Related Subjects:
|Assessing Chest Pain
|Achalasia
|Oesophageal Carcinoma
|Diffuse Oesophageal spasm
|Diffuse Oesophageal Perforation - Rupture
|Gastro-Oesophageal Reflux
|Barrett's oesophagus
Adenocarcinoma in the lower oesophagus is increasing in incidence and is associated with Barrett's oesophagus.
About
- Two different types of tumour with different aetiologies seen
- Prognosis is poor with only 10% 5-year survival
- In the UK approx. 7000-8000 cases per year
Aetiology
- Squamous Cell Carcinoma: Upper 2/3rds
- Adenocarcinoma: Lower 1/3rd from Barrett's Oesophagus
- Lymphoma and melanoma are rare
Risks for Squamous Cell Cancer
- Heavy alcohol intake, heavy smoking
- Tylosis - Autosomal dominant with hyperkeratosis of palms and soles
- Dietary - high salted fish and pickled vegetables
- Achalasia, Coeliac disease
- Geographical risk - high incidence in Iran, South Africa, and China
- Strictures or previous thoracic radiotherapy
- Possibly linked to low levels of serum selenium
- Plummer-Vinson syndrome (Patterson-Brown-Kelly)
Risks for Adenocarcinoma
- Smoking, GORD, and Barrett's oesophagus (40-fold increased risk)
- Obesity
- Barrett's intestinal metaplasia → mild → severe dysplasia → carcinoma
Clinical Presentation
- Often asymptomatic until late
- Progressive dysphagia (solids to fluids), odynophagia
- Hoarseness, aspiration pneumonia, bleeding
- Hypercalcaemia (PTHrp) with squamous cell cancer
- Anaemia, weight loss, chest pain
- Metastases to supraclavicular nodes, hepatomegaly
Local Invasion
- Invasion into trachea, lung, pleura, and recurrent laryngeal nerve
- Lymphatic spread to paraoesophageal, supraclavicular, or coeliac nodes
- Bloodborne spread to liver and lung
Investigations
- FBC: look for anaemia, U&E/LFT, and hypercalcaemia
- CXR or CT for dysphagia to exclude lung lesion and metastases
- OGD: preferred procedure for visualizing the tumour and taking biopsies
- Endoscopic ultrasound and laparoscopy for staging
- Bronchoscopy if tracheobronchial infiltration is suspected
- Barium swallow to delineate the tumour (biopsy still needed)
- CT/MRI/PET for chest and upper abdomen staging
Management
- Mucosal Lesions: Treated with endoscopic therapy (mucosa and submucosa).
- Attempted Curative Treatment: Surgical resection for about 30% of patients with localized disease who are fit for thoracotomy. Chemotherapy (cisplatin + 5 FU) may be given pre-operatively, especially for squamous cell carcinoma, to reduce tumour size. For lower oesophageal or cardia tumours, the Ivor-Lewis procedure is used. For upper two-thirds oesophageal tumours, total oesophagectomy is preferable.
- Palliative Treatment: Dysphagia may be treated by stenting or laser ablation. Maximizing nutrition is key. Involvement of palliative services is recommended where appropriate.