Related Subjects:
|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 Iran, also South Africa and China
- Strictures or previous thoracic radiotherapy
- Possibly with Low levels of serum selenium
- Plummer-Vinson syndrome (Patterson-Brown-Kelly)
Risks for Adenocarcinoma
- Smoking, GORD and Barrett's oesophagus x 40-fold, Obesity
- Barrett's intestinal metaplasia → mild → severe dysplasia →carcinoma
Clinical
- Often asymptomatic until late, weight loss
- 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
- Into trachea, lung and pleura, recurrent laryngeal nerve
- Lymphatic to para oesophageal, supraclavicular or coeliac nodes
- Blood borne to liver and lung
Investigations
- FBC: anaemia. U&E/LFT, Hypercalcaemia
- CXR: (or CT) should be done in dysphagia to exclude lung lesion and metastases
- OGD is the procedure of choice as allows visualisation of the tumour and tissue biopsy and cytology
- Endoscopic USS and laparoscopy for staging
- Bronchoscopy if tracheobronchial infiltration suspected
- Barium swallow delineates tumour but biopsies needed
- CT/MRI/PET of the chest and upper abdomen for staging
Management
- Mucosal lesions can receive endoscopic therapy to mucosa and submucosa.
- Attempted Curative: Surgical resection is indicated about 30% in those with localized disease fit enough for thoracotomy. Chemotherapy may be given pre-op, especially with squamous cell to reduce tumour size. The Ivor-Lewis procedure where the tumour in the lower oesophagus or cardia is resected by mobilizing the stomach and performing a high anastomosis in the right chest. Tumours of the upper two-thirds of the oesophagus, a total oesophagectomy is preferable. Chemotherapy (cisplatin + 5 FU) can be used pre-op to improve 5-year mortality at the expense of toxicity by reducing tumour bulk
- Palliative: Dysphagia may be treated by stenting or laser ablation. Aim to maximise nutrition. Involvement of palliative services where appropriate