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Case History

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Image not available. A 54-year-old woman with a long-standing history of gastro-oesophageal reflux disease presents with progressive dysphagia and weight loss. An oesophagogastroduodenoscopy confirms a mid-oesophageal tumour and biopsy confirms adenocarcinoma.

What initial investigations are needed? Outline the immediate management.

If there is no evidence of metastatic disease what further staging investigations are needed before deciding to operate?

What are the treatment options if, after all investigations, there is no evidence of metastases and the cancer is considered to be operable?

How would the management change if the tumour is found to be locally advanced and inoperable?

If there is evidence of distant metastatic disease what are the management options?

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Background

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What initial investigations are needed? Outline the immediate management.

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Image not available. Initial investigations include upper gastrointestinal endoscopy and biopsies and computed tomography (CT).1 An assessment of the severity of dysphagia is essential. If nutritional intake is severely limited rapid palliation of dysphagia can be achieved by dilatation, stent insertion or palliative radiotherapy.1 Parenteral nutrition may be required, which can be achieved by nasogastric feeding, percutaneous endoscopic gastroscopy or jejunostomy.

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Endoscopic stent insertion is relatively safe and non-invasive providing almost immediate results. Palliative radiotherapy is also usually well tolerated but is not without toxicity, and it can take longer than the other treatments before symptoms improve.

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If there is no evidence of metastatic disease what further staging investigations are needed before deciding to operate?

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Prognosis of oesophageal cancer is strongly stage dependent and accurate clinical staging is essential as is an assessment of operability. Endoscopic ultrasound provides the most accurate estimate of disease stage and is superior to CT at detecting lymph node metastases.1 Laparoscopy is also increasingly being done and is especially helpful in identifying coeliac nodes and subcapsular liver metastases.

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Positron emission tomography (PET) scanning with 18F-fluoro-deoxyglucose is used increasingly to detect distant metastases. It is non-invasive and more sensitive than CT, particularly at detecting occult metastases, obviating the need for aggressive treatments. However, evaluation of the primary site and loco-regional nodes is not as accurate.

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What are the treatment options if, after all investigations, there is no evidence of metastases and the cancer is considered to be operable?

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Surgery alone as a treatment option for locally advanced disease (T3 or T4) is considered suboptimal with 5-year survival rates of 15–20%. Preoperative and adjuvant treatment strategies are therefore important. Radiotherapy alone is of value in patients with locally advanced disease who are unfit for surgery or chemotherapy. In a study of 101 selected patients with local disease the 3-year and 5-year survival rates were 27% and 21%, respectively.2 Most patients, however, benefit from preoperative chemotherapy or chemoradiotherapy.

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A UK Medical Research Council (MRC) trial randomized 802 patients with operable oesophageal carcinoma to either resection alone ...

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