Oesophageal cancer

Carcinoma of the oesophagus remains one of the most challenging conditions confronting the surgeon today. Oesophagectomy is associated with the highest mortality of any elective general surgical procedure despite advances in perioperative care. Adenocarcinomas account for over two-thirds of oesophageal cancers in the UK, and their incidence has increased dramatically in the past few decades, particularly among white males. Early detection of symptomatic patients and endoscopic surveillance of high-risk groups (such as those with Barrett’s oesophagus) is essential because outcome is strongly dependent on the stage of disease. Accurate disease staging involves endoscopy, CT, endoscopic ultrasound, but may also include bone scintigraphy, PET CT, laparoscopy or endoscopic mucosal resection. An assessment of patient fitness is equally vital in determining management strategies within a multidisciplinary setting. Resection for stage 1a and 2a tumours achieves good 5-year survival, but surgery alone provides poor cure rates for more advanced disease. Patients with node-positive disease should be considered for neo-adjuvant chemotherapy with the OE02 regimen or as part of the OE05 trial. Only 30–40% of patients are suitable for resection, predominantly due to the advanced stage at presentation but in some individuals due to co-morbidity. Palliation of symptoms in the remaining patients might involve self-expanding metal stents, chemotherapy, external beam or intraluminal radiotherapy.