Oesophageal cancer Flashcards
Two main types
- Squamous cell carcinoma
- Adenocarcinoma
Squamous cell carcinoma - who and where
- More common in low and middle income countries
- Occurs in middle and upper 1/3rds of oesophagus
- Associated with smoking, excessive alcohol
Adenocarcinoma
- High income countries
- Lower 1/3rd oesophagus
- From metaplasia of epithelium - Barretts oesophagus, this then progresses to dysplasia and then malignancy
- RF long standing GORD, obesity, high fat intake
Symptoms of oesophageal cancer
- Lacks well defined symptoms - often presents late
- Dysphagia - progressive (solids only then liquids)
- Weight loss - dysphagia and cancer causing
- Others - odonophagia or hoarseness (less common)
Examination findings oesophageal cancer
- Weight loss/cachexia
- Signs of dehydration
- Supraclavicular lymphadenopathy
- Metastatic disease signs eg jaundice, hepatomegaly, ascites
Criteria for upper GI endoscopy - URGENT
- Any patient with dysphagia
- Any patient over 55 with weight loss and upper abdominal pain, dyspepsia or reflux
Investigations ?oesophageal cancer
- Upper GI endoscopy - OGD
- Biopsied if malignancy seen
- Sent for urgent histology
- If unfit for endoscopy - CT neck and thorax but less sensitive and specific
Futher investigations after upper GI endoscopy
- CT chest abdomen pelvis and PET CT scan - investigate for distant mets
- Endoscopic USS - measure penetration into oesophageal wall (T stage) and assess and biopsy suspicious lymph nodes
- Staging laparoscopy - assess for intraperitoneal mets (if junctional oesophageal tumours)
What should be done for palpable lymph nodes in oesophageal cancer patient?
Fine needle aspiration biopsy
What if the patient has hoarseness or haemoptysis?
May need bronchoscopy
Management oesophageal cancer - general
- MDT
- Majority of patients present with advanced disease so will receive palliative treatment
Curative treatment options
- Surgical or endoscopic resection
- With or without neoadjuvant chemo or chemo-radiotherapy
Squamous cell carcinoma management
- Difficult to operate on due to upper oesophagus location
- But are sensitive to chemo-radiotherapy - treatment of choice
- If early stage some may be able to be endoscopically resected
Adenocarcinoma management
- Neoadjuvant chemotherapy or chemoradiotherapy
- Followed by surgical resection
- If early stage and are small with no lymphovascular invasion and not poorly differentiated histology - may be able to be resected
Two types of endoscopic resection
- Endoscopic submucosal dissection (ESD)
- Endoscopic mucosal resection (EMR)
ESD vs EMR
- ESD allows for en-bloc resection of larger lesions with lower recurrence rates
- BUT more technically demanding with higher complication rates
- EMR may result in bit by bit resection in larger lesions and incomplete resections
Surgical treatment for oesophageal cancer - problem
- Major surgery
- Abdominal and chest cavities need to be accessed
- One lung is deflated for significant proportion of surgery
Surgical procedure for oesophageal cancer
- Oesophagectomy - may be partial or total +/- partial gastrectomy
- Following resection, residual stomach is brought to chest cavity and anastomosed proximally to allow GI tract to be continious
- Most of the time have feeding tube into small bowel (jejunostomy) to aid nutrition post op
Surgery - open or laparoscopic?
- Can be either (or robitcally)
Open approaches inc: - right thoractomy with lapartomy
- right thoracotomy with abdominal and neck incision
- left thoracoabdominal incision - one incision from umbilicus extending round back to below left shoulder blade
Problems post op
- Post operative nutrition - lose reservoir function of stomach, feeding jejunostomy can be used to help. Most patients will need 5-6 small meals per day for nutrition
- Anastomotic leak
- Pneumonia
- Mortality
Palliative management - when
- Metastatic tumours
- Non-metastatic unresectable tumours
- Too unfit for curative therapy
Palliative options for oesophageal cancer
- Oesophageal stent
- Radiotherapy, chemotherapy or immunotherapy - control disease, reduce tumour size or bleeding so improve symptoms
- Nutritional support - thickened fluid and supplements
- If dysphagia becomes too severe - radiologically inserted gastrostomy may be inserted
Prognosis for oesophageal cancer
- Poor - late presentation
- Median survival = 4 months
- 10yr survival rate - 10-15%