Cancer of the oesophagus
Epidemiology:
- Far East >> West
- In Europe 2-8 per 100,000 population
Aetiology:
Squamous cell carcinoma (55%) – 40% in middle 1/3, 15% in upper 1/3:
- Diet is probably of the most importance:
- High intake of nitrosamines derived from nitrates used in food preservatives
- Low intake of both vitamin A and nicotinic acid
- Fe deficiency anaemia
Adenocarcinoma (45%) – occurs in the lower 1/3:
- Metaplastic change in the oesophageal mucosa from Squamous to columnar epithelium as a result of reflux (Barrett’s oesophagus) predisposes to the development of adenocarcinoma
Pathological features:
Nearly all lesions are a combination of narrowing and ulceration, although the extent of each varies. Spread takes place by:
Direct invasion:
- Into adjacent structures such as:
- Trachea
- Bronchi
- Pericardium
- Chest wall
- Diaphragm
- Once a fistula into the air passages has occurred, the condition is incurable and the life expectancy is short
Submucosal infiltration
Lymph node involvement:
- In the mediastinum and, in distal lesion, around the stomach
- Upward spread in the mediastinum may produce a sentinel node in the supraclavicular fossa
The bloodstream:
- Unusual in the early stages
- By the time of death, 90% of pts may have distant metastases (liver, lung and brain)
Symptoms:
Early ill-defined symptoms:
- Feeling of an oesophageal obstruction
- Retrosternal discomfort
- Belching
- Dyspepsia
Cancer of the oesophagus
Progressive dysphasia:
- Most common and important presenting symptom
- At first there is dysphagia for solids only, only later is there difficulty with liquids
Weight loss
Acute obstruction:
- Usually precipitated by the impaction of a large (usually inadequately chewed) bolus of food
Hoarseness:
- Caused by the involvement of the recurrent laryngeal nerve
Signs:
- Lymphadenopathy (25%) – usually of the supraclavicular region. Is an indication of metastatic disease.
Investigations:
Barium swallow:
- Preferred first-line ix
- High sensitivity in the dx of a stricture (although this does not, necessarily, mean that it is malignant)
- Accurate determination of the anatomical site
- Simple
- Cheap
Endoscopy:
This is done under LA and allows:
- Biopsy and brush cytology
- Partial assessment of the extent of the lesion
- Concurrent dilatation and temporary relief of obstruction
However there are some dangers, such as:
- Failure to detect a small lesion
- Perforation of a growth
Ultrasound:
- May demonstrate liver metastases and/or enlarged lymph nodes
CT:
- Helpful in determining the size of the primary tumour and whether it is attached to surrounding structures
- To detect metastases
Surgical resection:
In the overwhelming no. of cases, surgical intervention is purely palliative (e.g. to relieve dysphagia)
There are two main procedures available for resecting tumours of the oesophagus that do not require a thoracotomy. These are described below.
Cancer of the oesophagus
Trans-hiatal removal:
- The abdomen alone is opened and the oesophagus freed in the chest by blunt dissection through the diaphragmatic hiatus
- Stomach or colon for reconstruction is then passed through the posterior mediastinum to the neck, where it is anastomosed to the upper oesophagus through a cervical incision.
Endoscopic removal:
- The whole procedure can now be done endoscopically by dissection within the chest (thoracoscopy) and abdomen (laparoscopy), although there is no evidence that this method is better than an open operation.
Other methods of alleviating dysphagia:
Radiotherapy:
- Relief is not immediate and up to 1/3 of pts develop a fibrous stricture
Chemotherapy with 5-Fluouracil (5-FU):
- Can lead to total disappearance of the local tumour in 25% of pts. However, recurrence after some months is inevitable
Dilation and intubation:
Local endoscopic destruction of the tumour by laser
Local injection of absolute alcohol
Prognosis:
- When tumour is confined to the mucosa – 5yr survival of 60%
- If tumour has penetrated the full thickness of the gullet – 5yr survival is < 5%
