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Malignant Oesophageal Tumours (Clinical Presentation (Progressive…
Malignant Oesophageal Tumours
Key Facts
Squamous cell carcinoma occurs in the middle third and in the upper third
Adenocarcinomas occur in the lower third of the oesophagus and at the cardia and represent around 45% of tumours
Sixth most common cancer world-wide
Carcinoma of the oesophagus occurs mainly in those aged 60-70 years
Squamous cell carcinoma (SCC)
Causes
Tobacco use
Obesity - since increased reflux
Achalasia (disorder where oesophagus has reduced/no ability to do peristalsis and transport food down)
Smoking
High levels of alcohol consumption
Low fruit & veg consumption
Diets rich in fibre, carotenoids (carrots), folate and vitamin C decrease risk
Epidemiology & aetiology
Int he UK the incidence is 5-10 per 100,000
Incidence is decreasing in contrast to adenocarcinoma
Common in Ethiopia, China and South & East Africa
More common in MALES than females
Occurs in the middle third and upper third of the oesophagus
Adenocarcinoma
Epidemiology & aetiology
In Barrett's oesophagus recurrent acid exposure results in the squamous epithelium being replaced by metaplastic columnar mucosa
Incidence is increasing in Western countries
Primarily arise in the columnar-lined epithelium in the lower oesophagus
Previous reflux symptoms increase risk up to 8x
Arise in the lower third of the oesophagus and account for 45% (majority of oesophageal tumours)
Causes
GORD
Obesity - since increased reflux
Tobacco
Smoking
Risk Factors
Achalasia
Obesity
Obesity - since increased reflux
Diet low in Vit A & C
Smoking
Barretts oesophagus
Alcohol
Pathophysiology
Squamous cell carcinoma occurs in upper 2/3rds of the oesophagus
Adenocarcinoma occurs in the lower 1/3rd of the oesophagus
Clinical Presentation
Anorexia
Pain due to importation of food or infiltration of cancer into adjacent structures
Lymphadenopathy
Weight loss
Oesophageal obstruction eventually causes difficulty in swallowing saliva, coughing and aspiration into the lungs
Progressive dysphagia
Initially there is difficulty in swallowing solids but dysphagia for liquids follows within weeks
If there is dysphagia to solids & liquids from the start this indicated benign disease
Signs from upper third of oesophagus
Hoarseness and cough
Most patients with upper GI cancer have NO PHYSICAL SIGNS and when the cancer is found it is extremely advanced
Treatment
Treatment of dysphagia
Endoscopic insertion of expanding metal stent across tumour to ensure oesophageal patency
Laser and alcohol injections to cause tumour necrosis and increase lumen size
Palliative care may be only option
If locally incurable or metastatic then systemic chemotherapy
Survival rates as a whole are low
Surgical resection
Best chance of cure if tumour has not infiltrated outside the oesophageal wall (stage 1)
Combined with chemotherapy BEFORE SURGERY +/- radiotherapy
Diagnosis
Barium swallow
To see strictures
CT scan/MRI/PET for tumour staging - PET more sensitive in detecting metastases
Oesophagoscopy with biopsy
To confirm diagnosis with histological proof of carcinoma