Oesophageal cancer

Overview

Adenocarcinoma vs squamous cell carcinoma of the oesophagus

Feature	Adenocarcinoma	SCC
UK prevalence	More common (predominant type in UK)	Less common in UK
Location	Lower third / GOJ	Upper or middle third
Key risk factors	GORD, Barrett's oesophagus, obesity, smoking	Smoking, alcohol, achalasia, nitrosamines (processed/smoked foods)
Premalignant condition	Barrett's oesophagus (metaplastic columnar epithelium)	Squamous dysplasia; achalasia → stasis → mucosal irritation

🎯

Achalasia increases risk of SCC, NOT adenocarcinoma. Barrett's oesophagus drives adenocarcinoma. This is a classic exam distractor.

Presentation

•Progressive dysphagia - solids first (bread, meat), then soft foods, then liquids; reflects growing intraluminal obstruction

•Odynophagia - painful swallowing; suggests local tumour infiltration

•Unintentional weight loss - reduced intake + cancer cachexia

•Hoarse voice - recurrent laryngeal nerve compression; implies mediastinal extension and inoperability

•Regurgitation - especially upper/middle third tumours

•Anaemia - chronic occult blood loss

•Supraclavicular lymphadenopathy - Virchow's node (left); late metastatic sign

💡

Progressive dysphagia (solids then liquids) = growing obstruction = oesophageal cancer until proven otherwise. Achalasia causes dysphagia for both solids AND liquids from the outset - a key discriminating feature.

Investigations

•Any new dysphagia is a red flag - refer urgently under the 2-week-wait pathway for suspected upper GI malignancy

🥇 First-line

•OGD (oesophagogastroduodenoscopy) with biopsy - direct visualisation and histological confirmation; urgent direct access, within 2 weeks

•Staging: CT chest, abdomen and pelvis with contrast - first cross-sectional staging investigation

•FDG-PET-CT - detects occult distant metastases; guides resectability

•Endoscopic ultrasound (EUS) - most accurate local staging (T and N stage); essential before curative resection

•Barium swallow - shows characteristic 'shouldering' (abrupt irregular narrowing with overhanging mucosal edges); used when OGD cannot pass beyond tumour

•FBC - iron-deficiency anaemia from chronic blood loss

Management

•All cases discussed at specialist upper GI MDT; ~50% present with unresectable/metastatic disease

•Curative intent (early/localised): neoadjuvant chemotherapy followed by oesophagectomy

•Palliative (advanced/unresectable): goal shifts to symptom control - palliation of dysphagia, nutrition support

Prognosis

•Overall 5-year survival ~15-20% due to late presentation

•Early-stage disease (T1-T2, node-negative) with curative resection: 5-year survival up to 40-50%

•Absence of a serosal layer facilitates early local spread to trachea, aorta, and mediastinum