High Yield points Carcinoma Esophagus

These are for last minute exam preparation only. They are to be supplemented by proper knowledge from the books

Epidemiology

United States esophageal adenocarcinoma > incidence of esophageal squamous cell carcinoma (SCC),

Wrldwide SCC most common

 Etio

Genetico predisposition

 Smoking and alcohol, SCC,

 Gastroesophageal reflux disease (GERD) : Barrett esophagus and adenocarcinoma.

 

Anatomy of esophagus

20 to 30 cm in length and is located in the posterior mediastinum

 3 critical anatomic points of narrowing are identified:

the cricopharyngeus muscle,

 the bronchoaortic constriction

 esophagogastric junction, 

These sites of iatrogenic and mechanical perforation.

Prognostic factors for Ca esophagus

 The location of the tumor has been included in the tumor, node, metastasis (TNM) seventh edition staging system of the SCC.

 Middle or upper esophagus  higher stage compared with the lower one-third of the esophagus.

Lymphatic channels in the submucosa facilitate the longitudinal spread of neoplastic cells along the esophageal wall.

They can drain to cervical, tracheobronchial, mediastinal nodes, and gastric and celiac nodes.

Type of tumor

SCC more sensitive to chemotherapy, chemoradiation, and radiotherapy than adenocarcinoma,

SCC are more avid to FDG

Adenocarcinoma may be associated with a better long-term prognosis after resection than SCC. It is less avid to FDG

 Staging

T stage is important in the prognostication and is crucial to determining suitability for surgical resection and establishing a treatment plan.

T4: Tumor invades adjacent structures ‡ 

T4a for resectable tumor invading pleura, pericardium, or diaphragm

T4b for unresectable tumor invading other adjacent structures such as aorta, vertebral body, trachea, etc.

 

Imp - Number of lymph nodes recovered—rather than their location—is an independent predictor of survival after esophagectomy

Endoscopy

The diagnostic yield 100% when six or more samples are obtained

Once diagnosis of CA esophagus is made do a CT /PET scan to evaluate distant metastasis, then do locoregional staging

PET scans can detect primary tumors as well as provide a functional assessment of metabolically active lymph nodes or metastatic sites.

IT has no value in T stage and limited value in N stage.

EUS

The modified EUS criteria (four standard criteria plus EUS-identified celiac lymph nodes, >5 lymph nodes, or EUS T3/4 tumor) were more accurate than standard criteria (hypoechoic, smooth border, round, or width >5 to 10 mm) at identifying malignant lymph nodes

EMR

Depth of infiltration, presence of lymphovascular invasion, and degree of differentiation,

Laparoscopy or Thoracoscopy

Thoracoscopy and laparoscopy identified nodes or metastatic disease missed by CT in 50% of patients, by MRI in 40%, and by EUS in 30%.