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Oesophageal cancer

Introduction and epidemiology

For introduction, epidemiology, and etiology, see the corresponding pathology 2 topic. Treatment is mainly surgical and is therefore covered in surgery.

Clinical features

Both types of oesophageal cancer have similar clinical features. It’s usually asymptomatic in the early stages, and therefore is rarely discovered until the late stages. In the late stages it may present with non-specific symptoms like dysphagia, odynophagia, cough, weight loss, and dyspepsia.

At the time of presentation most patients already have advanced cancer.

Diagnosis and evaluation

Upper endoscopy is the investigation of choice, as it allows for both visual diagnosis and biopsy. Endoscopic ultrasound may also be necessary to assess the depth of invasion accurately, to distinguish T1A and T1B stages.

CT thorax and abdomen is required for staging. Bronchoscopy is required if extension into the bronchial system is suspected.

Prognosis

The prognosis is very poor, with a 5-year survival of 15%. The 5-year survival of patients treated with curative surgery is around 30 – 40%. Squamous cell carcinoma has a worse prognosis than adenocarcinoma.

Gastric adenocarcinoma

Introduction and epidemiology

Gastric adenocarcinoma accounts for 95% of gastric cancers. It’s a cancer of elderly, mostly men, and it’s the fifth most common cancer worldwide. It is more common in Asian countries like Japan and Korea, as well as certain regions in Africa and South America.

It causes no or only nonspecific symptoms in the early stages. If diagnosed early, the prognosis is excellent, but at the time of diagnosis, 50% of cancers have already spread and are incurable, which leads to a poor prognosis overall.

The mortality of this cancer is higher in the countries with low prevalence because screening is not performed as often as in high-prevalence countries. Therefore, the cancer is often discovered too late.

For etiology and pathology, see the corresponding pathology 2 topic. For treatment, see the corresponding surgery topic.

Classification

We distinguish “early” and “advanced” gastric cancer. Per definition, “early” gastric cancer infiltrates no deeper than the submucosa, but even early cancer can give metastasis to the lymph nodes, while “advanced” cancers infiltrate the muscularis propria and deeper.

Clinical features

The stomach is large and spacious, meaning that the tumour may grow large before symptoms appear. Early symptoms of gastric cancer include dyspepsia and mild epigastric discomfort or pain. Later, symptoms like anorexia, early satiety, weight loss, anaemia, and nausea/vomiting.

Diagnosis and evaluation

Physical examination may reveal a tumour in the epigastrium, and an enlarged Virchow’s node (left supraclavicular lymph node). DRE may reveal positive Blumer sign.

Upper endoscopy is the investigation of choice, as it allows for both visualisation and biopsy. After the diagnosis, CT thorax and abdomen are necessary for staging.

If peritoneal carcinosis is suspected but not visible on imaging, laparoscopy may be necessary to visualise the peritoneum and diagnose the carcinosis. Cytology may be obtained from the ascitic fluid.

MALT lymphoma

MALT lymphoma arises from B-cells in the MALT tissue of the stomach. It’s caused by H. pylori gastritis. The lymphoma regresses following treatment of the bacterial infection.

Small bowel cancer

Small bowel cancer is very rare, accounting for <5% of GI cancers. Most small bowel tumours are benign. Cancer may be adenocarcinoma, neuroendocrine, lymphoma, GIST, or other mesenchymal cancers.

Gastrointestinal stromal tumour (GIST) is a mesenchymal tumour of the GI tract. It may occur anywhere in the GI-tract, but most frequently in the stomach and small intestine.