OESOPHAGEAL CANCER 3rd year SSU

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OESOPHAGEAL CANCER3rd year SSU

• Dr Bernard Stacey
• Southampton General Hospital

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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

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Incidence of Oesophageal Cancers

Blot WJ et al. JAMA 19912651287-9
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The lower oesophagus pressure control mechanisms

1. Lower oesophageal sphincter
2. Crural diaphragm
3. Sling fibres of the stomach

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Oesophageal wall histology
Circular
Longitudinal
? distance in lower oesophagus
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How??
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How??
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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
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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

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Anatomy of the Esophagogastric Junction
Mittal, R. K. et al. N Engl J Med 1997336924-932
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The phreno-oesophageal ligament Origin - fascia
transversalis Insertion oesophageal wall Rich
in collagen and elastic fibres
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The phreno-oesophageal ligament
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Fatty infiltration
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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

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Does weight loss help reflux?

• Remarkably little data!
• Yes Derby 1999
• 23 pts BMI gt23, GORD 6/12
• - 80 lost wt and symptoms improved
• r 0.548, plt0.001
• 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

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One extra oesophageal adenocarcinoma for every
5000 men over 60 treated
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?
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Clinical consequences of GORD
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Reflux - Barretts - Cancer
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Barretts Oesophagus

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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

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The oesophagitis-metaplasia-dysplasia-adenocarcino
ma sequence
95 dont present
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3.5
100 of adults gt30yrs
1.2
Normal oesophagus
Mild Oesophagitis
Severe Oesophagitis
Barretts Metaplasia
months
months
days - weeks
years
Role of chemoprevention ?
0.25
0.08
0.06
High Grade Dysplasia
Adenocarcinoma
Low Grade Dysplasia
2 - 5 years
0 - 3 years
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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

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Reflux, Barretts and cancer

• 10 of population have reflux
• 10-15 of these have Barretts change
• (short gt long segment)
• These get adenocarcinoma at 0.5/year
• 40 of adenocarcinomas have no history of GORD
• lt5 of adenocarcinomas are known to have
  Barretts on presenting with symptoms of their
  cancer

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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

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• Dysphagia
• Weight loss
• Nausea and vomiting
• Pain uncommon (unless metastases)

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AGE DISTRIBUTION
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STAGING

• 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

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T1
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T2
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T3
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T4
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Stenting
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Endoscopic palliation of dysphagia

• Stenting
• Dilatation
• Alcohol injection
• Laser
• Brachytherapy

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Ultraflex
Esophacoil
Z-stent
Wall stent
Plastic stents
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Complications
Systemic cancer effects

• Common
• Food bolus
• Tumour overgrowth
• Knuckle of stomach
• Reflux

• Rarer
• Stent migration
• Perforation
• Aspiration
• Airway compression

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Who will get the most problems?
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Predictors

• Weight loss
• Length of stricture
• (tumour volume)
• Not
• Age, histology, BMI

r0.63
r0.59
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Are we doing any good?
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QOL
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Swallowing
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Weight
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Resected oesophageal cancers

• 1990 - 1996

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Resected oesophageal cancers (No. surviving v
months survived)
Median
14
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Age (yrs) v survival (months)(R 0.007)
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Survival v Degree of differentiation
Poor Poor-mod Mod
Mod-well Well
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Survival v Tumour stage
1 2a 2b 3
4
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Stage at presentation
Stage
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Does co-morbidity matter?
Nil
Non-malignant Other malignancy Cardio-resp
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Smoking and survival
Never Ex
Current
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Smokers
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Survival figures

• Median 14 months
• Mean 41 months
• 1-year survival 42.3 (58 / 137)
• 5-year survival 12.4 (17 / 137 )