PPRT2: Gastrointestinal overview + oesophageal cancer

Oesophageal cancer + gastrointestinal overview

What is gastrointestinal cancer?

It refers to malignant conditions of the GI tract and accessory organs of digestion including the oesophagus, pancreas, small intestine, large intestine, rectum and anus.

What symptoms will appear relating to the organs affected?

• Obstruction: leads to difficulty swallowing or defacating

• Abnormal bleeding

• Other associated problems

What is some information and support for oesophageal-gastric cancer?

• Offer access to an oesophgo-gastric clinical nurse specialist through their MDT.

• Make sure they are given information that is given in an appropriate way and that they can review it in their own time after speaking to them about their cancer and care.

• Inform them about peer-to-peer local or national support groups if they want to join.

• Provide psychosocial support to the person and those important covering things such as:

  • Potential impact of family life, changing roles and relationship

  • Uncertainty about the disease course and prognosis

  • Concerns over heredity (inheritance) of cancer, recovery and recurrence

  • Where they can get further support

What support is there for a radical patient?

• Provide information about possible treatment options such as surgery, radiotherapy and chemotherapy

• Information should be consistent and cover:

  • Treatment outcomes (prognosis and future treatments)

  • Recovery including consequences of treatment and how to manage them

  • Nutrition and lifestyle changes

  • Following recommendations in NICE guidelines on patient experience

What support is there for a palliative patient?

Offer personalised information and support to them and the people important to them, at a suitable pace including:

• life expectancy

• Treatment and care available - how to access for both current and future symptoms

• Holistic issues and how to get support and help

• Dietary changes, how to manage and access specialist support

• Which sources give good public advice

Consider support from a specialist care dietician, specialist palliative care team and peer support group if available.

What two groups of organs compose the digestive system?

1. The GI tract

2. The accessory digestive organs

What is the GI tract?

A continuous tube that extends from the mouth to the anus through the thoracic and abdominopelvic cavities.

The organs include: mouth, pharynx, oesophagus, stomach, small intestine, large intestine.

It is about 5-7 meters in an adult person.

What are the accessory digestive organs?

It includes the teeth, tongue, salivary glands, liver, gall bladder and pancreas.

Apart from the teeth and the tongue, the other organs never come into contact with the food but they produce or store secretions that flow into the GI tract through ducts.

These secretions will assist in the breakdown of the food.

What are the 6 digestive system processes?

Ingestion, secretion, mixing and propulsion, digestion, absorption, defecation.

What is ingestion?

This involves taking in food and liquid into the mouth.

What is secretion?

Cells in the GI tract and accessory digestive organs secrete approximately 7 litres of water, acids, buffers and enzymes into the lumen of the tract.

What is mixing and propulsion?

Alternately contracting and relaxing the smooth muscle in the walls of the GI tract mixed food and secretions and propels this towards the rectum.

What is digestion?

Mechanical and chemical processes break down ingested food into small molecules.

What is absorption?

The entrance of ingested and secreted fluids, ions and products of digestion into the epithelial cells lining the lumen of the GI tract.

What is defecation?

Wastes, ingestible substances, bacteria, cells that are shed from the lining of the GI tract and digested materials that were not absorbed in their journey through the digestive tract leave the body via the anus.

What areas can cancer arise in the GI system?

Cancers can arise in all parts of the GI system, including the oesophagus, stomach, pancreas, liver, colon, rectum and anus.

What consists the upper GI?

Mouth, oesophagus, stomach and first part of the small intestine (duodenum)

What consists of the lower GI?

Majority of the small intestine, large intestine (colon), rectum and anus.

What are some radiotherapy risk factors for acute and late toxicity?

The target volume size, total dose, fractionation schedule and dose per fraction.

Does combines therapy with chemo increase acute toxicity?

Yes

Patients who have radiotherapy to head and neck tumours are also at risk of damage to the upper GI structures.

What is the incidence and epidemiology for oesophagus cancer?

• It is the 14/15th most common cancer in the UK

• There is around 9200 new cases each year

• It is more common in men than in women (could be due to men smoking more)

• The peak incidence is around 75 years for the UK

• Men have around 6500 cases per year

• Women have around 2500 cases per year

• Rates have increased since the early 90s by 5%, over the last decade tit has been stable and is predicted to fall by over 3% over the next decade (could be due to the decrease in smokers).

• Incidence rates worldwide are more prevalent in men, the highest rates are in South Africa and Eastern Asia, the lowest rates are in Middle Africa

• Around 59% of cases are avoidable/preventable

What is the aetiology of oesophagus cancer?

• Tobacco

• Drinking alcohol

• Drinking hot drinks

• Obesity

• Gastro-oesophageal disease, the stomach acid leaking up into the oesophagus

• Barrett’s oesophagus, an abnormal change in mucosal cells (squamous cells) lining the oesophagus

• Occupational exposure, such as asbestos

• Radiation exposure

• HPV risk

• Aspirin

What are some signs and symptoms of oesophagus cancer?

• Dysphagia, difficulty swallowing

• Nausea, vomiting

• Persistent heartburn or acid reflux

• Persistent indigestion symptoms i.e. burping a lot

• Cough that doesn’t go away

• Hoarse voice

• Loss of appetite, weight loss

• Fatigue

• Pain in your throat, middle of chest or back

• Haemoptysis, coughing up blood

• Regurgitation of food

What is the histology of SCC in the oesophagus?

SCC is most likely to occur in the upper and middle oesophagus, which is linked to smoking and drinking.

What is the histology of adenocarcinoma?

It is most likely to occur in the lower third of the oesophagus, which can be linked to acid reflux.

It can also be related to location and proximity to the gastro-oesophageal junction, these risk factors vary depending on the type.

What does T1 mean in oesophageal cancer?

Cancer grown no further than the submucosa (layer of supportive tissue)

What does T1a mean in oesophageal cancer?

Cancer in the inner layer (mucosa)/thin muscle layer of oesophageal wall.

What does T1b mean in oesophageal cancer?

Cancer has grown into the supportive tissue (submucosa)

What does T2 mean in oesophageal cancer?

Cancer has grown into the mucosa (muscle layer of oesophagus wall)

What does T3 mean in oesophageal cancer?

Tumour grown into tunica adventitia (membrane covering outside of oesophagus)

What does T4 mean in oesophageal cancer?

Tumour grown into other organs/body structures next to oesophagus

What does T4a mean in oesophageal cancer?

Cancer grown into pleura (tissue covering the lungs), pericardium (outer lining of the heart), diaphragm (muscle at bottom of ribcage) + peritoneum (lining of abdomen)

What does T4b mean in oesophageal cancer?

Cancer has spread into other nearby structures i.e. Trachea (windpipe), vertebrae (spinal bone) or aorta (major blood vessel)

What does N0 mean in oesophageal cancer?

No lymph nodes contain cancer

What does N1 mean in oesophageal cancer?

Cancer is present in 1 or 2 nearby lymph nodes 

What does N2 mean in oesophageal cancer?

Cancer cells are present in 3-6 nearby lymph nodes

What does N3 mean in oesophageal cancer?

Cancer cells are present in 7 or more lymph nodes

What does M0 mean in oesophageal cancer?

Cancer has not spread to other organs

What does M1 mean in oesophageal cancer?

Cancer has spread to other parts of the body.

What are the most common oesophageal metastases?

• The lymph nodes 

• Lung 

• Liver 

• Bone 

• Adrenal glands 

• Brain 

List some investigations that may take place for oesophageal cancer?

• FBC through routine blood tests, urea and electrolytes

• Barium swallow, x-ray which makes it easier to see inside the oesophagus and see tumours and growth

• Endoscopy/gastroscopy, allows to see inside patient oesophagus and remove small sample for biopsy. Camera used to check for abnormal growth e.g, bronchoscopy.

• CT scan - see extent of the tumour

• MRI

• PET - metastases

• Screening only for high risk individuals

What are some managements for oesophageal cancer?

• Surgery

• Pre-operative management

• RT with chemo

• RT

What is the principle treatment for oesophageal cancer?

Oesophagostomy

Lymphadenectomy

What are some things to be considered before surgery?

• Poor prognosis (45%, 1 year survival)

• Severe malnutrition

• Vocal cord palsy

• Bronco-oesophageal fistula

• Invasion of great vessels/pericardium

• Cervical or celiac node involvement

• Distant metastases

What is the limitations of pre-op management?

Pre-op RT doesn't improve cure rates

Pre-op chemo benefits are unclear

There are concerns regarding patient tolerance for these regimens

What are some prescriptions for RT with chemo?

• 50Gy in 25# with cisplatin-5FU

• 50.4Gy in 28# with cisplatin-5FU

What are some radiotherapy prescriptions for patients who can’t have chemo?

Radical - 50-55Gy 20#

Palliative - 30Gy 10# or 20Gy 5#

Describe the local invasion of the oesophagus:

It can occur longitudinally and circumferentially through the sub-mucosa and mucosa to surrounding organs. 

Adjacent structures of the neck and thorax including the thyroid gland, trachea, larynx, lung, pericardium and aorta. 

Describe the lymphatic invasion:

Depending on the position of the tumour it can spread superiorly in the cervical region into deep cervical lymph nodes and paratracheal nodes in the thoracic region to mediastinal nodes and in the lumbar region to the gastric and coeliac nodes.

What is the vascular spread?

liver, lungs, bone, adrenal glands, kidney and brain

What is the immobilisation for head and neck patients?

• Supine 

• Head first supine 

• Arms above head 

• Vac-bag 

• Omni-board 

• Wing-board 

• 9 point shell - if the cancer is in cervical region then it will be a 5 point shell 

Describe the localisation of oesophageal cancers?

• CT scans, from the hyoid bone to the inf border of the kidney (3-5mm), to include/account for whole of tumour and accounts for a 5cm sup/inf margin.

• Markers, 1-2 ant markers (SSN-TOX) and 2 lateral markers = 4 markers in total.

What is the tumour volume definition?

• CTV margin = GTV + 2cm longitudinally + 1cm axially

• PTV margin = CTV + 1cm longitudinally + 0.5cm axially

It accounts for growth in all directions.

What are the organs at risk?

• Lungs 

• Heart

• Stomach

• Kidneys

• Spinal cord 

• Occasionally the bowel if it is very inferior 

Describe the palliative planning?

An AP field to minimise lung dose, high dose to lung and heart with this.
Any conformal plan can also be used

Why might VMAT be used for oesophageal cancer?

• Most likely to be used

• Better plan

• Better dose conformity

• Lower dose to the OARs

What verification imaging will take place for a conformal/palliative plans?

• KV daily 

• Bony match to the spine and ribs 

What verification imaging will take place for a VMAT plan?

• CBCT daily, soft tissue match to the PTV

• Bony match, followed by assessment of soft tissue coverage

What are some acute side effects of oesophageal cancer treatment?

Tiredness/fatigue

Hair-loss in treatment are (neck and chest)

Erythema (skin reaction - treatment area only)

Sore throat

Sore mouth

Difficulty swallowing (dysphagia)

Nausea and vomiting

Voice changes - more likely in tumours located near larynx

What are some management of the acute side effects of oesophageal cancer?

Rest and exercise

Reassurance for hair-loss

Skin care - emollient creams, avoid sun exposure, wear loose clothes

Amend diet, soft foods only, pain killers, water with every meal, prescribed mouth washes, peg feeding?

Ondansetron - antiemetics