Oesophageal cancer

• The oesophagus is a muscular tube that is situated within the thorax and runs from the pharynx to the stomach
• 2 major types of cancer that arise from the oesophagus:

  • Most common = adenocarcinoma - affects lower third, develops from glandular cells, associated with Barrett's oesophagus, obesity and GORD
  • Squamous cell carcinoma - affects upper 2/3rd, develops from squamous cells, associated with smoking and alcohol use
• The hallmark clinical feature of oesophageal cancer is dysphagia, which refers to difficulty swallowing. This is due to obstruction of the oesophageal lumen.
• The biggest risk factors for the development of squamous cell carcinoma include alcohol consumption and smoking
• The majority of adenocarcinoma arise from Barrett's oesophagus - columnar metaplasia of the lower oesophagus due to chronic reflux
• SCC pathophysiology:

  • Chronic alcohol use and smoking damages cellular DNA
  • Genetic mutations that promote abnormal cell growth
  • May be seen as an infiltrating and ulcerated mass in the middle oesophagus
  • Early invasion into surrounding lymph nodes
  • May metastasize to liver, bone and lung
• Adenocarcinoma pathophysiology:

  • Chronic reflux
  • Columnar metaplasia - transformation of the mature squamous cell type to columnar cell type
  • Metaplastic epithelium may become more dysplastic - cells with abnormal growth and development
  • Most commonly located near the gastro-oesophageal junction
  • Early lymph node involvement
• Oesophageal cancer is rare in young people and more common as we age, most common in 70-80 year olds
• Symptoms:

  • Constitutional symptoms - weight loss, lethargy and fever
  • Dysphagia
  • Odynophagia - pain when swallowing
  • Weight loss - tumour related and poor nutrition from dysphagia
  • Bleeding - haematemesis and melaena
  • Pain - typically retrosternal
  • Aspiration from fistula with trachea - cough, shortness of breath, fever
  • Hoarseness - if recurrent laryngeal nerve involved
  • Hiccups - if the tumour locally invades into the phrenic nerve
• Signs:

  • Lymphadenopathy
  • Cachexia
  • Pallor - anaemia
  • Hepatomegaly - if metastatic spread
• 2WW referral:

  • Dysphagia
  • >55 with weight loss and one of: upper abdominal pain, reflux or dyspepsia
• Oesophageal cancer is diagnosed using upper GI endoscopy (gastroscopy) and biopsies of suspected lesions
• Bloods:

  • FBC
  • Iron studies
  • U+Es
  • LFTs
  • Bone profile
  • Clotting screen
• Further imaging:

  • First line = OGD + biopsy. PPIs should be stopped 2 weeks prior.
  • CT TAP: for staging
  • Abdominal USS: asses for liver metastasis
  • PET-CT
• Human epidermal growth factor receptor 2 (HER2) testing should be completed on tumour or biopsy specimens - targeted therapy against the HER2 receptor may be offered to patients with HER2 positive metastatic oesophageal cancer
• Cancer stage is based on tumour size, presence of lymph node involvement and distant spread. These factors are called 'TMN' - tumour, nodes, metastasis
• Treatment options:

  • Surgery: resection of oesophageal or gastro-oesophageal tumours (e.g. oesophagectomy)
  • Endoscopic techniques - mucosal resection
  • Radiotherapy
  • Chemotherapy
  • Targeted cancer drugs: monoclonal antibodies against certain receptors e.g. HER2
  • Palliative care
  • Best supportive care
• Performance status:

  0 - fully active

  1 - restricted but ambulatory and able to carry out light sedentary work

  2- Ambulatory and capable of all self care but unable to carry out any work. out of bed >50% of day

  3- capable of limited self care, confined to bed/chair >50% day

  4- completely disabled

  5 - death
• The 5 year survival of oesophageal cancer is poor at around 16%
• The oesophagus is lined by stratified squamous epithelium
• Men are at twofold greater risk than women
• In advanced disease there may be an enlarged left supraclavicular lymph node (Virchow node)
• The oesophagus is connected to the pharynx via the upper oesophageal sphincter

  Connected to the stomach via the lower oesophageal sphincter

  Both relax during swallowing, lower sphincter is tightly closed between meals to prevent reflux
• 4 layers of oesophageal wall (from outside in)

  • Adventitia
  • Muscular layer
  • Submucosa
  • Mucosa - direct contact with food, prevents friction
• In the distal oesophagus squamous epithelium joins columnar gastric epithelium to form the gastro-oesophageal junction
• Plummer-Vinson syndrome is a rare condition characterised by the classic triad of dysphagia, iron deficiency anaemia and oesophageal webbing

  • Risk factor for squamous cell carcinoma
• Lymphatic drainage of oesophagus:

  • Superior third - deep cervical lymph nodes
  • Middle third - mediastinal lymph nodes
  • Lower third - gastric lymph nodes
• Modifiable risk factors include:

  • Smoking
  • Alcohol
  • Obesity
  • Consuming drinks and foods at high temperatures
  • Low-socioeconomic status
• Non-modifiable risk factors include:

  • Older age (peak incidence 80-84 years old)
  • Male sex
  • Gastro-oesophageal reflux disease (GORD)
  • Barrett’s oesophagus
  • Achalasia
  • Hiatus hernia
  • Family history of oesophageal cancer/hereditary cancer syndromes