Oesophageal Cancer Flashcards
How common is oesophageal cancer?
8th most common malignancy in UK
3:1 male to female ratio
SCC more common but geographical variation (high in China, Iran, Russia)
Adenocarcinoma more common in Western countries and
Define oesophageal carcinoma.
Malignant tumour arising in the oesophageal mucosa. Two major histological types: squamous cell carcinoma and adenocarcinoma.
What are the risk factors for oesophageal cancer in general?
- Diet
- Alcohol excess
- Smoking
- Achalasia
- Reflux oesophagitis +/- Barrett’s oesophagus
- Obesity
- Hot drinks
- Nitrosamine exposure
- Plummer-Vinson syndrome
What are the risk factors for squamous oesophageal cancer?
- Alcohol
- Tobacco
- Certain nutritional deficiencies - vitamins, trace elements
- HPV infection
- Achalasia
- Paterson-Kelly (Pulmmer-Vinson) syndrome
- Tylosis (Howel-Evans syndrome)
- Scleroderma
- Coeliac disease
- Lye stricture
- History of previous thoracic radiotherapy or upper aerodigestive squamous cancer
- Dietary nitrosamines
What are the risk factors for adenocarcinoma of the oesophagus?
- GORD
- Obesity
- High fat intake
- Barrett’s oesophagus metaplasia → dysplasia → carcinoma
Where do most oesophageal cancers occur?
- 20% in upper part
- 50% in middle
- 30% in the lower part
Squamous in the upper two thirds
Adenocarcinoma in the distal third
How does oesophageal cancer spread?
Spread is typically initially direct and longitudinal via an extensive network of submucosal lymphatics to tracheobronchial, mediastinal and coeliac, gastric or cervical nodes.
What is a typical presentation of oesophageal carcinoma?
Early: asymptomatic/reflux.
Later:
- dysphagia,
- odynophgia
- retrosternal chest pain, worse for solids initially,
- regurgitation,
- cough or choking after food,
- weight loss,
- fatigue,
- voice hoarseness
- hiccups
What are the signs of oesophageal carcinoma on examination ?
- No physical signs may be evident
- Weight loss
- Supraclavicular lymphadenopathy , hepatomegaly with metastatic spread
- Respiratory sigs with aspiration/direct tracheobronchial involvement
Why might you get hiccups and hoarseness in oesophageal cancer?
Voice hoarseness (may indicate recurrent laryngeal nerve palsy)
Hiccups (with phrenic nerve involvement)
What investigations would you do for oesophageal carcinoma?
- OGD + biopsy +/- dilation of strictures
- Barium swallow - may be done to confirm obstruction
- U&Es - dehydration and hypokalaemia due to inability to swallow own-potassium rich saliva
- Endoscopic ultrasound +/- FNA - for regional staging
- CT chest/abdo or PET - staging
Bloods - metabolic profile (in advanced cases: hypokalaemia, elevated creatinine, serum urea/nitrogen)
What does a postprandial/paroxysmal cough indicate in oesophageal cancer?
Presence of oesophagotracheal/ oesophagobronchial fistula from local invasion by tumour
Which 3 of these are used for staging oesophageal cancers?
- CT chest only
- CT chest and abdomen
- Endoscopic ultrasound
- V/Q scan
- Position emission tomography (PET)
- MR of the chest
CT chest and abdomen- abdominal nodes/liver metastases may also occur in mid/distal oesophageal malignancy.
Endoscopic ultrasound- can demonstrate local peri-oesophageal nodes and allow fine needle aspiration. Local nodal involvement renders tumours inoperable
Position emission tomography (PET)- can identify metastases in nodes which appear of normal size on CT – this is a weakness of CT which uses nodal enlargement as suggestive of malignancy (big nodes can be benign and small nodes can contain tumour).
Which of these is true about oesophageal cancer?
- Gastro-oesophageal reflux is associated with an increased risk of squamous cell carcinoma
- Gastro-oesophageal reflux is associated with increased risk of adenocarcinoma
- Alcohol excess and smoking are important risk factors
- Tumours are most common in the upper oesophagus
- Oesophageal stents are the treatment of choice for mild dysphagia
- Achalasia is a risk factor for oesophageal carcinoma
Tumours are most common in the lower oesophagus.
Gastro-oesophageal reflux is linked to Barrett’s oesophagus which is associated with a x40↑ in adenocarcinoma.
Stents are used for severe dysphagia.
- Gastro-oesophageal reflux is associated with increased risk of adenocarcinoma
- Alcohol excess and smoking are important risk factors
- Achalasia is a risk factor for oesophageal carcinoma
What does this show?
- No significant abnormality
- Probable oesophageal varices
- Oesophageal spasm
- Achalasia with oesophageal dilatation
- Probable oesophageal candidiasis
- Extensive ulcerating oesophageal carcinoma
- Extrinsic compression of oesophagus, possibly relating to lung carcinoma
- Peptic stricture
Extensive ulcerating oesophageal carcinoma - There is an extensive polypoidal and ulcerating tumour in the mid-oesophagus.
