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Oesophageal carcinoma
Oesophageal carcinoma
The majority of oesophageal cancers are squamous cell (SCC) or adenocarcinoma (AC).
Adenocarcinoma | Squamous cell carcinoma |
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Incidence is rising dramatically | Incidence is falling |
Largely a disease of male caucasians | Highest rates in blacks and Asians |
Alcohol not an important risk factor. Smoking is a risk factor especially in Barrett’s oesophagus |
Smoking and alcohol- major risk factors |
Predisposing factors- Barrett’s, Chronic reflux, Obesity, absence of H.Pylori (?) |
Achalasia, caustic strictures, Tylosis |
Majority are located near GO junction | Midportion of the oesophagus |
Clinical manifestations
Investigations
TNM staging
T1- Tumor invades lamina propria or submucosa (a-lamina propria, b-submucosa) T2- Tumor invades muscularis propria T3- Tumor invades adventitia T4- Tumor invades adjacent structures N1- Regional lymph node metastasis M1- Distant metastasis |
Stage I- T1N0M0 Stage IIa- T2T3/N0M0 Stage IIb- T1T2/N1M0 Stage III- T3N1M0, T4, any N, M0 Stage IV- M1 |
Management of resectable tumours
Who are surgical candidates?
What is the type of surgery needed?
Patients with either AC or SCC involving the middle or lower third of the oesophagus generally require total oesophagectomy because of the risk of submucosal skip lesions. The most popular methods used are the transhiatal and transthoracic (Ivor-Lewis) approaches. Gastric interposition is most commonly used as a conduit for reconstruction following oesophagectomy.
A radical two-field (abdominal and thoracic) lymph node dissection is also undertaken. Japanese do a three field (including neck) lymph node dissection.
What are the risks of surgery?
Clinical anastomotic leakage should not exceed 5%. Curative (R0) resection rates should exceed 30%. Overall hospital mortality for oesophageal resection should be less than 10%.
What is the prognosis?
Five year survival rate is over 80% when tumours are confined to the mucosa and between 50% and 80% when the submucosa is involved.
What is the role of adjuvant chemotherapy?
There is no evidence for a role of adjuvant chemotherapy in oesophageal cancer. However, for patients with completely resected node-positive disease who have not received neoadjuvant therapy, postoperative adjuvant chemotherapy should be considered, although whether chemotherapy alone or chemoradiotherapy should be used is unclear.
Is there any role of chemo-radiation?
What is the role of local treatments?
All submucosal tumors have a substantial risk of lymph node metastases. Local lymph node invasion occurs early and quickly because the lymphatics in the oesophagus are located in the lamina propria, in contrast to the rest of the gastrointestinal tract, in which they are located in the submucosa. Hence, local treatments like Endoscopic mucosal resection (EMR) and photodynamic therapy (PDT) may be considered in selected patients (especially poor surgical risk patients) as potentially curative options for superficial oesophageal cancer, confined to the mucosa.
Who is fit for surgery?
The previous medical history and concurrent morbidity remain the strongest predictors regarding fitness for surgery. Pre-existing ischaemic heart disease, poorly controlled hypertension, and pulmonary dysfunction are all associated with increased operative morbidity. The American Society of Anaesthesiologists (ASA) classification of physical status is well recognised. Perioperative risk increases with increasing ASA score. Only those patients with an ASA score of 3 or less should be considered for surgery.
How do you follow up these patients post treatment?
There is little consensus for the mode, duration, or intensity of follow up in patients with malignant disease. There is no evidence that intensive follow up improves the speed of detection of recurrent disease in oesophageal or gastric cancers. However, majority of patients prefer regular follow up.
Management of unresectable oesophageal cancer
What is an unresectable tumour?
The current staging system for oesophageal cancer is based largely on retrospective data from the Japanese Committee for Registration of Oesophageal Carcinoma. It is most applicable to patients with SCC of the upper- and middle-thirds of the oesophagus, as opposed to the increasingly common distal oesophageal and GO junction adenocarcinomas. In particular, the classification of involved abdominal lymph nodes as M1 disease has been criticized. The presence of positive abdominal lymph nodes does not appear to carry as grave a prognosis as metastases to distant organs. Patients with regional and/or coeliac axis lymphadenopathy should not necessarily be considered to have unresectable disease due to metastases. Complete resection of the primary tumor and appropriate lymphadenectomy should be attempted when possible.
What are the Palliative options for unresectable disease?
Combined chemoradiotherapy should be first line of treatment as this offer a small but real chance of sustained disease control and long term survival. Approximately 60% of patients would be dysphagia free till death. However, the time to onset of improvement of dysphagia is slow. In a study, median time to improvement in symptoms was two months after radiotherapy, variable but prolonged after chemotherapy, and immediate after stent insertion.
Who is fit for chemotherapy?
Fitness for chemotherapy is generally assessed by using The World Health Organisation performance scale. It has categories from 0 to 4.
0 – fully active patient.
1 – cannot carry out heavy physical work, but can do anything else.
2 – up and about more than half the day; can look after himself, but not well enough to work.
3 – in bed or sitting in a chair for more than half the day; need some help in looking after him
4 – in bed or a chair all the time and need a lot of looking after
Good performance status is 0 or 1. Poor performance status is 2-4.
Generally patients are considered fit for chemotherapy with good performance status (PS0, PS1). Good PS2 (leaning towards PS1) are also generally considered fit for chemotherapy
Survival
Reported five-year survival rates for stages I to IV disease are 60, 31, 20, and 4 percent, respectively.
Table 1. ASA Scores. | ||
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Class | Physical status | Example |
I | A completely healthy patient | A fit patient with an inguinal hernia |
II | A patient with mild systemic disease | Essential hypertension, mild diabetes without end organ damage |
III | A patient with severe systemic disease that is not incapacitating | Angina, moderate to severe COPD |
IV | A patient with incapacitating disease that is a constant threat to life | Advanced COPD, cardiac failure |
V | A moribund patient who is not expected to live 24 hours with or without surgery | Ruptured aortic aneurysm, massive pulmonary embolism |
E | Emergency case |
Normal oesophageal structure:
Ref:
Self assessment
Answers :
F T T T F F F F F T
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