Oesophageal Cancer

Malignancy of the esophagus, divided into two histological types with distinct risk factors and geography.

• Squamous cell carcinoma arises in the upper and mid esophagus, is strongly linked to smoking and alcohol use, and remains the dominant subtype in high incidence regions of Asia and East Africa.

• Adenocarcinoma arises in the lower esophagus and gastroesophageal junction from Barrett's metaplasia secondary to chronic GERD, and is now the dominant subtype in Western countries, closely associated with obesity and reflux disease.

Progressive dysphagia is the hallmark symptom, classically solids before liquids, reflecting luminal narrowing.

Presentation is often late because dysphagia typically implies over 60% circumferential luminal involvement.

Associated features include unintentional weight loss, odynophagia, retrosternal pain, regurgitation of undigested food, hoarseness from recurrent laryngeal nerve invasion, hematemesis, and iron deficiency anemia from occult bleeding.

Signs suggesting metastatic spread include a palpable supraclavicular node (Virchow's node), hepatomegaly, and ascites.

Upper GI endoscopy with biopsy is the investigation of choice, providing direct visualization and histological confirmation.

Staging requires CT of the chest, abdomen, and pelvis; endoscopic ultrasound to assess depth of invasion and locoregional nodal involvement; and PET CT to detect distant metastasis, now standard practice prior to committing to radical treatment.

Staging laparoscopy is added for adenocarcinoma involving the gastroesophageal junction to detect occult peritoneal disease before major surgery.

Baseline FBC (assessing for anemia), LFTs, and formal nutritional assessment complete the workup.

Differentials include benign peptic or caustic stricture, achalasia, diffuse esophageal spasm, extrinsic compression from a mediastinal mass, and eosinophilic esophagitis.

For early, localized, resectable disease in a patient with good performance status, treatment combines neoadjuvant chemoradiotherapy (the CROSS protocol using carboplatin and paclitaxel with concurrent radiotherapy) or perioperative chemotherapy (the FLOT regimen of fluorouracil, leucovorin, oxaliplatin, and docetaxel, particularly favored for adenocarcinoma), followed by esophagectomy. Surgical approach (Ivor Lewis, McKeown, or transhiatal) depends on tumor location and surgeon preference.

Endoscopic resection by EMR or ESD is reserved for very early T1a disease confined to the mucosa.

Definitive chemoradiotherapy is used for squamous cell carcinoma in patients unfit for surgery, or as an alternative to surgery for some upper third tumors.

Metastatic or unresectable disease is managed with palliative platinum fluoropyrimidine based chemotherapy, trastuzumab if the tumor is HER2 positive adenocarcinoma, and immunotherapy with pembrolizumab or nivolumab, particularly when PD-L1 expression is high.

Palliation of dysphagia itself uses esophageal stenting, palliative radiotherapy, and nutritional support, including consideration of a feeding jejunostomy in severe cases.

Referral: upper GI or thoracic surgery and oncology multidisciplinary team for all confirmed cases; urgent endoscopy for any dysphagia accompanied by alarm features.