22. Tumors of the esophagus

Tumours of the oesophagus

The two major histological types are squamous-cell carcinoma and adenocarcinoma. Squamous carcinoma may occur throughout the oesophagus and is associated with tobacco, alcohol, hot beverages, nutritional factors and achalasia.
Adenocarcinoma usually arises in the distal oesophagus and is associated with chronic reflux, Barrett oesophagus, obesity and smoking.
Other tumours include gastrointestinal stromal tumour, leiomyoma, lymphoma and metastatic lesions; these are less common.

Progressive dysplasia and invasion lead to circumferential wall thickening and luminal narrowing. The oesophagus has rich longitudinal lymphatic drainage, allowing early spread to regional nodes.
Local invasion may involve trachea, bronchi, aorta or mediastinum. Distant metastases commonly affect liver, lung and bone.

Progressive dysphagia, initially to solids then liquids, is a classic presentation. Weight loss, odynophagia, regurgitation, chest discomfort, hoarseness and aspiration may occur.
Advanced disease may cause fistula formation, haematemesis, recurrent pneumonia or severe malnutrition. Many patients present late.

Upper GI endoscopy with multiple biopsies establishes histology. Contrast-enhanced CT chest/abdomen assesses local and distant disease.
Endoscopic ultrasound assesses depth of invasion and regional nodes in potentially curable disease. PET-CT helps detect occult metastases. Bronchoscopy is considered for upper/mid-oesophageal tumours near the airway.
Staging uses TNM and incorporates tumour location, depth, nodal involvement and metastasis. Nutritional status, cardiopulmonary fitness and performance status are essential to treatment planning.
Differential diagnosis includes benign stricture, achalasia, reflux oesophagitis, motility disorder and extrinsic compression.

Management is multidisciplinary. Very early mucosal lesions may be treated endoscopically by resection/ablation in selected cases.
Resectable locally advanced disease commonly receives neoadjuvant chemoradiotherapy or perioperative systemic therapy according to histology, location and current protocol, followed by oesophagectomy in suitable patients.
Definitive chemoradiotherapy is used for selected squamous cancers or patients unsuitable for surgery. Metastatic disease is treated with systemic therapy, immunotherapy/targeted therapy where indicated, and palliation.
Support nutrition with dietetic input, enteral feeding where appropriate and symptom-directed endoscopic interventions. Stents may palliate dysphagia or fistula but require careful selection.
Complications include obstruction, aspiration, fistula, bleeding, malnutrition, postoperative leak, pulmonary complications and recurrence.