oesophageal carcinoma Flashcards
definition of oesophageal cancer
Malignant tumour arising in the oesophageal mucosa. Two major histological types: squamous cell carcinoma and adenocarcinoma.
RF for adenocarcinoma of the oesophagus
GOR - Barret’s oesophagus
obesity
smoking
achalasia
mostly in lower 1/3 of oesophagus or gastro-oesophageal junction
RF for squamous cell carcinoma of the oesophagus
alcohol consumption
smoking
diet low in fruit and veg - nutritional deficiencies (vitamins and trace elements)
drinking hot beverages
achalasia
nitrosamines exposure - cured meat, fish, bacon
plummer - vinson syndrome
caustic strictures
diverticular eg zenker’s diverticulum
radiotherapy
oesophageal candidiasis
betel or areca nut chewing
HPV infection
tylosis (howel-evans syndrome)
scleroderma
coeliac disease
lye stricture
history of upper areodigestive squamous cancer
dietary nitrosamines
mostly in upper 2/3 of oesophagus
pathology of oesophageal ca
20% occur in the upper part, 50% in the middle, and 30% in the lower part
Barretts intestinal metaplasia can progress to low-grade dysplasia,
high-grade dysplasia and invasive carcinoma.
Spread is typically initially direct (oesophagus has no serosa) and longitudinal via an extensive network of submucosal lymphatics to tracheobronchial, mediastinal, coeliac, gastric or cervical nodes. Later via blood
Rare oesophageal tumours include lymphoma, melanoma and leiomyosarcoma
epidemiology of oesophageal ca
men>women
peak incidence 60-70yrs
8th most common malignancy
adenocarcinoma - most common type of oesophageal cancer in US
UK incidence <9/100000/yr
SCC - most common oesophageal cancer worldwide
sx of oesophageal ca
early stages - often asymptomatic - may present with swallowing difficulties or retrosternal discomfort, or reflux
late stages
common - progressive dysphagia (from solids to liquids) with possible odynophagia, regurg, cough or choking after food, weight loss, retrosternal chest or backpain, poor eppetite
less common - hematemesis, melena, hoarseness
signs of upper oesophagus - hoarseness/cough (may be paroxysmal if aspiration pneumonia)
signs of oesophageal ca
anaemia
signs of weight loss
with met disease - may be supraclavicular lymphadenopathy, hepatomegaly
resp signs may be due to aspiration or direct tracheobronchial involvement
Ix for oesophageal ca
oesophagogastroduodenoscopy with biopsy
barium swallow
staging - transoesophageal endoscopic US, chest and abdo CT/PET/MRI, bronchoscopy or laparoscopy
Bronchoscopy (if risk of trancheobronchial invasion),
bone scan is symptoms of bony involvement.
Laparoscopy and peritoneal washings, thoracoscopy. - laproscopy if significant infra-duaphragmatic component
Careful cardiac and respiratory assessment if surgery planned.
oesophagogastroduodenoscopy for oesophageal ca
best initial and confirmatory diagnosis, direct visualisation of the tumour, with biopsy of any suspicious lesions
Early high-grade dysplasia and cancer detection is improved by endoscopic techniques such as narrow band imaging or magnification, staging.
barium swallow for oesophageal ca
asymmetrical and irregular borders of the oesophagus with characteristic stenosis and proximal dilation (apple core lesion)
- doesnt allow confirmation or staging of a malignancy, inferior to endoscopy,
indicated if severe stricture that inhibits endoscopic evaluation, suspected tracheoesophageal fistula due to oesophageal cancer
staging of oesophageal ca
CT chest, abdo and pelvis to assess nodal spread (liver and lung met are the commonest met of oesophageal malignancy)
radial endoscopic US is best for T staging and local N staging
linear endoscopic US is needed if nodal sample is needed
PET identify distant met inc in lymph nodes
staging of oesophageal ca
Tis - in situ
T1 - invading lamina propria/submucosa
T2 - invading muscularis propria
T3 - invading adventitia
T4 - invasion of adjacent structures
Nx - nodes cant be assessed
N0 - no node spread
N1-3 regional node med
M0 - no distant spread
M1 - distant met
