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It is a barium swallow showing a stricture involving the middle third of the oesophagus. There is shouldering at both proximal and distal ends and evidence of mucosal destruction and filling defects. There is free flow of barium distal to the stricture. These are typical features of carcinoma of oesophagus. The diagnosis can be confirmed by performing oesophagoscopy and biopsy.

Macroscopically: the disease assumes one of the three forms:

• Polypoid (fungating).
• Stenosing (scirrhous) - like this x-ray.
• Ulcerative.

Microscopic: histologically, the vast majority of malignant tumours of the oesophagus are carcinomas. Other types can also occur.

Carcinomas

• Squamous cell (95%) - middle 1/3 } common
• Adenocarcinoma (1-2%) - lower 1/3 } types.
• Melanoma.

  Sarcomas

• Leiomyosarcomas.
• Rhabdomyosarcomas.
• Fibrosarcomas.

  Mixed tumours can occur

Elderly patients are affected and they present with painless progressive dysphagia, initially to solids and then to liquids. There is history of food sticking in the chest at the site corresponding to the tumour. They may have pseudo-vomiting, regurgitation of food and liquid with streaks of blood. There is loss of appetite and weight.

On examination there is tell-tale evidence of starvation, pallor and dehydration. Abdominal examination may not reveal any abnormality. Chest examination may show aspiration pneumonitis.

The differential diagnosis for a patient with dysphagia is:

Dysphagia to solids
Painless and progressive	Painful with heartburn
Carcinoma	Peptic stricture

Dysphagia to liquids and solids
Painless - no heartburn		Painful
	+ heartburn	No heartburn
Achalasia of cardia	Scleroderma	Diffuse spasm or corkscrew oesophagus
	Motility disorders

The treatment options available for management of oesophageal cancer are:

• Surgical resection.
• Radiotherapy.
• Intubation.
• Laser (or) electro-coagulation.
• Combined modality treatment.

  Surgical resection

  This is the treatment of choice provided:

  • the patient is considered fit for major surgical intervention.
  • pre-operative staging tests indicate that the tumour is resectable and there is no metastatic disease.
    
    
  Staging is carried out by Endoscopic ultrasound, CT/MRI of chest, U/S of abdomen, CT of abdomen and Laparoscopy + ultrasound, the last being done when resection is contemplated.

  The procedures most commonly performed are:

  • Ivor-Lewis procedure: This is performed for tumours of middle 1/3 and lower 1/3 of oesophagus. Mobilisation is done by abdominal and right upper postero-lateral thoracotomy. The anastomosis is done in the thorax.
  • Mc-Keown's procedure: This is a 3-stage subtotal oesophagectomy; it is performed by mobilisation of oesophagus through abdominal and thoracic approach. The anastomosis is in the neck. This procedure is performed for higher thoracic tumours.
  • Radical resection with jejunal or colonic transposition.

  
  Radiotherapy

  Squamous cell carcinoma is radio-sensitive. Palliative radiotherapy for dysphagia can be administered by an external beam radiation after stent insertion.

  Intubation (Palliation)

  The aim is to make the patient swallow by inserting a stent across the tumour after dilatation. They can be:

  • Plastic.
  • Self-expanding metallic - gives better results.

  
  Photocoagulation

  Laser photocoagulation using NdYAG laser can achieve good tumour destruction which can be combined with dilatation and intubation for relief of dysphagia.

  Combined modality treatment

  In certain cases adjuvant pre-operative radiotherapy +/or chemotherapy may be used in squamous carcinoma.