Oesophageal Cancer
Summary
Oesophageal cancer is a malignancy of the oesophagus with two main histological types: adenocarcinoma (lower third, associated with Barrett's oesophagus, obesity, and GORD) and squamous cell carcinoma (middle/upper third, associated with smoking and alcohol). The cardinal symptom is progressive dysphagia - initially for solids, then liquids - often accompanied by weight loss. Prognosis is generally poor due to late presentation, with 5-year survival around 15-20%. Diagnosis is by upper GI endoscopy with biopsy. Curative treatment (oesophagectomy with or without neoadjuvant chemotherapy) is possible in early stages; palliative options include stenting and radiotherapy.
Key Facts
- Types: Adenocarcinoma (lower 1/3; Barrett's, obesity) vs Squamous (middle/upper; smoking, alcohol)
- Symptoms: Progressive dysphagia, Weight loss, Hoarseness, Odynophagia
- Investigation: Urgent OGD + Biopsy
- Staging: CT, EUS, PET-CT
- Treatment: Oesophagectomy +/- neoadjuvant chemo (curative); Stenting (palliative)
- Prognosis: Poor overall (5-year survival ~15-20%)
Clinical Pearls
"Solids Before Liquids": Progressive dysphagia starting with solids then liquids is classic for a mechanical obstruction (cancer). Immediate difficulty with both suggests motility disorder.
"Barrett's Is the Precursor for Adenocarcinoma": Long-standing GORD → Barrett's (intestinal metaplasia) → Dysplasia → Adenocarcinoma.
"Upper = Squamous, Lower = Adeno": Squamous cell carcinoma in upper/middle oesophagus; adenocarcinoma in lower oesophagus/GOJ.
"Hoarseness = Bad Sign": Hoarse voice suggests recurrent laryngeal nerve involvement - usually indicates incurable disease.
Incidence
- ~9,000 cases/year in UK
- 6th most common cause of cancer death
Demographics
- M:F = 3:1
- Peak age: 60-80 years
- Adenocarcinoma: Increasing (linked to obesity)
- Squamous: Decreasing (linked to smoking decline)
Risk Factors
| Adenocarcinoma | Squamous Cell |
|---|---|
| Barrett's oesophagus | Smoking |
| GORD | Alcohol |
| Obesity | Hot beverages (some regions) |
| Male sex | Achalasia |
| Caucasian | Plummer-Vinson syndrome |
| Coeliac disease (historical) |
Adenocarcinoma Sequence
- GORD → Chronic acid exposure
- Barrett's oesophagus → Intestinal metaplasia
- Low-grade dysplasia
- High-grade dysplasia
- Adenocarcinoma
Squamous Cell Carcinoma
- Arises from squamous epithelium
- Chronic irritation (alcohol, smoking, heat) → Dysplasia → Cancer
Spread
- Local: Mediastinal structures, trachea, aorta
- Lymphatic: Upper/mid → Cervical; Lower → Coeliac nodes
- Haematogenous: Liver, Lungs, Bone
Symptoms
| Symptom | Notes |
|---|---|
| Dysphagia | Progressive; solids → liquids |
| Weight loss | Often significant |
| Odynophagia | Painful swallowing |
| Regurgitation | Undigested food |
| Hoarseness | RLN involvement (advanced) |
| Cough | Aspiration or tracheal fistula |
| Chest pain | Retrosternal |
Late/Advanced Features
General
- Cachexia
- Pallor (anaemia)
- Dehydration
Specific
- Supraclavicular lymphadenopathy (especially left - Virchow's node)
- Hepatomegaly
- Ascites
Voice
- Hoarse (recurrent laryngeal nerve palsy)
Diagnosis
| Test | Notes |
|---|---|
| Upper GI Endoscopy (OGD) | Direct visualisation + biopsy; Gold standard |
| Histology | Adenocarcinoma or Squamous cell |
Staging
| Test | Purpose |
|---|---|
| CT Chest/Abdomen | Distant metastases |
| EUS (Endoscopic Ultrasound) | T and N staging (depth of invasion) |
| PET-CT | Detect occult metastases |
| Staging Laparoscopy | For GOJ tumours (peritoneal disease) |
Additional
- Bloods: FBC (anaemia), U&E, LFTs, Albumin
- Nutritional assessment
Management Approach
┌──────────────────────────────────────────────────────────┐
│ OESOPHAGEAL CANCER MANAGEMENT │
├──────────────────────────────────────────────────────────┤
│ │
│ CURATIVE INTENT (Early stage, fit patient): │
│ • Neoadjuvant chemotherapy or chemoradiotherapy │
│ • Oesophagectomy (Ivor Lewis, McKeown, transhiatal) │
│ • Resection + nodal dissection │
│ │
│ EARLY CANCER/DYSPLASIA (T1a): │
│ • Endoscopic mucosal resection (EMR) │
│ • Endoscopic submucosal dissection (ESD) │
│ • Ablation (RFA) for Barrett's with HGD │
│ │
│ PALLIATIVE (Advanced/Metastatic): │
│ • Oesophageal stenting (SEMS) for dysphagia │
│ • Palliative radiotherapy │
│ • Palliative chemotherapy │
│ • Nutritional support (NG/PEG/Jejunostomy) │
│ • Best supportive care │
│ │
│ MDT DISCUSSION: │
│ • All cases discussed at Upper GI MDT │
│ • Oncology, Surgery, Radiology, Pathology, CNS │
│ │
└──────────────────────────────────────────────────────────┘
Oesophagectomy
- Ivor Lewis: Right thoracotomy + laparotomy; anastomosis in chest
- McKeown: Three-stage; cervical anastomosis
- Transhiatal: Avoids thoracotomy
Of Disease
- Complete obstruction (unable to swallow saliva)
- Aspiration pneumonia
- Tracheo-oesophageal fistula
- Massive haemorrhage (aortic erosion)
- Malnutrition
Of Treatment
- Oesophagectomy: Anastomotic leak, stricture, recurrent laryngeal nerve injury, pneumonia
- Stent: Migration, perforation, tumour overgrowth
Survival
| Stage | 5-Year Survival |
|---|---|
| Stage I | 40-60% |
| Stage II | 20-40% |
| Stage III | 10-20% |
| Stage IV | <5% |
Overall
- Overall 5-year survival: 15-20%
- Poor prognosis due to late presentation
Prognostic Factors
- Stage at diagnosis (most important)
- Tumour grade
- Performance status
- Response to neoadjuvant therapy
Key Guidelines
- NICE NG83: Oesophago-gastric Cancer (2018)
- ESMO Clinical Practice Guidelines
- BSG Guidelines: Barrett's Oesophagus
Key Evidence
Neoadjuvant Chemoradiotherapy
- CROSS trial: Improved survival vs surgery alone
Barrett's Surveillance
- Reduces cancer mortality
What is Oesophageal Cancer?
Oesophageal cancer is cancer of the food pipe (oesophagus), which connects your throat to your stomach.
What Are the Types?
- Adenocarcinoma: Usually in the lower oesophagus; linked to acid reflux, Barrett's oesophagus, and being overweight
- Squamous cell carcinoma: Usually in the upper/middle; linked to smoking and alcohol
What Are the Symptoms?
- Difficulty swallowing (food gets stuck, starting with solids then liquids)
- Weight loss
- Heartburn that doesn't go away
- Hoarse voice
- Bringing food back up
How is it Diagnosed?
An endoscopy (camera down your throat) is used to look at the oesophagus and take samples (biopsies).
How is it Treated?
- Early cancer: May be removed with an endoscopy or surgery
- More advanced cancer: Surgery to remove part of the oesophagus, often with chemotherapy before
- If it can't be cured: A stent can be placed to help you swallow; radiotherapy and chemotherapy can control symptoms
What's the Outlook?
It depends on how early the cancer is found. If caught early, outcomes are good. Unfortunately, many cancers are found late, which makes treatment more difficult.
Primary Guidelines
- NICE. Oesophago-gastric Cancer: Assessment and Management in Adults (NG83). 2018. nice.org.uk/guidance/ng83
Key Studies
- 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