Oesophageal cancer

Question 1

Two main types

Answer 1

• Squamous cell carcinoma
• Adenocarcinoma

Question 2

Squamous cell carcinoma - who and where

Answer 2

• More common in low and middle income countries
• Occurs in middle and upper 1/3rds of oesophagus
• Associated with smoking, excessive alcohol

Question 3

Adenocarcinoma

Answer 3

• High income countries
• Lower 1/3rd oesophagus
• From metaplasia of epithelium - Barretts oesophagus, this then progresses to dysplasia and then malignancy
• RF long standing GORD, obesity, high fat intake

Question 4

Symptoms of oesophageal cancer

Answer 4

• Lacks well defined symptoms - often presents late
• Dysphagia - progressive (solids only then liquids)
• Weight loss - dysphagia and cancer causing
• Others - odonophagia or hoarseness (less common)

Question 5

Examination findings oesophageal cancer

Answer 5

• Weight loss/cachexia
• Signs of dehydration
• Supraclavicular lymphadenopathy
• Metastatic disease signs eg jaundice, hepatomegaly, ascites

Question 6

Criteria for upper GI endoscopy - URGENT

Answer 6

• Any patient with dysphagia
• Any patient over 55 with weight loss and upper abdominal pain, dyspepsia or reflux

Question 7

Investigations ?oesophageal cancer

Answer 7

• Upper GI endoscopy - OGD
• Biopsied if malignancy seen
• Sent for urgent histology
• If unfit for endoscopy - CT neck and thorax but less sensitive and specific

Question 8

Futher investigations after upper GI endoscopy

Answer 8

• CT chest abdomen pelvis and PET CT scan - investigate for distant mets
• Endoscopic USS - measure penetration into oesophageal wall (T stage) and assess and biopsy suspicious lymph nodes
• Staging laparoscopy - assess for intraperitoneal mets (if junctional oesophageal tumours)

Question 9

What should be done for palpable lymph nodes in oesophageal cancer patient?

Answer 9

Fine needle aspiration biopsy

Question 10

What if the patient has hoarseness or haemoptysis?

Answer 10

May need bronchoscopy

Question 11

Management oesophageal cancer - general

Answer 11

• MDT
• Majority of patients present with advanced disease so will receive palliative treatment

Question 12

Curative treatment options

Answer 12

• Surgical or endoscopic resection
• With or without neoadjuvant chemo or chemo-radiotherapy

Question 13

Squamous cell carcinoma management

Answer 13

• Difficult to operate on due to upper oesophagus location
• But are sensitive to chemo-radiotherapy - treatment of choice
• If early stage some may be able to be endoscopically resected

Question 14

Adenocarcinoma management

Answer 14

• Neoadjuvant chemotherapy or chemoradiotherapy
• Followed by surgical resection
• If early stage and are small with no lymphovascular invasion and not poorly differentiated histology - may be able to be resected

Question 15

Two types of endoscopic resection

Answer 15

• Endoscopic submucosal dissection (ESD)
• Endoscopic mucosal resection (EMR)

Question 16

ESD vs EMR

Answer 16

• ESD allows for en-bloc resection of larger lesions with lower recurrence rates
• BUT more technically demanding with higher complication rates
• EMR may result in bit by bit resection in larger lesions and incomplete resections

Question 17

Surgical treatment for oesophageal cancer - problem

Answer 17

• Major surgery
• Abdominal and chest cavities need to be accessed
• One lung is deflated for significant proportion of surgery

Question 18

Surgical procedure for oesophageal cancer

Answer 18

• Oesophagectomy - may be partial or total +/- partial gastrectomy
• Following resection, residual stomach is brought to chest cavity and anastomosed proximally to allow GI tract to be continious
• Most of the time have feeding tube into small bowel (jejunostomy) to aid nutrition post op

Question 19

Surgery - open or laparoscopic?

Answer 19

• Can be either (or robitcally)
  Open approaches inc:
• right thoractomy with lapartomy
• right thoracotomy with abdominal and neck incision
• left thoracoabdominal incision - one incision from umbilicus extending round back to below left shoulder blade

Question 20

Problems post op

Answer 20

• Post operative nutrition - lose reservoir function of stomach, feeding jejunostomy can be used to help. Most patients will need 5-6 small meals per day for nutrition
• Anastomotic leak
• Pneumonia
• Mortality

Question 21

Palliative management - when

Answer 21

• Metastatic tumours
• Non-metastatic unresectable tumours
• Too unfit for curative therapy

Question 22

Palliative options for oesophageal cancer

Answer 22

• Oesophageal stent
• Radiotherapy, chemotherapy or immunotherapy - control disease, reduce tumour size or bleeding so improve symptoms
• Nutritional support - thickened fluid and supplements
• If dysphagia becomes too severe - radiologically inserted gastrostomy may be inserted

Question 23

Prognosis for oesophageal cancer

Answer 23

• Poor - late presentation
• Median survival = 4 months
• 10yr survival rate - 10-15%