Cardiothoracic Surgery: Esophageal Cancer

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 associated with smoking and drinking.

00:23 But don't forget that chronic reflex also can lead to esophageal cancer.

00:27 Do you remember our discussion about gastroesophageal reflux disease and Barrett's esophagus? In chronic reflux disease, patients tend to get adenocarcinomas.

00:39 What are some physical findings of esophageal cancer.

00:42 In late disease, patients can have dysphasia.

00:45 And this dysphasia may be progressive.

00:47 The reason is, as the tumor grows, the lumen of the esophagus is narrowed.

00:52 Additionally, similarly with all other patients presenting with dysphasia, inability to tolerate PO may lead to weight loss, and this can be significant.

01:02 Additionally, as you may remember, any patient with cancer also secrete tumor necrosis factor, which can cause anorexia.

01:13 Unfortunately, no routine laboratory studies is indicative of esophageal cancer.

01:19 Typically, an EGD is necessary.

01:22 An EGD is performed by a GI doctor.

01:24 And in this image, on the left, you notice there is a mass.

01:28 Distally, you see the GE junction, also known as the lower esophageal sphincter.

01:32 On the right of the screen, you note a normal esophagus.

01:36 Here, you see a retroflex view of the EGD.

01:39 This image actually shows a proximal stomach or lower esophageal sphincter cancer.

01:46 In these situations, although it may involve the esophagus, it is treated like a proximal stomach tumor.

01:52 Tumor staging is very important for esophageal cancer.

01:53 And like all oncologic processes, it's done according to the AJCC TNM system.

02:01 T for tumor, N for node status or lymph node involvement.

02:06 And M for metastasis or distant spread.

02:11 For esophageal cancer, especially because of its invasive nature, the T is very important.

02:17 Let’s discuss little bit what the tumor staging involves.

02:20 T1 disease are masses that invades the submucosa.

02:25 T2 invades the muscularis.

02:29 T3 invades the adventitia.

02:32 And lastly, T4 invades adjacent structures.

02:35 These are more advanced disease.

02:38 In this schematic, you notice that there is a dot in the middle of the esophagus.

02:43 That's actually the endoscopic ultrasound probe.

02:46 Endoscopic ultrasound probe has given us incredible images to allow us to accurately determine the actual depth of invasion.

02:56 Now, radiographic imagings, this is a barium swallow examination.

03:01 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.

03:11 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.

03:20 Vast majority of the time, the patients undergo EGD and potentially axial images by CAT scan.

03:27 In this image, you notice a combined anatomic CT scan as well as a PET scan.

03:34 Remember, cancers are PET-avid.

03:37 Now, remember I talked about endoscopic ultrasound.

03:40 It's incredibly important to use endoscopic ultrasound to evaluate for the depth of penetration as well as endobronchial involvement.

03:49 Remember, the esophagus sits very, very close to the trachea and main airways.

03:54 Invasion of these structures is a poor prognostic sign.

03:57 Here, you see an endotracheal ultrasound, showing invasion, highlighted by the green.

04:03 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.

04:16 Neoadjuvant means you have curative intent surgically, but the patient receives chemoradiation before surgery actually occurs.

04:27 And when the patient has had neoadjuvant therapy or if clinically appropriate, the patient undergoes an esophagectomy.

04:35 An esophagectomy is a large, morbid case.

04:39 And before surgery, you will want to make sure that your patient can tolerate the procedure from a cardiac standpoint.

04:46 Esophagectomy involves removing the section around the tumor and reconstructing the GI system.

04:52 This can involve using the stomach or the colon as a conduit.

04:57 The conduit is usually brought into the chest and a connection is made.

05:01 Unfortunately, given the number of layers of lining in the esophagus, these anastomoses or connections are prone to anastomotic leaks.

05:11 Anastomotic leaks in these patients are fraught with complications and can lead to septic shock.

05:19 Now, it's time to visit some important clinical pearls and high-yield information.

05:23 Remember, extensive metastatic workup should be completed prior to resection of the esophagus, particularly if the patient may be a candidate for neoadjuvant therapy.

05:34 Additionally, if the patient has metastatic disease, you should not offer the patient a morbid procedure such as esophagectomy.

05:42 At that point, the patient is likely a candidate either for clinical trials or palliative surgery.

05:48 And remember, the gastroesophageal junction cancers are treated like stomach cancers.

05:54 Thank you very much for joining me on this discussion of esophageal cancers.