B21, 22. Squamocellular carcinoma and adenocarcinoma of the oesophagus and their surgical management

Introduction

For introduction, epidemiology, and etiology, see the corresponding pathology 2 topic.

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.

Treatment

Proper evaluation and staging are essential to determine the resectability of the disease. Only around 1/3 of patients are operated on.

In the rare case where very early cancers are discovered, we may use minimally invasive methods like endoscopic resection or laser ablation.

Most patients present in a stage where radical surgery is required for cure. However, oesophageal resection is a large and complicated procedure, and patients often develop post-operative complications like nutritional problems, stenosis in the anastomosis, and slow passage of foodstuffs.

After surgical resection of the oesophagus, either total or partial, the resected part of the oesophagus should be substituted with stomach (first choice) or colon. Because of the localisation of the oesophagus, oesophageal surgery may involve the neck, thorax, and/or the abdomen, making for a large and complicated surgery.

Surgery may be performed open, laparoscopically, or in combination.

Locally advanced oesophageal cancer is treated with neoadjuvant chemoradiation, followed by surgery if the tumour is considered resectable on restaging.

Palliative therapy is often employed for stage IV disease. The placement of stents is the major palliative option for oesophageal cancer.

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.


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B18. Malignant tumors of the stomach

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B23. Types of pneumothorax. Treatment options. Indication of surgical intervention

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