Diagnosis

History

Presenting Complaint

Dysphagia is the most common complaint. Odynophagia is less common. Irritation may lead to cough. Patients may have significant weight loss if they have been undiagnosed for some time.

Past History

There is a close relationship of squamous cell carcinoma of the oesophagus with squamous cell carcinoma of the head and neck mucosa.
Most adenocarcinomas will arise from a region of Barrett's oesophagus (60-70%), but a number arise de novo. The annual risk of progression from Barrett's to adenocarcinoma is about 1/250. Patients may be obese and have a history of gastro-oesophageal reflux disease.

Social History

There is significantly higher risk in some regions of the world for squamous cell carcinoma - South America (hot drinks) and China (dietary, HPV).

Examination

Examination should assess for regional nodal disease (supraclavicular lymphadenopathy) or metastatic disease (chest, liver examination).

Investigations

Bloods

Imaging

Imaging is used initially for diagnosis but more so for staging. It is essential to distinguish between T1 and T2 disease, as T1 disease is highly curable with surgical excision (low rate of lymph node metastases) whereas higher T scores are associated with far worse prognosis.

Barium Swallow

Barium swallow is often able to visualise a stenosed area. After this test, most patients proceed to endoscopy and biopsy (below) before undergoing further imaging.

PET Scan

PET is the predominant method of staging oesophageal cancer. Oesophageal tumours are usually PET avid, and it allows assessment of the extent of local, regional and distant disease. 15% of patients are upstaged to M1 disease on the basis of PET, preventing futile surgery or intensive chemoradiotherapy.

Endoscopic Ultrasound

Endoscopic Ultrasound remains the most accurate method of local staging for oesophageal cancer (80-90% accuracy in determining T and N Stage). It allows visualisation of the different layers of the oesophageal wall (mucosa, submucosa, muscle, adventitia) as well as detection of regional lymph nodes. It suffers from inability to traverse advanced, stenotic tumours which limits it s accuracy. When compared to PET, endoscopic ultrasound has been proven to be more accurate in local staging.
EUS is less useful in assessment of local disease following neoadjuvant chemoradiotherpay, with accuracy of between 40-50%.

Histological Diagnosis

Histological diagnosis is obtained by gastroscopy and biopsy. PET has largely replaced the need for biopsy of suspicious lymph nodes or distant metastatic sites.

Staging

Importantly, adenocarcinoma and squamous cell carcinoma are staged differently according to the AJCC/IUCC. This is predominately due to the different patterns of lymphatic spread, relapse and overall outcomes (adenocarcinoma better than squamous cell carcinoma). As well as the usual T, N and M stage, the grade of disease plays a role in staging.

T Stage

Tis: High grade dysplasia (includes carcinoma in situ
T1a: Invades lamina propria/muscularis mucosae
T1b: Invades submucosa
T2: Invades muscularis propria/externa
T3: Invades adventitia but not other organs
T4a: Invasion of adjacent organs, resectable (eg. diaphragm, pleura, pericardium)
T4b: Invasion of adjacent organs, unresectable (eg. heart, aorta, vertebral body)

N Stage

N1: 1-2 regional nodes
N2: 3-6 regional nodes
N3: > 6 regional nodes

M Stage

M1: Distant metastases

G Stage

G1: Well differentiated
G2: Moderately differentiated
G3: Poorly differentiated
G4: Undifferentiated

Site

Cervical: Above sternal notch
Upper: From sternal notch to inferior margin of azygos vein
Middle: Between inferior margin of azygos vein and inferior margin of pulmonary vein
Lower: Below the inferior margin of the inferior pulmonary vein, including the proximal 5 cm of stomach for tumours arising within the proximal stomach that invade the gastro-oesophageal junction

Final Squamous Cell Carcinoma Stage

Stage T N M G Site
IA T1 N0 M0 G1 Any
IB T1
T2-3		 N0 M0 G2-3
G1,,		 Any
Lower
IIA T2-3 N0 M0 G1
G2-3		 Upper, middle
Lower
IIB T2-3
T1-2,,		 N0
N1		 M0 G2-3
Gany		 Upper, middle
Any
IIIA T1-2
T3
T4a		 N2
N1
N0		 M0 Gany Any
IIIB T3 N2 M0 Gany Any
IIIC T4a
T4b
Tany		 N1-2
Nany
N3		 M0 Gany Any
IV Tany Nany M1 Gany Any

Final Adenocarcinoma / Gastro-oeophageal Junction Stage

The site does not play a role in the stage for adenocarcinoma, as most occur in the distal oesophagus anyway.

Stage T N M G
IA T1 N0 M0 G1-2
IB T1
T2		 N0 M0 G3
G1-2
IIA T2 N0 M0 G3
IIB T3
T1-2		 N0
N1		 M0 GAny
IIIA T1-2
T3
T4a		 N2
N1
N0		 M0 GAny
IIIB T3 N2 M0 GAny
IIIC T4a
T4b
TAny		 N1-2
NAny
N3		 M0 GAny
IV TAny NAny M1 GAny

Links