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Dr Bernard Stacey Southampton General Hospital. OESOPHAGEAL CANCER 3rd year SSU. INTRODUCTION. Incidence of adenocarcinoma of the oesophagus is fastest rising cancer in Western world Majority present late when only palliation possible

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Dr Bernard Stacey

Southampton General Hospital

OESOPHAGEAL CANCER3rd year SSU


INTRODUCTION

  • Incidence of adenocarcinoma of the oesophagus is fastest rising cancer in Western world

  • Majority present late when only palliation possible

  • Resection implies a major procedure and many have concurrent disease


Incidence of Oesophageal Cancers

Blot WJ et al. JAMA 1991;265:1287-9


The lower oesophagus: pressure control mechanisms

  • Lower oesophageal sphincter

  • Crural diaphragm

  • Sling fibres of the stomach


Oesophageal wall histology

Circular

Longitudinal

 distance in lower oesophagus


How??


How??


Oesophagitis as a cause of oesophageal shortening

  • Experimental oesophagitis

    • Distal peristaltic contractions disappear

    • LOS pressure  by 60%

    • Oesophagus 1-2cm shorter

    • Oesophageal compliance  by 30%

    • Largely recovered by 4 weeks

Zhang X et al. Am J Physiol Gastrointest Liver Physiol; 2005


The longitudinal muscle of the oesophagus

  • Attached to hypopharynx and diaphragm

  • At lower end it blends with phreno-oesophageal ligament

  • More muscle bulk than circular muscle

  • Can shorten oesophagus by 5-6cm


Anatomy of the Esophagogastric Junction

Mittal, R. K. et al. N Engl J Med 1997;336:924-932


The phreno-oesophageal ligament:

Origin - fascia transversalis

Insertion: oesophageal wall

Rich in collagen and elastic fibres


The phreno-oesophageal ligament


Fatty infiltration


Obesity: challenges OGJ integrity

  • BMI and waist circumference correlates to  in:

    • intra-gastric pressure and

    • G-O pressure gradient

  • Also separation of LOS and

    crural diaphragm

    = perfect scenario for reflux


Does weight loss help reflux?

  • Remarkably little data!

  • Yes: Derby 1999

  • 23 pts BMI >23, GORD 6/12

  • - 80% lost wt and symptoms improved

  • r = 0.548, p<0.001

  • No: Stockholm 1996

  • 20 pts; pH study confirmed reflux

  • - no significant improvement despite mean of 10kg wt loss

  • Maybe: Amsterdam 2002

  • 42 pts BMI 43

  • - wt loss, no gastric distension improved

  • - with gastric distension  continued reflux


One extra oesophageal adenocarcinoma for every 5000 men over 60 treated


?


Clinical consequences of GORD


Reflux - Barrett’s - Cancer


Barrett’s Oesophagus


Symptomatic GORD as a risk factor for oesophageal adenocarcinoma

  • Lagergren J. NEJM 1999; 340: 825-31

    OesCardia

    Recurrent symptoms7.72.0

    ‘Long-standing’ reflux43.54.4


The oesophagitis-metaplasia-dysplasia-adenocarcinoma sequence

95% don’t present

10%

3.5%

1.2%

100% of adults >30yrs

Normal

oesophagus

Mild

Oesophagitis

Severe

Oesophagitis

Barrett’s

Metaplasia

months

months

days - weeks

years

Roleof chemoprevention ?

0.25%

0.08%

0.06%

High Grade

Dysplasia

Adenocarcinoma

Low Grade

Dysplasia

2 - 5 years

0 - 3 years


‘Natural history’ of HGD

  • 43% had Ca in resection specimen

  • 24% progressed to Ca during 2-46 months follow up

  • Ca incidence at 3 yrs

    • 56% if diffuse

    • 14% if focal HGD

  • Veterans’ study – 7.3 yrs F/U:4 / 79  Ca in 1st year

    12 / 75  Ca of whom 11 cured

    • But: single pathologist


Reflux, Barrett’s and cancer

  • ~10% of population have reflux

  • 10-15% of these have Barrett’s change

    (short > long segment)

  • These get adenocarcinoma at 0.5%/year

  • 40% of adenocarcinomas have no history of GORD

  • <5% of adenocarcinomas are known to have Barrett’s on presenting with symptoms of their cancer


Symptomatic GORD as a risk factor for oesophageal adenocarcinoma

  • Lagergren J. NEJM 1999; 340: 825-31

    OesCardia

    Recurrent symptoms7.72.0

    ‘Long-standing’ reflux43.54.4


  • Dysphagia

  • Weight loss

  • Nausea and vomiting

  • Pain uncommon (unless metastases)


AGE DISTRIBUTION


STAGING

Stage TNM 1st seen5yr surv

1 T1 N0 M010%90%

2a T2/3 N0 M025%50%

2b T1/2 N1 M0

3 T3 N1 M045%15%

Any T4

4 Any M120%0%


T1


T2


T3


T4


Stenting


Endoscopic palliation of dysphagia

  • Stenting

  • Dilatation

  • Alcohol injection

  • Laser

  • Brachytherapy


Ultraflex

Esophacoil

Z-stent

Wall stent

Plastic stents


Complications

Systemic cancer

effects

  • Common

  • Food bolus

  • Tumour overgrowth

  • “Knuckle” of stomach

  • Reflux

  • Rarer

  • Stent migration

  • Perforation

  • Aspiration

  • Airway compression


Who will get the most problems?


Predictors

  • Weight loss

  • Length of stricture

    (tumour volume)

    Not:

  • Age, histology, BMI

r=0.63

r=0.59


Are we doing any good?


QOL


Swallowing


Weight


1990 - 1996

Resected oesophageal cancers


Resected oesophageal cancers (No. surviving v months survived)

Median

14


Age (yrs) v survival (months)(R = 0.007)


Survival v Degree of differentiation

Poor Poor-mod Mod Mod-well Well


Survival v Tumour stage

1 2a 2b 3 4


Stage at presentation

Stage:


Does co-morbidity matter?

Nil Non-malignant Other malignancy Cardio-resp


Smoking and survival

Never Ex Current


Smokers


Survival figures

  • Median = 14 months

  • Mean = 41 months

  • 1-year survival = 42.3%(58 / 137)

  • 5-year survival = 12.4%(17 / 137 )


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