Oesophageal cancer

Oesophageal cancer is increasing in overall incidence worldwide with squamous cell carcinoma predominating in the third world and adenocarcinoma predominating in the first world. They have both common and different aetiological factors. Rarer types are melanoma, leiomyosarcoma and small cell carcinoma. The prognosis in most detected by symptoms is poor - most less than 6 months, due to the late presentation. Tumour detected by surveillance endoscopy has a much better prognosis but surveillance can only be justified in those at highest risk.

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Epidemiology

Squamous cell carcinoma tends to occur in the upper two thirds and is associated with factors common in those with low socioecomic status. Probably life style factors such as obesity predisposing to GORD, and exposure to differential carcinogens associated with high meat diets (eg nitrosamines) explains the increasing incidence of adenocarcinoma in the first world.

Risk factors

Common

For the two common types of oesophageal cancer:

Smoking
Thoracic radiation
Age, but more marked for oesophageal adenocarcioma

Squamous

Alcohol
- Mutations that increase aldehyde production from alcohol
Achalasia
Poor dental hygiene
Trauma as with caustic injury
Low socioeconomic status
- Nutritional deficiency

Adenocarcioma

Symptomatic GORD
Low fruit and vegetable intake
Occurs most commonly in males (7:1)
Post-cricoid carcinoma in females as part of Plummer-Vinson syndrome
Barrett's oesophagus
- Thus tendency to be in middle or lower third
Medications that relax oesophageal spincter
Genetics
- Familial history is rare but possible

Symptoms

Dysphagia
- usually rapid onset
- solids before liquids
Weight loss
Anorexia
Anaemia

Signs

palpable supraclavicular nodes
palpable irregular liver

Investigations

Endoscopic view of an oesophageal cancer

Blood

FBC
ESR
U&Es
LFTs

Radiology

Barium swallow
CXR (though information obtained also obtainable from CT)
- Mediastinal widening
- Secondaries in lung
Bronchoscopy - exclude invasion into airway
CT
USS liver

Others

Oesophagoscopy & biopsy
- Defines extent of disease
- Proximally, need to be able to achieve adequate margins from the cricopharyngeus. If tumour is too close, surgical resection will entail removal parts of the upper airway structures.
- Distally, extent will define amount of stomach to remove.
Biopsies
- Squamous vs. Adenocarcinoma
Endoscopic ultrasound
Staging laparoscopy
- May reveal peritoneal spread not seen on CT.
- Peritoneal washings may also permit more accurate staging. In one series, having excluded macroscopic peritoneal or liver disease, peritoneal washings were positive in about 7% of the remaining cases.^[1]

Staging

The TNM classification of oesophageal cancer:

Primary Tumour (T)

TX: Primary tumor cannot be assessed
T0: No evidence of primary tumour
Tis: Carcinoma in situ
T1: Tumour invades lamina propria/submucosa
T2: Tumour invades muscularis propria
T3: Tumour invades adventitia
T4: Tumour invades adjacent structures

Regional Lymph Nodes (N)

NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph nodes involved

Distant metastasis (M)

MX: Distant metastasis cannot be assessed
M0: No distant metastasis

The definition of metastatic disease depends on the tumour location.

Upper thoracic oesophageal tumours (ICD C15.3):
- M1a: Metastasis in cervical nodes
- M1b: Other distant metastasis
Mid-thoracic oesophageal tumours (ICD C15.4):
- M1a: Not applicable
- M1b: Non-regional lymph nodes and/or other distant metastasis
Lower oesophageal tumours (ICD C15.5)
- M1a: Metastasis in coeliac lymph nodes
- M1b: Other distant metastasis

Treatment

Resection
- Ivor-Lewis operation
- Open oesphagectomy is being replaced in selected patients by minimally invasive oesphagectomy as it decreases pulmonary complications mandating longer inpatient stays
- Suitable for middle and lower third tumours
- Standard treatment for stages I (T1N0) and IIa (T2–T3N0)^[2]
- Possibly with neoadjuvant chemotherapy or chemoradiotherapy for stage IIb (T1–T2N1) disease, although controversial^[2]
- May have role as salvage treatment in patients with no morphological response or persistent tumour after definitive chemoradiotherapy^[2]
Chemoradiotherapy alone only in patients with squamous-cell carcinoma who show a morphological response to it^[2]
- Chemoradiotherapy followed by surgery has greater post-treatment morbidity
Chemotherapy
- Locally advanced squamous cell carcinoma (stage III; T3–T4N1) neoadjuvant chemotherapy^[2]
- Locally advanced adenocarcinoma (stage III; T3–T4N1) chemoradiotherapy followed by resection^[2]
Oesophageal stent

Spread

Local invasion
- trachea
- lung
- aorta
Lymphatic to
- paraoesophageal
- supraclavicular
- abdominal
Blood
- liver
- lung

Prognosis

5 year survival rate 5-6%

References

↑ Nath J, Moorthy K, Taniere P, Hallissey M, Alderson D. Peritoneal lavage cytology in patients with oesophagogastric adenocarcinoma. The British journal of surgery. 2008 Jun; 95(6):721-6.(Link to article – subscription may be required.)
↑ ^a ^b ^c ^d ^e ^f Mariette C, Piessen G, Triboulet JP. Therapeutic strategies in oesophageal carcinoma: role of surgery and other modalities. The lancet oncology 2007;8(6):545-53. (Direct link – subscription may be required.)

[0] Nath J, Moorthy K, Taniere P, Hallissey M, Alderson D. Peritoneal lavage cytology in patients with oesophagogastric adenocarcinoma. The British journal of surgery. 2008 Jun; 95(6):721-6.(Link to article – subscription may be required.)

[pmid:17540306-1] ↑ ^a ^b ^c ^d ^e ^f Mariette C, Piessen G, Triboulet JP. Therapeutic strategies in oesophageal carcinoma: role of surgery and other modalities. The lancet oncology 2007;8(6):545-53. (Direct link – subscription may be required.)

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