Oesophageal Cancer

Question 1

Aetiology and risk factors of adenocarcinoma of the oesophageal

Answer 1

85% of oesophageal cancers
Mainly occur at the distal oesophagus and gastro-oesophageal junction
Lower 1/3rd of the oesophagus
Histology: glandular epithelium + mucin

Male sex
GORD and Barrett’s oesophagus
Hiatus hernia
Obesity
GTN, anticholinergics, beta-adrenergics, aminophyllines, benzos

Question 2

Aetiology and risk factor of squamous cell carcinoma of the oesophagus

Answer 2

Upper 2/3rd of the oesophagus (most common in the mid, then lower, then upper)
Produces keratin

Male sex
Tobacco use
Alcohol use
FHx of oesophageal, stomach, oral or pharyngeal cancer
Non-white race
High temp. beverages and foods
HPV
Achalasia

Question 3

Symptoms of oesophageal cancer

Answer 3

Dysphagia
- Only after there is obstruction of > 2/3 of the lumen
- Initially solids then liquids
- Regurgitation
- Aspiration (cough or choking after food)
Odynophagia
Weight loss, fatigue
Hoarseness
- Due to involvement of the recurrent laryngeal nerve
Hiccups
- Due to phrenic nerve involvement
Postprandial/paroxysmal cough
- This may indicate the presence of an oesophagotracheal or oesophagobronchial fistula resulting from local invasion by a tumour

Question 4

Signs of oesophageal cancer on examination

Answer 4

No physical signs may be evident
Signs of weight loss
Metastases -> supraclavicular lymphadenopathy, hepatomegaly
Tracheobronchial involvement / aspiration -> resp. signs

Question 5

Investigations for oesophageal cancer

Answer 5

U&es: hypokalaemia, elevated Cr, serum Urea/nitrogen
Bone profile

OGD with biopsy (stop PPI/H2B 2 weeks prior)
CT/MRI thorax and abdomen: identify mets
FDG-PET: mets
Endoscopic US: Used for surveillance, indicates extent of local invasion + lymph node status
Bronchoscopy: normal/may show involvement of tracheobronchial tree
Thoracoscopy and laparoscopy
Cardiac stress test + pulmonary function tests
Barium swallow: apple core

Question 6

Management for oesophageal cancer

Answer 6

MDT: surgical oncology, medical oncology, radiation oncology, radiology, gastroenterology, pathology

Endoscopic therapy
- Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)
- Endoscopic ablation - cryoablation/radiofrequency ablation
Surgery (oesophagectomy)
- Radical oesophagectomy
- Transthoracic oesophagectomy (Ivor Lewis/Mckeown)
- Transhiatal oesophagectomy
Radiotherapy
Chemotherapy
Chemoradiotherapy
Palliative/supportive care
- Dilating balloons
- Bougie
- Metal stents
- Photodynamic therapy: localised tissue destruction
- Cryotherapy

Question 7

Complications of oesophageal cancer

Answer 7

Aspiration pneumonia
Oesophago-aortic fistula
Tracheo-oesophageal fistula

Question 8

Prognosis for oesophageal cancer

Answer 8

Poor prognosis
Without aggressive treatment, the cancer tends to obstruct the oesophagus and cause severe dysphagia. In addition to local progression causing pain, the disease tends to metastasise widely to the lungs, liver, and bone
Oesophagectomy is a high-risk procedure with an incidence rate of major complications around 25% to 40%