Oesophageal Cancer

Question 1

In what age group is oesophageal cancer most common?

Answer 1

> 60s

Question 2

What is the cause of 9/10 oesophageal cancers?

Answer 2

Lifestyle factors - obesity, smoking, alcohol

Question 3

What are 4 other causes of oesophageal cancer other than lifestyle factors?

Answer 3

1) Barrett’s oesophagus (1-5%)
2) Radiotherapy
3) Achalasia of the cardia
4) GORD

Question 4

What is Barrett’s oesophagus?

Answer 4

A condition causing reflux which causes metaplasia/dysplasia/adenocarcinoma and oesophagitis

Question 5

People with which type of cancer are at risk of getting oesophageal cancer from radiotherapy?

Answer 5

Lymphoma in the head and neck - radiotherapy for this makes them prone to oesophageal carcinoma

Question 6

What happens to the oesophagus achalasia of the cardia?

Answer 6

Failure of the lower oesophagus to relax leads to stasis of food above it

Question 7

What is a hiatus hernia?

Answer 7

Part of the stomach being pushes above the diaphragm - diaphragmatic supra hiatus hernia

Question 8

What is the difference between the lining of the oesophagus and stomach?

Answer 8

• Oesophagus - wear and tear epithelium, squamous, white

- Stomach - gastric mucosa, columnar, pink

Question 9

What is metaplasia?

Answer 9

Changing from one mucosa type to another

Question 10

Describe what causes metaplasia in Barrett’s oesophagus

Answer 10

• Oesophageal mucosa is damaged by reflux - gastric acid, pancreatic digestive enzymes, pepsin
• In order to protect the oesophagus from this acid attack the mucosa has changed from squamous to columnar
• Therefore the oesophageal mucosa is very irregular

Question 11

What are the two types of oesophageal cancer?

Answer 11

1) Adenocarcinoma (more common in west)

2) Squamous carcinoma (more common in east)

Question 12

Describe how adenocarcinoma occurs

Answer 12

1) Reflux oesophagitis (from lifestyle factors)
2) Lower oesophageal mucosa damaged by reflux of acid and gastric content in hiatus hernia
3) Results in metaplasia (Barrett’s oesophagus)
4) Progresses to dysplasia and adenocarcinoma

Question 13

How does squamous carcinoma occur?

Answer 13

Arises from squamous epithelium of the oesophagus

Question 14

What are the 6 symptoms of oesophageal cancer?

Answer 14

1) Dysphagia
2) Persistent indigestion or heartburn
3) Pain in throat or behind sternum (retrosternal chest pain)
4) Persistent cough (due to reflux)
5) Regurgitation of food (due to obstructive symptoms)
6) Weight loss
7) Anaemia
8) Proximal hoarseness

Question 15

How do you diagnose oesophageal cancer?

Answer 15

1) Upper GI endoscopy (OGD) + biopsy

2) OR barium studies

Question 16

What investigation would you do to stage oesophageal cancer?

Answer 16

CAP CT scan ± EUS

- Laparoscopy ± PET/CT

Question 17

How would you treat early oesophageal cancer?

Answer 17

Endoscopic therapy - resection of the cancer endoscopically

Question 18

Describe features of early oesophageal cancer

Answer 18

• Within the mucosa/submucosa
• Like Barrett’s oesophagus when it has just turned to high grade dysplasia and hasn’t really invaded too deeply under the mucosa

Question 19

What are the two types of endoscopic therapy?

Answer 19

1) Endoscopic mucosal resection (EMR)

2) Endoscopic submucosal resection (ESD) - cut away mucosa down to muscle

Question 20

What is the treatment for advanced oesophageal cancer (stage 2 or 3)?

Answer 20

• Oesophagectomy (surgery)

- Neo-adjuvant chemotherapy before surgery

Question 21

What is the palliative treatment for advanced oesophageal cancer?

Answer 21

1) Radiotherapy/chemotherapy
2) Stenting if obstruction of oesophagus due to cancer if patient can’t swallow
3) Lasers

Question 22

For which locations of oesophageal cancer would you need peri-operative chemotherapy in addition to neo-adjuvant?

Answer 22

• Lower oesophageal cancer

- Cancer at the oesophagogastric junction

Question 23

What surgical procedure would you do to treat cancer of the middle and lower ⅓ of the oesophagus?

Answer 23

Ivor-Lewis oesophago-gastrectomy - need to prevent anastomotic leak in the chest

Question 24

What is the prognosis of oesophageal cancer confined to the oesophagus?

Answer 24

40% survival 5 years or more

Question 25

Which type of oesophageal cancer is more common in the west?

Answer 25

Adenocarcinoma (glandular cells)

Question 26

What is a complication of oesophageal cancer?

Answer 26

Anaemia

Question 27

What other investigations can you do in oesophageal cancer?

Answer 27

• Blood tests
• Laparoscopy (distal)
• Bone scan (metastatic)

Question 28

How do you curatively treat oesophageal cancer?

Answer 28

Neoadjuvant chemo + radical oesophagectomy (surgery)