Squamous Cell Carcinoma of the Oesophagus

Oesophageal squamous cell carcinoma arises from squamous epithelium and commonly affects the middle and upper thoracic oesophagus.

Important risk factors include tobacco, alcohol, nutritional deficiencies, caustic oesophageal injury, achalasia and environmental or dietary carcinogen exposure.

Squamous cancer frequently spreads longitudinally through the oesophageal wall and through an extensive submucosal lymphatic network. Regional nodal disease may therefore occur even when the primary lesion appears relatively localised.

Compared with adenocarcinoma, squamous carcinoma is generally more radiosensitive and definitive chemoradiation has a particularly important role.

Progressive solid food dysphagia advancing to liquid dysphagia is typical.

Weight loss may be profound because both mechanical obstruction and tumour related catabolism reduce nutritional reserve.

Odynophagia suggests ulcerating disease.

Hoarseness suggests recurrent laryngeal nerve involvement.

Coughing after swallowing, recurrent pneumonia or aspiration should raise concern for tracheobronchial invasion or fistulation.

Cervical and supraclavicular lymphadenopathy indicates advanced regional disease.

Upper gastrointestinal endoscopy with biopsy: establishes squamous histology.

CT chest and abdomen plus FDG PET CT: define nodal and metastatic disease.

Endoscopic ultrasound: refines T and nodal stage when the tumour is traversable and curative treatment remains possible.

Bronchoscopy is appropriate for upper and middle thoracic tumours abutting the trachea or main bronchi when airway invasion is possible.

Very superficial mucosal squamous cancer without nodal risk features can undergo endoscopic resection in specialist centres.

Most clinically significant localised squamous cancers require chemoradiation with or without oesophagectomy.

For a fit patient with resectable middle or distal thoracic locally advanced squamous carcinoma, one established approach is preoperative chemoradiation:

Paclitaxel 50 mg/m² IV weekly plus carboplatin AUC 2 IV weekly for five weeks with 41.4 Gy radiotherapy in 23 fractions, followed by oesophagectomy. Squamous cancers demonstrate particularly high pathological response rates to this regimen.

Definitive chemoradiation is a curative treatment option for cervical oesophageal squamous carcinoma, unresectable disease and selected thoracic cancers where organ preservation is preferred or surgery would produce excessive morbidity.

One established definitive regimen uses:

Cisplatin 75 mg/m² IV with fluorouracil 1000 mg/m² per day by continuous IV infusion on days 1 to 4, combined with approximately 50 to 50.4 Gy radiotherapy.

Concurrent FOLFOX based chemoradiation is an alternative when cisplatin is unsuitable.

Escalating radiotherapy well above approximately 50.4 Gy during conventional definitive chemoradiation has not demonstrated a survival advantage and increases treatment burden.

For patients undergoing surgery, the operation is determined by tumour level. Middle thoracic lesions commonly require transthoracic oesophagectomy with regional lymphadenectomy. Proximal lesions require careful assessment because obtaining adequate proximal margins may require cervical dissection and carries greater recurrent laryngeal nerve risk.

Definitive chemoradiation can achieve survival comparable with trimodality treatment in selected squamous cancers, although surgery improves local disease control in some patients. Salvage oesophagectomy after failed definitive chemoradiation is technically difficult and carries substantially greater leak, pulmonary and mortality risk than planned oesophagectomy.

Persistent or recurrent dysphagia after definitive treatment requires endoscopic and cross sectional reassessment. Do not assume post treatment dysphagia is benign fibrosis until recurrent malignancy has been excluded.

For metastatic or unresectable recurrent squamous carcinoma, systemic therapy commonly combines platinum based chemotherapy with immune checkpoint inhibition according to PD L1 status, previous therapy and patient fitness.