Epidemiology
- Incidence: 10.00 cases per 100,000 person-years
- Peak incidence: 60-70 years
- Sex ratio: more common in males 4:1
| Condition | Relative incidence |
|---|---|
| Gastro-oesophageal reflux disease | 500.00 |
| Oesophageal cancer | 1 |
| Pharyngeal pouch | 0.20 |
| <1 | 1-5 | 6+ | 16+ | 30+ | 40+ | 50+ | 60+ | 70+ | 80+ |
Aetiology
Risk factors
- smoking
- alcohol
- GORD
- Barrett's oesophagus
- achalasia
- Plummer-Vinson syndrome
- squamous cell carcinoma is also linked to diets rich in nitrosamines
- rare: coeliac disease, scleroderma
Pathophysiology
Until recent times oesophageal cancer was most commonly due to a squamous cell carcinoma but the incidence of adenocarcinoma is rising rapidly. Adenocarcinoma is now the most common type of oesophageal cancer and is more likely to develop in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett's.
The majority of tumours are in the middle third of the oesophagus.
The majority of tumours are in the middle third of the oesophagus.
Clinical features
Features
- dysphagia: the most common presenting symptom
- anorexia and weight loss
- vomiting
- other possible features include: odynophagia, hoarseness, melaena, cough
Referral criteria
NICE cancer referral guidelines for oesophageal cancer suggest the following:
Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people:
Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis.
Consider non‑urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:
Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people:
- with dysphagia or
- aged 55 and over with weight loss and any of the following:
- upper abdominal pain
- reflux
- dyspepsia.
Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis.
Consider non‑urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:
- treatment‑resistant dyspepsia or
- upper abdominal pain with low haemoglobin levels or
- raised platelet count with any of the following:
- nausea
- vomiting
- weight loss
- reflux
- dyspepsia
- upper abdominal pain, or
- nausea or vomiting with any of the following:
- weight loss
- reflux
- dyspepsia
- upper abdominal pain.
Investigations
- Upper GI endoscopy is the first line test
- Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours
- Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If overt metastatic disease is identified using this modality then further complex imaging is unnecessary
- If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound
- Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy. Thoracoscopy is not routinely performed.
Management
- Operable disease is best managed by surgical resection.
- The most standard procedure is an Ivor- Lewis type oesophagectomy. This procedure involves the mobilisation of the stomach and division of the oesophageal hiatus. The abdomen is closed and a right sided thoracotomy performed. The stomach is brought into the chest and the oesophagus mobilised further. An intrathoracic oesophagogastric anastomosis is constructed. Alternative surgical strategies include a transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis.
- The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality. The McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage.
- In addition to surgical resection many patients will be treated with adjuvant chemotherapy.