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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

Dr Bernard Stacey

Southampton General Hospital

OESOPHAGEAL CANCER3rd year SSU


Introduction
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
Incidence of Oesophageal Cancers

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


The lower oesophagus pressure control mechanisms
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




Oesophagitis as a cause of oesophageal shortening
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
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




Obesity challenges ogj integrity
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



? 60 treated





Symptomatic gord as a risk factor for oesophageal adenocarcinoma
Symptomatic GORD as a risk factor for oesophageal adenocarcinoma

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

    Oes Cardia

    Recurrent symptoms 7.7 2.0

    ‘Long-standing’ reflux 43.5 4.4


The oesophagitis metaplasia dysplasia adenocarcinoma sequence
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
‘Natural history’ of HGD sequence

  • 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
Reflux, Barrett’s and cancer sequence

  • ~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 adenocarcinoma1
Symptomatic GORD as a risk factor for oesophageal adenocarcinoma

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

    Oes Cardia

    Recurrent symptoms 7.7 2.0

    ‘Long-standing’ reflux 43.5 4.4


  • Dysphagia adenocarcinoma

  • Weight loss

  • Nausea and vomiting

  • Pain uncommon (unless metastases)


Age distribution
AGE DISTRIBUTION adenocarcinoma


Staging
STAGING adenocarcinoma

Stage TNM 1st seen 5yr surv

1 T1 N0 M0 10% 90%

2a T2/3 N0 M0 25% 50%

2b T1/2 N1 M0

3 T3 N1 M0 45% 15%

Any T4

4 Any M1 20% 0%


T1 adenocarcinoma


T2 adenocarcinoma


T3 adenocarcinoma


T4 adenocarcinoma


Stenting
Stenting adenocarcinoma


Endoscopic palliation of dysphagia
Endoscopic palliation of dysphagia adenocarcinoma

  • Stenting

  • Dilatation

  • Alcohol injection

  • Laser

  • Brachytherapy


Ultraflex adenocarcinoma

Esophacoil

Z-stent

Wall stent

Plastic stents


Complications
Complications adenocarcinoma

Systemic cancer

effects

  • Common

  • Food bolus

  • Tumour overgrowth

  • “Knuckle” of stomach

  • Reflux

  • Rarer

  • Stent migration

  • Perforation

  • Aspiration

  • Airway compression



Predictors
Predictors adenocarcinoma

  • Weight loss

  • Length of stricture

    (tumour volume)

    Not:

  • Age, histology, BMI

r=0.63

r=0.59


Are we doing any good
Are we doing any good? adenocarcinoma


QOL adenocarcinoma


Swallowing
Swallowing adenocarcinoma


Weight
Weight adenocarcinoma


1990 1996

1990 - 1996 adenocarcinoma

Resected oesophageal cancers


Resected oesophageal cancers no surviving v months survived
Resected oesophageal cancers adenocarcinoma(No. surviving v months survived)

Median

14


Age yrs v survival months r 0 007
Age adenocarcinoma(yrs) v survival (months)(R = 0.007)


Survival v degree of differentiation
Survival v Degree of differentiation adenocarcinoma

Poor Poor-mod Mod Mod-well Well


Survival v tumour stage
Survival v Tumour stage adenocarcinoma

1 2a 2b 3 4


Stage at presentation
Stage at presentation adenocarcinoma

Stage:


Does co morbidity matter
Does co-morbidity matter? adenocarcinoma

Nil Non-malignant Other malignancy Cardio-resp


Smoking and survival
Smoking and survival adenocarcinoma

Never Ex Current


Smokers
Smokers adenocarcinoma


Survival figures
Survival figures adenocarcinoma

  • Median = 14 months

  • Mean = 41 months

  • 1-year survival = 42.3%(58 / 137)

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


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