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Oesophageal cancer

Dr Yuranga Weerakkody and Dr Frank Gaillard et al.

Carcinoma of the oesophagus 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.

Demographics and clinical presentation

Oesophageal cancer is responsible for <1 % of all cancers and 4 - 10% of all GI malignancies. There is recognised male preponderance : M : F = 4 : 1 and blacks are more susceptible than caucasians : 2 : 1.

Additionally, there are certain regions where individuals are at particularly high risk of developing oesophageal cancer, e.g. Iran, parts of Africa, Italy, China.

Predisposing factors include:

Pathology

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

See : Oesophageal cancer staging

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

Radiographic features

Plain film / Chest radiograph

Many indirect signs can be sought on CXRs. These include:

  • widened azygo-esophageal recess with convexity toward right lung (in 30% of distal + midesophageal cancers)
  • thickening of posterior tracheal stripe + right paratracheal stripe >4 mm (if tumour located in upper third of oesophagus)
  • widened mediastinum
  • tracheal deviation
  • posterior tracheal indentation / mass
  • retrocardiac mass
  • oesophageal air-fluid level
  • lobulated mass extending into gastric air bubble
  • repeated aspiration pneumonia (with tracheo-oesophageal fistula)
CT
  • eccentric or circumferential wall thickening is greater than 5 mm.
  • peri-oesophageal soft tissue and fat stranding
  • dilated fluid- and debris-filled oesophageal lumen is proximal to an obstructing lesion.
  • tracheo-bronchial 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

Complications

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

Treatment 

Surgical options include

Differential diagnosis

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