Epidemiology
- Most common in China and South Africa
- Most common in men >45 years old
- When patient presents with dysphagia it is usually advanced and inoperable
Etiology
- Diet, deficiencies – vit A, C, riboflavin
- Mycotoxin
- Alcohol and tobacco
- Achalasia cardia, oesophageal webs, Barrett’s oesophagus, Plummer-Vinson’s syndrome
- Corrosive strictures
Pathology
- Most common in middle third (50%); lower third (33%); upper third (17%)
- Squamous cell carcinoma (SCC) – arises from epithelial cells that line the oesophagus
- Adenocarcinoma – arises from glandular cells in the lower third of the oesophagus
- Lowest 3cm of oesophagus is lined by columnar cells so adenocarcinoma is more common here
- Barrett’s oesophagus – metaplastic change in the mucosal cells lining the lower portion of the oesophagus, from normal stratified squamous epithelium to simple columnar epithelium. Predisposes to adenocarcinoma
- Gross types – annular, ulcerative, fungating, polypoid, varicoid
Spread
- Direct – lack of serosal layer in oesophagus favours local extension
- In the upper third it spreads through muscular layer and adheres to left main bronchus, trachea, left recurrent laryngeal nerve, aorta
- May perforate and cause mediastinitis
- Lymphatic – by both lymphatic permeation and embolisation
- Can cause satellite nodules elsewhere in oesophagus away from the main tumour
- Above the neck it spreads to supraclavicular LNs
- In thorax it spreads to paraoesophageal and tracheobroncheal LNs
- In abdomen to celiac LNs
- Blood – to liver, lungs, brain, bones
Clinical features
- Recent onset of dysphagia – means that two thirds of lumen has been occluded
- Regurgitation; anorexia, weight loss, cachexia
- Pain – substernal or in abdomen
- Liver secondaries, ascites
- Bronchopneumonia, melaena
- Features of bronco-oesophageal fistula when carcinoma is in the upper third of oesophagus
- Troisier sign – Virchow’s node enlarged and palpable
- Hoarseness – involvement of recurrent laryngeal n.
- Hiccup – involvement of phrenic n.
- Back pain – due to nodal spread (paraoesophageal/celiac nodes)
Investigations
- Barium swallow – shouldering sign and irregular filling defect
- Oesophagoscopy – to see lesion, extent and type
- Biopsy – for histological typing
- CXR – aspiration pneumonia, vocal cord palsy, fistula
- Oesophageal endosonography – involvement of layers, nodes, left lobe of liver
- CT – to look for local extension, nodal status, vascular infiltration, obliteration of mediastinal fat
- US abdomen – liver and LN status
- Blood test – Hct, ESR, LFT
- Laparoscopy – peritoneal, liver, nodal spread. To take biopsy from different places
Treatment
Post cricoid tumours (SCC)
- Radiotherapy
- Pharyngolaryngectomy with gastric/colonic transposition
Upper third growth (SCC) – usually advanced with left recurrent laryngeal n. palsy
- Radiotherapy
- McKeown three phased oesophagectomy and anastomosis done in the neck
- Oesophagus with growth removed and anastomosis between pharynx and stomach done in neck
Middle third growth (SCC)
- Ivor Lewis operation – after laparotomy stomach is mobilised and pyloroplasty done
- Partial oesophagectomy and oesophagogastric anastomosis is done in thorax
Lower third growth (SCC and adenocarcinoma)
- Partial oesophagogastrectomy is done with oesophagogastric anastomosis
Post-operative management
- Fluid and electrolyte management
- Antibiotics and analgesia
- Respiratory care, physiotherapy
- Prevention of DVT – elevation, exercise, heparin
- Monitor for bleeding, sepsis, leak O2 saturation
Palliative treatment
- Indications – to relieve pain and dysphagia; prevent bleeding and aspiration
- External and intraluminal radiotherapy
- Chemotherapy – cisplatin, methotrexate
- Intubation – for trachea-oesophageal fistula
- Endoscopic laser – to improve dysphagia
- Self-expanding metal stents
- Surgery – palliative gastric bypass