Oesophageal carcinoma Flashcards
What are the two main types of oesophageal cancer?
- Squamous cell carcinoma
- Adenocarcinoma
Describe oesophageal cancer?
- More common in men
- Incidence of lower oesophagus / GO junction cancer rising
Describe squamous cell carcinoma of the oesophagus?
- Developing world
- Middle and upper 1/3s of the oesophagus
- Assoication with alcohol, smoking, chronic achalasia, low vitamin A and hot drinks
Describe adenocarcinoma of the oesophagus?
- Developed world
- Lower third of the oesphagus
- Occurs due to metaplasia
- Risks are GORD and obesity
Describe the clinical features of oesophageal carcinoma?
- Progressive dysphagia
- Weight loss
- Odynophagia, hoarseness, horners syndrome
- Coughing when consuming liquids (fistula)
What do NICE guideliness say are the red-flag symptoms which require urgent endoscopy?
- Dysphagia
- >55yrs with weight loss, upper abdominal pain, dyspepsia or reflux
Differentials for oesophageal carcinoma?
Any patient should be presumed to have oesophageal cancer until proven otherwise
Describe investigations into oesophageal cancer?
- Barium swallow
- Urgent upper GI endoscopy (OGD)
- Biopsy -> histology
- CT scan for those not suitable for OGD
- Further investigations
- PET-CT for mets
- Endoscopic US (measure penetration (T stage) and biopsy lymph nodes
Describe the management of oesophageal cancer?
- 70% can only have palliative treatment
- Curative management:
- For most people this is surgery +/- chemo/chemoradiotherapy
Describe the curative management of SSCs of the oeosphagus?
- Upper oesophagus SSCs are difficult to operate on
- Chemoradiotherapy (CRT)
- SSCs in middle/lower oesophagus
- CRT +/- surgery
Describe the curative management of adenocarcinomas of the oeosphagus?
- Neoadjuvant chemo/CRT followed by oesophageal resection
- Less fit patients may only receive surgery
Describe the surgical management of oesophageal cancer?
- Major surgery as both abdominal and chest cavities are opened
- Patients have one lung deflated for 2 hours during surgery
- Main complications: anastomotic leak, re-operation, pneumonia, death
What is a major post-op side effect in patients with oesophageal carcinoma?
- Post-operative nutrition
- Lose the reservoir function of the stomach
- Some centres insert feeding tube into small bowel to aid nutrition
- Most will need to eat 5-6 small meals per day to ‘graze’
Surgical techniques involved in oesophageal cancer surgery?
- Oesophagectomy
- Remove tumour, top of the stomach and lymph nodes.
- The stomach is made into a tube and brought into chest to replace oesophagus.
Which surgical approach is termed the Ivor-Lewis procedure?
Right thoracotomy with laparotomy
Which surgical approach is termed the McKeown procedure?
Right thoracotomy with abdominal incision and neck incision
Describe the left thoraco-abdominal incision technique?
One large incision starting above the umbilicus and extending round the back to below the left shoulder blade
Describe an alternative procedure in those with early cancers or high grade Barret’s oesophagus?
- Endoscopy mucosal resection (EMR)
- Removal of just the mucosal layer of the oesophagus
- Can be combined with radiofrequency ablation (RFA) or photodynamic therapy (PDT)
Describe the palliative management of those with severe oesophageal cancer?
- If there is difficulty swallowing => oesophageal stent where possible
- Radiotherapy/chemotherapy can reduce tumour size and bleeding to improve symptoms
- Photodynamic treatment can be used to kill certain cells
- Nutritional support through thickened fluid and supplements
- If dysphagia is too severe to tolerate enteral feeds:
- Radiologically inserted gastrostomy (RIG) tube can bypass obstruction
Describe the prognosis of oesophageal carcinoma?
- Generally poor due to late presentation
- 5-10% 5 year survival
what vertebral level does the oesophagus originate?
C6
