CARCINOMA OF THE OESOPHAGUS
BASIC ANATOMY
- length of oesophagus:
• from incisors to cricopharyngeus: 15cm
• from circopharyngeus to GO junction: 25cm
• total length 40cm
- divided into upper, middle and lower third:
• upper third : C6- T4 (striated muscle→ voluntary control, can
regurgitate food)
• middle third: T4- T8
• lower third : T8- T12 (smooth muscle→involuntary)
- 4 layers:
• mucosa
• submucosa
• muscularis propria
• adventitia
AETIOLOGY OF DYSPHAGIA
Luminal In oesophageal wall Extraluminal
- foreign body - benign structures: peptic, caustic - lymph nodes: infective,
- fungating tumour - malignant strictures: SCC, inflammatory, neoplastic
- Plummer Vinson Syndrome- adenocarcinoma (lymphoma, bronchial Ca)
premalignant condition - infective: oesophageal - tumours: bronchial Ca
candidiasis, viral ulceration - thyroid enlargement
(CMV) - aortic aneurysm
RISK FACTORS
1. smoking (direct heat and carcinogenic) and alcohol
2. previous neck irradiation
3. poor nutrition ( fibre and fat, smoked, pickled and heavily salted food)
4. black, males
5. corrosive ingestion (lye, thermal irritants) SCC (more common)
6. other oesophageal disease (achalasia, oesophageal diverticulae → mid oes mainly
7. infections (atrophic gastritis, HPV)
8. tylosis (hereditary condition with hyperpigmented palms and soles)
9. Plummer-Vinson Syndrome (Fe deficiency anaemia, dysphagia and oesophageal webs)
10. Barrett’s oesophagus and GERD
11. smoking adenocarcinoma
12. obesity (related to intra-abdominal pressure and GERD) → distal oes mainly
CLINICAL FEATURES
Symptoms
- progressive dysphagia
→ dysphagia occurs late, when 60% of oesophagus occluded. There is no serosa therefore muscular layer
stretches easily before there is obstruction
- odynophagia
- inanition (exhaustion d/t lack of nourishment)
- weightloss
- GERD (heartburn and regurgitation)
- chest discomfort
- hoarseness (d/t recurrent laryngeal nerve compression)
- post prandial coughing (usu d/t trachea-oesophageal fistula (TOF))
- bone pain (bony metastases)
,- respiratory distress (phrenic nerve involvement)
- eye symptoms (Horner’s syndrome)
Signs of advanced disease
- aspiration pneumonia (bronchial breathing, dullness) Metastases to:
- pallor
• abdomen: hepatomegaly, jaundice, ascites
- pleural effusion
• lungs: cannonball lesions, pleural effusions
- hepatomegaly
• bones: bone pain
- ascites
- lymphadenopathy→ Virchow’s node
(on clinical exam, start with neck, chest and then abdomen)
INVESTIGATIONS
Radiological (Diagnostic)
1. CXR - widened mediastinum
- air fluid levels
- raised hemidiaphragm (phrenic nerve involvement)
- consolidation (if aspiration pneumonia)pleural effusion and
cannonball lesions
- lytic bone lesions
2. Barium swallow In order of occurrence:
→ done before endoscopy because 1. stricturing with irregular lining
endoscopy will ause trauma to diverticulum 2. proximal dilatation with shouldering and axis deviation
or oes webs 3. also angulation and formation of sinuses with evidence of
→ do Gastrogaffin swallow if suspecting contrast in the lung
TOP because barium can cause aspiration - length and site of stricture→ if >8cm= irresectable
pneumonitis - “rat;s tail” or “apple core” appearance
3. Upper endoscopy and biopsy - biopsy any irregular strictures, ulcerations or fungating tumours
- number of biopsies= diagnostic accuracy
- chromoendoscopy with Lugol’s iodine (SCC) or methylene blue
(metaplasia in Barrett’s)
- can also temporarily dilate oesophagus
Radiological (Staging)
US abdomen - liver metastases
- hepatomegaly
CT chest and abdomen - extent of tumour invasion, lung mets
Bone scan - bony mets
Haematological
• FBC : Hb (Fe deficiency anaemia), WCC (infection)
• U+E : renal impairment (pre-renal failure d/t dehydration)
• LFT : albumin will be low (<35) if malnourished
• CMP : calcium raised of tumour present (?)
MANAGEMENT
- is the tumour resectable or is the patient for palliation?
,Resectable if:
Patient factors
1. age <75 years
2. no irreversible co-morbidities e.g. renal failure
3. FEV1 > 1L in 1 second (during oesophagectomy, 1 lung is collapsed therefore both need to be functioning
adequately)
4. EF >40%
5. albumin >30
Tumour factors
1. no mets
2. length of stricture:
• upper and mid: <6cm
• distal: <8cm
3. no angulation >30 degrees
4. axis deviation <15 degrees
5. no TOF or invasion of aorta, trachea, heart or great vessels
CURATIVE MANAGEMENT
- Stage 1: surgical resection only. If surgical specimen reveals more advanced disease, adjuvant chemo is considered
- Stage 2: can give neoadjuvant chemotherapy and surgical resection
- Stage 3: aggressive surgical resection
- upper third: pharyngolaryngoesophagectomy (very dangerous, will require permanent tracheostomy, join laryng
to stomach)
- middle third: 3 stage oesophagectomy with gastric pull through and appropriate LN dissection or 2 stage
oesophagectomy
- lower third: oesophagogastrectomy
- after resection, go for radiotherapy to increase survival rate
PALLIATIVE MANAGEMENT
- surgical palliation: palliative resection, surgical bypass (but high risk of complications)
- endoscopic palliation: self-expanding plastic or metal stents (SEPS or SEMS), endoscopic dilatation, cryotherapy,
Celestin tube
- oncologic palliation: external beam radiotherapy with chemotherapy, brachytherapy
- other: ensure adequate nutrition and analgesia
, NON-MALIGNANT OESOPHAGEAL CONDITIONS
1. GERD
2. Complications of GERD (short oesophagus, peptic stricture, Barrett;s oesophagus)
3. Motility disorders (achalasia)
BASIC ANATOMY AND PHYSIOLOGY
- gastro-oesophageal sphincter (GOS/ LOS) is a high pressure zone at junction of oesophagus and stomach
- LOS provides barrier to prevent gastric contents from entering oesophagus
- LOS is 3-4cm long
- LOS pressure is between 10-30mmHg
1.GASTRO-OESOPHAGEAL REFLUX DISEASE (GERD)
- abnormal exposure of the oesophagus to gastric contents which results in symptoms
AETIOLOGY
Inflow problems Problems at the sphincter Outflow problems
1. oesophageal hypomotility 1. transient LOS relaxations 1. gastric dilatation
2. oesophageal 2. LOS hypotension 2. impaired motility and
hypersensitivity 3. anatomic disruption of GO emptying
junction (hiatus hernia) 3. excessive gastric acid
secretion
CLINICAL FEATURES
Typical Atypical symptoms Extra-oesophageal symtoms
- regurgitation (gastric content - dysphagia - hoarseness
refluxed into mouth) - odynophagia - chronic cough
- heartburn (retrosternal burning) - chest pain - recurrent aspiration
- dental erosions
INVESTIGATIONS
1. trial of PPIs→ 8 week therapy, 1x daily and then 2x daily if neccessary
2. barium swallow
3. endoscopy and biopsy
• grade severity of mucosal injury (Los Angeles Classification
Grade A 1/more mucosal break <5mm, that does not extend between the tops of 2 mucosal folds
Grade B 1/more mucosal break >5mm, that does not extend between the tops of 2 mucosal folds
Grade C 1/more mucosal break that is continuous between the tops of 2/more mucosal folds but which involves
<75% of the circumference
Grade D 1/more mucosal break involving at least 75% of oesophageal circumference
4. oesophageal manometry Indications for endoscopy
5. intraluminal pH monitoring 1. >45 years
2. failure to respond to PPIs
MANAGEMENT 3. alarm symptoms:
- lifestyle modification: elevate head of bed, avoid tight fitting • dysphagia/odynophagia
clothing, eat small and frequent meals, avoid eating prior to • unexplained weight loss
bedtime, avoid alcohol, coffee, peppermint and chocolate • haematemesis
- medical therapy: PPI therapy (provide symptomatic relief, heal • anaemia
oesophageal mucosal damage, prevent development of
complications)
- anti-reflux surgery: Nissen fundoplication (fundus of stomach is wrapped around oes to reinforce sphincter).
Indications: non-compliance to PPIs, desire to discontinue medical therapy, side effects of PPIs, large hiatus hernia
- endoluminal therapy: implantations of biopolymers, radiofrequency, suturing of LOS (not recommended)
