In the past few decades there has been a dramatic increase in the incidence of adenocarcinoma of the oesophagus, predominantly in the lower oesophagus and gastro-oesophageal junction. This trend has been noted across most patient populations worldwide, but is most noticeable in the younger, white male population, and it appears to be primarily with gastro-oesophageal reflux disease (GORD) and less strongly with alcohol and smoking. Meanwhile, the incidence of squamous cancer worldwide has remained steady or has fallen slightly, although there are large geographical variations.
The majority of patients have developed locally advanced or metastatic disease by the time they present with symptoms and this limits their survival from any treatment. Staging is increasingly more accurate with the routine use of positron emission tomography (PET) and endoscopic ultrasound (EUS) enabling those with advanced disease to be excluded from more intensive treatment options, thus avoiding unnecessary adverse effects on the quality of life.
Combined modality therapy is increasingly used in patients who are suitable for curative treatment. There is evidence that preoperative chemotherapy is superior to surgery alone. There is a continuing controversy about the exact role of surgery combined with chemoradiotherapy (CRT) and which modality should be used first. To date it has not been possible to recruit to a comparative clinical trial.
It is known that CRT is more effective than radiotherapy alone and there is now clear evidence of the effectiveness of definitive chemoradiotherapy (dCRT) in oesophageal cancers. dCRT should therefore be considered a treatment option for selected patients such as those who are unfit for surgery, whose local disease extent precludes surgery or those with squamous cancers.
Optimum radiotherapy and chemotherapy regimens are being defined in the preoperative and definitive setting. Despite this, the majority of patients still present with advanced incurable disease where treatment options are more limited, but palliative chemotherapy has a role in some cases.
Early assessment of response to treatment is becoming an area of interest with early PET scans currently being incorporated into several trial protocols.
Types of oesophageal tumour
The types of oesophageal tumours are shown in Table 12.1.
The oesophagus is a relatively common site for a second primary cancer. For instance, following successful treatment for head and neck cancer, 4% of patients per year develop a second primary, 30% of which are oesophageal, especially squamous cancers.