Oesophageal cancer incidence is increasing across the Western world. Men are considerably more likely than women to develop the disease.
The two main histological types are squamous cell carcinoma and adenocarcinoma. In the US, adenocarcinomas predominate.
Low socioeconomic status, smoking, excessive alcohol use, GORD, Barrett's oesophagus, and obesity are some of the main risk factors.
Tumours are often locally advanced at the time of diagnosis. Accurate staging is important for prognosis and treatment planning.
Superficial intramucosal oesophageal cancer is best managed by endoscopic resection and surveillance. Early-stage cancers in surgical candidates are best treated by oesophagectomy.
For locally advanced disease, combined modality therapy is considered the current standard. This involves chemotherapy or chemoradiotherapy followed by surgery.
High-risk patients should be treated with a combination of chemotherapy and radiotherapy for best results, but local recurrence rates remain high.
Most oesophageal cancers are mucosal lesions that originate in the epithelial cells lining the oesophagus.
History and exam
Key diagnostic factors
- presence of risk factors
- weight loss
Other diagnostic factors
- postprandial/paroxysmal cough
- male sex
- tobacco use (squamous cell carcinoma)
- alcohol use (squamous cell carcinoma)
- GORD and Barrett's oesophagus (adenocarcinoma)
- hiatus hernia (adenocarcinoma)
- family history of oesophageal or other cancer (squamous cell carcinoma)
- low socioeconomic status
- non-white race (squamous cell carcinoma)
- high-temperature beverages and foods (squamous cell carcinoma)
- drinking maté (squamous cell carcinoma)
- low intake of fresh fruit and vegetables
- obesity (adenocarcinoma)
- human papillomavirus (squamous cell carcinoma)
- achalasia (squamous cell carcinoma)
- glyceryl trinitrate, anticholinergics, beta-adrenergics, aminophyllines, benzodiazepines (adenocarcinoma)
- vitamin and mineral deficiencies (squamous cell carcinoma)
- poor oral hygiene
1st investigations to order
- oesophagogastroduodenoscopy (OGD) with biopsy
- comprehensive metabolic profile
Investigations to consider
- CT thorax and abdomen
- MRI thorax and abdomen
- FDG-PET scan
- endoscopic ultrasound (EUS) ± fine needle aspiration (FNA)
- bronchoscopy ± FNA
- thoracoscopy and laparoscopy
- pulmonary function tests
- cardiac stress test
limited disease (cT1, cN0, M0)
localised disease (cT2, cN0, M0): suitable for surgery
localised disease (cT2, cN0, M0): unsuitable for surgery
locally advanced disease (cT3-4, cN1-3, M0): suitable for surgery
locally advanced disease (cT3-4, cN1-3, M0): unsuitable for surgery
metastatic (M1) disease
Naureen Starling, BSc(Hons), MBBS, MD(Res), FRCP
Consultant Medical Oncologist in GI Cancers
Associate Director of Clinical Research, GI and Lymphoma
The Royal Marsden Hospital NHS Trust
NS has received research funding from AstraZeneca, BMS, and Pfizer; travel and accommodation funding from AstraZeneca, BMS, Eli Lilly, Merck, Roche, and MSD Oncology; honoraria from Eli Lilly, Merck Serono, MSD Oncology, Pierre Fabre, Servier, GSK, and Amgen. She has been on the advisory board for Pfizer, AstraZeneca, Servier, and MSD (Merck). NS is an Honorary Clinical Senior Lecturer within the Division of Clinical Studies at the Institute of Cancer Research and serves on the UK National Cancer Research Institute (NCRI) oesophago-gastric sub-group. NS has acted as a clinical expert in oesophago-gastric cancer for NICE (guideline committee and technology appraisal) and is an upper GI expert for International Cancer Benchmarking Partnership. She is a Trustee for Pancreatic Cancer UK and a member of the EORTC General Assembly representing The Royal Marsden, as well as a member of the European Society for Medical Oncology (ESMO) Gastrointestinal Faculty. Educational roles include the NIHR Training Lead for NIHR Biomedical Research Centre, member of the Cancer Research Centre of Excellence training committee, Deputy Training Programme Director (one of three) for South London Medical Oncology Training, member of the pan-London specialist Medical oncology training committee, and member of the Medical Oncology National Recruitment steering committee.
Caroline Fong, MBChB, MRes, MRCP
Clinical Research Fellow
GI and Lymphoma Unit
The Royal Marsden Hospital NHS Trust
CF declares that she has no competing interests.
Dr Naureen Starling and Dr Caroline Fong would like to gratefully acknowledge Dr Mark J. Krasna and Dr Ghulam Abbas, previous contributors to this topic.
MJK is an author of several references cited in this topic. GA declares that he has no competing interests.
Peter McCulloch, MBChB, MA, MD, FRCS (Ed), FRCS (Glas)
Clinical Reader in Surgery
Nuffield Department of Surgery
University of Oxford
PM declares that he has no competing interests.
Nikhil I. Khushalani, MD
Assistant Professor of Oncology
Roswell Park Cancer Institute
NIK has received funding for the conduction of clinical trials and associated translational studies from Merck, Pfizer, and Astra-Zeneca. NIK has a grant from the National Comprehensive Cancer Network (from research support by Roche).
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