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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 cancer 3rd year ssu

Oesophageal wall histology

Circular

Longitudinal

 distance in lower oesophagus


Oesophageal cancer 3rd year ssu

How??


Oesophageal cancer 3rd year ssu

How??


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


Oesophageal cancer 3rd year ssu

Anatomy of the Esophagogastric Junction

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


Oesophageal cancer 3rd year ssu

The phreno-oesophageal ligament:

Origin - fascia transversalis

Insertion: oesophageal wall

Rich in collagen and elastic fibres


Oesophageal cancer 3rd year ssu

The phreno-oesophageal ligament


Oesophageal cancer 3rd year ssu

Fatty infiltration


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


Oesophageal cancer 3rd year ssu

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


Oesophageal cancer 3rd year ssu

One extra oesophageal adenocarcinoma for every 5000 men over 60 treated


Oesophageal cancer 3rd year ssu

?


Clinical consequences of gord

Clinical consequences of GORD


Reflux barrett s cancer

Reflux - Barrett’s - Cancer


Barrett s oesophagus

Barrett’s Oesophagus


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

    OesCardia

    Recurrent symptoms7.72.0

    ‘Long-standing’ reflux43.54.4


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

  • 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

  • ~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

    OesCardia

    Recurrent symptoms7.72.0

    ‘Long-standing’ reflux43.54.4


Oesophageal cancer 3rd year ssu

  • Dysphagia

  • Weight loss

  • Nausea and vomiting

  • Pain uncommon (unless metastases)


Age distribution

AGE DISTRIBUTION


Staging

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%


Oesophageal cancer 3rd year ssu

T1


Oesophageal cancer 3rd year ssu

T2


Oesophageal cancer 3rd year ssu

T3


Oesophageal cancer 3rd year ssu

T4


Stenting

Stenting


Endoscopic palliation of dysphagia

Endoscopic palliation of dysphagia

  • Stenting

  • Dilatation

  • Alcohol injection

  • Laser

  • Brachytherapy


Oesophageal cancer 3rd year ssu

Ultraflex

Esophacoil

Z-stent

Wall stent

Plastic stents


Complications

Complications

Systemic cancer

effects

  • Common

  • Food bolus

  • Tumour overgrowth

  • “Knuckle” of stomach

  • Reflux

  • Rarer

  • Stent migration

  • Perforation

  • Aspiration

  • Airway compression


Oesophageal cancer 3rd year ssu

Who will get the most problems?


Predictors

Predictors

  • 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?


Oesophageal cancer 3rd year ssu

QOL


Swallowing

Swallowing


Weight

Weight


1990 1996

1990 - 1996

Resected oesophageal cancers


Resected oesophageal cancers no surviving v months survived

Resected oesophageal cancers (No. surviving v months survived)

Median

14


Age yrs v survival months r 0 007

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


Survival v degree of differentiation

Survival v Degree of differentiation

Poor Poor-mod Mod Mod-well Well


Survival v tumour stage

Survival v Tumour stage

1 2a 2b 3 4


Stage at presentation

Stage at presentation

Stage:


Does co morbidity matter

Does co-morbidity matter?

Nil Non-malignant Other malignancy Cardio-resp


Smoking and survival

Smoking and survival

Never Ex Current


Smokers

Smokers


Survival figures

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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