QuestionSBA
QuestionChoice
This is correct because patients with oesophageal adenocarcinoma who undergo chemotherapy or radiation therapy as supportive treatment can get painful sores in the mouth and throat. This reduces appetite causing further weight loss. A gastrostomy tube is a feeding tube which can provide nutrition. In the question stem, it states that he is significantly cachectic and not eating well. This feeding tube is placed into the stomach and can be removed when no longer needed. Note that in this context, chemotherapy will be palliative, to relieve symptoms and slow down the growth, rather than to cure the cancer.
53137
a
Gastrostomy tube
QuestionChoice
This is incorrect because palliative radiotherapy, as would be offered in a patient with metastatic cancer, is used to control local, advanced symptoms, such as pain, bleeding, dysphagia, and spinal cord or cerebral metastases. This patient may have palliative radiotherapy needs, but he is going to start chemotherapy soon, and as such his nutrition  is the next priority, in the absence of any  other red flags necessitating early radiotherapy such as bleeding or cord compression.
53138
b
Radiation therapy
QuestionChoice
Oesophageal resection in the treatment of adenocarcinomas is an option for early stage presentations where curative intent is possible. In this case, our patient has evidence of metastases to the liver, and so treatment options available to him would only be palliative and supportive in nature.
53141
e
Oesophageal resection
QuestionChoice
This is incorrect because dilation is required for areas that are narrowed or blocked to improve difficulty swallowing. A balloon-like device is placed into the throat to stretch the area which can help with symptoms of dysphagia. However, this question stem points towards the main issue as poor nutrition and reduced appetite, leading to cachexia. He reports no dysphagia.
53139
c
Oesophageal dilation
QuestionChoice
This is incorrect because although an oesophageal stent can improve difficulty swallowing, this patient does not report any dysphagia. An oesophageal stent is a hollow tube which is placed in the area of a tumour resulting in oesophageal narrowing to relieve dysphagia.
53140
d
Oesophageal stent placement
Concept
Chapter
# Summary

Oesophageal carcinoma, primarily categorised as adenocarcinoma or squamous cell carcinoma, is a malignancy impacting the oesophagus. Adenocarcinoma is most prevalent in the Western world, typically located in the lower third of the oesophagus and linked to gastro-oesophageal reflux disease. Squamous cell carcinoma is prevalent globally and typically seen in the upper two-thirds of the oesophagus. Smoking is a significant risk factor for both types. Key signs and symptoms include progressive dysphagia, weight loss, and possible hoarseness. The primary investigation method is upper GI endoscopy, with further assessments for staging including CT scans, MRI, endoscopic ultrasound, FDG-PET scan, and occasionally laparoscopy. Management approaches depend on the staging of the disease, but include surgical, endoscopic, and non-surgical options such as radiotherapy and chemotherapy.

# Definition

Oesophageal carcinoma is a type of cancer that originates from the epithelial cells lining the oesophagus, primarily categorised into adenocarcinoma or squamous cell carcinoma.

# Epidemiology

Squamous cell carcinoma of the oesophagus is the most prevalent type globally, often seen in the upper two-thirds of the oesophagus. Conversely, adenocarcinoma has become the most common cause of oesophageal carcinoma in the Western world, owing to the increasing prevalence of GORD, and is often seen in the lower one-third of the oeseophagus.

# Aetiology

Risk factors for oesophageal carcinoma include:

-   **Smoking**: The most significant risk factor for both adenocarcinoma and squamous cell carcinoma.
-   High alcohol intake
-   Obesity and gastro-oesophageal reflux disease: Linked specifically to adenocarcinoma, as recurrent reflux leads to metaplastic formations of mucin-producing glandular tissue known as Barrett's oesophagus, which can further develop into neoplasia.
-   Achalasia
-   Zenker diverticulum
-   Oesophageal web
-   High intake of hot beverages
-   Dietary intake of:
    -   Increased dietary nitrosamines
    -   Areca or betel nuts

# Signs and Symptoms

Patients with oesophageal carcinoma often present with the following symptoms:

-   Progressive dysphagia: Initially for solids, and later for liquids. Dysphagia typically occurs when there is obstruction of more than two-thirds of the lumen.
-   Weight loss: This symptom, the second most common, results from a combination of anorexia and dysphagia.
-   Odynophagia: Pain on swallowing can occur.
-   Hoarseness: Can develop if there is local invasion of the recurrent laryngeal nerve.

# Differential Diagnosis

-   Gastro-oesophageal reflux disease (GORD): GORD also presents with dysphagia and odynophagia, but is often associated with heartburn, regurgitation, and chest pain.
-   Achalasia: Achalasia is characterised by dysphagia for solids and liquids from the start, regurgitation of undigested food, and chest pain.
-   Peptic stricture: Presents with intermittent dysphagia for solid foods, heartburn, and acid regurgitation.
-   Zenker diverticulum: Presents with dysphagia, regurgitation of undigested food, halitosis, and possible aspiration pneumonia.
-   Neurological causes of dysphagia such as motor neuron disease, mysaesthenia gravis
-   Oesophagitis - often due to candidiasis and presents with odynophagia more than dysphagia. May be underlying immunosuppression e.g. HIV.

# Investigations

### NICE 2-week-wait criteria:

- Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people with **dysphagia** or those aged 55 years and over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.
- Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people with haematemesis.

Investigations for oesophageal carcinoma encompass:



-   Initial investigation: Upper GI endoscopy is performed to visualise and grade the tumour via biopsy.
-   Staging:
    -   CT chest, abdomen and pelvis: Assesses the size of the tumour, local and lymph node spread, and any visceral metastases.
    -   MRI: Identifies metastatic spread to the liver and advanced local disease.
    -   Endoscopic ultrasound: Assesses whether a tumour is amenable for resection.
    -   FDG-PET scan: Identifies distant and nodal metastases.
    -   Laparoscopy: Used to identify intra-abdominal metastases if all other imaging has been negative.

# Management

Management of oesophageal carcinoma is based on the stage of the disease and may include:

-   Surgical resection: The primary choice for localised disease.
-   Endoscopic therapies: Such as endoscopic mucosal resection or endoscopic submucosal dissection for early-stage disease.
-   Non-surgical options: Such as radiotherapy, chemotherapy or chemoradiotherapy for advanced disease, or as neoadjuvant or adjuvant therapy with surgery.

# NICE Guidelines

[Click here to see the NICE guidelines on oesophageal cancer](https://www.nice.org.uk/guidance/conditions-and-diseases/cancer/oesophageal-cancer)
773
806
Oesophageal carcinoma
Topic
7
General Surgery
10688
A 55-year-old man presents to the gastroenterology outpatient clinic with his wife. His wife is very concerned because his voice has changed over the past year and his appetite has reduced, though he reports no dysphagia. He has no significant past medical history. He has been smoking since the age of 16. On examination, he appears significantly cachectic. An endoscopy shows evidence of an oesophageal adenocarcinoma and a CT chest, abdomen, pelvis identifies metastases to the liver. His consultant decides to begin a course of chemotherapy in a few weeks.

Which of the following is the best next step in the management of this patient?
a