Should you have this? Fuck off and die.

Andrew Davidson
Oesophageal Carcinoma Essay

Oesophageal cancer counts for 5% of all cancer deaths, and affects around 9 in 100,000
people.
Relatively uncommon in the west compared to far and middle east, where is can be as common
as 1 in 100. Thought to be to do with a mould that grows on foodstuffs naturally in those
regions.

Pathology
Oesophagus is normally stratified squamous epithelium
By far the 2 most prevalent cancers are adenocarcinoma and squamous cell carcinoma.
AC has overtaken SCC as the most prevalent form.
Others include leiomyosarcoma, malignant melanoma, carcinoid tumours and
lymphoma
Upper oesophagus = 20% of cases, Middle = 50%, Lower = 30%
If at the eosophagogastric junction:
Type I - Distal oesophagus (Barretts aetiology likely) infiltrating junction from
above
Type II - arises from gastric cardia in the OJ junction
Type III - arising from below the cardia, infiltrating junction from below
Risk Factors
Squamous Cell Carcinoma (28%)

Tobacco (chewed or smoked)

Alcohol (increasing use, increasing risk)

(tobacco and alcohol are synergistic, they are worse together than they are when you add
up the risks seperately)
Nitrosamines (BBQd meat, pickled vegetables) in diet, or poor diet, poor oral hygiene
Betel nut consumption
Field cancerisation from H&N tumours
HPV is controversial. Probably.
Adenocarcinoma (55%)
7-10x as common in men

GORD is huge. Barretts oesophagus has 0.5% risk per patient-year

Obesity relates to GORD but also visceral obesity is a separate risk factor

Prof Reynolds is publish here. IGF-1 inreases, this increases cancer risk.
http://www.ncbi.nlm.nih.gov/pubmed/22146489

RXT, achalasia, Plummer Vinson syndrome

Women are protected from GORD by hormonal status so delay onset by 20 years compared
to men. H Pylori is also protective
Presentation
Dysphagia

Odynophagia

Should you have this? Fuck off and die. Andrew Davidson
Weight Loss
Hx of heartburn or reflux
Hoarseness or cough (upper third of oesophagus causes these signs)
Increased BMI as a risk factor or cachectic as a result of dysphagia
Lymphadenopathy (Virchows node especially)
Hepatomegaly (mets)
Tender spine (mets)
Pleural Effusion
Investigation
FBC (anaemia of chronic disease), U&E (dehydration from dysphagia, malnourishment, Preop), LFT (hepatic mets), albumin (malnourishment)
CXR (mediastinal fluid level, aspiration pneumonia, lung CA)
Barium Swallow (apple core stricture)
OGD +/- biopsy +/- EUS
CT-TAP and probably PET
Exploratory laparoscopy or thoracoscopy unlikely with CT PET and EUS so good
Staging
Tumour in situ - high grade dysplasia

T1a - invasion into lamina propria or muscular mucosae

T1b - invasion into submucosa
T2 - Muscularis propriae
T3 - Adventitia

T4 - Adjacent structures (a = resectable involving pleura, pericardium or diaphragm, b =

unresectable involving vertebral body, aorta, trachea)
N1-3
M 0 or 1
Management
Consider palliation. Radiotherapy, laser removal, stent, argon tissue coagulation,
analgesia
If High Grade Dysplasia or T1 can consider mucosal resection under endoscopy or
radio frequency ablation
Otherwise - surgery. Only 30% are resectable at presentation
The principles are to remove the tumour with appropriate margins, remove mediastinal and
abdominal lymph nodes and to re-anastomose the GI tract.
3 stage oesophagectomy - if above carina (Siewart types can also be used here)
Mobilise tumour and oesophagus via R thoractomy (in L lateral position)
Patient supine, laparotomy to mobilise stomach and to create conduit
Neck incision where oesophagus and tumour are removed and the stomach re-anastomosed.

Should you have this? Fuck off and die. Andrew Davidson
2 stage oesophagectomy - if below carina
Laparotomy to mobilise stomach, turn into a conduit
Left lateral position and right thoractomy to mobilise and remove oesophagus and tumour and
lymph nodes, stomach is drawn up and re-anastomosed.
If you cant re-anastomose to stomach then bring up the jejunum and re-anastomose
oesophagus to there via Uddin loop or Roux-en-Y.
Trans-hiatal
Not as good as the others as you cant take out chest lymph nodes. Done through the neck and
laparotomy.
Laparoscopy can be safely used.
Chemotherapy
Cisplatin and 5-FU. Add in epirubicin if no surgery being done. Can be adjuvant or neoadjuvant.
The REAL-2 trial is one looking into this with 4 groups.
Radiotherapy can be used but not so much in SJH.
Complications
Early: GA, bleeding/transfusion, scars, pain, infection, ICU stay, mortality, RLN damage, chest
drain, chest collections, jejunal tube, NPO for at least 5 days, anastomotic leak, ileus,
pneumothorax, liver trauma, perforated viscus
Late: weight loss, dysphagia, neuralgia from thoracotomy, recurrence, failure of surgery
Post op
HDU or ICU
NPO x 5 days, swallow test done on day 5 and if OK then slow meals
Discharge at 2w, OPD at 6 w
Monitor with CT-TAP
Prognosis
Stage dependant. Around 15% 5 YEAR SURVIVAL in USA. Mets less than 3, T1 80%.