Oesophageal Cancer

Question 1

Epidemiology

Answer 1

8500 new cases each year in the UK

Incidence is rising

Three times more common in men

Question 2

Two main types

Answer 2

Squamous cell carcinoma

Adenocarcinoma

(Rare: leiomyosarcoma, rhabdomyosarcoma, lymphoma)

Question 3

Explain SCC of oesophagus

Answer 3

More common in the developing world

Typically occur in the middle and upper thirds of the oesophagus

Question 4

What is SCC of oesophagus associated with?

Answer 4

Smoking and excessive alcohol consumption

(Chronic achalasia, low vitamin A and iron deficiency)

Question 5

Explain adenocarcinoma of the oesophagus

Answer 5

More common in the developed world

Typically occur in the lower third of the oesophagus

Question 6

What is adenocarcinoma of the oesophagus associated with?

Answer 6

Metaplastic epithelium from BO that progress to dysplasia

Risk factors such as long-standing GORD, obeisty and high fat intake

Question 7

Clinical features

Answer 7

Early stages often lack well-defined symptoms

Dysphagia (starting with solids only but progress to also liquids)

Weight loss

Odynophagia or hoarseness

Loss of appetite

Malaise

Question 8

Examination findings

Answer 8

Weight loss or cachexia

Signs of dehydration

Supraclavicular lymphadenopathy

Signs of metastatic disease like jaundice, hepatomegaly or ascites

Any patient with dysphagia should be assumed to have oesophageal cancer until proven otherwise

Question 9

Criteria for upper GI endoscopy

Answer 9

Any patient with dysphagia

Any patient >55ys with weight loss, upper abdo pain, dyspepsia or reflux

Question 10

Initial investigations

Answer 10

Urgent upper GI Endoscopy (OGD) withing 2 weeks,

Any malignancy seen on OGD will be biopsied and sent for histology

Question 11

What if the patient isn’t fit for an OGD?

Answer 11

CT scan (neck and thorax) but this is much less sensitive and specific

Question 12

Further investigations before undergoing curative treatment

Answer 12

Staging investigations

Question 13

Give staging investigations

Answer 13

CT chest-abdomen-pelvis and PET-CT scan to investigate distant metastases

Endoscopic ultrasound to measure penetration into oesophageal wall (T-stage) and assess and biopsy suspicious mediastinal lymph nodes

Staging laparoscopy to look for intra-peritoneal metastases

Question 14

What might palpable cervical lymph nodes be investigated via?

Answer 14

Fine needle aspiration (FNA)

Any hoarseness or haemoptysis may warrant ix via bronchoscopy

Question 15

General management

Answer 15

Majority have advanced disease and therefore aroudn 70% are only treated palliatively.

Treatment should be determiend by a MDT with input from general surgeons, oncologists, specialist nurses, nutritionists, and if required, palliatve care team.

Question 16

What does the choice of curative treatment depend on?

Answer 16

Tumour type

Tumour site

Patient factors

Question 17

Treament of choice SCC

Answer 17

Technically difficult to operate on

This means that definitive chemo-radiotherapy is most commonly the treatment of choice.

Question 18

Treatment of choice adenocarcinomas

Answer 18

Typically neoadjuvant chemotherapy or chemoradiation followed by oesophageal resection

Question 19

Explain surgical treatment

Answer 19

A major undertaking since both the abdominal and chest cavities need to be opened.

30 days mortality rates are around 4% and takes 6-9 months for patients to recover

Question 20

Explain the general principle of surgical techniques.

Answer 20

Oesophagectomy.

Removal of tumour, top of the stomach and surrounding lymph nodes.

The stomach is then made into a tube (the conduit) and brough up into the chest to replace the oesophagus.

Question 21

Give examples of surgical techniques

Answer 21

Right thoracotomy with laparotomy (Ivor-Lewis procedure)

Right thoractomy with abdominal and neck incision (McKeown procedure)

Left thoractomy with or without neck incision

Left thoraco-abdominal incision

(EMR can be done in very early cancer stage or high grade BO)

Question 22

Main complications of surgery

Answer 22

Anastomotic leaks (8%)

Re-operation

Pneumonia (305)

Death (4%)

Question 23

Post-operative nutrition

Answer 23

Major problem since the patient loses their reservoir function of the stomach.

Feeding jejunostomy might be inserted to aid nutrition.

Most patients will need to eat 5-6 small meals per day to meet nutritional needs.

Question 24

Palliative management

Answer 24

Dysphagia -> Oesophageal stent placed

Radiotherapy +/- chemo can be used to reduce tumour size and bleeding

Nutritional support with thickened fluids and nutritional supplements

If dysphagia becomes too severe to tolerate enteral feeds radiologically-inserted gastrostomy (RIG) tube may need to be inserted.

Question 25

Prognosis

Answer 25

Generally poor due to late presentation

Overall five-year is 5-10%