Oesophageal cancer

Carcinoma of the oesophagus is one of the most challenging conditions confronting the surgeon. Despite advances in perioperative care, oesophagectomy is associated with the highest mortality of any routinely performed elective surgical procedure. Adenocarcinomas account for 65% of oesophageal cancers in the UK, and their incidence in the Western world has increased rapidly since the 1980s, particularly among white males, at a rate of about 5–10% per year. Early detection of symptomatic patients and endoscopic surveillance of high-risk groups (e.g. those with Barrett’s oesophagus) is vital because outcome is strongly dependent on stage. Accurate disease staging using endoscopy, CT, endoscopic ultrasound and a detailed fitness assessment within a multidisciplinary setting is essential to determine treatment strategy. 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 stage 2b/3 (node-positive) disease should be considered for neo-adjuvant chemotherapy plus surgery using the OE02 regimen or as part of the OE05 trial. Nevertheless, owing to advanced disease and co-morbidity, fewer than one-third of patients are suitable for resection; palliation is the basis of treatment for the remainder, with an emphasis on quality of life. Therapeutic options for palliating dysphagia include expandable metal stents, external beam and intraluminal radiotherapy, and chemotherapy.