Oesophageal Cancer Clinical Overview
I. The "On-Call" Snapshot
Clinical Significance in Malaysia: This is a key cause of progressive dysphagia and significant weight loss in our older male population; you will be clerking these patients from the emergency department or clinic.
High-Yield Definition: Esophageal carcinoma is a malignancy arising from the mucosa of the esophagus, predominantly classified into Squamous Cell Carcinoma (SCC) or Adenocarcinoma.
Clinical One-Liner: Basically, it's a cancer of the food pipe that blocks swallowing, most often in elderly smokers or those with chronic reflux.
II. Etiology & Risk Factors
Etiology: Malignant proliferation of esophageal epithelial cells. In Malaysia, SCC is historically more common, but the incidence of adenocarcinoma is rising, especially in urban areas.
Squamous Cell Carcinoma (SCC): Arises from squamous cells, typically in the upper to mid-esophagus.
Adenocarcinoma: Arises from glandular cells, almost always in the distal esophagus, and is strongly associated with a precursor lesion, Barrett's esophagus.
Risk Factors:
Squamous Cell Carcinoma (SCC):
Non-modifiable: Age > 60, Male gender.
Modifiable:
Smoking (Major)
Alcohol consumption (Major)
Diet low in fruits and vegetables.
Consumption of very hot beverages.
Achalasia.
Previous radiotherapy to the chest.
Adenocarcinoma:
Non-modifiable: Age > 60, Male gender, Caucasian ethnicity (less common locally but important).
Modifiable:
Gastroesophageal Reflux Disease (GERD) (Strongest risk factor)
Barrett's Esophagus (Intestinal metaplasia of the lower esophagus)
Obesity (Increases intra-abdominal pressure and reflux)
Smoking
III. Quick Pathophysiology
SCC: Chronic irritation from carcinogens (e.g., tobacco, alcohol) leads to squamous dysplasia and subsequently invasive carcinoma.
Adenocarcinoma: Chronic acid reflux from GERD injures the normal squamous epithelium of the distal esophagus. This leads to a metaplastic change to columnar epithelium (Barrett's esophagus), which then progresses through dysplasia to become adenocarcinoma. The tumor grows locally, invades the muscularis propria, and spreads via lymphatics to regional nodes and hematogenously to distant organs (liver, lungs, bone).
IV. Clinical Assessment
Red Flags & Immediate Actions:
Complete dysphagia / Inability to swallow saliva: Risk of aspiration. -> ACTION: Keep Nil By Mouth (NBM), alert senior, start IV drip, consider nasogastric (NG) tube for drainage (but do NOT force it if obstruction is felt).
Hematemesis or Melena with hemodynamic instability (Tachycardia, Hypotension): Active upper GI bleed. -> ACTION: Alert senior immediately, secure two large-bore IV cannulas, send Group & Screen/Crossmatch, start IV fluids/blood transfusion as per protocol, start IV Pantoprazole 40mg BD.
Hoarseness of voice: Suggests recurrent laryngeal nerve invasion (advanced disease). -> Document finding and inform senior.
Stridor or respiratory distress: Possible tracheo-esophageal fistula or airway compression. -> ACTION: High-flow oxygen, keep patient sitting up, urgent senior review, prepare for potential airway emergency.
History:
Common (>50%):
Progressive Dysphagia: Initially for solids (like bread, rice), progressing to liquids. This is the hallmark symptom.
Significant Weight Loss: Unintentional, often >10% of body weight.
Less Common (10-50%):
Odynophagia (painful swallowing).
Retrosternal chest pain or discomfort.
Epigastric pain, often mimicking GERD.
Regurgitation of undigested food.
Pertinent Negatives: Ask to rule out differentials. No history of neurological deficit (rules out stroke), no intermittent dysphagia (less likely achalasia), no skin changes (rules out scleroderma).
Physical Examination:
General: Look for cachexia and signs of dehydration.
Neck: Palpate for cervical lymphadenopathy, especially supraclavicular nodes (Virchow's node on the left).
Abdomen: Palpate for epigastric tenderness and hepatomegaly (suggests metastasis).
Respiratory: Check for signs of aspiration pneumonia (crepitations).
Clinical Pearl: Always check for supraclavicular lymph nodes. The presence of a hard, fixed Virchow's node is a classic sign of metastatic gastric or esophageal cancer and often means the disease is incurable.
V. Diagnostic Workflow
Differential Diagnosis:
Peptic Stricture:
Points For: Long history of GERD, dysphagia.
Points Against: Less likely to have profound weight loss unless dysphagia is severe.
How to Differentiate: Endoscopy and biopsy will show benign fibrotic tissue, not malignant cells.
Achalasia:
Points For: Dysphagia to both solids and liquids from the start.
Points Against: Usually presents in younger patients; weight loss is less dramatic.
How to Differentiate: Barium swallow shows a 'bird's beak' appearance. Manometry is the gold standard.
Extrinsic Compression (e.g., Lung Cancer, Lymphoma):
Points For: Dysphagia, may have other symptoms like cough, shortness of breath.
Points Against: Primary symptoms are often respiratory.
How to Differentiate: CT Thorax will show the primary mass outside the esophagus.
Investigations Plan:
Bedside / Initial (First 15 Mins):
Vital signs: To assess for hemodynamic instability.
ECG: Rule out cardiac causes of chest pain.
First-Line Labs & Imaging:
Full Blood Count (FBC): Look for iron deficiency anemia from chronic occult bleeding.
Renal Profile, Liver Function Test (LFT), Albumin: Assess nutritional status and check for liver metastases.
Coagulation Profile: If planning for invasive procedures.
CXR: Look for aspiration pneumonia, mediastinal widening, or lung metastases.
Confirmatory / Gold Standard:
Oesophago-Gastro-Duodenoscopy (OGDS) with Biopsy: This is the main diagnostic tool. It allows direct visualization of the tumor, noting its location and extent, and provides tissue for histology. Take multiple biopsies (at least 6-8) from the lesion.
Staging Investigations (Once diagnosis is confirmed):
CT Thorax, Abdomen, and Pelvis (CT TAP) with contrast: This is the workhorse for staging. It assesses the primary tumor (T-stage), regional lymph nodes (N-stage), and distant metastases (M-stage) in the liver, lungs, and distant nodes.
VI. Staging & Severity Assessment
We use the AJCC TNM Staging System, 8th Edition. The stage determines the treatment plan and prognosis. You don't need to memorise the entire thing, but understand the principles.
T (Tumor): Depth of invasion into the esophageal wall.
T1: Invades lamina propria or submucosa. (Early)
T2: Invades muscularis propria.
T3: Invades adventitia. (Locally advanced)
T4: Invades adjacent structures (e.g., aorta, trachea, pleura). (Very advanced)
N (Nodes): Number of regional lymph nodes involved.
N0: No nodal metastasis.
N1-N3: Increasing number of involved nodes.
M (Metastasis): Presence of distant spread.
M0: No distant metastasis.
M1: Distant metastasis present (e.g., liver, lung).
Impact on Management:
Early Disease (e.g., T1N0M0): Potentially curable with endoscopic resection or surgery alone.
Locally Advanced (e.g., T2-T3, N+ M0): The most common presentation. Requires multimodal therapy - usually neoadjuvant chemoradiotherapy followed by surgery.
Metastatic Disease (Any T, Any N, M1): Incurable. Management is palliative chemotherapy and/or radiotherapy to control symptoms.
VII. Management Plan
Immediate Stabilisation (The ABCDE Plan):
Airway/Breathing: Ensure patent airway. Administer oxygen if hypoxic. Watch for aspiration.
Circulation: Secure IV access. Resuscitate with IV fluids or blood products if bleeding and hypotensive.
Disability: Assess GCS.
Exposure: Keep NBM if actively vomiting or severe dysphagia. Monitor urine output.
Nutrition: Crucial. Most patients are malnourished. Start nutritional support early after discussion with your senior - may require NG tube feeding or even a feeding jejunostomy later on. Correct electrolyte imbalances.
Definitive Treatment (The Ward Round Plan): This is decided in a multidisciplinary team (MDT) meeting with surgeons, oncologists, and radiologists.
For Curative Intent (Locally Advanced Disease):
Neoadjuvant Therapy: The standard of care for most resectable tumors (T2-T3, N+). This means giving chemotherapy and radiotherapy before surgery.
The goal is to downstage the tumor, making it easier to resect completely (R0 resection).
Common Regimen (Refer to MOH Systemic Protocol 2016): CROSS protocol (Carboplatin + Paclitaxel weekly for 5 weeks with concurrent radiotherapy).
Surgery: Oesophagectomy with lymph node dissection. This is a major operation.
For Palliative Intent (Metastatic or Unfit for Surgery):
Palliative Chemotherapy: To slow disease progression and improve quality of life. Regimens often based on Fluoropyrimidine and Platinum agents (e.g., FOLFOX).
Palliative Radiotherapy: To relieve dysphagia or pain from bone metastases.
Esophageal Stenting: An endoscopically placed stent can be used to open up the esophagus and allow the patient to eat. This is a very important intervention for improving quality of life.
VIII. Complications
Immediate (From Disease/Presentation):
Aspiration Pneumonia: Management: IV antibiotics, chest physiotherapy.
Esophageal Obstruction: Management: NBM, IV hydration, stenting.
Tracheo-esophageal Fistula: Management: Often requires covered esophageal stent; very poor prognosis.
Short-Term (Post-Op/Treatment):
Anastomotic Leak: Management: This is a surgical emergency requiring immediate senior review.
Chemo/Radiotherapy Side Effects: (Nausea, vomiting, mucositis, neutropenia). Management: Prophylactic antiemetics, G-CSF if needed, symptomatic relief.
Long-Term:
Anastomotic Stricture: Management: May require endoscopic dilatation.
Nutritional Deficiencies: Management: Lifelong dietetic support.
Disease Recurrence: Management: Palliative care.
IX. Prognosis
Prognosis is generally poor because most patients present at an advanced stage.
5-Year Overall Survival:
Localized disease: ~45%
Regional spread: ~25%
Distant metastasis: <5%
Key Prognostic Factors: Stage at diagnosis (especially N and M status), completeness of surgical resection (R0 vs R1/R2), and patient's performance status.
X. How to Present to Your Senior
"Dr, for review please. This is Mr. [Name] in Bed [X], a [Age]-year-old gentleman with a background of [e.g., chronic smoking], who presented with a 3-month history of progressive dysphagia and 10kg weight loss. On examination, he is cachexic and has a palpable left supraclavicular node. My main differential is esophageal carcinoma. I have sent off the initial bloods and kept him NBM for a planned OGDS. I am concerned about his poor nutritional status."
XI. Summary & Further Reading
Top 3 Takeaways:
Progressive dysphagia and weight loss in an elderly patient is esophageal cancer until proven otherwise.
The single most important initial investigation is OGDS with biopsy. Staging is done with CT TAP.
Management for resectable disease is multimodal, typically neoadjuvant chemoradiation followed by major surgery. Most patients, however, will require palliative care.
Key Resources:
Malaysian Guideline: Ministry of Health Malaysia. (2016). Systemic Therapy Protocol for Cancer, 3rd Edition. (Specifically section 9.1 Oesophageal Cancer).
UpToDate: Search for "Clinical manifestations, diagnosis, and staging of esophageal cancer" and "Management of localized esophageal cancer".
Amboss: Search for "Esophageal cancer".
