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Hi, everyone. Welcome to this episode of the MLA teaching series on Esophageal Cancer presented by Exposure Leads in association with I RJ. We'll be talking through a typical case of esophageal cancer, discussing pathophysiology, diagnosis and management options to give a bit of context to the topic that we're discussing today. We'll be talking through a patient case which we'll touch on again at the end of the presentation. So our case today involves a 68 year old male who presented to his GP with a four month history of dysphasia and unintentional weight loss, which began with the difficulty eating solids that has now progressed to liquids. Some important differentials to consider for this presentation include gastric cancer, esophageal cancer strictures as well as bout's esophagus, which is a complication of gastroesophageal reflux disease. And achalasia typically, esophageal cancer presents at an advanced stage as it's usually asymptomatic in the early stages. Presentations could include dysphasia which is difficulty swallowing, ady aphasia which is pain when swallowing, hoarseness and coughing, nausea, vomiting, decreased appetite, weight loss, and bleeding from the upper gi tract. This could include presentations such as blood in the stools, which is known as melena or blood in the vomit known as hematosis as with all cancer. The pathophysiology involves the growth of abnormal cells specifically in this case, chronic irritation and genetic mutations such as TP 53 lead to malignant transformation of esophageal cells. There are two main types of esophageal cancer. Adenocarcinoma is the most common in the UK and it is most commonly linked to Barrett's esophagus. Whereas squamous cell carcinoma is more common in the developing rod and it's most commonly associated with smoking. Adenocarcinoma. Arising from glandular cells is usually found near the gastroesophageal junction, gland formation with mucin production may be visible microscopically bouts. Esophagus is a complication of gold in which the normal squamous epithelium is replaced by columnar epithelium with goblet cells. This intestinal metaplasia is a precursor to adenocarcinoma. Squamous cell carcinoma may show the keratinization and intercellular bridges which are desmosomal connections between squamous cells. The complications for both types include metastases and postoperative complications such as anastomotic leaks when patients present with suspected esophageal cancer. Nice guidelines recommend that they undergo endoscopy with biopsy to rule out or identify any malignancies. Patients are then also offered further imaging based on histology including barium swallow as seen on the left pet CT, as seen on the right and endoscopic ultrasound as well. These imaging techniques are used to identify the presence of any metastases and location of structures present throughout the esophagus. Moving on to the management options if the cancer is suitable for radical treatment. Nice guidelines recommend definitive chemoradiotherapy as well as surgical resection, including both open and minimally invasive esophagectomy. Open radical surgical resection is potentially curative and it provides definitive pathological staging but it has a high risk of complications and a long recovery period. Minimally. Invasive surgical resection provides similar oncological outcomes for early stages of esophageal cancer and involves less preoperative pain and scarring as well as a quicker recovery, meaning a shorter hospital stay and thus reducing the chance of hospital acquired infections. Both options have a high risk of POSTOP complications and require general anesthesia which is not suitable for all patients and poses its own risks. The managements discussed on the previous slides are also supported by certain interventional radiology techniques which aim to provide support and symptomatic relief to patients, which is especially important for palliative patients for whom radical treatment is not suitable esophageal stenting as the name suggests involves placing a stent in the esophagus to relieve the symptoms of strictures. It's a minimally invasive and quick procedure that provides immediate relief and is also suitable for high-risk patients. However, patients can still face issues including the risk of stent related complications such as pain, bleeding or stent migration. Another supportive procedure is the use of radiologically inserted gastrostomy, also known as rig. This involves inserting a small tube through the skin directly into the stomach under X ray guidance to allow administration of food liquids and medication. This technique is also minimally invasive and aids quick recovery. It can also be performed under local anesthesia. So it is also suitable for high risk patients. Complications would include infection or dislodgement of the tube and it does require ongoing intention. These diagrams give a better visual understanding of the IR procedures mentioned. The description of the procedures is not exhaustive but aims to give a general idea of what it entails. The procedure for inserting an esophageal stent involves administration of contrast to allow visualization of the stricture as seen on the left wrist diagram. Then under local anesthetic, a wire and catheter containing device is inserted through the mouth to the obstruction. A balloon is then inflated in the area of the stricture in tics to expand the esophagus. Finally, after sufficient expansion, a stent is put in place allowing the blockage to open up radiologically inserted. Gastrostomy, also known as rig is a minimally invasive procedure used to place a feeding tube directly into the stomach under image guidance such as fluoroscopy. A nasogastric tube is inserted to distend the stomach so that there is a reduced distance between the gastric wall and the anterior abdominal wall. As seen on the image on the right. The patient is then given local anesthesia and a small incision is made in the abdomen. A gastropexy device is used to puncture the stomach. After placement of the device is confirmed, a guidewire is inserted over the guidewire. A gastrostomy tube is placed into the stomach and the position of this is confirmed using real time imaging. Coming back to the original case we introduced to provide some further details. This patient has a history of Barrett's esophagus and a twenty-year pack history which are both risk factors for the development of esophageal cancer. On examination, he appears to have had significant weight loss and there is also mild tenderness in the epigastric region based on presentation and suspicion of esophageal cancer. Due to the history of barretts, esophagus and smoking. Endoscopy with biopsies carried out and reveals an adenocarcinoma with at one N zero M zero grading for this tumor grade. The most appropriate management would be minimally invasive surgical resection using the either Lewis type esophagectomy. This involves removing the tumor and surrounding lymph nodes through two small incisions in the abdomen and back and reconstructing the esophagus using part of the stomach to summarize. We have covered some of the key ma presentations such as upper gi bleeding, decreased appetite, nausea, difficulty swallowing, and voice changes. As we discussed previously, the pathophysiology of esophageal cancer involves chronic irritation and genetic mutations specifically in the TP 53 gene which lead to malignant transformation of esophageal cells. There are also two main subtypes which are histologically distinct. We've got squamous cell carcinoma which is mostly linked to smoking and adenocarcinoma, which is most commonly associated with gord and barretts, esophagus. Moving on to diagnosis. It is diagnosed by an upper gi endoscopy with biopsy to histologically confirm malignancy. Then this is followed by imaging such as pet CT and endoscopic ultrasound for ongoing management. The cancer stage determines the management options which can involve chemoradiotherapy radical resection and minimally invasive surgical resection with esophageal stenting and rig being options for supportive and palliative management. If you wish to do any further reading, we provided a list of references for the nice guidelines and imaging techniques taken from case studies. Here is the list of our image credits including the diagrams for esophageal stenting and radiologically inserted gastrostomy. Thank you so much for watching. Please make sure to check out the other episodes in this MLA series by I RJ. There are already lots of episodes in the MLA series, but some of the new episodes include topics such as BPH, so benign prostatic hyperplasia, uterine fibroids, DVT, and PE as well. Thanks again.