Oesophageal Cancer

Background and Epidemiology

•  Common and aggressive tumours with poor prognoses.  Approximately 70% of patients have extensive disease at diagnosis
• Two types:
  • Squamous cell carcinoma (SCC)
    • Associated mainly with smoking/alcohol consumption (incidence declining)
  • Adenocarcinoma
    • Associated with GORD and Barrett’s oesophagus- obesity and poor diet (incidence increasing- now more common in the UK; NB worldwide, SCC accounts for 95%)
• Ninth most common malignant tumour in the UK: incidence is thought to be arond 3-6/100,000/year although some reports up to 18/100000 in men (much more common in men (5:1 male:female ratio); more common in patients >55 years old
  • AC more common in Caucasians and SCC more common amongst African/Caribbean people

Aetiology/Risk Factors

• SCC
  • Smoking
  • Alcohol excess
• AC
  • Smoking and alcohol excess also
  • Obesity
  • GORD
  • Barrett’s Oesophagus
  • Achalasia
  • Post-caustic stricture

Pathophysiology

• Chronic inflammation caused by GORD can promote genetic changes in a number of genes, include tumour-suppressor genes and oncogenes such as p53, p16 and ERB-B2.
• These eventually can dysregulate cell cycle to induce cancerous growth

Presentation

•  Important symptoms to ask about include
  • Dysphagia/globus
    • Will often occur gradually, beginning with solid foods but progressing to soft and then liquid foods
    • Whilst this is usually the first presenting complaint and predominant feature of oesophageal cancer, this is usually a late feature of oesophageal obstruction (>75% obstruction)
      • As a result, most patients present late with unresectable and metastatic disease
  • Odynophagia
  • Vomiting
  • Anorexia/weight loss
  • Anaemia- lethargy, fatigue, weakness
  • Night sweats
  • Haematemesis
  • Retrosternal chest pain or bony pain
  • Hoarseness (involvement/pressure on the laryngeal nerve)
  • Respiratory symptoms e.g. cough, chest infection
    • Can be a result of simple aspiration or as a result of tracheobronchial invasion
• Lymph nodes of the neck may be enlarged if the upper third of the oesophagus is involved.  Otherwise, examination is non specific although there may be signs e.g. cachexia, bone pain etc

Investigations

• Blood tests: FBC, U&Es, LFTs, Glucose, CRP
• Urgent endoscopy with biopsy of lesions
• Other investigations
  • CXR (looking for mets)
  • Barium swallow may be done, although is not necessary after endoscopy- may be useful as a primary investigation if a motility disorder is suspected
• CT/MRI imaging for staging (important) +/- PET imaging
• Oesophageal ultrasound may be useful as estimating the depth of local invasion (however, often other imaging techniques will be required and will define this better any way)

Management

• Surgery should be considered for patients with potentially curable disease (i.e. no distal metastases or local invasion – T3 or below with relatively low lymph node burden)
  • Aim for radical resection (usually oesophagectomy – partial or complete)
  • Minimally invasive techniques e.g. endoscopic resection, is recommended
• Neoadjuvant chemotherapy is recommended for AC
• Chemoradiotherapy is suitable for SCC
• Palliative treatments 
  • Stenting
  • Palliative radiotherapy/chemotherapy
  • Pain relief