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Oesophageal Cancer / Gastric Cancer - Coggle Diagram
Oesophageal Cancer / Gastric Cancer
Histological Subtypes
Oesophageal Squamous Cell Carcinoma
Most common in IRE
Location
Proximal 2/3rd of oesophagus
Oesophageal Adenocarcinoma
Cause
Barrett's Oesophagus neoplasia
Location
Lower 1/3 of oesophagus
OG junction
Gastric Adenocarcinoma
Presentation
Progressive Dysphagia
Dyspepsia
Anaemia
Stomach pain
Bloating
Nausea and vomiting
Haememesis
Melena?
Weight loss
Early satiety
Diagnosis
Biopsy
OGD / Gastroscope
Histological Confirmation
Molecular Subtyping
HER2
MSI
MMR
SCC
Staging
+/-Staging laparoscopy
Gastric / Type III - Peritoneal washings
Endocopic Ultrasound
T stage, nodal assessment
+/- FNA
Resectability
Cross Sectional Imaging
Gastic: CT w Contrast
Oesophageal: FDG PET CT
+/- Bronchoscopy
Mid oesophageal tumours T4 assessment
Indx
Suspected invasion of trachea
OGD with biopsy
SCC Treatment
Locally Advanced
Curative Intent
Definitive CRT (+/- salvage Oesophagectomy)
Decision based on Fitness
PFT
Echo
Other
CPET
Timed up and go
Sit stands
6 min walk test
Stair climbing
Experience
Neoadjuvant CRT → 3 stage oesophagectomy
#
SCC is radiation sensitive
Pre-OP
Nutrition
Feeding jejunostomy
Dietary supplements
Nasogastric tube
Parenteral nutrition
PEG
Smoking cessation
Prehabilitation
Re-Staging after neoadjuvant therapy
Repeat OGD
PET CT
Reassess fitness
?Complete Clinical response
Post Op Regimen
HDU post op
Epidural for pain control if open
PCA
Monitoring
Cardiac
O2 sats
UC
Chest drain
Arterial line
Central line
NG tube
Maintenance
Hydration
Analgesia
Nutrition
NPO 4 days
Swallow test day 5 check anastomosis
Jejunostomy feeding tube for enteral nutrition
VTE prophylaxis
Mobilise
pLMWH
Oesophagectomy Complications
General
1st 24hrs
Haemorhage
Respiratory depression
Atelectasis
1st 4/5 days
Pneumonia 20%
Arrhythmias - 15% afib
UTI
Thromboembolism
Pneumothorax
MI
Line sepsis
SSI
Specific
Anastomotic leak 5-7%
Hiatus hernia
Reflux
RLN injury - increased risk of aspiration
Delayed gastric emptying
Chylothorax
Outcomes
Surgery is the most high risl cancer operation
Mortality 2-10%, 1.7% in St James
Morbidity 30-50%
Reduction from 30% due to specialist centres, precise staging
Anaesthetics, epidurals, surg technique, pt selection, post op care, ERAS
3 yr survival w radical surgery and lymphadenectomy and neoadjuvant therapy is 50%
TNM Staging
T
Tis
T1a
T1b
T2
T3
T4a
T4b
Epidemiology
Most common
Stage 4
at presentation
Poor prognosis
5 year survival rates:
Stage1/2 : 42.9%
Stage 2/3 23.4%
Stage 4 4.6%
Percentage die within 90 after Oesophagectomy
1-3%
Complications at 30 days : 10-15%
Alive 5 years after tx with curative intent: 40-60%
Adenocarcinoma
Epidemiology
Less common in IRE
Risk Factors
Barrett's Oesophagus
Long segment > short segment
Treatment
Limited disease (cT1, cN0, M0)
Endoscopic Treatment
EMR Endoscopic mucosal resection
ESD Endoscopic submucosal dissection
Larger lesions
RFA Radiofrequency ablation
Rlat lesions - dysplasia
At least 2 treatement usually more
High Risk
Oesophagectomy
Locally Advanced Disease
Definitive Chemoradiation
Neoadjuvant chemoradation (CROSS) + surgery
Peri-operative chemotherapy (FLOT) + sugery
Palliative Intent chemo (FOLFOX) + stent
Palliative intent chemo (FOLFOX) + palliative RT
Palliation
All Stage 4
Very common
Management of Dysphagia
Palliative RT (radiation therapy)
Stent
Feeding tubes
GOO
Gastric Outlet Obstruction
Stent
Palliative STG
Loop gastrojejunostomy
Feeding jejunostomy
Symptom Control
Pain
Nausea
Fatigue
Loss of appetite
Staging
Endoscopic Assessment - EArly Oesophageal Neoplasia
Prague Criteria
EUS
PET CT
Classification Systems
Prague Criteria
Paris Classification
High risk features for nodal metastasis
.>2cm
Poorly differentiated
T1b
Involved in submucosa (lower than sm1 level)
Involved deep margin
Trials
Neo-AGES
EsoPec Trial
Materhorn??
Perioperative Durvalumab In Gastric Cacner
SANO trial
Surgery as needed only
Investigational Agesn
HER2 Tagerted therapy
RTOG 1010 trial
Added Trastuzumab to neoadjuvant chemoradiation therapy for HER2 pos oesophageal adenocarcinoma
Did not improve overall survival
Neoadjuvant immunotherapy for dMMR Tumours
Further trials needed
Types of Oesophagectomies
Three phase
Squamous cell cancer following neoadjuvant chemo radiation therapy
Two phase
Adenocarcinoma
adenocarcinomas where the tumor is lower, allowing more normal esophagus to remain
Transhiatal Oesophagectomy
Neck and abdo incision
Reserved for early tumors or patients who might not tolerate one-lung ventilation or the chest phase of the operation
Extended Total Gastrectomy
Involves removing all of the stomach as well as the lower part of the esophagus
Used for type three junctional esophageal cancers and gastric cancers in the proximal part of the stomach
Gastric Cancer
Presenting
Weight loss
Epigastric pain
Early satiety
Priorities
Histological Diagnosis (biopsies)
Staging - CT vs PET CT, laparoscopy, EUS
Nutrition
MDT
Mx
Perioperative FLOT + surgery
Surgery
Total Gastrectomy w RNY
Subtotal gastrectomy
Lyphadenectomy
Three levels
D1 Limited Dissection
Perigastric lymph nodes
D2 Extended
Nodes along hepatic, left gastric, coeliac, splenic and splenic hilum
D3 Superextend
Differing definitions
Survivorship Issues
Significantly decreased HRQL
Weight loss universal
Malnutrition and nutritional / GI issues
Fatigue
5.Psychosocial issues
Chemo related toxicity
