Question 1

How do you differentiate gastroesophageal junction cancer and lower esophageal cancer, and the difference in their care?

Dr. Preeti Vijayakumaran · Accepted Answer

The protocol we follow is endoscopic mapping. Our medical gastroenterologists are usually able to tell us exactly where the tumour is located with respect to the GE junction. The standard landmark we expect is 40 cm, which varies slightly with the length of the patient's oesophagus. Once that is determined, the malignancy is mapped with respect to the gastroesophageal junction, and we also correlate the gastroesophageal junction on axial imaging with the endoscopic picture. If there is any incongruency between the two, we go with the axial imaging representation and decide the diagnosis accordingly.

Question 2

What is the role of immunotherapy in esophageal cancer?

Dr. Preeti Vijayakumaran · Accepted Answer

Immunotherapy's role is currently established in the adjuvant setting, more so for esophageal squamous cell carcinoma. A patient who completes neoadjuvant therapy, undergoes surgery, and is found to have residual disease is followed with adjuvant nivolumab. If there is no residual disease, adjuvant nivolumab is not advocated. In advanced or metastatic disease, chemotherapy with immunotherapy or targeted therapy gives a possible benefit, perhaps a couple of months. In the neoadjuvant setting, its role is still experimental and yet to be answered.

Question 3

Cryotherapy is one of the treatment options for the cancer. Would you repeat the disadvantages of applying cryotherapy for esophageal cancer?

Dr. Preeti Vijayakumaran · Accepted Answer

Cryotherapy, along with the other ablative therapies, is applicable only in very early, and especially screen-detected, oesophageal malignancy. The problem is that staging must be extremely accurate. If endoscopy and endoscopic ultrasound detect a flat high-grade dysplastic lesion or an early intramucosal carcinoma, ablation can be applied, but it results in structural abnormalities at that site that make surveillance difficult. Hence, if there is any suspicion of nodular disease or of deeper invasion, we recommend an endoscopic resection rather than an ablative procedure such as cryotherapy alone.

Question 4

Given that the prevalence is much higher in men than in women, is there a predisposing genetic factor?

Dr. Preeti Vijayakumaran · Accepted Answer

This is a question on my mind as well. There is no established genetic risk factor explaining why esophageal cancer is more common in men than women. A lot of it is attributed to other risk factors instead, like smoking habits and diet habits, but on the genetic side there really isn't an answer yet.

Question 5

In cases of widespread metastasis, can chemotherapy improve the prognosis?

Dr. Preeti Vijayakumaran · Accepted Answer

Yes. In widespread metastasis there is a possible benefit from chemotherapy combined with immunotherapy or targeted therapy. How much survival advantage this brings is, statistically, maybe a couple of months, but it will definitely improve the patient's quality of life during that period.

Question 6

What is the role of imaging in the workup of esophageal cancer?

Dr. Preeti Vijayakumaran · Accepted Answer

Essentially, whole-body axial imaging: a PET-CT if it is available, and if not, a contrast-enhanced scan covering the neck, thorax, abdomen and pelvis for staging. In addition, endoscopic ultrasound is used in early-stage disease for more accurate T and N staging, and bronchoscopy and laparoscopy may be used in locally advanced disease, laparoscopy specifically to rule out peritoneal metastasis in cases of adenocarcinoma.

Question 7

What are the methods of preventing esophageal cancer?

Dr. Preeti Vijayakumaran · Accepted Answer

Prevention starts with understanding the risk factors, which depend on the histological subtype. For adenocarcinoma, the drivers can be obesity, reflux disease, smoking and alcohol, so limiting smoking and alcohol matters, and an existing reflux disease needs to be managed medically. Patients with an already existing condition should also be started early on more stringent endoscopic surveillance. For squamous cell carcinoma, the pathology is more related to smoking and diet habits, and regulating those can make a difference.

Question 8

Based on your experience, what do you recommend to junior doctors about such an annoying disease of our patients?

Dr. Preeti Vijayakumaran · Accepted Answer

There is a lot of ignorance in our community, especially in our country, about a complex disease like oesophageal cancer. Patients have early, subtle symptoms of difficulty in swallowing, but these are often ignored and taken as a sign of some other common ailment. So the need for awareness is foremost. Patients need to understand why they should go for an early medical evaluation, because early endoscopy and early detection make a big difference to the outcome. As doctors, we should involve ourselves in educating more and more of the public about the disease, its diagnosis and the treatments we have in hand, so that the message spreads: if it is detected early, we can offer maximum curative options.

Question 9

In routine practice we frequently encounter cases of PPD poisoning due to suicide attempts, which lead to caustic esophageal injury resulting in chronic esophagitis. In such cases, can chronic esophagitis be considered a precancerous lesion?

Dr. Preeti Vijayakumaran · Accepted Answer

That is a very valid question. Even in our community we see a lot of cases of caustic esophageal injury, and this chronic esophagitis can eventually lead to stricturous disease and become a predisposing cause for esophageal cancer. Patients who survive such an injury and go on to develop stricturous disease should be kept on a very stringent surveillance protocol.

Question 10

Is there any specific age at which to start screening by endoscopy or another modality?

Dr. Preeti Vijayakumaran · Accepted Answer

In our country, our practice is to recommend screening after the age of 35 to 40 years, though this number varies with the institutional protocol and guidelines followed by each hospital and specialty centre. We expect patients with GERD symptoms or a risk of Barrett's oesophagus to start screening at 35 to 40. These patients are taken up for endoscopic mapping, and every area showing dysplastic change is biopsied. If multiple biopsies show no evidence of dysplasia, the patient is kept on surveillance. Confirmed low-grade dysplasia is kept on follow-up. High-grade dysplasia in a flat lesion under 2 cm is ablated. High-grade dysplasia over 2 cm, or with a nodular appearance, goes for endoscopic resection, with follow-up of the histopathology on the EMR specimen.

Question 11

In this case of caustic injury from PPD poisoning, what preventive measures should be taken?

Dr. Preeti Vijayakumaran · Accepted Answer

Many of these patients go on to develop stricturous disease, leading to significant dysphagia and a chronic inability to take oral nutrition; they are offered an esophagectomy with a neo-esophagus. Those who do not develop stricture should have endoscopy every six months, with biopsy of any suspicious area, and further imaging is not required unless a biopsy proves disease.

Live Discussion with Dr. Preeti Vijayakumaran