CA Esophagus - AI Generated Trial - PDF

CA esophagus ------------ Epidemiology - - - +-----------------------+-----------------------+-----------------------+ | | Squamous cell | Adenocarcinoma (ADC) | | | carcinoma (SCC) | | +======================...

CA esophagus ------------ Epidemiology - - - +-----------------------+-----------------------+-----------------------+ | | Squamous cell | Adenocarcinoma (ADC) | | | carcinoma (SCC) | | +=======================+=======================+=======================+ | Risk factors | Lifestyle: | **GERD** | | | **[smoking, | | | | alcohol]* | **Barrett | | | *, | oesophagus** | | | **hot drink, | | | | nitrosamine**, betel | | | | nut, corrosive / | | | | caustic injury | | | | | | | | **Oesophageal | | | | disorders**: | | | | achalasia, | | | | Plummer-Vinson | | | | syndrome\^, | | | | long-standing | | | | esophagitis | | | | | | | | Genetics: tylosis\^ | | +-----------------------+-----------------------+-----------------------+ | Site | Mostly in upper 2/3 | Mostly in lower 1/3 | +-----------------------+-----------------------+-----------------------+ | Morphology | Fungating \> | | | | ulcerative \> | | | | infiltrative | | +-----------------------+-----------------------+-----------------------+ | Tumor spread | Direct extension | | | | (e.g. | | | | tracheo-esophageal | | | | fistula) | | | | | | | | Vascular and | | | | lymphatics | | +-----------------------+-----------------------+-----------------------+ | Management | More sensitive to | Less sensitive to | | | chemoRT | chemoRT surgery | +-----------------------+-----------------------+-----------------------+ Other possible pathology: neuroendocrine tumor, leiomyoma, GIST, lymphoma - - Clinical features - - - - - - - - - - [Investigations] - - - - - - - - T: Assess depth of wall invasion: important to distinguish T1a vs T1b (need open surgery) - N: EUS-guided FNAC of suspicious LN (hypoechoic, \>1cm, spherical, homogenous) - Can also implant metallic markers for delineation of RT - - - Can also assess the metabolic activity after neoadjuvant chemoRT / detect recurrence - May pick up additional signals (e.g. reactive hilar LN due to smoking) - - - - - - - [Management:] - **Tumor factor (staging):** size and location of tumor, location of anastomosis, regional invasion, LN - Resectable: pleura, pericardium, diaphragm - Unresectable: aorta, trachea, vertebral body - **Patient factor:** age, smoker, comorbidities, [lung function] (**FEV1 \> 1.5L**), [exercise tolerance] (**\> 2 flight of stairs**) - **Organ factor:** method of reconstructing esophagus +-----------------------+-----------------------+-----------------------+ | Stage | TNM staging | Treatment | +=======================+=======================+=======================+ | 0 | Tis, N0, M0 | Tis/T1a (confined to | | | | mucosa): **EMR / | | | | ESD** | | | | | | | | T1b (invades | | | | submucosa): | | | | **esophagectomy** | +-----------------------+-----------------------+-----------------------+ | 1 | T1, N0, M0 | | +-----------------------+-----------------------+-----------------------+ | 2 | T2-3, N0, M0 | Operable SCC: | | | | **neoadjuvant chemoRT | | | T1-2, N1, M0 | + esophagectomy** | | | | | | | | Inoperable SCC: | | | | upfront chemoRT +/- | | | | esophagectomy (if | | | | downstaged) | | | | | | | | Operable ADC: | | | | **esophagectomy** | | | | | | | | Inoperable ADC: | | | | chemoRT | +-----------------------+-----------------------+-----------------------+ | 3 | T3, any N, M0 | | +-----------------------+-----------------------+-----------------------+ | 4 | any T, any N, M1 | Esophageal balloon | | | | dilation +/- stenting | | | | | | | | Palliative chemoRT | +-----------------------+-----------------------+-----------------------+ Endoscopic therapy: **Endoscopic mucosal resection (EMR)** / **Endoscopic submucosal dissection (ESD)** - Only for **T1a cancers (limited to mucosa)** - Preserves esophagus, less invasive, safe and highly effective (90% survival) - ESD has higher en-bloc resection rate - Procedure: using hyaluronic acid + saline to elevate the lesion snare and remove [Esophagectomy] - - - - - - - - - - - For OGJ tumour, partial gastrectomy may be required - - +-----------------------+-----------------------+-----------------------+ |   | Two-stage | **Three-stage | | | (Ivor-Lewis) | (McKeown) - preferred | | | | for SCC** | +=======================+=======================+=======================+ | Site of tumour | **Mid/lower** | All (including | | | | proximal) | +-----------------------+-----------------------+-----------------------+ | Incisions | 2 incisions |  | | | | 3 | | | - Upper midline | incisions | | | abdominal | | | | incision | - Upper midline | | | | abdominal | | | - **Right** | incision | | | thoracotomy | | | | (above 5^th^ | - **Right** | | | rib)A diagram of | thoracotomy | | | the scapula | | | | Description | - **Left** neck | | | automatically | incisions | | | generated | | +-----------------------+-----------------------+-----------------------+ | **Anastomosis** | **Thorax** | **Neck** | +-----------------------+-----------------------+-----------------------+ | Stages\* | 1\. **Abdominal:** | 1\. **Thoracic:** | | | gastric | mobilization and | | | mobilization + | dissection of | | | pyloroplasty | esophagus | | | | | | | 2\. **Thoracic**: | 2\. **Abdominal:** | | | mobilization and | gastric | | | transection of | mobilization **+** | | | esophagus, O-G | pyloroplasty | | | anastomosis | | | | | 3\. **Cervical:** | | | | mobilization and | | | | transection of | | | | upper esophagus, | | | | O-G anastomosis | +-----------------------+-----------------------+-----------------------+ | Pros | Reduced OT time | **Less severe | | | | consequence** of | | | Lower risk of | anastomotic leak can | | | anastomotic leak | control by lay-open | | | | cervical wound | +-----------------------+-----------------------+-----------------------+ | Cons | Severe consequence of | Higher risk of **left | | | anastomotic leak: | RLN injury** | | | **mediastinitis high | | | | mortality** | **Higher risk of | | | | anastomotic leak** | | | Not suitable for | (10%): gastric | | | higher tumour | conduit has more | | | | tension and poorer | | | | blood supply | +-----------------------+-----------------------+-----------------------+ - - - - - - - - - - - - - - - - - [Neoadjuvant therapy] (CROSS 2012 trial) - - - 6-8 weeks for 2 courses wait 4 weeks and repeat PET-CT + OGD wait 4 weeks for surgery - [Complications of esophagectomy] Early complications - **Post-op pneumonia (20%)**: due to smoker status, thoracotomy, one-lung ventilation, vocal cord palsy - **Reactional bleeding:** transection of azygos vein / aortic branches to esophagus - Conduit related: - **Anastomotic leak (10%)** *-- DDx: conduit ischemia* - Risk factors: poor blood supply of oesophagus, tension of conduit, absence of serosa, use of neoadjuvant RT, surgeon technique - Management: - NPO, IV fluids, TPN, antibiotics, monitor drain output - Conservative: **lay open** for drainage (three-stage only) - Endoscopic: stenting, endoscopic vacuum therapy (e.g. **EndoSponge**) - **Conduit ischaemia** - Suspect if sepsis or metabolic acidosis within first 24h - Prevention: **intra-op ICG** - Investigations: **CT thorax + abdomen with contrast, OGD** - Management: - Conservative if mild (Types 1 / 2) - Take down anastomosis if severe (Type 3): cervical esophagostomy + resection of ischemic conduit - Injury to neighbouring structures - **RLN injury** (20%) during LN dissection - Vagus nerve injury: delayed gastric emptying routine pyloroplasty - **Thoracic duct injury**: **chylothorax** - Diagnosis: ↑drain output (milky appearance), TG \>110 or chylomicrons in pleural fluid - Management - Monitor: clinical (SOB), CXR, drain output - Determine drain output: low volume (\1L/day) - Diet: **NPO + TPN** - **Octreotide** - Re-operation (Suture ligation of thoracic duct stump) if output \>1L/day - Other organs: descending aorta, pulmonary vein, trachea/bronchus, heart - GA complications: e.g. atelectasis -- **one lung ventilation** during surgery Late complications - **Anastomotic stricture**: require endoscopic dilation - **Post-op GERD**: PPI, motility agents - Biliary reflux - Delayed gastric emptying [Primary chemoRT] - - [Palliative treatments] - **Endoscopic stenting:** SEMS with silicon coating to palliate significant dysphagia, unable to go RT after this - **Endoscopic local ablation** (e.g. argon plasma coagulation, laser ablation): open esophageal lumen / unblock stent - Nutritional support: NG tube / PEG tube / open gastrostomy / jejunostomy - External radiotherapy / brachytherapy (intraluminal RT)