Overview
Oesophageal Cancer
1. Clinical Overview
Summary
Oesophageal cancer is a malignant tumour arising from the oesophageal epithelium, representing a significant cause of cancer-related mortality worldwide. There are two main histological types: Squamous Cell Carcinoma (SCC) and Adenocarcinoma. SCC typically arises in the upper and middle oesophagus and is associated with smoking and alcohol. Adenocarcinoma typically arises in the lower oesophagus/Gastro-oesophageal junction (GOJ) and is strongly associated with Barrett's Oesophagus, GORD, and Obesity. In Western countries, Adenocarcinoma now predominates. The cardinal symptom is progressive dysphagia (Initially to solids, Then liquids), often accompanied by weight loss. Diagnosis is by OGD with Biopsy. Staging uses CT-PET and EUS. Treatment is determined by stage and fitness: Early-stage (T1-2, N0) may be amenable to Endoscopic Resection (EMR/ESD) or Surgery; Locally advanced (T3-4 or Node-positive) typically requires Neoadjuvant Chemoradiotherapy followed by Surgery (Oesophagectomy); Metastatic disease is managed with Palliative Chemotherapy and Best Supportive Care. Prognosis is generally poor, with overall 5-year survival ~15-20%. [1,2,3]
Clinical Pearls
"Progressive Dysphagia = Think Cancer": Dysphagia progressing from solids to liquids is the classic presentation. Urgent 2WW OGD.
"SCC = Smoking/Alcohol. Adenocarcinoma = Barrett's/GORD/Obesity": Risk factor profiles differ by histology.
"Barrett's is Precancerous": Intestinal metaplasia → Dysplasia → Adenocarcinoma. Surveillance is key.
"Multidisciplinary Team (MDT)": All oesophageal cancers should be discussed at an Upper GI MDT.
2. Epidemiology
Demographics
| Factor | Notes |
|---|---|
| Incidence (UK) | ~9,000 cases/year. 8th most common cancer. |
| Age | Peak 60-80 years. |
| Sex | Male > Female (3:1 for Adenocarcinoma, 2:1 for SCC). |
| Geography | SCC: Higher in Asia, Africa. Adenocarcinoma: Higher in Western countries. |
Histological Types
| Type | Proportion (UK) | Location | Risk Factors |
|---|---|---|---|
| Adenocarcinoma | ~70% (and rising) | Lower oesophagus / GOJ | Barrett's Oesophagus, GORD, Obesity, Smoking |
| Squamous Cell Carcinoma (SCC) | ~25% | Upper / Middle oesophagus | Smoking, Alcohol, Hot beverages, Nutritional deficiencies (Plummer-Vinson), Achalasia |
| Other | less than 5% | Lymphoma, GIST, Melanoma, Small cell |
Risk Factors
| Risk Factor | Adenocarcinoma | SCC |
|---|---|---|
| Barrett's Oesophagus | ✓✓✓ (Major) | |
| GORD | ✓✓ | |
| Obesity | ✓✓ | |
| Smoking | ✓ | ✓✓ |
| Alcohol | ✓✓ | |
| Hot Beverages | ✓ | |
| Achalasia | ✓ | |
| Plummer-Vinson Syndrome | ✓ | |
| Caustic Injury | ✓ | |
| Tylosis | ✓ (Rare genetic) |
3. Pathophysiology
Barrett's Oesophagus Pathway (Adenocarcinoma)
- Chronic GORD: Acid reflux damages squamous epithelium.
- Metaplasia: Squamous → Columnar (Intestinal-type) epithelium = Barrett's.
- Dysplasia: Low-grade → High-grade dysplasia.
- Adenocarcinoma: Malignant transformation.
SCC Pathway
- Chronic irritation (Smoking, Alcohol, Thermal injury) → Squamous dysplasia → SCC.
Anatomy
| Segment | Distance from Incisors |
|---|---|
| Cervical Oesophagus | 15-18 cm |
| Upper Thoracic | 18-24 cm |
| Middle Thoracic | 24-32 cm |
| Lower Thoracic / GOJ | 32-40 cm |
4. Clinical Presentation
Symptoms
| Symptom | Notes |
|---|---|
| Dysphagia | Cardinal symptom. Progressive. Initially solids → Then liquids. Implies >50-60% luminal obstruction. |
| Weight Loss | Often significant. Due to dysphagia + Cachexia. |
| Odynophagia | Painful swallowing. Suggests ulceration or invasion. |
| Regurgitation | Of undigested food. |
| Retrosternal Chest Pain | May indicate local invasion. |
| Cough / Aspiration | Tracheo-oesophageal fistula. Aspiration pneumonia. |
| Hoarseness | Recurrent Laryngeal Nerve involvement. Poor prognosis. |
| Haematemesis / Melaena | GI bleeding. |
| Cervical Lymphadenopathy | Virchow's node (Left supraclavicular). |
Examination Findings
| Finding | Notes |
|---|---|
| Cachexia | Significant weight loss. |
| Cervical Lymphadenopathy | Virchow's node (Troisier's sign). |
| Hepatomegaly | Metastases. |
| Ascites | Peritoneal disease. |
| Pallor | Anaemia (Chronic blood loss). |
5. Investigations
Diagnostic
| Investigation | Notes |
|---|---|
| OGD (Oesophagogastroduodenoscopy) | Gold standard. Visualises tumour. Location, Size, Morphology. Biopsy for histology. |
| Biopsy | Confirms diagnosis. Histological type. HER2 status (Adenocarcinoma – Predictive for Trastuzumab). |
Staging
| Investigation | Notes |
|---|---|
| CT Chest/Abdomen/Pelvis with IV Contrast | Initial staging. Local extent. Lymph nodes. Distant metastases (Liver, Lung, Adrenals). |
| PET-CT | More sensitive for nodal and distant metastases. Standard for staging if curative treatment considered. |
| Endoscopic Ultrasound (EUS) | Best for T stage (Depth of invasion) and Regional lymph node assessment (N stage). Allows FNA of suspicious nodes. |
| Staging Laparoscopy | If GOJ/Gastric extension and curative surgery considered. Detects occult peritoneal disease. |
TNM Staging (8th Edition)
| Stage | Description |
|---|---|
| T1a | Lamina propria / Muscularis mucosae |
| T1b | Submucosa |
| T2 | Muscularis propria |
| T3 | Adventitia |
| T4a | Resectable adjacent structures (Pleura, Pericardium, Diaphragm) |
| T4b | Unresectable structures (Aorta, Vertebra, Trachea) |
| N0-N3 | Based on number of regional lymph nodes |
| M1 | Distant metastases |
Other Investigations
| Test | Notes |
|---|---|
| FBC | Anaemia. |
| LFTs / Albumin | Nutrition. Liver mets. |
| Renal Function | Pre-chemotherapy. |
| Nutritional Assessment | Dietitian. Consider supplemental feeding. |
6. Management
Management Algorithm
SUSPECTED OESOPHAGEAL CANCER
(Progressive Dysphagia, Weight Loss)
↓
URGENT 2WW OGD
- Biopsy for histology
- Location of tumour
↓
STAGING
- CT Chest/Abdomen/Pelvis
- PET-CT
- EUS (T and N stage)
- Staging Laparoscopy (If GOJ, Curative intent)
↓
MDT DISCUSSION
(Upper GI Cancer MDT)
↓
STAGE-BASED MANAGEMENT
┌─────────────────┬─────────────────┬─────────────────┐
EARLY STAGE LOCALLY ADVANCED METASTATIC
(T1-2, N0, M0) (T3-4 or N+, M0) (M1)
↓ ↓ ↓
**ENDOSCOPIC **NEOADJUVANT **PALLIATIVE
RESECTION** CHEMO(RADIO)THERAPY TREATMENT**
(EMR/ESD for T1a) + SURGERY
OR **SURGERY** (Oesophagectomy)
(Oesophagectomy)
↓
ENDOSCOPIC TREATMENT (Early T1a)
┌──────────────────────────────────────────────────────────┐
│ - EMR (Endoscopic Mucosal Resection) │
│ - ESD (Endoscopic Submucosal Dissection) │
│ - For T1a (Intramucosal) with favourable features │
│ - Avoids morbidity of oesophagectomy │
│ - Requires surveillance │
└──────────────────────────────────────────────────────────┘
↓
SURGICAL TREATMENT
┌──────────────────────────────────────────────────────────┐
│ **OESOPHAGECTOMY** │
│ - Ivor Lewis: Laparotomy + Right thoracotomy. Intrathoracic│
│ anastomosis. For lower/Middle tumours. │
│ - McKeown (3-stage): Laparotomy + Thoracotomy + Cervical│
│ incision. Cervical anastomosis. For upper tumours. │
│ - Transhiatal: Laparotomy + Cervical incision (No thoracotomy)│
│ - Minimally Invasive (MIO): Laparoscopic/Thoracoscopic │
│ - Gastric conduit or Colonic interposition for reconstruction│
│ - High morbidity (~30-50%): Anastomotic leak, Respiratory│
│ complications, Chyle leak │
│ - Perioperative mortality ~2-5% (High-volume centres) │
└──────────────────────────────────────────────────────────┘
↓
NEOADJUVANT TREATMENT
┌──────────────────────────────────────────────────────────┐
│ **CHEMORADIOTHERAPY (CROSS Regimen)** │
│ - Carboplatin/Paclitaxel + 41.4 Gy radiotherapy │
│ - Standard for SCC and Adenocarcinoma (If fit) │
│ - Followed by surgery 6-8 weeks later │
│ │
│ **PERIOPERATIVE CHEMOTHERAPY (FLOT)** │
│ - For GOJ/Gastric-type Adenocarcinoma │
│ - Docetaxel/Oxaliplatin/5-FU/Leucovorin │
│ - 4 cycles pre-op + 4 cycles post-op │
└──────────────────────────────────────────────────────────┘
↓
PALLIATIVE TREATMENT
┌──────────────────────────────────────────────────────────┐
│ - **Oesophageal Stenting (SEMS)**: Palliate dysphagia │
│ - **Palliative Chemotherapy**: Platinum-based + │
│ Fluoropyrimidine. Trastuzumab if HER2+. │
│ - **Palliative Radiotherapy**: For bleeding, Pain, │
│ Obstruction │
│ - **Nutritional Support**: NG/NJ/RIG feeding │
│ - **Best Supportive Care**: Symptom control │
│ - **Palliative Care Team**: Early involvement │
└──────────────────────────────────────────────────────────┘
Chemotherapy Regimens
| Regimen | Use |
|---|---|
| CROSS (Carboplatin/Paclitaxel + RT) | Neoadjuvant chemoradiotherapy (SCC and Adeno). |
| FLOT (Docetaxel/Oxaliplatin/5-FU/Leucovorin) | Perioperative chemotherapy (GOJ/Gastric Adeno). |
| Cisplatin/5-FU | Palliative. |
| Trastuzumab | HER2-positive Adenocarcinoma. |
| Pembrolizumab/Nivolumab | Immunotherapy for advanced/Metastatic (PD-L1 positive). |
7. Complications
Disease Complications
| Complication | Notes |
|---|---|
| Complete Obstruction | Unable to swallow. Emergency stenting. |
| Tracheo-Oesophageal Fistula | Devastating. Aspiration. Covered stent may palliate. |
| GI Bleeding | Haematemesis. Melaena. |
| Malnutrition / Cachexia | Significant contributor to morbidity. |
| Aspiration Pneumonia | |
| Metastatic Disease | Liver, Lung, Bone, Brain. |
Treatment Complications
| Complication | Notes |
|---|---|
| Anastomotic Leak | Major surgical complication. 5-15%. High mortality. |
| Respiratory Complications | Pneumonia, ARDS. ~20%. |
| Chyle Leak | Thoracic duct injury. |
| Recurrent Laryngeal Nerve Injury | Hoarseness. |
| Stricture | Anastomotic stricture. May need dilatation. |
| Dumping Syndrome | Post-gastrectomy/Gastric conduit. |
| Chemotherapy Toxicity | Myelosuppression, Neuropathy, Nausea. |
8. Prognosis and Outcomes
| Stage | 5-Year Survival |
|---|---|
| Stage I | ~50-80% |
| Stage II | ~30-40% |
| Stage III | ~10-20% |
| Stage IV | less than 5% |
| Overall | ~15-20% |
| Factor | Impact |
|---|---|
| Early Detection | Best prognosis. T1a amenable to endoscopic cure. |
| Response to Neoadjuvant Treatment | Complete pathological response = Better outcome. |
| Surgical Centre Volume | High-volume centres have better outcomes (Centralization). |
| Performance Status / Nutrition | Fitness for treatment. |
9. Screening and Prevention
Barrett's Surveillance
| Findings | Surveillance Interval |
|---|---|
| Barrett's, No Dysplasia | Every 3-5 years |
| Low-Grade Dysplasia | Every 6 months (Or ablation) |
| High-Grade Dysplasia | Endoscopic ablation (RFA) or Resection (EMR/ESD) |
Prevention
- Treat GORD: PPI therapy reduces Barrett's progression risk.
- Weight Management: Reduce obesity.
- Smoking Cessation: Reduces SCC risk.
- Alcohol Moderation: Reduces SCC risk.
10. Evidence and Guidelines
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Oesophageal Cancer | NICE NG83 | 2WW referral. Staging. MDT. Neoadjuvant + Surgery for locally advanced. Palliative stenting. |
| Upper GI Cancer | AUGIS / BSG | Centralisation. EMR/ESD for T1a. CROSS or FLOT neoadjuvant. |
| Barrett's | BSG | Surveillance. Ablation for dysplasia. |
Key Trials
| Trial | Findings |
|---|---|
| CROSS | Neoadjuvant chemoradiotherapy + Surgery improves survival vs Surgery alone. |
| FLOT4-AIO | Perioperative FLOT improves survival vs ECF/ECX for GOJ/Gastric Adeno. |
| CheckMate 577 | Adjuvant Nivolumab improves DFS after neoadjuvant chemoRT + surgery. |
11. Patient and Layperson Explanation
What is Oesophageal Cancer?
Oesophageal cancer is cancer of the food pipe (Oesophagus), the tube that carries food from your mouth to your stomach.
What are the symptoms?
- Difficulty swallowing (Dysphagia) – This usually starts with solid foods and may progress to liquids.
- Weight loss.
- Pain or discomfort when swallowing.
- Heartburn that doesn't get better.
Who is at risk?
- Long-term acid reflux (GORD) and Barrett's oesophagus.
- Smoking.
- Heavy alcohol use.
- Obesity.
How is it diagnosed?
A camera test (Endoscopy / OGD) is used to look at the oesophagus and take samples (Biopsies).
What is the treatment?
- Early cancer: May be removed through the camera (Endoscopic resection) or by surgery.
- Locally advanced cancer: Usually treated with chemotherapy and radiotherapy, followed by surgery.
- Advanced/Spread cancer: Treatment focuses on controlling symptoms, such as placing a tube (Stent) to help swallowing, chemotherapy, and supportive care.
What is the outlook?
Oesophageal cancer is serious. Outcomes are best when it is caught early. For advanced disease, treatment can help control symptoms and improve quality of life.
12. References
Primary Sources
- National Institute for Health and Care Excellence. Oesophago-gastric cancer (NG83). 2018.
- van Hagen P, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer (CROSS Trial). N Engl J Med. 2012;366(22):2074-2084. PMID: 22646630.
- Al-Batran SE, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4). Lancet. 2019;393(10184):1948-1957. PMID: 30982686.
13. Examination Focus
Common Exam Questions
- Risk Factor for Adenocarcinoma: "What is the major risk factor for oesophageal adenocarcinoma?"
- Answer: Barrett's Oesophagus (Secondary to chronic GORD).
- Classic Presentation: "What is the cardinal symptom of oesophageal cancer?"
- Answer: Progressive Dysphagia (Solids → Liquids) + Weight Loss.
- Staging Modality: "What investigation is best for T staging?"
- Answer: Endoscopic Ultrasound (EUS).
- Neoadjuvant Regimen: "What is the CROSS regimen?"
- Answer: Neoadjuvant Chemoradiotherapy (Carboplatin/Paclitaxel + 41.4 Gy RT) followed by Surgery.
Viva Points
- SCC vs Adenocarcinoma: Know risk factors, Location, Epidemiology.
- Virchow's Node: Left supraclavicular lymphadenopathy = Metastatic GI malignancy.
- Centralisation: Oesophagectomy should be performed in high-volume centres.
- HER2 Testing: For metastatic adenocarcinoma (Trastuzumab eligibility).
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.