In the UK, <9/100,000 cases of oesophageal cancer are diagnosed annually. However, the incidence is rising faster than any other solid organ tumour.
🔢 Classification
There are actually 2 main types of oesophageal cancer:
- Squamous cell carcinoma - usually in the upper-middle 2/3rds of the oesophagus.
- Adenocarcinoma - usually in the lower 1/3rd of the oesophagus.
⚠️ Risk factors
- SCC - smoking, alcohol, achalasia.
- Adenocarcinoma - GORD (and Barrett’s), obesity, high fat intake.
20% happen in the upper part. 50% in the middle and 30% in the lower third.
😷 Presentation
Most patients unfortunately present later in the disease stage.
- ⭐️ Dysphagia - solids only at first before progressing to liquids.
- ⭐️ Weight loss/cachexia - both due to dysphagia and anorexia (due to cancer).
- Retrosternal chest pain - especially when swallowing.
- Hoarse voice
- Cough
- Melaena
Dysphagia is an important differential but it’s aetiology needs to be identified as either mechanical or neuromuscular.
On examination you may notice:
- Supraclavicular lymphadenopathy
- Jaundice
- Hepatomegaly
- Ascites
🔍 Investigations
- CT-CAP + PET scan may be useful for assessing metastasis.
- Endoscopic US may be used to see how far the tumour has progressed through the wall of the oesophagus.
- Laparoscopy may be used for staging.
NICE states that we should offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people with:
- Dysphagia, OR
- Aged 55+ with weight loss and any of the following:
- Upper abdominal pain
- Reflux
- Dyspepsia
🧰 Management
Survival rates are poor. Most patients present with advanced disease and approximately 70% are palliative cases. Palliative management aims to restore swallowing with an oesophageal stent.
Treatment depends on the type of tumour and it’s location.
- SCC - 🏆 chemo-radiotherapy
- Adenocarcinoma - neoadjuvant chemo (cisplatin + fluorouracil)/chemo-radiotherapy + resection
Involves an oesophagectomy through numerous approaches. All involve removal of the oesophagus, fund us of the stomach, lymph nodes. The rest of the stomach is turned into a conduit which is brought into the thoracic cavity to replace the oesophagus.
- 🥇 Right thoracotomy + laparotomy (Ivor-Lewis procedure)
- Right thoracotomy + abdominal & neck incision (McKeown procedure)
- Left thoracotomy ± neck incision
- Left thoraco-abdominal incision
💡 Follow-up with a CT scan 6 months post-op is needed.
🚨 Complications
- Anastomotic leak
- Post-operative pneumonia - this is the most common complication post-oesophagectomy and can occur in up to 25% of patients who undergo the procedure and is the most frequent cause of death in these patients. The majority of cases involve organisms such as E. coli and S. aureus (including MRSA). Aspiration pneumonia is also a risk in these patients so careful feeding and monitoring is needed post-operatively.