Oesophageal carcinoma

Question 1

What are the two most common types of oesophageal carcinomas?

Answer 1

1. Squamous cell carcinoma

2. Adenocarcinoma

Question 2

How common are oesophageal carcinomas?

Answer 2

6th most common cancer worldwide.

SCC occurs in middle third of oesophagus = 40% of all tumours
SCC occurs in upper third of oesophagus = 15% of all tumours

Adenocarcinoma in the lower third of oesophagus and at the cardia = 45% of all tumours

Primary small cell cancer of the oesophagus = very rare

Incidence of adenocarcinoma is increasing, whilst SCC is decreasing.

Question 3

What are the risk factors for oesophageal SCC?

Answer 3

Tobacco smoking 
Excess alcohol
Achalasia (lower oesophageal sphincter fails to open up during swallowing)
Corrosive strictures
Coeliac disease
Breast cancer treated with radiotherapy 
Men > Women

Low veg/fruit diet/low fibre diet => diet rich in fibre, carotenoids, folate, vitamin C decrease the risk

Question 4

What are the risk factors for oesophageal adenocarcinoma?

Answer 4

Long-term heart-burn/reflux oesophagitis (increase risk 8-fold)
Barret's oesophagus 
Tobacco smoking 
Obesity
Hot drinks
Nitrosamine exposure
Breast cancer treated with radiotherapy 
Older age

Question 5

Oesophageal adenocarcinoma occurs in which tissue?

Answer 5

Columnar-lined epithelium in the lower oesophagus

Question 6

What is the incidence of adenocarcinoma?

Answer 6

> 70% of all new oesophageal tumours

Question 7

Which age range is oesophageal carcinomas most commonly seen in?

Answer 7

60-70 years

Question 8

What are the clinical features of oesophageal carcinomas?

Answer 8

Progressive dysphagia (first difficulty with solids then liquids)

Retrosternal chest pain - due to impaction of food. Persistent pain = infiltration of adjacent structures

Weight loss due to dysphagia + anorexia

Lymphadenopathy

Hoarseness (upper 1/3 oesophagus)

Oesophageal obstruction = difficulty swallowing saliva ==> coughing & aspiration into lungs

Question 9

In which 3 ways can oesophageal carcinoma lesions be described?

Answer 9

Ulcerative, proliferative or scirrhous = can result in strictures.

Question 10

Which method of invasion is more common in oesophageal cancers - direct or disseminated?

Answer 10

Direct invasion of surrounding structures & metastases to lymph nodes more common than disseminated metastases.

Question 11

Which investigations are carried out for oesophageal carcinomas?

Answer 11

Endoscopy + biopsy - histological proof of carcinoma

Barium swallow - useful if differential of dysphagia includes motility disorder i.e. achalasia

Question 12

Which staging system is used for oesophageal cancers?

Answer 12

TNM;

T = tumour invasion of the wall of oesophagus 
N = presence of tumour in lymph nodes
M = metastases

Question 13

Which modes of imaging is used to stage oesophageal carcinoma?

Answer 13

1. CT scan of thorax & upper abdomen : good for volume of tumour, local invasion, peritumoral & coeliac lymph node involvement, and metastases in lung
2. MRI : same as CT in local staging but not good for metastases
3. Endoscopic ultrasound : good for depth of tumour, infiltration and staging for lymph node involvement. (Useful if CT not demonstrated if cancer is too advance for surgery)

A fine-needle aspiration (FNA) of lymph node = for accurate staging. Accurate T-staging important as cancer confined to superficial mucusa can be removed endoscopically

4. PET scan : to confirm suspicion of metastases seen on CT

Question 14

What is the management/ treatment of oesophageal carcinomas?

Answer 14

Treatment is dependent on the age and stage of disease

1. Surgery: best cure but should only be performed when imaging has confirmed that tumour has not infiltrated near structures
2. Pre-operative (neo-adjuvant) chemo-radiation therapy (for stage 2 & 3)
3. Palliative therapy
4. Nutritional support

Question 15

Which healthcare professionals are involved in treatment of patients with oesophageal carcinomas?

Answer 15

Gastroenterologists, upper GI surgeons, oncologists, palliative care physicians and dieticians

Question 16

What is the prognosis of oesophageal carcinomas?

Answer 16

5-year survival at:

Stage 1 of disease = 80%

Stage 2 of disease = 30%

Stage 3 of disease = 18%

Stage 4 of disease = 4%

Question 17

Other oesophageal tumours i.e. gastrointestinal stroll tumours and leiomyomas are extremely rare. Which tissue do these tumours affect?

Answer 17

Submucosa

Question 18

How are the rare oesophageal cancers (gastrointestinal stroll tumours and leiomyomas) diagnosed and treated?

Answer 18

Usually found by chance
10% cause dysphagia or bleeding

Best treated via surgical removal for symptomatic lesions or lesions >3cm as these are more likely to become malignant.

Benign tumours are common and don’t need treatment

Question 19

Kaposi’s sarcoma is found in the oesophagus, mouth and hypopharynx in patients with AIDS.

What is kaposi’s sarcoma and how does it present?

Answer 19

Kaposi’s sarcoma is the most common cancer in HIV patients.

A spindle-cell tumour derived from capillary endothelial cells, caused by human herpes virus 8.

It presents as purple papule or plaques on skin.

Question 20

What is Barrett’s oesophagus?

Answer 20

Metaplasia of the normal stratified squamous epithelium of the distal oesophagus to a columnar epithelium, as a result of chronic GORD.

Always almost a hiatus hernia present.

Barrett’s increase the risk of progressing to adenocarcinoma.