Oesophageal cancer

From Ganfyd

(Redirected from Oesophagus cancer)
Jump to: navigation, search

Introduction

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.

Contents

_

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

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

Personal tools