Oesophageal cancer

Introduction

Oesophageal cancer is a malignant tumour of the oesophagus and is classified into two main histological types:

• Adenocarcinoma – Most commonly affects the distal third of the oesophagus. It typically arises from Barrett’s oesophagus and is associated with gastro-oesophageal reflux disease (GORD).
• Squamous cell carcinoma (SCC) – More commonly affects the upper and middle thirds of the oesophagus. It is strongly associated with smoking, alcohol use, and achalasia.

Peak Incidence

• Most commonly occurs between the ages of 60 and 70.

Pathophysiology

• Adenocarcinoma arises from metaplastic columnar epithelium in Barrett’s oesophagus due to chronic acid exposure.
• Squamous cell carcinoma originates from the native squamous epithelium and is associated with chronic irritants such as alcohol and tobacco.
• Both types can invade locally, cause strictures, and metastasise via lymphatic or haematogenous spread.

Symptoms

• Progressive dysphagia (initially to solids, later to liquids).
• Unintentional weight loss.
• Odynophagia (painful swallowing).
• Hoarseness or persistent cough – due to recurrent laryngeal nerve involvement.
• Haematemesis or melaena (upper gastrointestinal bleeding).
• Anorexia and vomiting.
• Respiratory symptoms (e.g. breathlessness, cough) – due to aspiration or a tracheo-oesophageal fistula.

Signs

• Cervical lymphadenopathy – May present as a palpable left supraclavicular node (Virchow’s node), suggesting metastatic spread.
• Hepatomegaly – Suggests liver metastases.
• Signs of anaemia (from chronic blood loss):
  • Koilonychia (spoon-shaped nails).
  • Angular cheilitis.
  • Glossitis.

Diagnosis

Urgent Referral

• Two-Week Wait (2WW) criteria in the UK:
  • Any patient with dysphagia.
  • Adults aged 55 and over with weight loss and any of:
    • Upper abdominal pain.
    • Reflux.
    • Dyspepsia.
  • Consider urgent referral in patients with haematemesis or other red flag features.

Investigations

• Blood tests:
  • Full blood count (FBC) – May show iron deficiency anaemia.
  • Liver function tests (LFTs) – May be abnormal if liver metastases are present.
• Oesophagogastroduodenoscopy (OGD) with biopsy – Gold standard for diagnosis.
• CT thorax, abdomen, pelvis (CT TAP): First-line imaging for staging.
• PET-CT scan: To detect distant metastases.
• Additional investigations (if indicated):
  • Bronchoscopy – If tumour is near the trachea or main bronchi to assess airway involvement.
  • Barium swallow – May show an “apple-core” lesion or irregular narrowing.
  • Diagnostic laparoscopy – Sometimes used to assess peritoneal spread, especially in adenocarcinoma.

Complications

• Progressive dysphagia:
  • Leads to weight loss and malnutrition.
  • Risk of aspiration pneumonia.
• Tracheo-oesophageal fistula:
  • Results in recurrent cough and repeated aspiration.
• Metastatic spread:
  • SCC – Tends to metastasise to lungs and mediastinum.
  • Adenocarcinoma – More likely to spread to liver, peritoneum, and bone.
• Oesophageal obstruction: Can lead to complete dysphagia.
• Anastomotic leak (post-surgery): May result in mediastinitis, a life-threatening complication.

Management

Curative Options (for localised disease)

• Endoscopic submucosal resection – For very early-stage tumours confined to the mucosa.
• Neo-adjuvant chemoradiotherapy – Used for locally advanced disease prior to surgery.
• Surgical resection (e.g. oesophagectomy): In fit patients with resectable disease.

Palliative Options (for advanced or metastatic disease)

• Endoluminal stenting: First-line to relieve dysphagia and improve oral intake.

• Chemotherapy and/or radiotherapy – Used to control tumour growth and symptoms.

• Percutaneous endoscopic gastrostomy (PEG): For nutritional support in those unable to eat.

• Supportive care and symptom management.