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Oesophageal cancer 

Written by Jiak Ying Tan 

Last Reviewed: August 2019

Review Due: August 2020

 

DEFINITION1

‘squamous cell carcinoma arises from cells lining the oesophagus which is commonly associated with tobacco, alcohol, achalasia and coeliac’s disease. Adenocarcinoma arises from the glandular tissue in association with Barrett's oesophagus’

 

AETIOLOGY2

Non-specific 

Achalasia  

Hot drinks 

Nitrosamine exposure 

Plummer-Vinson syndrome 

Associated with adenocarcinoma 

Reflux oesophagitis +/- Barrett’s oesophagus 

Obesity

Associated with squamous cell carcinoma 

Smoking 

Alcohol excess

HPV

SIGNS AND SYMPTOMS2

Symptoms 

Dysphagia 

Vomiting 

Weight Loss and loss of appetite  

Retrosternal Chest Pain 

Hoarseness 

Cough (may be paroxysmal if aspiration pneumonia) 

 

Signs 

Cachexia 

Malnourished

 

PATHOPHYSIOLOGY1,2

Adenocarcinoma 

Chronic gastro-oesophageal reflux causes inflammatory damage to the oesophageal lining. This leads to cellular metaplasia known as Barrett's oesophagus. This is where stratified squamous epithelium is replaced by abnormal columnar epithelium  due to this cell types potential ability to be more resistant to gastric acid. These cells are more likely to become dysplastic and malignant. 

 

Squamous Cell Carcinoma 

Smoking introduces a large number or carcinogens to the oesophagus, directly causing DNA damage. 

Alcohol is not itself a carcinogen but acetaldehyde, a product of alcohol metabolism is carcinogenic.

Site of cancer: 

20% - Superior oesophagus

50%-  Mid oesophagus  

30% - Inferior oesophagus

 

Investigations1,2,3

Blood tests 

FBC 

Anaemia due to bleeding or chronic disease

Imaging

Oesophagogastroduodenoscopy with biopsy 

Look at oesophagus structure in gross appearance to look for any evidence of growth of mass, ulcers, stricture 

CT chest, abdo-pelvis for staging 

CT is used to assess the following for TNM staging

laboratory

Imaging 

 

TREATMENT3

Treatment options are decided based on the TNM staging of the cancer, overall fitness and any underlying comorbidities of the patient. 

 

Endoscopic Resection +/- ablation 

For stage 0 or carcinoma in-situ patient 

Surgery – oesophagectomy 

The only radical curative treatment 

For localised T1/T2 disease 

There are three different approaches:

  1. Ivor Lewis Operation – for lower oesophageal tumour  

  2. McKeown Operation – for oesophageal tumour above trachea bifurcation 

  3. Transhiatal Oesophagectomy 

 

Radio/chemotherapy 

Can be used for pre-op neoadjuvant therapy 

Also used in palliative care when patient is unfit for surgery or the cancer is too advanced 

Aim to restore swallowing

 

Another palliative option with the aim to restore swallowing is stenting.

 

EPIDEMIOLOGY1

Incidence in the UK is estimated to be 5 to 12 cases per 100,000 people, and the prevalence is 50 per 100,000 people.

 

 
 

The UK has an incidence of  10/100 000/ yr. It is around 20 times more common in China and twice as common in France. The incidence is increasing in the Western world.

Male to Female = 5:1 

REFERENCES

1.    Ellis H, Calne R, Watson C. General Surgery: Lecture Notes. 13th ed. Wiley-Blackwell; 2016.

2.    Krasna M, Abbas G. Oesophageal Cancer. BMJ Best Practice 2018

3.    NICE Guideline 83. Oesophago-gastric cancer:assessment and management in adults. 2018;(January)