Oesophageal cancer
Until recent times oesophageal cancer was most commonly due to a squamous cell carcinoma but the incidence of adenocarcinoma is rising rapidly. Adenocarcinoma is now the most common type of oesophageal cancer and is more likely to develop in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett's.
The majority of adenocarcinomas are located near the gastroesophageal junction whereas squamous cell tumours are most commonly found in the upper two-thirds of the oesophagus.
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Adenocarcinoma |
Squamous cell cancer |
| Epidemiology |
Most common type in the UK/US |
Most common type in the developing world |
| Location |
Lower third - near the gastroesophageal junction |
Upper two-thirds of the oesophagus |
| Risk factors |
• GORD |
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| • Barrett's oesophagus |
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| • smoking |
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| • obesity |
• smoking |
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| • alcohol |
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| • achalasia |
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| • Plummer-Vinson syndrome |
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| • diets rich in nitrosamines |
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Features
- dysphagia: the most common presenting symptom
- anorexia and weight loss
- vomiting
- other possible features include:
- odynophagia
- hoarseness: advanced oesophageal tumours, especially in the upper third, may invade or compress the recurrent laryngeal nerve
- melaena
Diagnosis
- Upper GI endoscopy with biopsy is used for diagnosis
- Endoscopic ultrasound is the preferred method for locoregional staging
- CT scanning of the chest, abdomen and pelvis is used for initial staging
- FDG-PET CT may be used for detecting occult metastases if metastases are not seen on the initial staging CT scans.
- Laparoscopy is sometimes performed to detect occult peritoneal disease
Treatment
- Operable disease (T1N0M0) is best managed by surgical resection - the most common procedure is an Ivor-Lewis type oesophagectomy
- The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis resulting in mediastinitis
- In addition to surgical resection many patients will be treated with adjuvant chemotherapy