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Cardiothoracic Surgery: Esophageal Cancer

by Kevin Pei, MD
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    00:01 Thank you for joining me on this discussion of esophageal cancer in the section of cardiothoracic surgery.

    00:08 Unfortunately, esophageal cancer patients don't typically do very well.

    00:13 Let's start discussing the esophageal cancer types.

    00:17 Squamous cell cancer of the esophagus is the most common and it is associated with smoking and drinking.

    00:24 But don't forget that chronic reflex also can lead to esophageal cancer.

    00:29 Do you remember our discussion about gastroesophageal reflux disease and Barrett's esophagus? Do you remember our discussion about gastroesophageal reflux disease In chronic reflux disease, patients tend to get adenocarcinomas.

    00:41 What are some physical findings of esophageal cancer.

    00:44 In late disease, patients can have dysphasia.

    00:47 And this dysphasia may be progressive.

    00:49 The reason is, as the tumor grows, the lumen of the esophagus is narrowed.

    00:54 Additionally, similarly with all other patients presenting with dysphasia, inability to tolerate PO may lead to weight loss, and this can be significant.

    01:04 Additionally, as you may remember, any patient with cancer also secrete tumor necrosis factor, which can cause anorexia.

    01:15 Unfortunately, no routine laboratory studies is indicative of esophageal cancer.

    01:21 Typically, an EGD is necessary.

    01:23 An EGD is performed by a GI doctor.

    01:26 And in this image, on the left, you notice there is a mass.

    01:30 Distally, you see the GE junction, also known as the lower esophageal sphincter.

    01:34 On the right of the screen, you note a normal esophagus.

    01:38 Here, you see a retroflex view of the EGD.

    01:41 This image actually shows a proximal stomach or lower esophageal sphincter cancer.

    01:47 In these situations, although it may involve the esophagus, it is treated like a proximal stomach tumor.

    01:54 Tumor staging is very important for esophageal cancer.

    01:56 And like all oncologic processes, it's done according to the AJCC TNM system.

    02:03 T for tumor, N for node status or lymph node involvement.

    02:08 And M for metastasis or distant spread.

    02:13 For esophageal cancer, especially because of its invasive nature, the T is very important.

    02:19 Let’s discuss little bit what the tumor staging involves.

    02:22 T1 disease are masses that invades the submucosa.

    02:27 T2 invades the muscularis.

    02:31 T3 invades the adventitia.

    02:34 And lastly, T4 invades adjacent structures.

    02:37 These are more advanced disease.

    02:40 In this schematic, you notice that there is a dot in the middle of the esophagus.

    02:45 That's actually the endoscopic ultrasound probe.

    02:49 Endoscopic ultrasound probe has given us incredible images to allow us to accurately determine the actual depth of invasion.

    02:58 Now, radiographic imagings, this is a barium swallow examination.

    03:03 And although highlighted in the green circle is a lesion that appears to be apple core in nature, which is in fact the esophageal cancer.

    03:13 This finding is rare, though, on normal routine scans unless it's late in the course of the disease and the mass is large enough to show the actual defect.

    03:22 Vast majority of the time, the patients undergo EGD and potentially axial images by CAT scan.

    03:29 In this image, you notice a combined anatomic CT scan as well as a PET scan.

    03:36 Remember, cancers are PET-avid.

    03:39 Now, remember I talked about endoscopic ultrasound.

    03:42 It's incredibly important to use endoscopic ultrasound to evaluate for the depth of penetration as well as endobronchial involvement.

    03:51 Remember, the esophagus sits very, very close to the trachea and main airways.

    03:56 Invasion of these structures is a poor prognostic sign.

    03:59 Here, you see an endotracheal ultrasound, showing invasion, highlighted by the green.

    04:05 Now, before moving to surgery, if you’ve determined that the patient has advanced cancer, neoadjuvant chemo radiation therapy is actually standard protocol as first-line therapy for higher stage cancers.

    04:18 Neoadjuvant means you have curative intent surgically, but the patient receives chemoradiation before surgery actually occurs.

    04:29 And when the patient has had neoadjuvant therapy or if clinically appropriate, the patient undergoes an esophagectomy.

    04:37 An esophagectomy is a large, morbid case.

    04:41 And before surgery, you will want to make sure that your patient can tolerate the procedure from a cardiac standpoint.

    04:48 Esophagectomy involves removing the section around the tumor and reconstructing the GI system.

    04:54 This can involve using the stomach or the colon as a conduit.

    04:59 The conduit is usually brought into the chest and a connection is made.

    05:03 Unfortunately, given the number of layers of lining in the esophagus, these anastomoses or connections are prone to anastomotic leaks.

    05:13 Anastomotic leaks in these patients are fraught with complications and can lead to septic shock.

    05:21 Now, it's time to visit some important clinical pearls and high-yield information.

    05:25 Remember, extensive metastatic workup should be completed prior to resection of the esophagus, particularly if the patient may be a candidate for neoadjuvant therapy.

    05:36 Additionally, if the patient has metastatic disease, you should not offer the patient a morbid procedure such as esophagectomy.

    05:44 At that point, the patient is likely a candidate either for clinical trials or palliative surgery.

    05:50 And remember, the gastroesophageal junction cancers are treated like stomach cancers.

    05:56 Thank you very much for joining me on this discussion of esophageal cancers.


    About the Lecture

    The lecture Cardiothoracic Surgery: Esophageal Cancer by Kevin Pei, MD is from the course Special Surgery. It contains the following chapters:

    • Cardiothoracic Surgery: Esophageal Cance
    • Diagnosis of Esophageal Cancer
    • Management of Esophageal Cancer

    Included Quiz Questions

    1. Tumor invades muscularis propria.
    2. Tumor invades adventitia.
    3. Tumor invades submucosa.
    4. Tumor invades adjacent structures.
    5. Tumor invades pleura, pericardium, or diaphragm.
    1. Tumor invades adventitia.
    2. Tumor invades pleura.
    3. Tumor invades pericardium.
    4. Tumor invades submucosa.
    5. Tumor invades diaphragm.
    1. Endoscopic ultrasound.
    2. Esophagram.
    3. Esophagus-gastric-duodenoscopy.
    4. CAT scan.
    5. Radiographic imaging.

    Author of lecture Cardiothoracic Surgery: Esophageal Cancer

     Kevin Pei, MD

    Kevin Pei, MD


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