Typically situated at the border of the oesophagus and the stomach or low in the oesophagus.
An adenocarcinoma may develop in Barrett's columnar epithelium seen in association with GORD.
Squamous cell carcinoma
Develops through squamous dysplasia.
May develop in any part of the oesophagus.
Rare types of tumours include GISTs, melanoma and mesenchymal tumours.
Symptoms and findings
Early oesophageal cancer is often asymptomatic. A tumour obstructing the lumen will cause dysphagia, which is by far the most common symptom reported by patients.
Warning symptoms
Heartburn not responding to treatment
Dysphagia
Unintentional weight loss
Nausea and vomiting
Black stools, melaena, anaemia
Diagnosis and staging
Gastroscopy and biopsies
Whenever there are warning symptoms, and for patients over 55 with new upper abdominal symptoms Gastroscopy
PVK (basic blood count) to exclude anaemia
Whole-body CT for staging
Surgical treatment is suitable for less than 40% of patients at the time of diagnosis.
Whole-body PET-CT is performed before any surgery to detect any lymph nodes or metastases
To be done as necessary:
Endoscopic ultrasonography: depth of tumour invasion (T category)
Bronchoscopy: infiltration of the respiratory tract
Laparoscopy: spread in the abdominal cavity
Treatment
The lines of treatment of oesophageal cancer are assessed at a multiprofessional meeting.
Endoscopic treatment
Less than 10% of oesophageal cancers can be treated endoscopically.
High-grade dysplasias and incipient cancers can be treated by endoscopic submucosal dissection (ESD).
In association with the treatment of dysplasia or incipient cancer, Barrett's epithelium is treated by radiofrequency ablation.
Local recurrence is possible and is monitored by endoscopies.
Surgical treatment with a curative aim
Oesophagectomy is a major procedure often involving complications.
Surgical treatment cannot be used if the patient is in a poor condition.
Fitness for surgery can be assessed by a simple stair test. If the patient is capable of climbing 4 flights of stairs, their physical condition is sufficient for surgery.
Oesophagectomy is usually done by a mini-invasive endoscopic procedure, today often with robotic assistance.
The new oesophagus is usually made from the patient's stomach formed into a tube; the large and small intestine can also be used as spare parts.
If there is an upper oesophageal tumour, laryngectomy may sometimes be necessary.
Soft tissue and lymph node areas surrounding the oesophagus and the stomach are removed with the tumour.
About half of patients have postsurgical complications. The 90-day mortality rate after surgery is about 6%.
Quality of life will typically be affected for several months to a year after surgery.
Oncological treatment combined with curative surgery
Neoadjuvant therapy refers to radiotherapy and/or cytostatic therapy administered before surgery. Neoadjuvant therapy improves the prognosis of oesophageal cancer considerably.
Preoperative cytostatic treatment
To the extent possible, it is used for all but incipient disease.
A combination of fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) is the primary choice for patients who are in a good general condition.
Another useful option is the combination of epirubicin, a platinum-based cytostatic drug, and fluorouracil or capecitabine.
The most typical symptoms associated with the treatment include nausea, neutropenia and neuropathy.
Preoperative chemoradiotherapy
Due to the sensitivity of the disease to radiation, this is the primary choice for squamous epithelium cancer of the oesophagus.
It can also be used for adenocarcinoma.
The most typical pattern is radiotherapy (41.4 Gy) using a combination of paclitaxel and carboplatin as the radiosensitizer.
Postoperative adjuvant therapy
Postoperative adjuvant therapy is given to
patients with adenocarcinoma who have been given preoperative cytostatic therapy (no chemoradiotherapy)
patients whose disease has in pathological assessment proved to be more widely spread than expected.
Immuno-oncological treatment is being developed for adjuvant therapy of oesophageal cancer.
Definitive chemoradiotherapy
Squamous cell carcinoma may potentially be cured by chemoradiotherapy alone; this is called definitive chemoradiotherapy.
Definitive chemoradiotherapy is the primary form of treatment for upper oesophageal squamous cell carcinoma.
Definitive chemoradiotherapy is a good option for the treatment of patients with squamous cell carcinoma who are poor candidates for surgical treatment.
Palliative treatment
In metastatic disease, life expectancy is about 3-4 months without treatment and 12 months with cytostatic therapy.
In HER2-positive disease, adding the HER2-antibody trastuzumab to the regimen prolongs life expectancy significantly.
Immuno-oncological treatment has proved useful for the treatment of metastatic oesophageal cancer.
Oesophageal obstruction is treated with endoscopic stenting.
Radiotherapy may be beneficial for treating haemorrhage from the tumour and pain from metastases.
Follow-up
So far, follow-up has not been shown to improve the prognosis.
For the first years after surgery, patients with oesophageal cancer should be monitored in specialized care.
In long-term follow-up, alleviation of symptoms and follow-up of the patient's nutritional status are of central importance.
Detection of recurrence
Endoscopic follow-up particularly after endoscopic treatment
Whole-body CT is commonly done 2 years after surgery even though the evidence of its benefit is scarce.
Alleviation of symptoms and improvement of quality of life
Alleviation of gastroparesis by dietary treatment and metoclopramide
Detection of anastomosis stricture and its treatment by endoscopic dilation
Alleviation of dumping symptoms by lifestyle guidance and medication
Follow-up and maintenance of good nutritional status
Weight, basic blood count with platelet count, sodium, potassium, creatinine, plasma albumin, plasma glucose usually every 12 months to assess nutritional status
Assessment by a therapeutic dietitian on postsurgical checkup visits and subsequently, as necessary
Vitamin B12, calcium + vitamin D, iron and multivitamin replacement therapy for life as instructed by specialized care
References
Obermannová R, Smyth EC, ESMO Guidelines Committee. Electronic address: [email protected]. Reply to the Letter to the Editor 'Neoadjuvant radiochemotherapy and perioperative chemotherapy does not represent a standard at same priority level for oesophageal adenocarcinomas (in regard to "Oesophageal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up")' by Cellini et al. Ann Oncol 2023;34(6):554-555 [PubMed]
Deboever N, Jones CM, Yamashita K, et al. Advances in diagnosis and management of cancer of the esophagus. BMJ 2024;385():e074962 [PubMed]