Oesophageal cancer
There are two major types of oesophageal cancer, adenocarcinoma and squamous cell carcinoma. Both type typically affect elderly men. Oesophageal adenocarcinoma evolves from the Barrett-mucosa and is the most common type of oesophageal cancer in the Western world. Its incidence is rising. It’s usually found in the lower part of the oesophagus.
Oesophageal SCC is more common in developing countries, and the most common type overall. It’s usually found in the middle and upper parts of the oesophagus. Its prognosis is worse than adenocarcinoma.
It’s usually asymptomatic in the early stages, and therefore is rarely discovered until the late stages. In the late stages it may present with non-specific symptoms like weight loss, dysphagia, and dyspepsia. At the time of presentation, most patients already have advanced cancer.
Etiology
Because adenocarcinoma evolves from GERD and Barrett oesophagus, the risk factors are the same as for GERD, especially smoking.
The risk factors for SCC are:
- Alcohol consumption
- Smoking
- Diet low in fruits and vegetables
- Exposure to nitrosamines in diet
- Frequent consumption of very hot beverages, like the coffee at McDonalds.
Clinical features
Both types of oesophageal cancer have similar clinical features. It’s usually asymptomatic in the early stages, and therefore is rarely discovered until the late stages. In the late stages it may present with non-specific symptoms like dysphagia, odynophagia, cough, weight loss, and dyspepsia.
At the time of presentation most patients already have advanced cancer.
Diagnosis and evaluation
Upper endoscopy is the investigation of choice, as it allows for both visual diagnosis and biopsy. Endoscopic ultrasound may also be necessary to assess the depth of invasion accurately, to distinguish T1A and T1B stages.
CT thorax and abdomen is required for staging. Bronchoscopy is required if extension into the bronchial system is suspected.
Prognosis
The prognosis is very poor, with a 5-year survival of 15%. The 5-year survival of patients treated with curative surgery is around 30 – 40%. Squamous cell carcinoma has a worse prognosis than adenocarcinoma.
Treatment
Proper evaluation and staging are essential to determine the resectability of the disease. Only around 1/3 of patients are operated on.
In the rare case where very early cancers are discovered, we may use minimally invasive methods like endoscopic resection or laser ablation.
Most patients present in a stage where radical surgery is required for cure. However, oesophageal resection is a large and complicated procedure, and patients often develop post-operative complications like nutritional problems, stenosis in the anastomosis, and slow passage of foodstuffs.
After surgical resection of the oesophagus, either total or partial, the resected part of the oesophagus should be substituted with stomach (first choice) or colon. Because of the localisation of the oesophagus, oesophageal surgery may involve the neck, thorax, and/or the abdomen, making for a large and complicated surgery.
Surgery may be performed open, laparoscopically, or in combination.
Locally advanced oesophageal cancer is treated with neoadjuvant chemoradiation, followed by surgery if the tumour is considered resectable on restaging.
Palliative therapy is often employed for stage IV disease. The placement of stents is the major palliative option for oesophageal cancer.