A 68-year-old man is investigated for dysphagia. This has been getting progressively worse for the past 3-4 months. It occurs mostly with foods such as bread and meat and is associated with some odynophagia. He has vomited once after eating. There is no history of weight loss or anorexia. His bowel motions have not changed in terms of consistency or colour. A barium swallow is performed:
What is the most likely diagnosis?
Gastric cancer
Achalasia
Gastro-oesophageal reflux disease
Barrett’s oesophagus
Oesophageal cancer
Oesophageal cancer
Until recent times oesophageal cancer was most commonly due to a squamous cell carcinoma but the incidence of adenocarcinoma is rising rapidly. Adenocarcinoma is now the most common type of oesophageal cancer and is more likely to develop in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett’s.
The majority of tumours are in the middle third of the oesophagus.
Risk factors
smoking
alcohol
GORD
Barrett’s oesophagus
achalasia
Plummer-Vinson syndrome
squamous cell carcinoma is also linked to diets rich in nitrosamines
rare: coeliac disease, scleroderma
Diagnosis
Upper GI endoscopy is the first line test
Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours
Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If overt metastatic disease is identified using this modality then further complex imaging is unnecessary
If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound.
Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy. Thoracoscopy is not routinely performed.
Treatment
Operable disease is best managed by surgical resection.
The most standard procedure is an Ivor- Lewis type oesophagectomy. This procedure involves the mobilisation of the stomach and division of the oesophageal hiatus. The abdomen is closed and a right sided thoracotomy performed. The stomach is brought into the chest and the oesophagus mobilised further. An intrathoracic oesophagogastric anastomosis is constructed. Alternative surgical strategies include a transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis.
The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality. The McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage.
In addition to surgical resection many patients will be treated with adjuvant chemotherapy.