Oesophageal carcinoma

Question 1

What are the 2 types of oesophageal carcinomas?

Answer 1

1. Squamous-cell carcinomas: arise from epithelial cells that line the oesophagus.
2. Adenocarcinomas: arise from glandular cells present in the lower third of the oesophagus - often where they have already transformed to intestinal cell type (known as Barrett’s oesophagus).

Question 2

What is the epidemiology of oesophageal carcinomas?

Answer 2

·Increasing incidence across the Western world.

· Men are twice as likely as women to develop the disease.

Question 3

What is the prognosis for oesophageal carcinomas?

Answer 3

· Without aggressive treatment, the cancer tends to obstruct the oesophagus and cause severe dysphagia.
· In addition to local progression causing pain, it tends to metastasise widely to lungs, liver and bone.

Question 4

What are the risk factors for adenocarcinomas?

Answer 4

· GORD and Barrett’s.
· Hiatus hernia.
· Obesity.

Question 5

What are the risk factors for squamous cell carcinomas?

Answer 5

· Tobacco use.
· Alcohol use.
· FHx of oesophageal, stomach, oral or pharyngeal cancer.
·  Non-white race.
· HPV.
· Achalasia.

Question 6

What is the most common presenting symptom?

Answer 6

Dysphagia.

Question 7

What are the common signs and symptoms of oesophageal carcinomas?

Answer 7

· Dysphagia
· Odynophagia.
· Weight loss. 
· Hoarseness.
· Hiccups.
· Post-prandial/Paroxysmal cough.

Question 8

What 4 investigations can be requested?

Answer 8

1. Oesophagogastroduodenoscopy (OGD) with biopsies.
2. Comprehensive metabolic profile.
3. CT thorax and abdomen.
4. Endoscopic Ultrasound (EUS) +/- FNA.

Question 9

What does an EUS indicate?

Answer 9

The extent of local invasion and presence of any lymph node spread.

Question 10

Why might a CT thorax + abdomen be requested?

Answer 10

· To identify visceral metastases.

· Can also identify the thickness of the oesophageal lesion and presence of lymph node spread.

Question 11

When is a comprehensive metabolic profile performed and what does it show?

Answer 11

· Performed in advanced cases with near or complete oesophageal obstruction.

· May show hypokalaemia, elevated creatinine and urea/nitrogen.

Question 12

What patients receive an OGD first?

Answer 12

Patients with dysphagia, odynophagia or weight loss.

Question 13

What does an OGD do?

Answer 13

Differentiates oesophageal cancer from benign causes of dysphagia.

Question 14

Suggest some differential diagnoses.

Answer 14

· Benign stricture.

· Achalasia.

· Barrett’s oesophagus.

Question 15

What is the treatment for a Stage 0 and IA oesophageal carcinoma?

Answer 15

· 1st line - Endoscopic resection with or without ablation.

· 2nd line - Oesophagectomy - preferably minimally invasive.

Question 16

What is the treatment for a Stage IB and IIA oesophageal carcinoma?

Answer 16

· Surgical candidate:
- 1st line - Oesophagectomy - preferably minimally invasive.

· Non-surgical candidate:

• 1st line - Chemoradiotherapy or radiotherapy alone.
• 2nd line - Endoscopic ablation +/- stenting +/- brachytherapy for symptom relief.

Question 17

What is the treatment for a Stage IIB and III oesophageal carcinoma?

Answer 17

· Surgical candidate:

• 1st line - Oesophagectomy.
• Plus - Pre-operative chemoradiotherapy +/- post-operative chemotherapy.

· Non-surgical candidate:

• 1st line - Chemoradiotherapy or radiotherapy alone.
• 2nd line - Endoscopic ablation +/- stenting +/- brachytherapy for symptom relief.

Question 18

What is the treatment for a Stage IV oesophageal carcinoma?

Answer 18

· 1st line - Chemotherapy.
· Adjunct - Radiotherapy.
· Adjunct - Endoscopic ablation +/- stenting for symptoms relief.

Question 19

What complications may arise?

Answer 19

· Post-operative pneumonia. 
· Aspiration pneumonia. 
· Post-resection oesophageal reflux. 
· Oesophago-aortic fistula. 
· Tracheo-oesophageal fistula.