OESOPHAGIAL CARCINOMA

Issah J. kiswagala

(M.B.B.S)

SURGICAL ANATOMY

• Oesophagus is 25 cm in length, extending from the cricopharyngeal sphincter to the cardio-oesophageal junction.

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PHYSIOLOGY

• The main function of the oesophagus is to transfer food from the mouth to the stomach.
• Voluntary contraction of the oropharynx pushes food into the upper oesophagus through a relaxed cricopharyngeal sphincter Then, due to primary and secondary peristalsis, the food bolus is transferred to the stomach.

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EPIDERMIOLOGY

• Carcinoma oesophagus is common in China, South Africa and Asian countries.
• It is 6th most common cancer in the world.
• It is less than 1% of all cancers. It is 7% of all GI malignancies.
• It is less common in America and European countries.
• Male to female ratio is 3:1

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AETIOLOGY/RISK FACTORS

• GERD with Barrett's oesophagus (Oesophageal metaplasia due to chronic GERD)
• Achalasia -30% (failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed)
• Oesophageal web -20% (a thin mucosal membrane that grows across the lumen and may cause dysphagia)
• Plummer-Vinson syndrome -10% (a rare disease characterized by difficulty swallowing, iron-deficiency anemia, glossitis, cheilosis and esophageal webs)
• Alcohol and tobacco 20-25%
• Peptic oesophagitis

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• Human papilloma virus (HPV) infection increases squamous cell carcinoma. This oncogenic virus, has been associated with cervical and oropharyngeal cancers also.
• Nitrosamines - (A type of chemical preservative found in tobacco products and tobacco smoke. Nitrosamines are also found in many foods, including fish, beer, fried foods, and meats) Most nitrosamines are carcinogenic.
• Food (pickles) containing fungi - Geotrichum candidum as in endemic areas of China.
• Corrosive strictures – due to GERD, Injuries caused by an endoscope, etc.
• Tylosis - It is a condition inherited as an autosomal dominant trait. It has increased incidence of oesophageal cancer.
• Diet, deficiencies (vit. A, C, Riboflavin) - 5%

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���MNEMONIC FOR COMMON RISK FACTORS���

ABCDEF:

A - Achalasia�B - Barret's esophagus�C - Corrosive esophagitis�D - Diverticulitis�E - Esophageal web�F - Familial

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COMMON PATHOLOGICAL SITES

• 50%-middle 1/3rd of oesophagus (Adenocarcinoma)
• 33%-lower 1/3rd of oesophagus ( Adenocarcinoma)
• 17%-upper 1/3rd of oesophagus (Squamous Cell Carcinoma)

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• Squamous cell carcinoma is commonest type Asian countries e.g. India (90%)
• In western countries, adenocarcinoma is becoming more common.

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CLINICAL FEATURES

• Men more than 60 years
• Dysphagia which is progressive and mainly for solids then liquid foods (odinophagia is the one which makes progressive dysphagia)
• Regurgitation of the food contents. Haematemesis is not very common. Vomitus may contain streaks of blood and melaena is rare.
• Loss of appetite, loss of weight (severe) and cachexia
• Pain-substernal or in the abdomen
• Hoarseness of voice due to involvement of recurrent laryngeal nerve

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• Features of broncho-oesophageal fistula in carcinoma of upper third oesophagus (30%). >Bronchopneumonia
• Backache indicates enlarged lymph nodes (coeliac).
• Hiccough (attack of hiccups), due to phrenic nerve involvement
• When patient presents with dysphagia (difficult in swallowing), often it is fairly advanced and inoperable and only palliation is the possibility. But then surgery is the treatment of choice in early growths

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INVESTIGATIONS

• Hb% & hematocrit is low, which is the cause of generalised weakness
• Barium swallow: Shouldering sign and irregular filling defect.
• Ultrasound is done to rule out liver secondaries, lymph nodes in the porta hepatis, coeliac nodes, etc.
• Liver function test (LFT) is affected, if secondaries in liver occur (increased ALP).
• Oesophagoscopy to visualise the growth and to take biopsy
• Chest X-ray to rule out aspiration pneumonia

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Oesophageal carcinoma

Achalasia (rat tail or bird beak sign)

MANAGEMENT

• TREATMENT
• Pre-referral management :- Stabilization with parenteral feeding and IV fluids, analgesics.

MANAGEMENT IN THE HIGHER CENTRES.

• Surgery for tumors that have not penetrated or metastasised
• radiotherapy also depends upon location of the tumour, histology, site of the tumour, staging and cardiopulmonary reserve
• Palliative treatment since they often present at an advanced stage, 5-year survival is very low in the majority of cases.

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Indications for palliative therapy

• Relieve pain
• Relieve dysphagia
• Prevent bleeding
• Prevent aspiration

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FOLLOW UP

Follow-up visits for esophageal cancer are different for each person. Follow-up visits may include:

1. health history and physical exam every 3–6 months for 1–2 years, then every 6–12 months for 3–5 years, then once each year.

• During a follow-up visit, you will usually ask questions about the side effects of treatment, how a patient is coping and if he is having any nutrition problems, Then do a complete physical exam.
• If a patient had surgery, radiation therapy, he/she may have narrowing, or stricture, in the esophagus. You may need to do esophageal dilation regularly to help keep the esophagus open so he/she can swallow food and liquids.

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2. You may order the following tests and procedures as part of follow-up or to find out if the cancer has come back, or recurred.

-Complete blood count (CBC) may be done to check for anemia, which may suggest bleeding from a tumour.

-Blood chemistry tests, including liver and kidney function tests, may be done to see if the esophageal cancer has spread to these organs.

-Imaging tests, such as OGD, CT scan and ultrasound, may be done to check for recurrence.

*If a recurrence is found during follow-up, your healthcare team will assess you to determine the best treatment options.

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COMPLICATIONS

• Tracheo-esophageal fistulas. (holes that develop in the area between the windpipe and the esophagus)
• Weight loss. (tumor becomes too large to allow enough food through the esophagus, weight loss can occur, cancer may also affect metabolism)
• Pneumonia. (If food enters the lungs because a tumor is blocking the esophagus and forcing food and liquid down the windpipe, aspiration pneumonia)
• Anemia. (due to bleeding from eroded oesophagus)
• Metastases (In advanced esophageal cancer, the tumor may spread, or metastasize, to other areas of the body. Initially to the lymph nodes and organs surrounding the esophagus eventually throughout the body to the liver, the lungs, and even the brain)

PREVENTIVE MEASURES

• Avoiding tobacco and alcohol
• Watching your diet and body weight, A diet rich in fruits and vegetables may help protect against esophageal cancer. Obesity has been linked with esophageal cancer, particularly the adenocarcinoma type, so staying at a healthy weight may also help limit the risk of this disease
• Getting treated for reflux or Barrett’s esophagus

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