Oesophageal Cancer Flashcards
Epidemiology
8500 new cases each year in the UK
Incidence is rising
Three times more common in men
Two main types
Squamous cell carcinoma
Adenocarcinoma
(Rare: leiomyosarcoma, rhabdomyosarcoma, lymphoma)
Explain SCC of oesophagus
More common in the developing world
Typically occur in the middle and upper thirds of the oesophagus
What is SCC of oesophagus associated with?
Smoking and excessive alcohol consumption
(Chronic achalasia, low vitamin A and iron deficiency)
Explain adenocarcinoma of the oesophagus
More common in the developed world
Typically occur in the lower third of the oesophagus
What is adenocarcinoma of the oesophagus associated with?
Metaplastic epithelium from BO that progress to dysplasia
Risk factors such as long-standing GORD, obeisty and high fat intake
Clinical features
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
Examination findings
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
Criteria for upper GI endoscopy
Any patient with dysphagia
Any patient >55ys with weight loss, upper abdo pain, dyspepsia or reflux
Initial investigations
Urgent upper GI Endoscopy (OGD) withing 2 weeks,
Any malignancy seen on OGD will be biopsied and sent for histology
What if the patient isn’t fit for an OGD?
CT scan (neck and thorax) but this is much less sensitive and specific
Further investigations before undergoing curative treatment
Staging investigations
Give staging investigations
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
What might palpable cervical lymph nodes be investigated via?
Fine needle aspiration (FNA)
Any hoarseness or haemoptysis may warrant ix via bronchoscopy
General management
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.
What does the choice of curative treatment depend on?
Tumour type
Tumour site
Patient factors
Treament of choice SCC
Technically difficult to operate on
This means that definitive chemo-radiotherapy is most commonly the treatment of choice.
Treatment of choice adenocarcinomas
Typically neoadjuvant chemotherapy or chemoradiation followed by oesophageal resection
Explain surgical treatment
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
Explain the general principle of surgical techniques.
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.
Give examples of surgical techniques
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)
Main complications of surgery
Anastomotic leaks (8%)
Re-operation
Pneumonia (305)
Death (4%)
Post-operative nutrition
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.
Palliative management
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.
Prognosis
Generally poor due to late presentation
Overall five-year is 5-10%
