Oesophageal Cancer

Welcome to First Incision, the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. And we're back for another episode of First Incision. Let's do our team timeout. Our patient today is still the upper GI esophagogastric module from the general surgical curriculum. And the patient or topics we're going to be covering today is esophageal malignancies.

Esophageal malignancies is a pretty big topic. In general, there are two main different disease entities when we're talking about esophageal malignancy, and this is esophageal adenocarcinoma. and esophageal squamous cell carcinoma. And these have different etiologies and different treatments. Esophageal cancer is the ninth most common cancer in the world.

And there is a rising incidence of esophageal cancer in Western countries. There is quite a lot of geographical variation with esophageal adenocarcinoma being the most common esophageal malignancy in the Western world. above SCC, but in the developing world, SCC is of a higher incidence than esophageal adenocarcinoma.

At the diagnosis of an esophageal malignancy, more than 50% of patients will have either unresectable disease or radiographically visible metastases. Esophageal cancer is more common in men than women. and has a median age of diagnosis between 50 and 70 years. So as I mentioned, the two main types of esophageal malignancies are adenocarcinoma and squamous cell carcinoma, and these make up over 90% of esophageal cancers.

There are some other rarer types, such as neuroendocrine tumors or carcinomas, melanoma, leiomyosarcoma, and esophageal lymphomas.

Esophageal adenocarcinoma in the Western world makes up about 60% of presentations of esophageal malignancy. esophageal adenocarcinoma is most likely to occur in the distal esophagus approximately 75% of the time and more approximately about 25% of the time. When talking about distal esophageal adenocarcinomas, there is a classification that we use when talking about those tumours, and this is the Sievert classification, spelt S-I-E-W-E-R-T.

And this is just, as I said, looking at gastroesophageal junction or lower esophageal tumors. A C-vert type 1 tumor is a tumor that arises in the lower esophagus, usually from one to five centimetres from the gastroesophageal junction, and this may infiltrate the gastroesophageal junction from above. 2-severt tumor is a true gastroesophageal junction tumor which arises at the gastroesophageal junction and may extend no more than 2 centimeters into the cardia of the stomach.

And a type 3 severt tumor is considered for treatment as a gastric cancer.

This tumor has its center between 2 and 5 centimeters below the gastroesophageal junction and infiltrates the gastroesophageal junction from below. Predisposing factors for the development of esophageal adenocarcinoma are gastroesophageal reflux disease and Barrett's esophagus, abdominal obesity, smoking, alcohol use, a history of radiotherapy to the mediastinum, high intake of barbecued meats and processed meats, and low intake of fruits and vegetables.

The pathogenesis of esophageal adenocarcinoma is often referred to as the gastroesophageal reflux disease to adenocarcinoma sequence. And this is a concept that Chronic exposure of the squamous epithelium of the esophagus to gastric contents and reflux leads to inflammation, then leads to metaplasia of the esophageal. lining into Barrett's esophagus or gastric columna epithelium, which then progresses through a process of increasing dysplasia to eventually turn into an adenocarcinoma.

This process involves a stepwise accumulation of genetic mutations, and the p53 gene has been implicated in this as a significant gene. And additional changes also involve HER2.

the ERBB2, cyclin D1, cyclin E, the retinoblastoma protein, and P16. Esophageal SCC is the other... common type of esophageal malignancy and in the western world accounts for about 40% of esophageal cancers. Esophageal SCC is more likely to be found in the middle esophagus between the tracheal bifurcation and halfway to the gastroesophageal junction in about 50% of cases.

It's found in the distal third of the esophagus in about 35% of cases and in 15% of cases can be found in the proximal third of the esophagus or in the cervical esophagus. Risk factors for the development of SCC include socioeconomic and dietary factors such as smoking, alcohol and drinking hot beverages. exposure to HPV, especially strains 16 and 18, esophageal dysmotility disorders such as achalasia, a previous corrosive injury, a Zenka's diverticulum,

and Plummer-Vincent syndrome. Those last three risk factors, the achalasia, Plummer-Vincent syndrome, and Zenker's diverticulum, are all associated with retained food, and it's thought that the decomposing bacteria release various chemicals that irritate the mucosal lining and can predispose to malignancy. Similar to the pathway in adenocarcinoma, it's thought that the development of esophageal SCC is a multi-step progression from normal mucosa to carcinoma.

And there are a couple of precursor lesions that you may come across, again, similar to dysplastic Barrett's, for example. So there is squamous cell dysplasia, which is thought to predate the development of cancer by about five years. And this can be low grade where the architectural and cytological abnormalities are seen just in the basal half of the squamous epithelium and high grade where the...

Cytological abnormalities include the full thickness of the squamous epithelium. And some of the genes that are thought to be involved in this genetic process to the development of SCC are P53, the retinoblastoma gene.

MCC, APC, and DCC. So how do patients with esophageal cancers present in clinical practice? The majority of patients, about 74%, will present with dysphagia or difficulty swallowing. Usually the history is that this is initially to things such as bread and meats, which progresses into difficulty swallowing other solid foods and eventually into liquids as well.

Patients can also present with adenophagia, which is pain when swallowing. Some will present with weight loss. Others will have a history of long-standing reflux disease, which may have worsened. And uncommon presentations include shortness of breath. cough, a hoarse voice, retrosternal or back pain, but this is more likely to be a sign of locally advanced and unresectable disease.

In Australia, we don't screen for esophageal cancer because it is so rare and there's not really any hereditary forms of the disease for us to be able to put on screening. So it's not something that we do any population-based screening for. But we do surveil patients who have Barrett's esophagus, which we talked about in a previous episode, as these patients do have an increased risk of progressing to adenocarcinoma.

And there are treatment options, such as ablation of the Barrett's and treatment of dysplastic segments with EMR, which may prevent those patients progressing on to having an adenocarcinoma. In Australia, though, we do do fecal occult blood testing. for patients who are aged between 50 and 74. And if a patient has a positive fecal occult blood test, they may proceed to have a gastroscopy and colonoscopy to investigate this, and a occult esophageal malignancy may be.

detected due to that screening program. In addition, patients may present with anemia, which may be investigated with upper and lower GI endoscopy with a tumour found secondary to that.

When working up these patients, we start with a history and examination. And key as part of examining patients who may have an esophageal malignancy is to look for lymphadenopathy, and in particular, the left supraclavicular. and the cervical nodes, as well as to feel for hepatomegaly, looking for any malignancy in the liver and to examine the chest for any signs of pleural effusions, which may also indicate advanced disease.

Moving on now to diagnosis and investigation of esophageal malignancies. Diagnosis of an esophageal malignancy is often made at endoscopy. An endoscopy will find a lesion which may be sessile, ulcerated or polypoid and usually it looks quite abnormal compared to the normal esophageal mucosa. Some earlier lesions such as dysplastic lesions or early T1A or T1B malignancies may be difficult to see and it's important that a really detailed inspection is made of any.

mucosal abnormalities to ensure that you're not going to miss an early lesion at the time of endoscopy it's important as well to clearly document the location of the lesion as well as its proximal and distal extent and its relationship to any landmarks such as the gastroesophageal junction, the choral impression, any hiatus hernia. Six to eight biopsies of the lesion should be taken, as well as a Seattle Protocol biopsies of any area of Barrett's esophagus.

Histopathological findings of an adenocarcinoma will be invasive cell clusters or glands. with evidence of nuclear ATP with size variation, shape and staining variation and potentially mitoses. It's graded, as per other adenocarcinomas, as either well, moderately, or poorly differentiated. Special stains or immunohistochemistry is usually not required for an esophageal adenocarcinoma, but it's usually positive for PAS, CK7, and CK19.

Esophageal SCC is usually characterized by keratinization with keratin whorls and cytological atibia. And again, it's graded as either well, moderately or poorly differentiated. There are three main variants from the pure sort of squamous cell carcinoma type, and this includes verrucus carcinoma, which is a very rare and locally aggressive subtype. Spindle cell carcinoma, which is, again, a very highly aggressive tumour with evidence of squamous and spindle cells on the histopathology.

And there can also be a basaloid squamous cell carcinoma, which is another rare variant with a poor prognosis. So once a patient is diagnosed with an esophageal malignancy,

they should all undergo the same workup. So this includes a set of blood tests, including an FBE, UEC, CMP, LFTs, a baseline CEA, and iron studies. In addition, patients should undergo a staging CT chest, abdo, and pelvis, as well as a PET scan, as this is funded for esophageal cancer in Australia. CT chest-uptopelvis will upstage about 15% of patients. About 10% of gastroesophageal tumours are not PET-AVID.

which is good to keep in mind. But if the tumour is PET-AVID, then you may get more information about other distant metastases that were not visible on the CT scan. In addition, patients should undergo a diagnostic laparoscopy if they have a tumour that's in the mid to lower third of the esophagus.

This includes an inspection for peritoneal secondaries, occult liver metastases, gives you an idea about the local extent of the tumour and whether there is any obvious involvement of surrounding nodes. as well as the extent of the cancer down the stomach. And it should also include washings to rule out any occult peritoneal disease. There's some discussion about the role of endoscopic ultrasound in esophageal cancers.

At my institution, this isn't done routinely, but it can be used to help differentiate the depth of invasion of the tumor, which... is not good for differentiating t1a and t1b but will help you determine if it's a t1 or a t2 or a t3 or t4 and can also give you some more information about local invasion or involvement of local structures

as well as allow FNA of any suspicious lymph nodes. And if there were suspicious nodes that were not within the regional lymph nodes that you would usually remove at esophagectomy so that these were not considered regional nodes and therefore would change the staging of that patient. to metastatic disease and change their treatment pathway, then this may be an indication to proceed with an EUS and biopsy or a bronchoscopy and biopsy depending on how those nodes could be reached.

There is a potential practical issue, though, with endoscopic ultrasound and esophageal cancer, which is if you have a really large T3 or T4 tumor that's quite bulky, it may not be technically... possible to do an endoscopic ultrasound examination. In another sheet that I was listening into, they talked about how it may be useful if you were trying to determine whether an early tumor should go to surgery or should have neoadjuvant therapy.

upfront so if you're worried about a regional node then that would be an indication to do an eus so there is some controversy out there and i think it would be patient and institution dependent

Moving on now to staging of esophageal cancers. The AJCC TNM classification was updated to the 8th edition in 2016, and that has detailed staging information if you want to have a look at that. In general, esophageal adenocarcinoma and esophageal SCC are staged the same with TNM, but then the sub-staging into stage 1, 2, 3, etc. is slightly different.

Briefly, I'll go over the histology of the normal esophagus, just to remind us as this is a good way of remembering the TNM classification. So the esophagus has an epithelial layer. Underneath this is the... lamina propria and underneath that is the muscularis mucosa and those three layers together make up the mucosa. Under the mucosa is the submucosa.

And underlying the submucosa is the inner circular and outer longitudinal muscle layers. In the esophagus, there is no serosa. So after these muscle layers, which is the muscularis propria, is just adventitial tissue. So briefly running through the TNM staging. TIS is carcinoma in situ or high-grade dysplasia, which we talked about in the Barrett's esophagus podcast. T1 tumours.

are split into T1A, which invade just the lamina propria or the muscularis mucosa. And T1B tumours invade into the submucosa. T2 tumors invade into the muscularis propria, those muscle layers we talked about, and T3 tumors invade into the adventitia. T4, as with most TNM staging, classifications is a locally advanced tumor which invades into adjacent structures and this may involve T4A tumors that invade the pleura, pericardium, azagous vein, diaphragm or peritoneum.

and T4B tumours that invade the aorta, the vertebral body or the trachea. The end staging is split up into N1, N2, and N3, and this is regarding only regional lymph nodes. So these are nodes that would be removed with the esophagectomy. N1 is metastasis to one to two regional lymph nodes. N2 is metastases to 3 to 6 regional lymph nodes, and N3 is metastases to 7 or more regional lymph nodes. M1 is any distant metastases, which includes...

metastases to lymph nodes that are outside of that regional nodal basins. And the regional lymph nodes are considered celiac axis paraesophageal nodes. cervical lymph nodes but not supraclavicular lymph nodes. So you probably don't need to know it in that much depth, but it's good to know about T1A and T1B tumors and basically that stage 1 and 2 is no nodes involved and that stage 3 have lymph nodes involved.

The other key point when talking about TNM staging is to remember the different classifications. So if there's a C in front of it, that means it's the clinical staging. If there's a P, it's from the pathological resection specimens. And if there's a YP, then it's post neoadjuvant treatment.

Moving on now to treatment. As I said before, all of these patients should be discussed at a multidisciplinary team meeting. And the management of these patients is guided by both disease-related factors. which is usually the stage of the tumour, as well as patient-related factors, which usually means their fitness for surgery and their wishes.

Treatment options for esophageal malignancies are pretty wide. So this includes both conservative or palliative symptom control, endoscopic management, surgical management, chemotherapy. and radiotherapy. So first, I'll run through a little bit about all the different treatment options. And after I've done that, I'll talk about an overall summary of sort of the different pathways for treatments depending on the patient's pathology.

So first I'll mention different resection techniques. The first one is endoscopic resection. And there's two types. There's endoscopic mucosal resection. which remember when we talked about the layers of the esophagus, the mucosa is the epithelium, the lamina propria, and the muscularis mucosa. Or there's endoscopic submucosal dissection, which...

also removes the underlying submucosa. But for esophageal resections, we're mostly talking about endoscopic mucosal resections. This is typically done by gastroenterologists, in my institution at least. It's worth looking up some videos of how they do this. It's pretty clever. They can use a number of techniques, including injecting into the submucosa to elevate the mucosa before removing it. They can use snares.

They can use suction cups to assist with the resection, and they can use a ligation technique. Submucosal dissection may facilitate taking the lesion out as a big... sort of on-block lesion, and this is being increasingly used for esophageal lesions and gives you a really great biopsy. There are risks with this procedure that do include perforation.

bleeding. If there's a circumferential EMR then you can get fibrosis and stricturing and obviously you may not completely remove the lesion or require further treatments to complete the resection. remembering our TNM staging, T1A tumours invade into the muscularis propria. So they are the only tumours that are suitable for EMR. T2 tumours invade into the submucosa.

This is past the mucosa. Therefore, these are not suitable for EMR and they have a higher lymph node metastases rate, which I've mentioned before. So they are not usually suitable for this technique.

The other option for resection is esophagectomy. This is a major operation with an operative mortality between 1% and 2% and operative morbidity that extends up to 60% of patients. It's really important when considering esophagectomy to ensure adequate patient assessment and workup so that the correct patients are chosen for esophagectomy who have the most likelihood of A, benefiting from the procedure.

and B, avoiding morbidity and mortality associated with the procedure. So the first step to that is adequate staging to make sure that there's no evidence of disease that is not going to be resectable or metastatic disease. The next step is patient assessment. So the question you have to ask is, is this patient fit enough to survive an esophagectomy? And it's really a risk assessment. It combines a medical history, examination, routine blood tests.

and ECG, and usually further tests including stress echocardiogram, potentially pulmonary function tests, exercise tolerance tests. And this new technique of cardiopulmonary exercise testing, which is a good test for marginal patients where you can get a really good idea about what their...

anaerobic threshold is and if they have a level of 8 or below then that's really bad. If it's less than 10 then you should be really worried about whether or not that patient is fit enough to undergo esophagectomy. Because of the morbidity associated with this procedure as well, there's been a lot of discussion about prehabilitation and having these patients undergo preoperative exercise.

programs to try to improve their cardiopulmonary fitness to reduce the risk of them having complications after the operation. And in my institution, this is routine now.

The goal of esophageal resection is to remove the primary tumour with clear circumferential resection margins as well as clear proximal and distal margins, in addition to removing the regional lymph nodes. For tumors in the mid and lower esophagus, usually this will involve removing lymph nodes in what's considered a two-field radical lymphadenectomy. So this involves removal of abdominal lymph nodes.

including the upper abdominal, diaphragmatic, right and left pericardial, lesser curve, left gastric artery, celiac, common hepatic and splenic artery nodes. as well as the thoracic nodes that you would anticipate would be related to the esophagus. So paraesophageal nodes, paraaortic nodes, right and left pulmonary hilar, subcorinal and right paratracheal nodes.

If you had a tumour in the upper aspect of the esophagus or the cervical esophagus, especially if it was an SCC, then these patients may require a 3 field. lymphadenectomy which includes all of the previous ones I discussed as well as a neck dissection which clears the deep lateral and external cervical nodes and the right and left recurrent nerve lymphatic channels.

Some surgeons would also say that for a cervical or upper esophageal tumor, you may not need to remove the abdominal field lymph nodes. And another main consideration as per the AJCC guidelines is that you should aim to remove at least 15 to 18 lymph nodes in total in order to provide optimal staging information. And this has also been shown to improve loco-regional control and also result in improved cure rate.

So that's something to think about when you're talking about lymph nodes. In terms of different approaches to esophagectomy, mostly this is... guided by the type of tumor as well as the location of the tumor. The esophagus travels through the neck, through the thorax, and into the abdomen and can be...

approached through the neck, through the thorax, or through an abdominal incision. And often a combination of these is used depending on where the tumor is and the type of operation that you would like to perform. Common approaches to esophagectomy include a thoracic two-stage esophagectomy, also known as an Ivor Lewis esophagectomy. This is good for mid and distal esophageal tumours and involves an approach through the thorax and through the abdomen.

The esophagus is removed through these incisions and the anastomosis is made in the upper chest between the proximal esophagus and usually a gastric conduit. A three-stage esophagectomy or a McCowan esophagectomy involves an abdominal, thoracic, and neck incision. So the esophagus is... dissected through the chest and a gastric conduit is made through the abdominal incision and the anastomosis is made in the neck through a cervical incision. And this may be good for tumors that are in the...

proximal or mid-esophagus where you don't think you'll be able to get adequate proximal clearance with a two-stage procedure. You may also come across other approaches such as the transhiatal approach.

which involves a neck incision and abdominal incision with blunt dissection of the esophagus in the chest. This is a little controversial because it's not... necessarily possible to remove those lymph node stations on block due to the blind blunt dissection of the esophagus and I haven't seen this routinely done for esophageal tumors.

And a final approach you may come across is a thoracodorsal abdominal incision, where a large incision is made that extends from the chest into the abdomen. Again, this is allowing a similar operation to the Ivor Lewis operation. but through one incision. I briefly touched on, but I'll expand a little bit on what is used as a esophageal replacement. You're obviously removing the esophagus, so something needs to be used to replace the esophagus.

The most common organ used is the stomach with a gastric tube being created and this relies upon the right gastroepiploic arcade. You can use a colonic interposition graft or a jejunal graft. These are done less commonly and usually only if the stomach is not available, if that patient's had a previous. gastric resection if they have a pathology that involves the stomach and there's not enough stomach available to use for a conduit or sometimes in the case of significant caustic injuries or

acid injuries where the stomach is damaged in the same way that the esophagus is, so it's not available to use as a conduit, then you may consider doing a colonic graft. Most commonly this is the transverse colon using the middle colic artery, but can also include the right or left colon, depending on what's available and how far you think that's going to reach up into the chest.

Conduits have been used. Usually this requires microsurgery with a vascular anastomosis to move the jejunum up into the chest. The root of reconstruction is another... technical consideration to talk about. The most common way that we reconstruct the esophagus is through the posterior mediastinum, which is where the esophagus was originally. This is the shortest distance between the abdomen and the apex of the thorax.

is usually quite acceptable for patients and allows the easiest passage of food and drink down to the abdomen. If this route is not possible to be used, which may be, for example, if a patient has had a leak or some sort of perforation or pathology in the posterior mediastinum in the past, then another option is to use the retrosternal route.

And this is where you are going up through the anterior mediastinum. It's slightly longer than using the posterior mediastinum, about two centimeters longer, but may be used, I guess, as an alternative. It can give patients quite a strange sensation though when they're swallowing, given the food bolus is going anterior to the trachea. And the last option is the pre-sternal root, which is used... only if those other two routes are not an option and is quite a bit further for reconstruction.

Potential complications of esophagectomy are pretty common. 60% of patients will have a complication following an esophagectomy. The main technical complications we worry about are an anastomonic leak, which occurs in about 5-10% of patients, with only about 3% requiring any intervention for that leak.

One of the most feared complications is conduit necrosis. As I mentioned, the gastric conduit relies on the blood supply from the right gastroepipoic arcade. So there's a potential for ischemia of part or all of the conduit. emergency resection of an ischemic conduit and usually a delayed reconstruction. Other complications include pneumonia, cardiac complications, atrial fibrillation, chyle leaks.

recurrent laryngeal nerve palsies, and tracheoesophageal fistulas. And as I mentioned earlier, there's approximately 1% to 2% incidence of mortality associated with esophagectomy. I don't know whether this may be too much detail, but just briefly mentioning minimally invasive esophagectomies, by this I mean a laparoscopic or a VATS approach to the esophagectomy.

It seems like there is some evidence that there is reduced blood loss and especially respiratory complications with a minimally invasive approach. There doesn't appear to be any evidence that this reduces the oncological outcomes and it may improve their early recovery post-operatively, but it looks like the data at one to two years is pretty similar.

The key, I think, with talking about minimally invasive esophagectomy is that, in general, esophagectomies should be performed at centers that do large numbers of these or at specialized centers and that the best outcomes with... minimally invasive esophagectomies seem to be happening in these higher volume centers. Let's move on to discussing some of the chemotherapy options for esophageal malignancies. Focusing first on esophageal

adenocarcinoma. There are a few studies which are good to know when talking about this disease. The original trial, which has really been phased out now, but you may get asked about, is the MAGIC trial. And this was a randomized controlled trial of pre- and post-operative chemotherapy in patients with both gastric and lower esophageal cancers that were resectable.

And this used epirubicin, cyclophosphamide and 5-FU and did show a survival benefit for those patients. The next study, which is really what we're using currently, is the cross... And this is a study that looked again at preoperative chemo and radiotherapy for resectable esophageal and gastric cancers. And they gave these patients carboplatin, paclitaxel and radiotherapy.

for these tumours and they showed a survival advantage over the magic chemotherapy. In my institution, we give cross-protocol neoadjuvant chemoradiotherapy for all locally advanced. tumours that don't go directly to resection. However, a recent talk that I listened to as part of an upper GI series run by Anne Scoza, they said that the finer details of the esophageal cancer

chemo and radiotherapy seems to be institution specific. So we probably don't need to know much more detail than that apart from knowing what your institution does. So it'd be worth checking in on that. The last study to be aware of is the Top Gear trial, which is actually a Australia and New Zealand trial, which has not been published yet. So we don't have the outcome of this, but this is looking at FLOT. chemotherapy and radiotherapy in gastric and esophageal cancers um flot being a

Different type of chemotherapy regime, which is used as standard of care now for gastric cancers, but not yet for esophageal cancers. So it'll be good to know that that's happening. And if the results of that study come out before you sit your exam, then that's a good one to know. as well. For esophageal SCC these patients can have definitive chemoradiotherapy or neoadjuvant chemoradiotherapy. I'm not

really clear exactly whether or not the chemotherapy they're given is the same as they give for adenocarcinoma. So this will be something I can chat to our specialists about. And there is some, I guess, controversy around whether or not these tumors should be having definitive chemoradiotherapy. So that's chemoradiotherapy without resection or whether they should have neoadjuvant and then proceed with resection.

I'll talk about this a little bit when I do the summary of the different treatment options, but it does seem to depend on where the tumour is and also depends on the patient and the institution. Lastly, in terms of treatment options,

I'd like to discuss some of the options we have for symptom control in patients who have unresectable or metastatic disease. The majority of these patients will have trouble with dysphagia or obstruction due to their tumour. There are a number of options for these patients that include chemotherapy, radiation therapy, local radiation with brachytherapy, and local treatments such as laser ablation, photodynamic therapy.

balloon dilatation and stents. There are a lot of pros and cons of all of these different treatments. Stents are probably the treatment that has the most discussion about the benefits and risks. Typically, a stent would not be placed if there was a distal tumour and the stent would be covering the gastroesophageal junction, as this means the patients will suffer terribly with gastroesophageal reflux and regurgitation.

Stents can also migrate and erode and obviously the tumours can ingrow into the stents as well. Radiotherapy can be a good option but often causes inflammation and worsening of the dysphagia in the short term. Sometimes a temporary stent can be placed and radiotherapy done and the stent subsequently removed once there's an improvement in the tumour size.

So now we've briefly discussed the different treatment options, I'm going to do a little summary of an approach to treatment of this disease, which is going to be stratified based on the presentation or stage of the tumor. Again, remember that this is not set in stone and obviously this doesn't take into consideration the patient factors such as fitness for surgery and patient wishes, but this is sort of a general treatment algorithm.

And for the last time, I'll say all of these patients need to be discussed at an MDT to determine what treatment pathway they should go down. So first talking about early esophageal cancers. So this is... tumours in situ or high-grade dysplasia, and T1A tumours. These are being increasingly identified due to the surveillance of Barrett's patients, and the management of these early malignancies is

endoscopic mucosal resection because the risk of lymph node metastases is less than 2%. There's some concern that... doing an EMR on a T1B tumor is not going to be sufficient. And it's very difficult to determine preoperatively whether or not it's a T1A or a T1B tumor. If you do an EMR on a T1A tumor, you get a really good biopsy. And if you find on that big biopsy specimen that there is an area of invasion into the submucosa, then you can then proceed with further treatment for that patient.

anything by doing the EMR. The second group we will talk about is a group with localized disease. So these are patients who have T1B to T3 tumors with only regional nodes involved. And the approach to these patients, the buzzword should be that they get multimodal treatment. If they have limited disease, such as a T1 or potentially even a T2 N0 tumor, then they may proceed directly with resection. If we talk about locally advanced tumors, so these are T2 to T4.

N1 to 3, but M0 tumors. Then we can split these up into squamous cell carcinomas or adenocarcinomas. For squamous cell carcinomas, if they are in the upper third of the esophagus or they are unfit for surgery, then they may proceed with definitive chemoradiotherapy with an intensive follow-up with endoscopy every three months.

and a potential option for a salvage resection if the tumour recurs or progresses. If it's in the mid or distal third, then at least at our institution, these patients would have neoadjuvant chemoradiotherapy.

undergo restaging to exclude any evidence of metastatic disease, and then proceed with an esophagectomy. If we talk about adenocarcinomas, and we're still staying in that locally advanced but not metastatic group, then these patients routinely would undergo neoadjuvant chemotherapy as per the CROSS regime, restaging to rule out metastatic disease, and then proceed with an esophagectomy. And the last group to talk about is patients with locally advanced unresectable tumors or metastatic disease.

The focus for these patients is on management of their local disease. And there's a number of different approaches to this. Patients can have palliative radiotherapy for treatment of dysphagia or palliative brachytherapy, which can give similar results to radiotherapy and stents for dysphagia. They can have self-expandable metal stents placed for symptom relief of dysphagia for an obstructing tumour, but these stents can migrate.

they can re-abstruct and can present with gourd if they cover the gastroesophageal junctions. They're not always the best option. Patients can undergo endoscopic treatments such as YAG laser, which can laser out. the central canal of the esophagus to allow swallowing and can also treat tumour in growth of stents, for example. And there's always an option for palliative chemotherapy, but unfortunately with esophageal cancer, this is not.

hugely effective and patients who have metastatic disease at presentation have a very poor prognosis. Let's cap off this episode by talking about follow-up and prognosis. So for a patient who has had treatment, this may include neoadjuvant chemoradiotherapy and an esophagectomy, what sort of follow-up do they need?

So firstly, you'll see them in clinic, usually at the three, six, nine and 12 month marks in the first year. And you should take a clinical history about how they're going, how they're eating, whether their weight is stable, they're managing reflux. and making sure they're on a PPI. There's no routine surveillance that's required for these patients in terms of endoscopy or imaging, and really this needs to be...

guided by whether or not they have any symptoms or signs of recurrent disease. This may include weight loss or pretty much any new symptom that cannot be explained. In terms of prognosis for esophageal cancer, the overall survival at five years is pretty poor, but it has increased in the last 50 years from 4% in the 1970s to 14% currently. It definitely does relate to the stage of diagnosis and whether or not the patient has obviously undergone definitive treatment.

For an R0 resection of a stage 1 cancer, the prognosis at 5 years is 50% to 80%. And this goes down to 10% to 15% for patients with stage 3 disease.

Patients with stage 4 metastatic disease, even if they're treated with palliative chemotherapy, have a median survival that's less than one year. And indicators... that a patient may have a poor prognosis include if they present with significant weight loss, they have dysphagia, very large tumours, if the patient themselves are old, and if there is evidence of lymphatic spread in the resection specimen. Thank you.

And that finishes up our episode on esophageal malignancies. I hope that summary was enough information. Definitely seemed to be a lot of information from my end. There are a few questions that I have about... role of EUS, upfront surgery, chemoradiotherapy for SCC, and how much we really need to know about the different palliative treatments, which we will ask the specialist when we get them on the program.

It's time to close up. Thanks for listening to First Incision. If you have any comments or feedback, send us a message at firstincisionpodcast at gmail.com or follow us on Instagram at firstincision. Happy studying!