Information
Editors
JoonasH.Kauppila
OlliHelminen
Oesophageal Cancer
Essentials
- Dysphagia and weight loss are the most common symptoms of oesophageal cancer. Early-stage cancers are often asymptomatic.
- Gastroscopy is the primary examination.
- Modern endoscopic surgery and cytostatic treatment have greatly improved the prognosis.
Prevalence and prognosis
- Globally, oesophageal cancer is the 11th most common type of cancer and the 6th most common cause of death in cancer.
- The mean age at onset is 68 years but the disease is sometimes seen in patients younger than 50.
- Oesophageal adenocarcinoma is increasing significantly in western countries, whereas the incidence of squamous cell carcinoma is decreasing.
- Of patients with oesophageal cancer, 17% survive 5 years from diagnosis.
- Of those treated surgically, approximately 60% are alive after 5 years.
Histology
- Adenocarcinoma
- 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
- Treatment of gastro-oesophageal reflux by giving lifestyle guidance and proton pump inhibitors Gastro-Oesophageal Reflux Disease
- 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]