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Oesophageal carcinoma

Dr Frank Gaillard et al.

Oesophageal carcinoma is relatively uncommon. It tends to present with increasing dysphagia, initially to solids and progressing to liquids as the tumour increases in size, obstructing the lumen of the oesophagus.


Oesophageal cancer is responsible for <1% of all cancers and 4-10% of all GI malignancies. There is recognised male preponderance with the squamous cell subtype, M:F 4:1. Blacks are more susceptible than caucasians, 2:1.

The incidence of the subtypes has regional variation. The squamous cell subtype has the greatest worldwide incidence (~90%), but the adenocarcinoma subtype is more common in many parts of North America and Europe. In addition, there are certain regions where individuals are at particularly high risk of developing oesophageal cancer, e.g. Iran, parts of Africa, Italy and China.

Predisposing factors include:

Clinical presentation

  • progressive dysphagia
  • weight loss
  • gastroesophageal reflux
  • hoarseness, cough, vocal cord paralysis, or other signs/symptoms of mediastinal invasion


Histological types:
Macroscopic appearance
  • polypoid/fungating (most common)
    • sessile/pedunculated tumour
    • lobulated surface protruding
    • irregular, polycyclic, overhanging, step-like "apple core" lesion
  • ulcerating: large ulcer niche within bulging mass
  • infiltrating: gradual narrowing with smooth transition
  • superficial spreading carcinoma

See main article: oesophageal cancer staging.

  • lymphatic:
    • anterior jugular chain and supraclavicular nodes (primary in upper 1/3)
    • para-oesophageal and subdiaphragmatic nodes (primary in middle 1/3)
    • mediastinal and paracardial and coeliac trunk nodes (primary in lower 1/3)
  • haematogenous: lung, liver, adrenal glands

Radiographic features

Chest radiograph

Many indirect signs can be sought on a chest radiograph and these include:

  • widened azygo-oesophageal recess with convexity toward right lung (in 30% of distal and mid-oesophageal cancers)
  • thickening of posterior tracheal stripe and right paratracheal stripe >4 mm (if tumour located in upper third of oesophagus)
  • widened mediastinum
  • tracheal deviation
  • posterior tracheal indentation/mass
  • retrocardiac or posterior mediastinal mass
  • oesophageal air-fluid level
  • lobulated mass extending into gastric air bubble (Kirklin sign)
  • repeated aspiration pneumonia (with tracheo-oesophageal fistula)
Barium Swallow
  • irregular stricture
  • pre-stricture dilatation with 'hold up'
  • shouldering of the stricture
  • eccentric or circumferential wall thickening >5 mm
  • peri-oesophageal soft tissue and fat stranding
  • dilated fluid- and debris-filled oesophageal lumen is proximal to an obstructing lesion
  • tracheobronchial invasion appears as displacement of the airway (usually the trachea or left mainstem bronchus) as a result of mass effect by the oesophageal tumour
  • aortic invasion


  • fistula formation to trachea (5-10%), bronchi or mediastinum: can be either due to direct tumour progression or iatrogenic effects (e.g. radiation therapy) 
  • oesophageal perforation

Treatment and prognosis

The 5 yr mortality depends on the stage of the tumour. Unfortunately, most cases present with regional or distant metastatic disease (30% and 40%, respectively.

  • localized disease: ~40% 5-year survival
  • distant metastatic disease: ~5% 5-year survival

Endoscopic mucosal resection, without or with localized ablation is an option for localized (T1a) disease. These epithelial tumors are usually <2 cm, asymptomatic, and noncircumferential.

For T1b tumours and above, surgical options include:

Differential diagnosis

Imaging differential considerations include:

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