Cancer of the Oesophagus

Although an uncommon disease in the UK, cancer of the oesophagus (or "gullet") is a devastating condition for the patients affected by it.  

There is evidence to suggest that the incidence of the disease is increasing.  The symptoms of the disease result from obstruction of the relatively narrow gullet by growth of the tumour, as well as by spread of the tumour to other parts of the body.

Predisposition

Although any adult can be affected, it is predominantly a disease of the elderly.  Males are more commonly affected than females.

Smoking cigarettes and drinking alcohol may predispose to certain types of oesophageal cancer.  The process known a Barrett's oesophagitis is one of the few precursor conditions.

Symptoms

The commonest early symptoms are difficulty in swallowing and weight loss.  The former symptom should always be investigated for a cause.  Chest discomfort may occur but pain is uncommon.  "Indigestion" is very non-specific and not useful in diagnosis. Only a tiny percentage of patients with uncomplicated indigestion will have any form of malignancy.

Diagnosis

Difficulty in swallowing as a new symptom should always prompt urgent referral for an endoscopy (camera test). This is normally performed using mild sedation and allows biopsies to be taken so that the diagnosis can be confirmed under the microscope. This will take a few days.

Assessment

Once a diagnosis of cancer has been confirmed, tests are done to ascertain the extent of the disease. This process is known as “staging”. The most commonly used method of recording staging is known as the TNM classification. The meaning of this is;

    T       extent of primary tumour       1 – 4

    N       extent of lymph node involvement   0 – 2

    M       evidence of disease in other organs   0 - 1


Thus, a very early tumour might be expressed as T1N0M0, whilst advanced disease might be T4N2M1. At first diagnosis, the stage is an estimate which may be revised as more information becomes available. Accurate staging is crucial in making decisions on treatment and prognosis.

The responsibility for staging and treatment decisions lies with the multi-disciplinary team (MDT). The members of this are typically;
Gastroenterologist - endoscopy doctor
Surgeon - performs operation
Oncologist - cancer expert advising on drug and radiation treatments
Specialist nurse - for advice and guidance
Radiologist - X-ray and scan specialist
Pathologist - microscope expert


The following tests may be used during the staging process;

CT scan - nn X-ray machine which takes cross-sectional slices looking for abnormal anatomy
PET scan - often combined with CT, a (mildly) radioactive substance is used to look for abnormal tumour cell activity
Endoscopic ultrasound - similar to an ordinary endoscopy but with an ultrasound probe attached to the camera to provide detailed images
Staging laparoscopy - a telescope examination of the inside of the abdomen via a small cut around the umbilicus, requiring general anaesthetic and hospital admission


Barium X-ray showing irregularity of
the lower gullet (tumour) with dilation above



Telescope view of carcinoma of the
oesophagus viewed from above

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