Oeseophageal Carcinoma

Question 1

What is the most common type of oeseophageal cancer?

Answer 1

• unti recent times, squamous cell carcinoma was most common
• adenocarcinoma incidence rising rapidly
• adenocarcinoma now most common type
  
  • more likely to develop in pts w/ hx of GORD or Barrett’s

Majority of tumours are in middle third of oeseophagus

Question 2

What are the risk factors for oeseophageal cancer?

Answer 2

• smoking
• alcohol
• GORD
• Barrett’s
• achalasia
• Plummer-Vinson syndrome
• squamous cell carcinoma also linked to diets rich in nitrosamine
• rare: coeliac disease, scleroderma

Question 3

What are clinical features of oeseophageal carcinoma?

Answer 3

• dysphagia → most common presenting symptom
• anorexia + weight loss
• vomiting
• odynophagia, hoarseness, melaena, cough

Question 4

How is oeseophageal carcinoma diagnosed?

Answer 4

• first-line → upper GI endoscopy
• contrast swallow helps classify benign motility disorders but no place for assessing tumours
• staging initially w/ CT CAP; if overt metastatic disease identified then further complex imaging unnecessary
• if CT does not show metastatic disease → local stage may be more accurately assessed by use of endoscopic ultrasound
• staging laparoscopy to detect occult peritoneal disease
• PET CT in those with negative laparoscopy

Question 5

What is the management of oeseophageal cancer?

Answer 5

• Operable disease best managed surgically
• Ivor-Lewis type oesophagectomy
• Involves mobilisation of stomach + divison of oesophageal hiatus
• Abdomen closed + right sided thoractomy performed
• Stomach brought into chest + oesophagus mobilised further
• Intrathoracic oesophagogastric anastamosis constructed
• Alternative surgical strategies:
  
  • Transhiatal resection → for distal lesions
  • Left thoraco-abdo resection
  • Total oesophagectomy (McKeown) + cervical oeseophagogastric anastamosis
• In addition to surgical resection → most given adjuvant chemotherapy

Biggest surgical challenge is anastamotic leak, w/ an intrathoracic anastamosis this will result in mediastinitis. Has high mortality. McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage.