Carcinoma of the Oesophagus
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Direct answer
Oesophageal carcinoma is dominated worldwide by squamous cell carcinoma — associated with tobacco, alcohol, very hot beverages, nitrosamines, achalasia and Plummer-Vinson syndrome — with adenocarcinoma arising instead from Barrett's metaplasia in a background of chronic reflux and obesity; parts of north-east India report among the higher incidence rates of squamous cancer. Dysphagia is a late symptom that appears only once the tumour has substantially encircled the lumen, so most Indian patients present with locally advanced or metastatic disease and weight loss. Staging with contrast CT of chest and abdomen, often with PET and endoscopic ultrasound, determines treatment: neoadjuvant chemoradiotherapy followed by oesophagectomy (Ivor-Lewis, McKeown or transhiatal) for resectable disease, definitive chemoradiation for cervical tumours and unfit patients, and stenting for palliation of malignant dysphagia.
What you must remember
- Histology-site rule: squamous carcinoma predominates in the upper and middle thirds; adenocarcinoma arises in Barrett's metaplasia of the lower third in Western populations; Plummer-Vinson syndrome (iron deficiency with a postcricoid web), lye stricture and achalasia predispose to squamous cancer.
- Alarm features: progressive dysphagia solids then liquids, weight loss, hoarseness (recurrent laryngeal nerve), cough on swallowing suggesting tracheo-oesophageal fistula, and cervical nodes.
- Because submucosal lymphatic spread is extensive and skip lesions are common, resection demands generous margins and radical two- or three-field lymphadenectomy in fit patients.
- Staging: endoscopy with biopsy for diagnosis; CECT chest-abdomen and PET-CT for distant disease; endoscopic ultrasound is the most accurate for T staging and coeliac nodes.
- Surgical options: Ivor-Lewis two-stage (laparotomy plus right thoracotomy) for mid/lower tumours, three-stage McKeown, and transhiatal oesophagectomy (Orringer) avoiding thoracotomy; the stomach is the preferred conduit.
- Neoadjuvant chemoradiotherapy (for example the CROSS regimen of carboplatin and paclitaxel with 41.4 Gy) is standard for locally advanced resectable disease; cervical oesophageal cancer is treated like a head-and-neck tumour with definitive chemoradiation to preserve the larynx.
- Palliation: self-expanding metal stents for dysphagia and fistula, radiotherapy, and feeding gastrostomy or jejunostomy.
Common confusion
The classic error is diagnosing 'early' disease because dysphagia just started. The oesophageal lumen must be circumferentially narrowed by a substantial fraction before solids stick, so the clinical onset is a late event and prognosis remains poor even with swift surgery. The second confusion is Barrett's with squamous risk factors: Barrett's adenocarcinoma follows reflux, obesity and white male predominance, not tobacco-driven squamous carcinogenesis.
Exam-focused takeaway
Stems pair risk factors with sites (postcricoid web for Plummer-Vinson, hot tea and spirits for squamous, Barrett's for adenocarcinoma) and ask for the operation name or the neoadjuvant strategy. Hoarseness maps to recurrent laryngeal involvement, coughing while swallowing to tracheo-oesophageal fistula. Remember that cervical oesophageal cancers get chemoradiation to spare the larynx and that the stomach is the usual reconstruction conduit after oesophagectomy.
Frequently asked questions
Why is dysphagia a late feature in oesophageal cancer?
The tumour must encircle and narrow much of the lumen before solids lodge, and the lack of a serosa plus rich submucosal lymphatics allows early spread before symptoms begin.
What is Plummer-Vinson syndrome?
Iron-deficiency anaemia with dysphagia from a postcricoid oesophageal web, carrying a recognized risk of squamous carcinoma in the upper oesophagus.
Which operation suits a mid-oesophageal tumour?
An Ivor-Lewis oesophagectomy — laparotomy with gastric conduit formation plus right thoracotomy and intrathoracic anastomosis — in a fit patient after neoadjuvant therapy.
When is definitive chemoradiotherapy preferred over surgery?
For carcinoma of the cervical oesophagus (to preserve the larynx), for selected squamous tumours with complete-response strategies, and for patients unfit for major surgery.
How is malignant dysphagia palliated?
Self-expanding metal stents give rapid swallowing relief, with radiotherapy, brachytherapy, laser recanalisation or a feeding gastrostomy or jejunostomy as adjuncts.