocarcinoma.
- Treatment is combined with surgical lymph node dissection due to skip metastasis
- Esophagectomy with at least 10 cm solid margin.
- Ideal continuity: Colon
- Mostly stomach
- Less often: Jejunum
- Right gastroepiploic and right gastric arteries should be protected during surgery
Complications of Esophageal Cancer Treatment
- Anastomotic leakage (2-30%)
- Respiratory problems
- Mean mortality rate: 0.8-37.5%
- Life expectancy after surgical resection: 18% at 5 years.
- Early diagnosis improves survival to 50-75%
- Chemoradiotherapy is used both neoadjuvantly and adjuvantly.
Esophageal Sarcoma and Carcinosarcomas
- Finding: Dysphagia, aspiration pneumonia, airway obstruction, tracheoesophageal fistula
- Unlike carcinomas: Sarcomas remain on the muscularis propria and metastasize to lymph nodes less often.
- Diagnosis: Barium esophagus X-ray, endoscopy
- Histological types: Epidermoid, Mesenchymal (leiomyosarcoma, fibrosarcoma, rhabdomyosarcoma)
- Treatment: Surgical resection (wall invasion and LAP should be absent), Radiotherapy is often unsuccessful.
Benign Esophageal Tumors
- Leiomyoma: most common benign tumor (50%), smooth muscle origin, lower thoracic, 20-50 years old, male, symptoms include dysphagia, pain, bleeding is rare.
- Diagnosis: Barium esophagus X-ray (regular filling defect, movable with swallowing), Endoscopic USG, CT, Endoscopy (for distinction from carcinoma, biopsy not performed).
- Treatment: Enucleation (thoracomy or endoscopic).
Esophageal Cancer
- The 6th most common cause of death, with a 5-year survival rate of 18.8%
- Symptoms include odynophagia (painful swallowing), dysphagia (difficulty swallowing), and aspiration pneumonia
- Weight loss, weakness, and pyrosis (heartburn) can also occur
- Can spread through direct invasion, lymphatic invasion, and vascular invasion
- Most frequent site of spread is to the liver, lungs, and bones
- Can cause a tracheoesophageal fistula (a connection between the trachea and esophagus)
Types of Esophageal Tumors
-
Squamous Cell Carcinoma (SCC):
- Constitutes 60-80% of esophageal tumors
- Most common type
- Located mainly in the mid-thoracic esophagus
-
Adenocarcinoma:
- Leading cause of cancer in Western countries
- Accounts for more than 50% of cases
- Located primarily in the lower third of the esophagus
-
Mesenchymal Sarcoma:
- Represents 0.5-1.5% of all esophageal tumors
- More prevalent in rural areas and underdeveloped communities
Etiology of Squamous Cancer
- Alcohol and cigarette consumption
- Environmental factors:
- Contaminated drinking water
- Lead and heavy metal exposure
- Food additives, such as nitrous compounds in burnt meats and pickled vegetables
- Vitamin deficiencies:
- Riboflavin (B2)
- Vitamin A
- Mineral deficiencies:
- Zinc
- Molybdenum
- Achalasia
- Tylosis
- Plummer-Vinson syndrome
- Esophageal diverticulum
- Leukoplakia
Etiology of Adenocarcinoma
- Barrett's esophagus due to GERD
- Cigarette smoking
- Obesity
- Metabolic syndrome
- Achalasia
Siewert Classification for Esophagogastric Junction (EGJ) Adenocarcinomas
- EGJ adenocarcinomas, except Siewert 3 tumors, are considered esophageal tumors
- Siewert 3 tumors are located 2-5 cm distal from the EGJ
- Siewert classification helps determine the most appropriate surgical approach:
- Type 1: Esophagectomy is the preferred treatment.
- Type 2: A combination of esophagectomy and gastrectomy may be necessary.
- Type 3: Gastrectomy is typically performed.
Esophageal Cancer: Histological Types and Localization
-
Squamous cell carcinoma:
- Localized primarily in the thoracic region
-
Adenocarcinoma:
- Often originates in the bottom third of the esophagus
- Can also arise from Barrett's mucosa, resembling stomach cancer
Esophageal Cancer: Symptoms and Spread
-
Dysphagia (progressive):
- The most common symptom
- Late manifestation due to the absence of a serosa in the esophagus
-
Pain:
- Often associated with metastasis and direct invasion
-
Aspiration pneumonia:
- Occurs due to invasion and potential tracheoesophageal fistula formation.
-
Weight loss, weakness, and pyrosis:
- May be the initial symptoms of cardiac tumors
-
Systemic organ metastasis:
- Can cause jaundice and bone pain
- Occurs in over 40% of cases
Esophageal Cancer
- Barium esophagus X-ray can detect irregular narrowing of the lumen, which can be a sign of esophageal cancer.
- The "Finger-print" sign in a barium esophagus X-ray can indicate esophageal cancer.
- Esophagoscopy is the best diagnosis for esophageal cancer.
- Biopsy is the definitive diagnosis for esophageal cancer.
- Chromoendoscopy (using Lugol and toluidine blue) is an early diagnosis for esophageal cancer.
- NBI (Narrow Band Imaging) is used to help find early signs of esophageal cancer.
- Endoscopic ultrasound is used to determine the T staging and lymph node status of esophageal cancer.
- IT (Imaging Techniques) are used for locoregional disease staging, including thorax and upper abdomen imaging.
- PET (Positron Emission Tomography) is another technique for locoregional disease staging.
- Bronchoscopy is done to determine if there is any bronchial infiltration.
- Palliative treatments for esophageal cancer focus on symptom management and quality of life.
- Curative treatments for esophageal cancer aim to eradicate the disease.
- Endoscopic treatments are used for both palliative and curative purposes. Examples include bougie, intubation, stent, electrocoagulation, and laser.
- Radiotherapy can be used for both palliative and curative purposes.
- Neoadjuvant RT (radiation therapy before surgery) is sometimes used for esophageal cancer.
- Surgery is the primary curative treatment for esophageal cancer.
- Early-stage esophageal cancer is defined as no suspicious full-thickness wall involvement of the tumor or less than 8 lymph nodes involved.
- EMR (Endoscopic mucosal Resection) is a treatment option for early-stage esophageal cancer that is less than 2 cm in diameter, well or moderately differentiated, no muscularis mucosa invasion, no lymphovascular invasion, and clean borders.
- ESR (Endoscopic Submucosal Resection) is another minimally invasive treatment option for early stage esophageal cancer.
- The possibility of resection is low for tumors larger than 8 cm.
- N2 or more than 5 lymph node metastases make resection difficult.
- Advanced age (75), cachexia, pulmonary insufficiency, cardiac, or renal issues can make resection difficult.
- EF (Ejection Fraction) below 40% can also make surgery difficult.
- Cervical esophageal cancer can be treated with radiation or surgery.
- Thoracic inlet (Supraaortic region) esophageal cancer is difficult to resect due to the nearby structures.
- Neoadjuvant chemo-radiotherapy is used to reduce the size of the tumor before surgery.
- Lower esophageal and cardia tumors are more likely to be adenocarcinomas.
- Longitudinal lymph flow leads to the possibility of skip metastasis.
- Esophagectomy is the surgery to remove the esophagus.
- For esophagectomy, the ideal continuity is colon, followed by stomach, then jejunum.
- The right gastroepiploic and right gastric artery should be protected during esophagectomy.
- Anastomotic leakage is the most common complication after surgery.
- Respiratory problems can also occur after surgery.
- The mortality rate for esophageal cancer treatments can range from 0.8% to 37.5%.
- The average life expectancy after resection is 5 years with a 18% survival rate.
- Early diagnosis of esophageal cancer leads to a 50-75% survival rate.
- Chemoradiotherapy can be used before (neoadjuvant) or after (adjuvant) surgery.
Esophageal Sarcoma and Carcinosarcomas
- Dysphagia, aspiration pneumonia, and airway obstruction can occur due to esophageal sarcoma.
- Unlike carcinomas, sarcomas stay on the muscularis propria and tend to metastasize less to lymph nodes.
- Barium esophagus X-ray and endoscopy are used for diagnosis.
- Epidermoid carcinoma and mesenchymal tumors are the common histological types of esophageal sarcoma.
- Mesenchymal tumors include leiomyosarcoma, fibrosarcoma, and rhabdomyosarcoma.
- Surgical resection is the primary treatment for esophageal sarcoma.
- Radiotherapy is not as effective for sarcomas.
Benign Esophageal Tumors
- Leiomyoma is the most common benign tumor of the esophagus.
- It is of smooth muscle origin and frequently found in the lower thoracic region.
- The tumor is more frequent in males aged 20-50.
- Dysphagia and pain are common symptoms.
- Bleeding is rare.
- Barium esophagus X-ray can show a regular filling defect with distinct edges.
- Endoscopic ultrasound can help to diagnose a leiomyoma definitively.
- CT can also provide a definitive diagnosis.
- Endoscopy is used to rule out carcinoma, and biopsy isn't performed.
- Enucleation (either thoracotomy or endoscopic) can be used to remove leiomyomas.
- Treatment depends on the risk of malignancy.
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Description
Explore the critical facts about esophageal cancer, including common symptoms, survival rates, and histological types. Understand the progression of dysphagia and the significance of timely diagnosis to improve survival outcomes. This quiz will test your knowledge on this serious health condition.
