Dysphagia: oesophageal neoplasia

Summary

Incidence

Oesophageal cancers arise in up to 10–20 per 10⁵ of the population. It is more common in patients >60 years of age. M:F ratio of 5:1. Recently, incidence has increased in 30–50 yrs age group with M:F ratio decreasing. Adenocarcinoma is becoming more common in western white men predisposed by Barrett's oesophagitis.

Aetiology

Predisposed by excess alcohol intake (acts as a promoter), smoking (acts as direct carcinogen), low ‘protective’ vitamin and trace element intake in vegetables and fruits, achalasia, strictures; some genetic conditions such as Tylosis Type A and Plummer – Vinson syndrome.

Pathophysiology

Benign: most common is leiomyoma. Malignant: 90% are squamous cell carcinomas; 1–2% are adenocarcinomas. Tumours are commonly polypoid, but may be stenosing or ulcerative. Gastro-oesophageal junction tumours are the main type in western countries and are mostly adenocarcinomas. They may be extending from oesophagus, true cardial, or extending from stomach (Types I, II, III respectively).

Natural history

Spread is by direct invasion followed by lymph node and haematogenous spread. Longitudinal submucosal spread and skip lesions are not uncommon. Dysphagia might not be apparent until two-thirds of the oesophagus is occluded.

Presentation

Progressive dysphagia, regurgitation and weight loss. Rarely pain due to local invasion, and 25–30%of patients present with symptoms of distant metastases e.g. cervical lymph nodes, jaundice, bony aches, chest manifestations, vocal cord and phrenic nerve paralysis, which are indicators of inoperability.

Investigations

Blood tests: nutritional anaemia. Contrast radiology: ‘Rat tail’ appearance with mild proximal dilatation in the oesophagus. Endoscopy and biopsy is the gold standard for diagnosis.