Oesophageal cancer (GI)

Question 1

Describe the epidemiology of oesophageal cancer. (2)

Answer 1

• M>F
• 60-70 years old

Question 2

What are the two types of oesophageal cancer?

Answer 2

• squamous cell carcinoma (upper 2/3)
• adenocarcinoma (lower 1/3)

Question 3

What are the risk factors for oesophageal squamous cell carcinoma? (7)

Answer 3

• alcohol
• smoking
• diet low in fruit and veg
• hot beverages
• HPV
• achalasia
• Plummer-Vinson syndrome

Question 4

What are the risk factors for oesophageal adenocarcinoma? (5)

Answer 4

• obesity
• male
• GORD –> Barrett’s oesophagus
• Barrett’s oesophagus
• hiatus hernia (increased reflux)
• (smoking and alcohol intake not as important as they are for SCC - instead factors that increase reflux more important)

Question 5

Which type of oesophageal cancer is more common in the developed world?

Answer 5

Adenocarcinomas

Question 6

Describe the development of oesophageal cancer - adenocarcinoma.

Answer 6

• GORD –> Barrett’s oesophagus
  
  • Barrett’s oesophagus = metaplasia of mucosal lining of distal oesophagus due to long-standing reflux
  • stratified squamous epithelium replaced by abnormal columnar epithelium
• metaplasia –> dysplasia –> malignant

Question 7

What are oesophageal cancers usually like at time of diagnosis?

Answer 7

Locally advanced

Dysphagia (presenting Sx) only occurs after obstruction of >2/3 of the lumen

Question 8

What are the main clinical features of oesophageal cancer? (3)

Answer 8

• progressive dysphagia - first solids, then liquids
• odynophagia
• rapid weight loss (due to both lack of intake + cancer itself)

Question 9

What are the signs of advanced oesophageal cancer? (4)

Answer 9

• hoarseness - recurrent laryngeal nerve pressed
• Horner’s syndrome - ptosis, miosis, anhidrosis
• hiccups - phrenic nerve involvement
• postprandial/paroxysmal cough - oesophago-tracheal/bronchial fistula from local invasion

Question 10

What are the features of Horner’s syndrome? (3)

Answer 10

• ptosis - droopy eyelid
• miosis - constricted pupil
• anhidrosis - little/no sweat

Question 11

What signs of upper GI bleeding could there be in oesophageal cancer? (4)

Answer 11

• haematemesis
• melaena
• raised urea
• Sx of anaemia (fatigue, SOB)

Question 12

What might you see on examination in oesophageal cancer? (2)

Answer 12

• supraclavicular lymphadenopathy
• hepatomegaly - metastatic disease

Question 13

What are the first-line investigations for oesophageal cancer? (4)

Answer 13

• OGD with biopsy
• EUS +/- FNA
• CT thorax and abdomen
• FDG-PET scan

Question 14

What is the gold standard investigation for oesophageal cancer?

Answer 14

Upper GI endoscopy (OGD) with biopsy - 1st line in dysphagia, odynophagia and weight loss patients

Differentiates oesophageal cancer from benign causes of dysphagia e.g. achalasia

Question 15

How do we stage oesophageal cancer?

Answer 15

CT CAP/MRI - important for treatment

Question 16

What are some differential diagnoses for oesophageal cancer? (3)

Answer 16

• benign stricture
• Barrett’s oesophagus
• achalasia:
  
  • regurgitation w/o heartburn
  • may be clinically indistinguishable
  • bird’s beak filling defect in upper GI series
  • dysphagia of both solids and liquids
  • manometry

Question 17

How do we manage low grade dysplasia (oesophageal cancer)?

Answer 17

High dose PPI
Six-monthly endoscopic surveillance

Question 18

How can we manage superficial intramucosal well-differentiated oesophageal cancer?

Answer 18

Oesophagus-sparing approach - endoscopic mucosal resection +/- ablation and surveillance

Question 19

What is the management for locally advanced oesophageal cancer?

Answer 19

Combined modality therapy: chemotherapy/chemoradiotherapy followed by oesophagectomy

Question 20

What main management is there for oesophageal cancer apart from surgical management?

Answer 20

Chemoradiotherapy - better than radiotherapy alone

Question 21

What are some complications of oesophageal cancer? (4)

Answer 21

• post-operative pneumonia
• aspiration pneumonia
• post-resection oesophageal reflux
• fistula

Question 22

Describe the prognosis of oesophageal cancer.

Answer 22

Lethal malignancy - poor prognosis due to aggressive course and late diagnosis

Question 23

What is achalasia (oesophageal cancer differential)?

Answer 23

Incomplete relaxation of lower oesophageal sphincter –> hypomotility

Question 24

How does achalasia present (similar to oesophageal cancer)?

Answer 24

Dysphagia to both solids and liquids from start

(Oesophageal cancer = progressive with solids then liquids)

Question 25

What is the gold standard investigation for achalasia?

Answer 25

Manometry showing increased resting pressure of LOS

Question 26

What would barium swallow show in achalasia?

Answer 26

Bird’s beak appearance (grossly dilated oesophagus that tapers at the LOS)

Question 27

What would a CXR show in achalasia?

Answer 27

Wide mediastinum, fluid level

Question 28

What is the management of achalasia? (2)

Answer 28

Pneumatic dilatation or Heller’s cardiomyotomy (relieves pressure on LOS)