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Oesophageal cancer

Barrett's oesophagus

  • First described by Norman Barrett in 1950
  • Consists of columnar-lined distal oesophagus
  • Due intestinal metaplasia of distal oesophageal mucosa

Histology of Barretts oepsohagus

  • Can progress to dysplasia and adenocarcinoma
  • Its is an acquired condition due to gastro-oesophageal reflux
  • Bile reflux appears to be an important aetiological factor
  • 10% of patients with GORD develop Barrett's oesophagus
  • Approximately 1% of patients with Barrett's oesophagus per year progress to carcinoma
  • Barrett's oesophagus increase the risk of cancer by x30

Clinical features

  • Barrett's per se is usually asymptomatic
  • Usually recognised as an incidental finding at endoscopy

Endoscopic appearance of Barretts oesophagus

  • Appears as 'velvety' epithelium extending more than 3 cm above gastro-oesophageal junction
  • The significance of 'short segment' Barrett's (<3 cm long) is unclear

Management

  • If recognised at endoscopy most patients are started on life-long acid suppression
  • Little evidence exists that it causes regression of metaplasia
  • Anti-reflux surgery may reduce progression to dysplasia and cancer
  • Recent interest has been shown in endoscopic mucosal ablation
  • Usually achieved with photosensitisers and laser therapy
  • The role of endoscopic surveillance of Barrett's oesophagus is controversial
  • Aim of surveillance is to detect dysplasia before progression to carcinoma
  • 40% patients with dysplasia have focus of adenocarcinoma
  • Oesophagectomy for dysplasia has an 80% 5-year survival

Oesophageal carcinoma

  • 90% are squamous cell carcinomas

  • Occur in the upper or middle third of the oesophagus

  • 8% are adenocarcinomas
  • Occur in the lower third of the oesophagus
  • Overall 5 year survival is very poor and is at best 20%
  • Less than 50% patients are suitable for potentially curative treatment
  • Of those undergoing 'curative' treatment less than 40% survive one year

Risk factors

  • Squamous cell carcinoma
    • Alcohol / tobacco
    • Diet high in nitrosamines
    • Aflatoxins
    • Trace element deficiency - molybdenum
    • Vitamin deficiencies - vitamins A & C
    • Achalasia
    • Coeliac Disease
    • Genetic - Tylosis
    • High incidence in Transkei, Areas of Northern China and the Caspian littoral region
  • Adenocarcinoma
    • 15% associated with Barrett's Oesophagus

Clinical features

  • Progressive dysphagia
  • Respiratory symptoms due to overspill or occasionally a trachea-oesophageal fistula
  • Weight loss

Assessment

Diagnosis confirmed by:

  • Endoscopy plus biopsy / cytology
  • Barium swallow

oesophageal carcinoma

Resectability and fitness for surgery assessed by:

  • Chest x-ray
  • Lung function tests(FEV1 > 1L)
  • Liver ultrasound
  • Endoscopic ultrasound
  • Bronchoscopy
  • Laparoscopy
  • Thoracic CT

Management

  • Adenocarcinomas are not radiosensitive and surgery is mainstay of treatment
  • Squamous cell carcinomas can be treated with either surgery or radiotherapy

Radiotherapy

  • Pearson in Edinburgh (1977)
  • 19% 5 years survival with radiotherapy
  • Improved survival compared to surgery
  • Similar results not seen in other centres

Surgery

  • Only 40% tumours are resectable
  • Operative mortality now less than 10%
  • Treatment should be in centres who perform operation regularly
  • No place for the occasional operator
  • Preoperative chemotherapy may be beneficial

Operative approaches

Need 10 cm proximal clearance to avoid submucosal spread.

  • Total gastrectomy via thoracoabdominal approach (Adenocarcinoma)
  • Subtotal two-stage oesophagectomy (Ivor-Lewis)
  • Subtotal three-stage oesophagectomy (McKeown)
  • Transhiatal oesophagectomy

Palliative treatment

Aim to relieve obstruction and dysphagia with minimal morbidity

  • Oesophageal intubation
    • Open surgical intubation (Celestin or Mousseau-Barbin tubes) now obsolete
    • Endoscopic or radiological placement now most commonly practiced
    • Atkinson tube is the most commonly placed endoscopically
    • Requires dilatation with risk of oesophageal perforation
    • Recent increased use of self-expanding stents that require no pre-dilatation
    • Complications of stents and tubes:
      • Oesophageal perforation
      • Tube displacement or migration
      • Tube blockage due to ingrowth or overgrowth

Oesophageal tubes

  • Laser therapy
    • Produces good palliation in over 60% of cases
    • May need to be repeated every 4 to 6 weeks
    • Associated with oesophageal perforation in about 5% cases
  • External beam radiotherapy
  • Brachytherapy
  • Diathermy
  • Alcohol injection

Bibliography

Bancewicz J. Palliation in oesophageal neoplasia.  Ann R Coll Surg Eng 1999; 81; 382-386.

Basu K K,  de Caestecker J S.  Surveillance in Barrett's oesophagus.  Postgrad Med J 2002;  78:  263-268.

Cowling M G.  Stenting in the oesophagus.  Hosp Med 2000;  61: 33-66.

Chung S C S et al. Surgical therapy for squamous cell carcinoma of the oesophagus. Lancet 1994; 343: 521-524.

Ellul J P M, Morgan R. Palliation of malignant dysphagia from oesophageal cancer.  Br J Hosp Med 1996; 55: 272-274.

Hennessy T P J.  Barrett's oesophagus. J R Coll Surg Edinb 1992; 37: 69-73.

Hennessy T P J.  Cancer of the oesophagus. Postgrad Med J 1996; 72: 458-463.

Lagergren J, Bergstrom R, Lindgren A, Nyren O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med 1999; 340: 825-831.

Kubba A K, Krasner N.  An update in the palliative management of malignant dysphagia.  Eur J Surg Oncol 2000;  26: 116-129.

Medical Research Council Oesophageal Cancer Working Party.  Surgical resection with or without preoperative chemotherapy in oesophageal cancer:  a randomised controlled trial.  Lancet 2002;  359:  1727-1733.

Vickers J, Alderson D. Oesophageal cancer staging using endoscopic ultrasonography. Br J Surg 1998; 85: 994-998.

 

 
 

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