FFinalistSouthampton · 2027
Gastroenterology
AKT · Gastroenterology/Oesophagus & stomach

Oesophageal cancer

Squamous cell carcinoma (upper/mid; smoking/alcohol) or adenocarcinoma (lower; Barrett/GORD)

Overview

Cancer of the oesophagus presenting with PROGRESSIVE dysphagia (solids then liquids) and weight loss. Two main types: squamous cell carcinoma (upper/middle third — smoking, alcohol, achalasia) and adenocarcinoma (lower third — GORD/Barrett, obesity — now commonest in the UK). Diagnosed by endoscopy + biopsy; barium shows an irregular 'apple-core'/shouldered stricture. Often advanced at diagnosis.

Recognise

  • PROGRESSIVE dysphagia (solids first, then liquids), weight loss, odynophagia, regurgitation; hoarseness (recurrent laryngeal involvement)
  • Squamous: upper/mid third, smoking/alcohol/achalasia; Adenocarcinoma: lower third, GORD/Barrett/obesity
  • Barium swallow: irregular stricture with shouldering ('apple-core'); endoscopy confirms

Red flags

  • ANY dysphagia → urgent (2-week-wait) endoscopy
  • Aspiration, tracheo-oesophageal fistula, complete obstruction

Differentials & how to tell them apart

Benign peptic stricturesmooth stricture from chronic GORD; biopsy to exclude cancer
Achalasiadysphagia for solids AND liquids from the start, bird-beak on barium, manometry; can predispose to SCC
Eosinophilic oesophagitisyoung atopic, food-bolus impaction, rings/furrows, eosinophils on biopsy
External compressionmediastinal mass/lung cancer
'Apple-core' irregular shouldered stricture on contrast swallow — malignant oesophageal stricture

'Apple-core' irregular shouldered stricture on contrast swallow — malignant oesophageal stricture

Netha Hussain / CC BY-SA 3.0 — Wikimedia Commons

Investigations

Upper GI ENDOSCOPY + biopsy (diagnostic). Staging CT, endoscopic ultrasound, PET; barium swallow shows the stricture if endoscopy delayed.

Management

Urgent endoscopy + biopsy → oesophagectomy ± neoadjuvant therapy (palliative stent if advanced)

  1. 1Any dysphagia → urgent endoscopy + biopsy. Stage with CT/EUS/PET.Gate: PROGRESSIVE dysphagia (solids → liquids) + weight loss is cancer until endoscopy excludes it — never attribute new dysphagia to benign reflux without scoping
  2. 2Resectable → oesophagectomy ± neoadjuvant chemo/chemoradiotherapy; advanced → palliative stent/chemoradiotherapy and nutritional support.
Surgery (oesophagectomy) ± neoadjuvant chemo/chemoradiotherapy — curative-intent for resectable disease
Palliative stenting / chemoradiotherapy — advanced disease — relieve dysphagia

Key points

Progressive dysphagia (solids→liquids) + weight loss = oesophageal cancer → urgent endoscopy. SCC (upper, smoking/alcohol) vs adenocarcinoma (lower, Barrett/GORD). Apple-core stricture on barium. Dysphagia for solids AND liquids from the start = achalasia instead.

Monitor & prognosis

Staging; nutritional status; surveillance.

Often advanced/poor; better if early.

Source: NICE NG12; BSG