Oesophageal Cancer Flashcards
What are the 2 main types of oesophageal cancer?
There are two main types of oesophageal cancer, squamous cell carcinoma and adenocarcinoma.
Briefly describe squamous cell carcinomas of the oesophagus
Squamous cell carcinoma, which is more common in the developing world, typically occurring in the middle and upper thirds of the oesophagus.
This subtype is more associated with smoking and excessive alcohol consumption (other risk factors include chronic achalasia, low vitamin A levels and, rarely, iron deficiency).
Briefly describe adenocarinomas of the oesophagus
Adenocarcinoma, which are more common in the developed world, typically occur in the lower third of the oesophagus. This subtype arises as a consequence of metaplastic epithelium (termed Barrett’s oesophagus) which progresses to dysplasia, to eventually become malignant.
Risk factors for this subtype are long-standing GORD, obesity and high fat intake.
What are the clinical features of oesphageal cancer?
Early stage oesophageal cancer often lacks well-defined symptoms, which may account for the majority of patients presenting in the later course of the disease.
Dysphagia is a common presenting symptom of oesophageal cancer, typically progressive in nature (classically this starts with solids only, before affecting liquids).
Patients may also report significant weight loss, due to both dysphagia and cancer-related anorexia. Other less common symptoms include odynophagia or hoarseness.
On clinical examination, patients may have evidence of recent weight loss or cachexia, signs of dehydration, supraclavicular lymphadenopathy or any signs of metastatic disease (such as jaundice, hepatomegaly, or ascites).
What is the NICE criteria of upper GI endoscopy?
Current NICE guidance states the red-flag symptoms for a suspected oesophageal malignancy requiring urgent endoscopy are:
- Any patient with dysphagia
- Any patient >55yrs with weight loss and upper abdominal pain, dyspepsia or reflux
What investigations should be ordered for oesphageal cancer?
Note: intial
Any patient with a suspected oesophageal malignancy should be offered urgent upper GI endoscopy (also termed oesophago-gastro-duodenoscopy, OGD), to be performed within 2 weeks. Any malignancy seen on OGD will be biopsied and sent for histology.
What investigations should be ordered for oesophageal cancer?
Note: further imaging
Before undergoing curative treatment, patients often require a variety of the staging investigations including:
- CT Chest-Abdomen-Pelvis and PET-CT scan are used together to investigate for distant metastases
- Endoscopic ultrasound to measure the penetration into the oesophageal wall (T stage) and assess and biopsy suspicious mediastinal lymph nodes
- Staging laparoscopy (for junctional tumours with an intra-abdominal component) to look for intra-peritoneal metastases
Any palpable cervical lymph nodes may be investigated via Fine Needle Aspiration (FNA) biopsy and any hoarseness or haemoptysis may warrant investigation via bronchoscopy.
Why are the majority of cases treated palliatively?
Sadly, the majority of patients present with advanced disease. Approximately 70% of patients are therefore only treated palliatively.
Who is involved in the MDT of patients with oesophageal cancer?
The management of oesophageal cancer patients should be determined by the multidisciplinary team (MDT), with input from general surgeons, oncologists, specialist nurses, nutritionists, and, if required, the palliative care team.
Briefly describe the treatment for oesphageal cancer
Note: both squamous cell carcinoma and adenocarcinomas
The choice of curative treatment strategy will depend on tumour type, tumour site and patient factors (such as general fitness and co-morbidities).
For the majority of patients, this comprises surgery with or without neoadjuvant chemotherapy or chemo-radiotherapy:
- Squamous cell carcinoma
- SCCs of the upper oesophagus are technically difficult to operate on and definitive chemo-radiotherapy is therefore usually the treatment of choice
- Adenocarcinomas
- The treatment of choice is typically neoadjuvant chemotherapy or chemo-radiotherapy followed by oesophageal resection
Briefly describe the difficulties in undertaking surgical management of oesophageal cancer
Surgical treatment is a major undertaking as both the abdominal and chest cavities need to be opened. Patients have one lung deflated for about 2 hours during surgery; 30-day mortality rates are around 4% and it takes 6-9 months for patients to recover to their pre-operative quality of life.
Briefly describe the surgical management of oesophageal cancer
The main surgical management option for oesophageal cancer is an oesophagectomy, with a variety of approaches possible.
They all involve removal of the tumour, top of the stomach, and surrounding lymph nodes. The stomach is then made into a tube (“the conduit”) and brought up into the chest to replace the oesophagus.
What are the risks of surgical management of oesphageal cancer?
The main complications are anastomotic leak (8%), re-operation, pneumonia (30%), and death (4%).
Why is post-operative nutrition difficult following surgery for oesphageal cancer? And how is this treated?
Post-operative nutrition is a major problem for these patients as they lose the reservoir function of the stomach.
Many centres will routinely insert a feeding tube into the small bowel (a “feeding jejunostomy”) to aid nutrition. However, most patients will need to eat 5-6 small meals per day to meet their nutritional requirements.
Briefly describe the palliative management for patients with oesphageal cancer
Those patients deemed too unfit or unsuitable for curative therapy can be offered a range of palliative options.
Patients with difficulty in swallowing should have an oesophageal stent placed where possible. Radiotherapy and/or chemotherapy can be used for palliation to reduce tumour size and bleeding, temporarily improving the patient’s symptoms.
Nutritional support is essential for this patient group, as progression of the disease can lead to significant dysphagia and cachexia. Thickened fluid and nutritional supplements should be offered (usually via the nutrition team).
If dysphagia becomes too severe to tolerate enteral feeds, a Radiologically-Inserted Gastrostomy (RIG) tube may need to be inserted, to bypass the obstruction.
