Oesophageal Cancer
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Direct answer
Oesophageal cancer is a malignancy of the oesophageal lining, and its two main types differ by site and by cause. Squamous carcinoma affects the upper and middle oesophagus and is linked to tobacco, alcohol and very hot drinks, while adenocarcinoma favours the lower third and follows gastro-oesophageal reflux and Barrett oesophagus. Progressive dysphagia, first to solids and then to liquids, with weight loss is the typical presentation, and endoscopy with biopsy makes the diagnosis.
What you must remember
- Squamous carcinoma: commonest worldwide, arising in the upper and middle thirds and linked to tobacco, alcohol and very hot beverages.
- Adenocarcinoma: typical of the lower third and gastro-oesophageal junction, linked to reflux, Barrett oesophagus, obesity and smoking.
- Predisposing conditions: achalasia, Plummer-Vinson syndrome and long-standing caustic strictures raise the risk of squamous carcinoma.
- Dysphagia pattern: progressive, first to solids and then to liquids, and weight loss alongside it signals advanced disease.
- Diagnosis: endoscopy with biopsy establishes the histology, which then decides the treatment pathway.
- Local staging: endoscopic ultrasound is the most accurate test for depth of invasion (T) and regional nodes (N).
- Distant spread: CT of the chest and abdomen looks for metastasis, with PET-CT added in borderline cases.
- Treatment: early lesions may be resected endoscopically, resectable locally advanced disease is usually treated with neoadjuvant chemoradiotherapy before surgery, and unresectable disease is palliated with stenting or chemotherapy.
A staging pathway after biopsy-proven cancer
A 66-year-old smoker who drinks daily has six weeks of dysphagia and a 5 kg weight loss. Endoscopy shows an ulcerated mid-oesophageal mass, and biopsy confirms invasive carcinoma.
- Confirm histology: The biopsy report separates squamous from adenocarcinoma, which changes the chemotherapy choice and the surgical approach.
- Image the wall: Endoscopic ultrasound assesses the depth of invasion and regional lymph nodes, guiding whether surgery alone is adequate.
- Search for spread: CT of the chest and abdomen detects liver, lung and distant nodal disease, and PET-CT is added when resectability is borderline.
- Assess fitness: Performance status, nutrition and comorbidity are recorded early, since they decide whether major surgery is possible.
- Relieve obstruction: A self-expanding metal stent or a feeding tube can palliate dysphagia while staging continues.
- Choose definitive treatment: Early mucosal tumours may suit endoscopic resection, while resectable locally advanced disease is usually treated with neoadjuvant chemoradiotherapy before surgery.
Where the exam tries to catch you
Oesophageal cancer questions usually test the site, the histological type and the order of staging.
- Trap: Calling adenocarcinoma the usual type in the upper third. Correct: Squamous carcinoma dominates the upper and middle thirds, whereas adenocarcinoma is typical of the lower third and junction.
- Trap: Attributing every case to smoking. Correct: Tobacco drives squamous carcinoma, while reflux and Barrett oesophagus drive adenocarcinoma.
- Trap: Proceeding to surgery before staging. Correct: EUS and CT decide resectability, and neoadjuvant therapy may be needed before any operation.
- Trap: Treating progressive dysphagia as reflux and waiting. Correct: Progressive dysphagia with weight loss needs urgent endoscopy and biopsy.
Frequently asked questions
Which oesophageal cancer type is more common in the lower third?
Adenocarcinoma is the oesophageal cancer type more common in the lower third and at the gastro-oesophageal junction. It is strongly linked to gastro-oesophageal reflux and Barrett oesophagus.
What is the most accurate test for local staging of oesophageal cancer?
Endoscopic ultrasound is considered the most accurate test for local T and N staging of oesophageal cancer. It shows the depth of wall invasion and regional lymph nodes, while CT is used to look for distant metastasis.
Why is progressive dysphagia to solids a red flag in oesophageal cancer?
Progressive dysphagia to solids, which later extends to liquids, indicates luminal narrowing that is usually malignant in older adults. It warrants urgent endoscopy with biopsy rather than empirical treatment for reflux.
Which benign conditions raise the risk of squamous oesophageal cancer?
Achalasia, Plummer-Vinson syndrome and long-standing caustic strictures raise the risk of squamous oesophageal cancer. Tobacco and alcohol add to that risk, and surveillance after these conditions is individualised.