CANCER OF THE OESOPHAGUS

What is it?

The oesophagus (gullet) is the tube through which food and drink pass from the back of the throat to the stomach. It lies in the back of the chest just in front of the spine. The outer muscular layers of the oesophagus move fluid or food towards the stomach. At the lower end there is a muscular valve which prevents stomach acid from entering the gullet from below.

The cancer arises from the lining of the gullet and the effect is to narrow the oesophagus and cause difficulty in swallowing. First solid food tends to lodge or stick and then liquids. The cancerous cells may also spread outside the gullet to involve the neighbouring structures, such as lymph nodes and blood vessels in the chest, and they may be carried in the blood stream to form secondary tumours in the liver or elsewhere.

Most cancers in the upper two-thirds of the gullet are known as squamous carcinomas from the squamous (skin-like) cells which line the oesophagus. Those occurring near the join with the stomach, are usually adenocarcinomas, derived from stomach-like cells. This is particularly the case when stomach-type (columnar) cells have replaced squamous cells at the lower end of the gullet, a condition known as Barrett’s Oesophagus.

Who gets it?

This cancer is particularly common in some parts of Africa and China and is probably related to local diet or the way food is cooked. In the West, important risk factors are cigarette smoking and alcohol consumption. A combination of the two appears to increase the risk. Severe acid reflux from the stomach seems to be a major factor in a recent increase in the number of people with adenocarcinomas.

A rare muscular disorder, achalasia, a condition in which there is a failure of relaxation of the muscular valve at the lower end of the gullet, very occasionally leads to cancer.

What are the symptoms?

There is a progressive difficulty in swallowing, initially for solids such as meat, and then for softer foods. Eventually there is difficulty getting liquids down. Patients lose weight and may have other symptoms such as coughing, choking, unexplained chest infections or a hoarse voice.

What tests will the Doctor want to do?

Going to the doctor early when symptoms arise is essential, particularly if there is a progressive deterioration in the ability to swallow. Urgent referral to an appropriate specialist is then necessary and a barium swallow is often carried out. This involves swallowing a white liquid containing barium, which shows up on X-ray, outlining the oesophagus and revealing the level of obstruction. Another test is to pass a narrow flexible telescope (endoscope) into the gullet via the mouth. This test is done using an anaesthetic throat spray and/or a sedative injection. Any change in the lining of the gullet can be seen and samples taken (biopsy) for laboratory examination.

If cancer is diagnosed, other tests may be done to see how extensive it is. These include an X-ray of the chest, an ultra-sound investigation which can be done via the skin, or using an endosocope. Other possible tests include a CT scan or magnetic resonance imaging (MRI). A surgeon may also look inside the abdomen using a special tube called a laparoscope.

What is the treatment?

Surgery is the most commonly used treatment in the United Kingdom, particularly if the cancer has not spread beyond the oesophagus. Depending on the position of the tumour, the surgeon may need to enter the chest cavity, the abdomen or the neck and will remove the affected part of the oesophagus with the surrounding lymph glands. A tube is then made out of the stomach, which is drawn up into the chest or neck where it is joined to the remainder of the oesophagus. Patients are usually cared for in an intensive care ward after the operation. After leaving hospital, patients can eat normal foods but may feel full rather quickly. This usually improves over the next few months.

Radiotherapy is also used as a potential cure in some patients; it may be the only treatment but is sometimes used in conjunction with surgery. Even if the tumour cannot safely be removed by surgery then radiotherapy and chemotherapy can be used as a treatment. Radiotherapy can be given as an external beam or on the inside of the gullet via an endoscope (Brachytherapy).

If surgery is not possible, there are ways to help to relieve difficulties in swallowing.

Endoscopic intubation is usually done under sedation or anaesthetic in the endoscopy department. A tube is inserted to hold the walls of the gullet open so that food and fluid can be swallowed easily. These tubes may be made of plastic or of springy metal coils. The tubes can become blocked by large food particles so hospitals will give an instruction sheet to advise patients on their diet. Some patients are bothered by heartburn and regurgitation and this can be helped by taking acid suppressors.

Endoscopic laser treatment is also possible and a specialist endoscopist will use a laser to destroy any tumour that is growing into the gullet. In some patients, laser treatment and intubation need to be combined.