esophagus ca all

def. A highly muscular collapsible tube of the GI tract

term. esophagus

How long is the esophagus?

25 cm long

The esophagus

1. begins at:

2. ends at: 

1. C6: cricoid cartilage

2. T10-T11: gastroesophageal junction

How do the muscles of the esophagus propel food through it and downward into the stomach?

Peristalisis 

What are the 4 ways the esophagus is categorized?

1. Cervical | Thoracic

2. Cervical | Lower/ Distal

3. AJCC: Cervical | Upper Thoracic | Middle Thoracic | Lower Thoracic

4. The most common one:

   1. Upper 1/3: Cervical Esophagus

   2. Middle 1/3

   3. Lower 1/3: Thoracic Esophagus

The upper 1/3 of the esophagus extends from:

C6-T2: Cricoid Cartilage - Manubrium

The middle 1/3 of the esophagus extends from:

T2-T8: Manubrium - Hilum

The lower 1/3 of the esophagus extends from:

T8-T11: Hilum- GE (gastrointestinal) Junction  

Esophageal Cancer Epidemiology (6)

Higher incidence in:

1. mostly male

2. African American

3. ChIA: China, Iran, South Africa

Age

4. 55-65

Location where most occur in

5. lower 1/3

6. Uniformly fatal disease

Typical age for esophageal cancer

55-65

In what location of the esophagus does esophageal cancer most commonly occur?

lower third

Esophageal Cancer Etiology (7 underlying conditions)

1. Alcohol/ Tobacco

2. Achalasia

3. Plummer-Vinson Syndrome

4. Tylosis

5. Diet: ↓ Fruits & Veggies | ↑ Nitrates

6. Caustic Injury to Esophagus

7. Barrett’s Esophagus

AA B C D PT

What is the most common cause of esophageal cancer?

alcohol/ tobacco

__% of esophageal cancer is caused by alcohol/ tobacco

80

How does alcohol + tobacco cause esophageal cancer?

The combination of alcohol + tobacco has a synergistic effect on mucosal surfaces

FYI: Failure of the sphincter to relax with swallowing, the esophagus has lost much of its perstaltic activity

def. Achalasia

fyi: Iron-deficiency anemia characterized by esophageal webs, atrophic glottis and spoon-shaped brittle fingernails 

def. Plummer- Vinson Syndrome 

Plummer-Vinson Syndrome is most common in what population:

Women

def. An inherited condition characterized by epidermal thickening in the palms and soles of the feet

term. Tylosis

Tylosis predisposes you to what?

Esophageal carcinoma

Individuals with tylosis have a __% change of esophageal carcinoma

37

Patients with caustic injury to the esophagus, the incidence has been reported to be ___X greater than that of a normal individual

1000

What is Barrett’s esophagus

A condition where distal esophagus is lined with columnar epithelium instead of stratified squamous

What causes Barrett’s Syndrome

chronic acid reflux

Clinical presentation for esophageal cancer

List then in order from most common to least common

1. dysphagia - most common

2. weight loss - 2nd most common

3. Odynophagia - not as common

4. Gastroesophageal reflux- not as common

term. dysphagia

def. difficulty swallowing

term. Odynophagia

def. Pain on swallowing 

Diagnostic tests for esophageal cancer (5)

1. Barium swallow

2. Chest X-Ray/ CT

3. Esophagoscopy / Bronchoscopy

Routes of Spread

1. local mets

2. lymphatics- skip mets

3. Hematologic

T/F: Esophageal tumors are detected early cuz they cause obstruction

False: Tumors are often locally advanced 

Why can the esophageal cancer tumor grow large before it causes obstruction?

cuz esophagus is distensible 

How does esophageal cancer spread by direct invasion?

it is contiguous along the length of the esophagus

T/F: The esophageal area is rich with lymphatics

True

How does lymphatics flow in esophagus? Why is this bad?

Along entire length of esophagus draining into any adjacent draining nodal bed

Risk of skip mets

What are the 5 nodes esophageal cancer spreads to?

1. cervical 

2. supraclavicular

3. paraoesophageal 

4. celiac axis

5. paragastric nodes 

What organs does esophageal cancer spread to?

Liver- MOST COMMONLY

Lungs- secondly

Why do most esophageal cancer patients die?

Due to mets to liver

What is the pathology/pathologies of esophageal cancer?

1. Squamous cell carcinoma: upper 1/3

2. Adenocarcinoma: distal esophagus & patients with Barrett’s esophagus

Why is there an issue with differential diagnosis for esophageal tumors?

Cuz many stomach cancers are adenocarcinomas as well that can travel to esophagus

Location of esophageal cancer by %

1. Upper:

2. Middle:

3. Lower:

1. Upper: 10% of CAs

2. Middle: 40%

3. Lower: 50%

What is the single most important factor in selection of the type of therapy (cancer tx) for esophageal cancer

Site of origin of neoplasm

T/F: Treating esophageal cancer is easy.

False: It’s

1. highly complex

2. technically challening

In general how is esophageal cancer treated?

Patients do better with…

• Upper esophagus: RTT

• Lower esophagus: Surgery

Chemo: as a radiosensitizer

Name/ type of surgical procedure to treat esophageal cancer

esophagectomy with anastomosis

List the locations in which surgery with anastomosis for esophageal cancer can be performed

1. Upper

2. Middle

3. Lower

Middle and Lower

Upper is not surgically accessible 

How much of the esophagus is removed?

the entire esophagus or as much as possible

Cons of using esophagectomy to treat esophageal cancer

high operative mortality rate

even after resection, most patients die from distant mets (liver)

What chemos are combined with RTT to act as radiosensitizers?

5 FU

Cisplatin

What type of esophageal cancer pathology is fairly radiosensitive?

1. adenocarcinoma

2. squamous cell carcinoma

3. both

2, SCC

Treating esophageal SCC, specially with chemo, achieves:

1. local tumor control

2. regional tumor control

3. mets control

1. local tumor control

Radiation therapy is useful to treat cancers in the upper 1/3 of the esophagus, but above what anatomical structure specifically?

aortic arch

Types of RTT tx fields used to treat esophageal cancer

for…

Upper 1/3 lesions: APPA + shrinking field (boost) 

Middle and Lower lesions: APPA OR Rotational field (boost)

Boost after __ Gy for esophageal cancer. Why?

45

due to lung/ cord tolerance 

Boost field options for lesions in the thoracic region

3 field: AP + 2 Posterior Obliques w/ wedges

• prone, or

• supine on wing board, vac-lok, arms up

OR

POP lats

OR
HDR w/ iridium 192

What are the tumor margins for esophageal cancer?

5 cm above + 5 cm below 

(cuz of skip mets)

If you are taking an esophageal cancer sim, what should it be?

Orthogonal films

Total dose for esophageal:

1. If combined with surgery:

2. If combined with chemo:

3. If alone:

1. If combined with surgery: 45-50 Gy

2. If combined with chemo: 50 Gy

3. alone: 60-70 Gy

Why do we treat esophageal patients prone sometimes?

To pull esophagus away from cord

RTT complications of esophageal cancer (4)

1. esophagitis, substernal pain

2. Dysphagia

3. stricture & perforation- late effects

4. If RTT w chemo: synergistic effect mucosal rxns 

At what dose does dysphagia happen

20 Gy

5-year survival for esophageal cancer

6-8%

T/F: esophageal cancer is nearly a uniformly fatal disease

True

What are prognostic factors for esophageal cancer

1. Tumor size (FYI: tumors less than 5 cm have better survival rate)

2. Weight loss

3. Age: >65

4. Poor Karnofsky