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home - Oesophagus - Oesophageal Cancer - Superfial Oesophageal Cancer Written by Dr Sebastian Zeki
Knows the predisposing factors, presentation, diagnostic work-up and
staging

Knows the range of potential therapies (including palliative care), and
understand how the appropriate selection is made

Superfial Oesophageal Cancer

Written by Dr Sebastian Zeki All submucosal tumors have a substantial risk of lymph node metastases. Epithelium Lamina propria Muscularis mucosa Submucosa M1 M2 M3 SM1 SM2 SM3 Endoscopic mucosal resection5yr survival 96.6 %.Salvage surgery was needed in 3.7 %.Complications of EMR include acute perforations and bleeding (15%) and delayed esophageal strictures.22 % recurrence rate- can often be salvaged with repeat EMREMR versus surgerySurvival rates were the same after EMR and esophagectomy for superficial oesophageal cancerLesions>2cm1. Can use ESD2. EMR plus PDTMay allow treatment of larger lesions. Photodynamic therapyPhotosensitizing agent injected then light used to induce a nonthermal phototoxic reaction (5-aminolevulinic acid-5-ALA or photofrinRole: HGD in patients with Barrett's esophagus.Large early cancers in the setting of extensive Barrett's who are poor surgical candidates.Small tumors are better treated with EMR. Laser ablation3 lasers- each have a different wavelength and therefore penetration:* Neodynium:yttrium-aluminum-garnet (Nd:YAG) 1064 nm, depth of penetration 4 mm* Potassium titanyl phosphate 532 nm, depth of penetration 1 mm* Argon 514.5 nm, depth of penetration 1 mmRole: Uncertain Argon plasma coagulation.The depth of necrosis can reach up to 6 mm.Role: Uncertain Radiation With Or Without ChemotherapyExternal and internal (brachytherapy) radiotherapy with or without concurrent chemoradiotherapy are potentially useful Role: Varices, in whom EMR and/or PDT are contraindicated Radiofrequency ablationHalo system. Role: HGD and IMC Endoscopic Therapy M1 and M2 and well-differentiated M3 disease without lymphatic invasion,EMR is a good second best to surgery especially if patient not fit enough For submucosal cancer, oesophagectomy is better than EMR Limited esophagec-tomyFor a small subset of patients with small very early cancers right at the GEJ, a limited resection of the distal esophagus and proximal stomach with jejunal interposition and a regional lymphad-enectomy can be used.Almost never done as it is tricky and often need re-intervention Vagal-sparing esophagec-tomyVagal-sparing esophagec-tomy, is preferred over radical esophagectomy in those with intramucosal cancer as low rate of nodal metsOncological outcomes similar to transhiatal/ en-bloc resection for superficial cancer and less psot-op problems Minimally invasive esophagectomyBetter post op recovery but controversy regarding resection margins Less radical approaches Oesophagectomy OutcomesRecurrence rate 6 % Disease-specific five-year survival rate 100 % for superficial cancerEsophagectomy is frequently associated with long-term problems such as dysphagia, weight loss, gastroesophageal reflux, and dumping. Submucosal superficial cancer types:SM1 which penetrates the shallowest one-third of the submucosa.SM2 which penetrates into the intermediate 1/3rd of the submucosa.SM3 which penetrates the deepest one-third of the submucosa.All SM categories are considered T1b disease according to the AJCC stage definitions. Assessment of Nodal Mets Nodal metastasis rates higher than for SCC.Nodal met rates higher for non-flat lesions, but no difference for poorly vs well differentiated.EUS is the most accurate noninvasive method to assess depth of invasion.Conventional EUS cant distinguish subtypes of T1 lesions.High-frequency EUS catheters good for T1 subtyping but not for nodal staging. ) Risk of Mets with Mucosal LesionsM1 and M2 tumors are not associated with lymph node metasta-ses and so can be treated endoscopically.The risk of nodal metastases with M3 tumors is as high as 12 %.If any evidence of lymphatic invasion, very likely to have LN mets. Mucosal superficial cancerEarly oesophageal cancers are defined as in situ lesions (Tis) or T1 tumors, which are split into T1a and T1b subcategories depending on the depth of invasion.More comprehensive subclassification divides into 3 types based upon the depth of invasion. M1 is limited to the epithelial layer.M2 invades the lamina propria.M3 invades into but not through the muscularis mucosa.M1 tumors correspond to the Tis stage in the AJCC stage definition, while both M2 and M3 tumors would be considered T1a lesions. Superficial Oesophageal Cancer

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