25 Oesophageal Cancer

Oesophageal Cancer Brachytherapy

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THE GEC ESTROHANDBOOKOF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 10/06/2019

(double contrast), demonstrating both the tumour length and the resting lumen in obstructive lesions in AP and in lateral views. In addition, deviation of the oesophagus may be apparent indicating extra-oesophageal spread. On the radiograph, tumour extension must be reproducibly related to certain anatomical landmarks, e.g. carina of the trachea, and bony landmarks (e.g. thoracic vertebral bodies). A fistulamust be carefully excluded.The posterior-anterior and lateral chest X-ray are useful additional tools - if combined with barium swallow - to document tumour extension related to anatomical landmarks. For assessment of local tumour extension beyond the oesophageal mucosa, sectional imaging methods are necessary because barium swallow can only accurately estimate endo-oesophageal tumour growth. The gold standard to detect and document distant metastases is Fluorodeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) [Tangoku et al.]. Ameta-analysis on staging investigations showed that distant metastatic disease is best detected by FDG-PET with higher performance than CT and para-oesophageal lymph node metastases are detectable with the highest sensitivity by EUS [vanVliet et al.]. In addition, preoperative EUS is indispensable in T-staging providing the best cross-sectional method accuracy [Choi et al.]. FDG-PET is superior over CT in evaluating tumour response after neoadjuvant chemotherapy [Makino et al.] or chemoradiotherapy [Wieder et al.]. An SUV max reduction >70% after neoadjuvant therapy was associated with better survival outcomes. In addition, contrast enhanced computed tomography gives a relatively precise definition of transmural growth and of tumour infiltration into the surrounding fat and organs (aorta, trachea, major bronchi). MRI gives similar results with some advantages due to the coronal and sagittal imaging and the better soft tissue discrimination adding more information to assess the local and locoregional tumour extent. TNM clinical staging 8th edition [Brierly et al.] has changed the systematic tumour assessment mostly to depth of invasion, circumferential involvement and extra-oesophageal spread in contrast to the preceding classifications which addressed tumour length and amount of obstruction as well. Location categories (lesion epicentres) - assessed ideally during oesophagoscopy - are the following: upper location (cervical oesophagus to lower border at the azygos vein), middle location (lower border of azygos vein to lower border of inferior pulmonary vein), and lower location (lower border of inferior pulmonary vein to stomach including oesophagogastric junction). Pathologic stages correspond to clinical stages. However, pN0 is considered when a minimumof seven nodes are examined in the resection specimen. As neoadjuvant therapy replaces surgery alone pathologic staging is losing its clinical relevance with the exception of early stages (pT1-2). For those patients undergoing neoadjuvant therapy post- neoadjuvant staging includes adding yp to the TNM categories. As discussed before the role of ypTNM postneoadjuvant staging is limited. For adenocarcinoma subtypes only, the finding of residual nodal disease (ypN+) might be used for decision-making in adding adjuvant chemotherapy with a possible survival benefit. Burt et al. demonstrated a 40% lower risk of death for patients with adenocarcinoma and residual nodal disease after neoadjuvant chemoradiation and radical surgery [Burt et al.]. Dysphagia is a cause of significant morbidity in patients with OC which requires often nutritional interventions and specific therapies. Thus, the severity of patient-reported obstruction

the maximal cancer length also increased [Raja et al.]. The largest cancer width increased also according to the depth of invasion [Raja et al.]. Other established predictors for nodal metastatic disease are higher grade [Barbour et al.], higher T- category [Leers et al.], and lymphovascular invasion [Buskens et al.].

5. WORK UP

Screening, in general, is not recommended due to the lack of evidence for reduced cancer mortality. However, patients with Barrett’s oesophagus (BE) as a complication of GERD are considered at risk to develop oesophageal cancer especially OAC subtype [Dubecz et al.] and may benefit from screening upper gastrointestinal endoscopy [DE Carli et al.]. A detailed medical history including all risk factors (alcohol and tobacco abuse, Barrett’s disease, overweight and abdominal obesity etc.) is important. The work up then includes a clinical examination, that particularly addresses the patient's general condition and performance status, nutritional status, weight loss during the last six months, degree of dysphagia (i.e. dysphagia to solids, semi-solids, liquids, total dysphagia – indicating the degree of luminal obstruction) and associated symptoms like cough (due to fistula or aspiration), chest pain or back pain. The physical examination includes the chest, palpable lymph node drainage sites (supraclavicular and cervical nodes), and an abdominal examination (liver). Investigations which aim to define the extent of tumour spread so that appropriate treatment may be planned include endoscopic and radiological investigations. Endoscopic investigations include an endoscopy of the upper gastrointestinal tract and a bronchoscopy especially in carcinomas extending proximally above the carina.The gastroenterologist should take several biopsies and measure the precise distance between the macroscopic start of the tumour and its distal end, measured from the teeth (fig. 27.2). Furthermore, a detailed description of the tumour surface should be available with regard to the pattern of tumour growth (exophytic, ulcerative) and to vulnerability and risk of bleeding. The resting lumen in obstructive lesions should be given in mm (e.g. by comparison with the diameter of the oesophagoscope). In addition, endoscopic ultrasonography (EUS) is a significant advance for imaging the gastrointestinal (GI) tract wall and enables guidance for fine needle aspiration (FNA) biopsy of suspicious paraoesophageal nodes [Tangoku et al.]. EUS may be also used to place clips or other markers to visualize the cranial and caudal edges of the tumour lesions on cross sectional imaging or fluoroscopy during oesophagoscopy. Moreover, endosonography combinedwith oesophagoscopy can lead to amore accurate estimate of submucosal and intramural tumour spread and staging. EUS determines ideally the pattern of local tumour growth, in particular for limited tumours distinguishing between T1a (invasion lamina propria/muscularis mucosa) and deeper T2 lesions [Thosani et al.]. Thus, EUS plays an important role in selecting patients for endoscopic non-radical surgery. However, these excellent diagnostic and staging methods may be technically impossible in very advanced obstruction. In advanced disease (T3, T4) then, the pattern of intraluminal local tumour growth may be documented by classical barium swallow radiography