Oesophageal cancer (GI) Flashcards
Describe the epidemiology of oesophageal cancer. (2)
- M>F
- 60-70 years old
What are the two types of oesophageal cancer?
- squamous cell carcinoma (upper 2/3)
- adenocarcinoma (lower 1/3)
What are the risk factors for oesophageal squamous cell carcinoma? (7)
- alcohol
- smoking
- diet low in fruit and veg
- hot beverages
- HPV
- achalasia
- Plummer-Vinson syndrome
What are the risk factors for oesophageal adenocarcinoma? (5)
- 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
Which type of oesophageal cancer is more common in the developed world?
Adenocarcinomas
Describe the development of oesophageal cancer - adenocarcinoma.
- 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
What are oesophageal cancers usually like at time of diagnosis?
Locally advanced
Dysphagia (presenting Sx) only occurs after obstruction of >2/3 of the lumen
What are the main clinical features of oesophageal cancer? (3)
- progressive dysphagia - first solids, then liquids
- odynophagia
- rapid weight loss (due to both lack of intake + cancer itself)
What are the signs of advanced oesophageal cancer? (4)
- 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
What are the features of Horner’s syndrome? (3)
- ptosis - droopy eyelid
- miosis - constricted pupil
- anhidrosis - little/no sweat
What signs of upper GI bleeding could there be in oesophageal cancer? (4)
- haematemesis
- melaena
- raised urea
- Sx of anaemia (fatigue, SOB)
What might you see on examination in oesophageal cancer? (2)
- supraclavicular lymphadenopathy
- hepatomegaly - metastatic disease
What are the first-line investigations for oesophageal cancer? (4)
- OGD with biopsy
- EUS +/- FNA
- CT thorax and abdomen
- FDG-PET scan
What is the gold standard investigation for oesophageal cancer?
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
How do we stage oesophageal cancer?
CT CAP/MRI - important for treatment
What are some differential diagnoses for oesophageal cancer? (3)
- 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
How do we manage low grade dysplasia (oesophageal cancer)?
High dose PPI
Six-monthly endoscopic surveillance
How can we manage superficial intramucosal well-differentiated oesophageal cancer?
Oesophagus-sparing approach - endoscopic mucosal resection +/- ablation and surveillance
What is the management for locally advanced oesophageal cancer?
Combined modality therapy: chemotherapy/chemoradiotherapy followed by oesophagectomy
What main management is there for oesophageal cancer apart from surgical management?
Chemoradiotherapy - better than radiotherapy alone
What are some complications of oesophageal cancer? (4)
- post-operative pneumonia
- aspiration pneumonia
- post-resection oesophageal reflux
- fistula
Describe the prognosis of oesophageal cancer.
Lethal malignancy - poor prognosis due to aggressive course and late diagnosis
What is achalasia (oesophageal cancer differential)?
Incomplete relaxation of lower oesophageal sphincter –> hypomotility
How does achalasia present (similar to oesophageal cancer)?
Dysphagia to both solids and liquids from start
(Oesophageal cancer = progressive with solids then liquids)
What is the gold standard investigation for achalasia?
Manometry showing increased resting pressure of LOS
What would barium swallow show in achalasia?
Bird’s beak appearance (grossly dilated oesophagus that tapers at the LOS)
What would a CXR show in achalasia?
Wide mediastinum, fluid level
What is the management of achalasia? (2)
Pneumatic dilatation or Heller’s cardiomyotomy (relieves pressure on LOS)
