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home - Oesophagus - Oesophageal Cancer - Oesophageal Cancer Overview Written by Dr Sebastian Zeki
Knows the predisposing factors, presentation, diagnostic work-up and
staging

Knows the range of potential therapies (including palliative care), and
understand how the appropriate selection is made

Oesophageal Cancer Overview

Written by Dr Sebastian Zeki Oesophageal Cancer Epidemiology N-nitrosoBetel nutsHot foods EndoscopicFeaturesThe majority of adenocarcinoma cases are located near the GOJ.Most adenocarcinoma cases are associated with Barrett'soesophagus.Adenocarcinoma arising in Barrett's oesophagus may present as an ulcer, a nodule, or no endoscopic abnormality.Early AC not associated with Barrett's oesophagus arises from an ulcer, plaque, or nodule near the GOJ. Endoscopic Features of SCCSCC’s are usually in the midportion of the oesophagus.SCC arises from small polypoid lesions, denuded epithelium, or subtle plaques.Chromoendoscopy may be useful.SCC invades the submucosa at an early stage, and extends along the wall of the oesophagus usually cephalad.Local lymph node invasion occurs early and quickly because the lymphatics in the oesophagus are located in the lamina propria.SCCs can fistulate eg in to the trachea.Distant metastases to the liver, bone, and lung are seen in nearly 30 % of patients. Adenocarcinoma EpidemiologyRates are rising.Whites are affected 5x>blacks.M 8x>F.Most patients are > 60 yrs old with no increase among younger cohorts.Gastroesophageal reflux disease is a risk if long-standing (>20 years) and severe symptoms.Smoking increases risk by 2.4x.There is an increased risk with increasing intensity and duration of smoking.Risk in smokers is higher than in nonsmoking controls for 30 years after smoking cessation.Central adiposity (not BMI) is the strongest predictor.Helicobacter pylori infection is inversely related with cancer risk.Bisphosphonates are linked to both adenocarcinoma and squamous cell carcinomas.Cholecystectomy is a risk factor possibly due to bile reflux.Exposure to dietary nitroso compounds is associated with cancer.High luminal concentrations of nitric oxide are generated at the GOJ and within Barrett's oesophagus by the reduction of salivary nitrate to nitrous oxide by acidic gastric juice.An inverse relationship exists between total dietary cereal fiber intake and the risk of AC.The protection from cereal fibre may be due to wheat fiber neutrali-ing mutagen formation from the conversion of salivary nitrites to nitrosamines.Diets high in fibre, beta-carotene, folate, and vitamins C and B6 are protective.Diets high in dietary cholesterol, animal protein and vitamin B12 are associated with an increased risk.NSAIDs may be protective esp in context of Barrett’s. Squamous cell carcinomaIn high incidence regions, the disease has no gender specificity.The highest rates are in Asia (particularly in China and Singapore), Africa, and Iran.SCC is more common in men in low incidence regions.The incidence is higher in urban areas (compared to rural areas) of the United States, particularly among African-American men.Being in social class V is a risk factor.Smoking and alcohol are both major risk factors.Amount of alcohol is the most important risk factor.N-nitroso compounds exert their mutagenic potential by inducing alkyl adducts in DNA.Betel nut chewing is implicated-it may cause copper release with resulting induction of collagen synthesis by fibroblasts.Hot foods are associated with oesophageal SCC.Achalasia increases the risk 16 fold in first 25 years post diagnosis.Ingestion of lye is a risk factor.Partial gastrectomy patients may also be at increased risk.Human papilloma virus may be implicated but needs further studies.Tylosis (hyperkeratosis of the palms of the hands and soles of the feet) is a risk factor with a high rate of oesophageal SCC.The inherited type of tylosis (Howell-Evans syndrome) has been most strongly linked to oesophageal SCC-mapped to chromosome 17q25.1, which probably contains a tumor suppressor gene.Patients with tylosis need a surveillance OGD from age 30 every 1-3 yearsBisphosphonates may be linked to adenoCa and SCC.Upper aerodigestive tract SCC either past or current is a risk factor.

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