Oesophageal Cancer

Oesophageal cancer is a malignancy originating in the oesophagus, the tube that carries food from the throat to the stomach. It is predominantly associated with two main histological types: oesophageal squamous-cell carcinoma (OSCC) and oesophageal adenocarcinoma (OAC). OSCC is more prevalent in the developing world, while OAC is more common in developed regions.

Signs and Symptoms

Oesophageal cancer often presents late, with symptoms arising once the tumour has significantly narrowed the oesophageal lumen. The primary symptom is difficulty swallowing (dysphagia), initially with solid foods and later with liquids. Other symptoms include weight loss, pain during swallowing, persistent heartburn-like pain, and a hoarse voice due to recurrent laryngeal nerve involvement. Advanced disease may cause vomiting of blood, coughing, aspiration pneumonia, and hypercalcaemia. Metastatic spread to lymph nodes, liver, lungs, and bone can result in jaundice, pleural effusion, and dyspnea.

Causes

The two main types have distinct risk factors. OSCC is strongly associated with tobacco and alcohol use, and the combined effect is synergistic. Other factors include consumption of very hot drinks, poor diet, and chewing betel nut. OAC is linked to chronic gastrooesophageal reflux disease (GERD) and Barrett’s oesophagus, along with obesity and smoking. Protective factors against OAC include Helicobacter pylori infection, possibly due to its effect on reducing stomach acid, and female hormones.

Diagnosis

Diagnosis of oesophageal cancer typically involves endoscopic examination with biopsy. Imaging studies like CT, PET, and endoscopic ultrasound are used to assess the extent of the disease and potential metastasis.

Types

Oesophageal cancers are mainly divided into OSCC, which arises from the epithelial cells lining the oesophagus, and OAC, which originates from glandular cells in the lower oesophagus. Rare types include leiomyosarcoma, malignant melanoma, rhabdomyosarcoma, and lymphoma.

Staging

Staging is based on the TNM system, which assesses tumour invasion, lymph node involvement, and metastasis. The 2010 AJCC staging system also considers cell type, grade, and tumour location.

Treatment

A multidisciplinary approach is essential for treatment. Curative treatment is typically reserved for localised disease and involves surgery, chemotherapy, and radiotherapy. Surgery may include oesophagectomy, where part or all of the oesophagus is removed. Chemotherapy often involves cisplatin-based regimens, while radiotherapy can be used alone or in combination with chemotherapy.

Palliative care focuses on symptom relief and may involve stenting to keep the oesophagus open, along with nutritional support through feeding tubes.

Prognosis

The prognosis for oesophageal cancer is generally poor, with a five-year survival rate of around 15% in the United States. Early-stage disease has a better prognosis, with survival rates up to 80% if confined to the mucosa. Prognosis worsens significantly with deeper invasion and metastasis.

Epidemiology

Oesophageal cancer is the eighth-most frequently diagnosed cancer globally and the sixth leading cause of cancer-related deaths. OSCC is more common in developing countries, particularly in the "Asian oesophageal cancer belt," while OAC predominates in developed regions.

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Self-assessment MCQs (single best answer)

Which of the following is the primary symptom of oesophageal cancer?

Which type of oesophageal cancer is more common in developed regions?

What is a significant risk factor for oesophageal adenocarcinoma (OAC)?

Which imaging study is NOT typically used to assess the extent of oesophageal cancer?

What is the primary treatment for localised oesophageal cancer?

Which of the following is NOT a protective factor against oesophageal adenocarcinoma (OAC)?

Which stage of oesophageal cancer involves tumour invasion into adjacent structures?

Which region has the highest prevalence of oesophageal squamous-cell carcinoma (OSCC)?

What is the five-year survival rate for oesophageal cancer in the United States?

Which of the following symptoms suggests advanced oesophageal cancer?