Esophageal Cancer Lecture 2 PDF

ESOPHAGEAL CANCER  Epidemiology The most common types of esophageal cancer : Squamous cell carcinoma Adenocarcinoma is the fifth most common type of gastrointestinal malignancy The incidence of esophageal adenocarcinoma has been increasing e...

ESOPHAGEAL CANCER  Epidemiology The most common types of esophageal cancer : Squamous cell carcinoma Adenocarcinoma is the fifth most common type of gastrointestinal malignancy The incidence of esophageal adenocarcinoma has been increasing exponentially over the past three decades  Epidemiology Esophageal cancer is a disease in epidemiologic transition : Until the 1970s, the most common type of esophageal cancer was squamous cell carcinoma, (smoking and alcohol consumption as risk factors) Last 20 ys increase in the incidence of esophageal adenocarcinoma ( BE )  Epidemiology the incidence of esophageal adenocarcinoma in the 1970s was 0.4 new cases/100,000 people per year. Currently, the incidence is 4 cases/100,000 people per year. The incidence of squamous cell carcinoma in the United States is 2.6/100,000 people per year. In China and Iran, squamous cell carcinoma :132 /100,000 people per year Overall, neoplasms of the esophagus carry a poor prognosis. The 5-year overall survival rate ranges from 2% to 26%, depending on the stage at diagnosis.  Risk Factors for Squamous Cell Cancer Environmental risk factors: tobacco, alcohol, nitrosamines (eg, those generated by grilling meat) hot liquids and caustic substances chronic stasis (achalasia). Nutritional deficiencies, : deficiency in vitamin C, previous exposure to radiation  Risk Factors for Adenocarcinoma advancing age, male sex, chronic reflux of gastric contents into the tubular esophagus, white ethnicity obesity. RISC FACTORS AK - MODEL  Signs and Symptoms of Esophageal Cancer dysphagia that in a short time progresses It usually occurs when esophageal lumen diameter is under 13 mm and indicates locally advanced disease.!!! Odynophagia, or painful swallowing Unintentional weight loss is commonly reported with later-stage disease.  Bleeding - leading to iron deficiency anemia. Pain - in the epigastric or retrosternal area; pain over bony structures indicates metastatic disease. Hoarseness -caused by invasion of the recurrent laryngeal nerve Persistent cough Respiratory symptoms  Physical examination there are no signs of esophageal cancer. In most patients, the physical examination findings are normal. late-stage disease or disease of the proximal esophagus, supraclavicular lymphadenopathy can be palpated.  Imaging Studies Upper GI endoscopy CT scanning PET scanning Endoscopic ultrasound (EUS) Bronchoscopy Barium swallow  Approach Considerations 1. Flexible endoscopy +biopsy 2. Computed tomography (CT) of the chest and abdomen for staging 3. Positron emisison tomography (PET) is : optional test for staging of early-stage esophageal cancer recommended test for staging of locoregionalized esophageal cancer. In patients without metastatic disease, endoscopic ultrasonography is recommended to improve the accuracy of staging  Consultations Diagnosis and Staging Two main components must be considered in therapeutic decision making: the patient’s condition and the stage of disease. What is the patient’s performance status? Is the patient an adequate surgical candidate? Does the patient have comorbid conditions that need to be addressed before an operation ? consultations should be considered with a gastroenterologist, medical oncologist, radiation oncologist, and thoracic surgeon.  Treatment varies according to : stage—locoregional vs metastatic cancer histologic subtype—squamous cell carcinoma (SCC) vs adenocarcinoma.  National Comprehensive Cancer Network (NCCN) treatment recommendations for esophageal cancer include the following (1): Endoscopic therapy (endoscopic mucosal resection, endoscopic submucosal dissection and/or ablation) : high-grade dysplasia (HGD) or T1a tumors ≤2 cm  National Comprehensive Cancer Network (NCCN) treatment recommendations for esophageal cancer include the following (2): Esophagectomy is indicated for patients with : extensive HGD pT1a adenocarcinoma with nodular disease that is not adequately controlled by ER Tumors in the submucosa (T1b) or deeper  Treatment strategy T2 stage or beyond benefit from a multimodality treatment approach. The use of chemoradiation therapy before surgery(neoadjuvant) resulted in pathologic complete response (pCR)—meaning that there was no evidence of viable tumor in the specimen after surgery—in 15%-30% of patients. The 3-year survival rate for patients with pCR is 50%, compared with 27% for patients without pCR. 19 DISMOTILITY DISORDES OF OESOPHAGUS Disorders of esophageal motility can be identified with manometry  Achalasia Achalasia is a primary esophageal motility disorder characterized by : the absence of esophageal peristalsis impaired relaxation of the lower esophageal sphincter (LES) => obstruction at the gastroesophageal junction (GEJ).  Pathophysiology The hallmark pathologic feature of achalasia is a decreased number of nonadrenergic, noncholinergic inhibitory ganglion cells. The cause of achalasia is unknown. Infection, especially varicella-zoster virus A similar disease pathologically is Chagas’ disease, which is due to infection by Trypanosoma Achalasia has a possible genetic component.  Clinical Presentation Dysphagia for both liquids and solids. Symptoms typically are intermittent. Chest pain is common. No weight lost  Clinical Presentation there is a long history before the correct diagnosis is made. The dysphagia typically fluctuates, which is a hint Regurgitation occurs in 60% to 90% of patients. Heartburn is common Chest pain Weight loss may occur but not very often Cough and pulmonary symptoms from aspiration.  Diagnosis Barium swallow with fluoroscopy is an excellent screening test for achalasia. classic bird’s beak appearance + dilated esophagus + typical symptoms are present= diagnosis of achalasia  Diagnosis 2 Esophageal manometry (the criterion standard): Incomplete LES relaxation in response to swallowing, high resting LES pressure, absent esophageal peristalsis Esophagogastroduodenoscopy to rule out cancer of the GEJ or fundus  Differential Diagnosis malignancy-causing pseudoachalasia. Other conditions that can cause pseudoachalasia include amyloidosis, sarcoidosis, postvagotomy, chronic intestinal pseudo-obstruction, neurofibromatosis, and even pancreatic pseudocyst.  Management The four major options for management are : drugs, botulinum toxin, pneumatic dilatation, surgical myotomy.  Drugs : relax the LES. = have very limited efficacy. Nifedipine (10-30 mg), a calcium channel antagonist, Sublingual isosorbide dinitrate (a nitric oxide donor)  Botulinum Toxin The injection decreases LES pressure by more than 30% and induces a clinical response in 60% to 75% of patients symptoms usually recur within 3 to 12 months, leading to the need for repeated injections. antibodies develop against the botulinum toxin, usually resulting in its loss of efficacy.  Pneumatic Dilatation Pneumatic dilatation has more than a 60% and up to a 90% good response rate in achalasia. A major disadvantage of pneumatic dilatation is the risk of complications. (reported rate of esophageal perforation is approximately 3%) Surgical Myotomy, Open or Laparoscopic