Malignant tumours of the oesophagus usually develop from the mucous membrane. The upper part of the oesophagus contains squamous epithelial tissue, while the lower part can also contain glandular tissue. Accordingly, cancer of the oesophagus can also be made up of squamous epithelium (squamous cell carcinoma) or glandular tissue (adenocarcinoma).

Malignant tumours of the oesophagus are a relatively rare tumour disease with a total of 10 cases per 100,000 inhabitants per year. The disease occurs 3-4 times more frequently in men than in women.

Adenocarcinoma typically occurs in the lower third of the oesophagus. Carcinomas of the oesophagus with a different structure are rare. In recent years, there has been a noticeable increase in the frequency of adenocarcinomas in the lower third of the oesophagus, which are now more common there than squamous cell carcinomas.

The average age of onset for squamous cell carcinomas is around 55 years and around 63 years for adenocarcinomas.

Smoking and drinking, especially high-proof alcohol, are considered to be the most important risk factors for squamous cell carcinoma of the oesophagus. A multiplication of the risks has been demonstrated in the case of simultaneous high consumption of both cigarettes and alcohol. Nitrosamines (e.g. in cured food) or scar stenosis after alkali burns also increase the risk of developing the disease.

For adenocarcinoma, the presence of gastro-oesophageal reflux disease (chronic heartburn), which can lead to a particular transformation of the mucous membrane in the lower oesophagus (formation of a Barrett's oesophagus with the so-called Barrett's mucous membrane), is central. Barrett's oesophagus is considered a predisposing disease for adenocarcinoma of the oesophagus. In patients with Barrett's oesophagus, the risk of developing adenocarcinoma of the oesophagus can be estimated based on the cell changes. However, it should be noted that only a small proportion of people with gastro-oesophageal reflux disease develop oesophageal carcinoma (less than 0.01%). (>> Reflux outpatient clinic)

Symptoms are usually uncharacteristic and appear late. The main symptom of difficulty swallowing (dysphagia) only occurs when approx. 2/3 of the inner diameter of the oesophagus has been displaced. Other symptoms include weight loss, pain behind the breastbone and in the back as well as pneumonia (aspiration pneumonia), when food particles can enter the lungs in the presence of tumour-related connections between the trachea and oesophagus (oesophageo-tracheal fistulas).

Depending on the location and structure of the tumour (adenocarcinoma or squamous cell carcinoma), metastases can occur in lymph nodes and other organs.

Once a carcinoma of the oesophagus has been diagnosed, a series of examination procedures are used to diagnose and determine the treatment depending on the spread of the tumour.

In addition to the actual determination of the diagnosis, diagnostics primarily serve to differentiate between cancers of the oesophagus that can be operated on with the prospect of a cure and tumours where you as a patient will not benefit from an operation. It is important for us to differentiate between tumours that are spatially related to the respiratory system (especially the trachea) and oesophageal tumours below the trachea. It is also important to determine how deeply the tumours have infiltrated the wall of the oesophagus and whether there are metastases in lymph nodes and other organs.

The following examinations are available to us in individual cases:

Medical history and physical examination

During a detailed consultation, you will tell the doctor about all your symptoms and previous illnesses (including family hereditary diseases). A physical examination will also be carried out.
Laboratory

By analysing your blood, we obtain information about your general condition and certain organ functions. Frequent changes affect the blood count, for example, as the red blood pigment haemoglobin may be reduced due to chronic blood loss from the tumour.

Tumour markers are only of secondary importance in oesophageal tumours and are only used in patients who present for follow-up care after complete surgical removal of the tumour.

Gastroscopy (gastroscopy)

Gastro-oesophagoscopy with biopsy is usually the decisive examination for us, as it enables us to carry out precise localisation diagnostics as well as taking tissue samples to confirm the diagnosis through fine tissue examination. This examination technique can also be used to provide symptom-orientated treatment for swallowing problems (see below). The informative value of this examination can be improved by endoscopic staining methods (e.g. with methylene blue or Lugol's solution), which is used in particular in the context of screening examinations of high-risk groups such as patients with Barrett's oesophagus.

Endosonography

Endosonography provides the best information about the local extent of the tumour and whether regional lymph nodes are affected. This information is crucial in deciding whether surgery is possible.

X-ray pre-swallow

In the case of tumours that cannot be passed with an endoscope, an X-ray spread can provide information about the length of the tumour and the degree of narrowing. A pap swallow is also the method of choice for detecting connections between the trachea and oesophagus (oesophago-tracheal fistulas).

Computer tomography

Depending on the location of the tumour, computer tomography provides information about possible metastases of the tumour in other organs or lymph nodes. The disadvantages are a certain radiation exposure and a poorer sensitivity for assessing the infiltration depth of the tumour and the local lymph nodes compared to endosonography.

The tumour stage can be determined using the diagnostics mentioned above. This is necessary to determine the best possible therapy. However, a more precise assessment of the tumour stage is often only possible after surgery.

The TNM classification is usually used for this purpose, where T stands for the size and extent of the primary tumour, N for the number of affected lymph nodes and M for the occurrence of tumour metastases in other organs. The TNM classification can be used to differentiate between different tumour stages with different treatment objectives.

Basic principles

In most cases, treatment aimed at curing the tumour is only possible through complete surgical removal (R0 resection).

The prognosis of the disease worsens with further extension of the tumour (higher stage).

The further up the oesophagus the tumour is located, the worse the chances of recovery.
The primary goal for every patient is to ensure nutrition

The appropriate therapy must be selected with the patient based on the stage of the tumour AND the patient's general condition. The following treatment methods are available:

Surgery

Surgery with the aim of curing the tumour (with curative intent)

In the case of small tumours with no evidence of metastases in lymph nodes or distant metastases, surgical removal of the tumour is the treatment of choice if there are no other reasons (e.g. heart and lung disease) for not undergoing surgery. The type and extent of the operation depends primarily on the location of the tumour in the oesophagus. Additional follow-up treatment with radiotherapy or chemotherapy is usually of no benefit in this case.

Immediate surgery without pre-treatment can also be discussed for patients with small tumours and few affected lymph nodes close to the tumour (without distant metastases). However, if larger tumours are suspected on imaging, pre-treatment (neoadjuvant therapy) should be carried out (see below).

Radiotherapy

Exclusive radiotherapy can achieve a good therapeutic effect with relatively good tolerability in the case of local problems, such as pain caused by tumour metastases in other organs (e.g. in the bones).

Chemotherapy

Chemotherapy can be used in patients with adenocarcinoma of the lower oesophagus with evidence of several affected (e.g. > 3) lymph nodes close to the tumour to reduce the size of the tumour before a possible operation in order to improve the chance of recovery (neoadjuvant/perioperative therapy).

In addition, chemotherapy can be used in patients with oesophageal cancer for whom surgery is not possible. In addition to the aim of prolonging life, chemotherapy should be used in particular to alleviate the symptoms caused by the tumour.

Combination therapies are primarily used. If chemotherapy is planned for you, the doctor in charge will inform you in detail about the procedure and possible side effects.

Combined treatment of radiotherapy and chemotherapy

Combined therapy is primarily useful if the tumour has not yet metastasised. This therapy can be used for patients whose tumour is too large to be operated on immediately with the aim of curing it. In this case, the aim of the therapy is to shrink the tumour before surgery in order to increase the chances of recovery. Therapy prior to a possible operation is known as neoadjuvant therapy. This combined therapy is particularly useful for patients with adenocarcinomas. However, it is problematic if the tumour is very close to the trachea, as this can lead to connections between the trachea and oesophagus.

This form of therapy also offers a good alternative to surgery for patients who, despite a relatively small tumour, cannot be operated on with the aim of curing it (unfavourable location of the tumour or diseases of the heart and lungs). It can achieve a cure (at least for squamous cell carcinomas) and patients benefit from radio-chemotherapy to the same extent as from surgery in these circumstances.

Compared to radiotherapy or chemotherapy alone, however, the combination is generally associated with a higher number of side effects for the patient, so that the indication for this therapy is discussed in detail with you as the patient by the doctors treating you.

Supportive therapy methods

These therapies are primarily based on the symptoms reported to us by the patient or serve to prevent impending complications caused by the tumour.

The aims of supportive therapy for oesophageal cancer are

• Improving swallowing difficulties so that food intake is as normal as possible
• Pain relief
• Treatment of connections to the windpipe and thus prevention of pneumonia

In detail, we have the following options available to us for widening a tumour-related narrowing in the oesophagus

• Dilation (bougienage) of the narrowing under fluoroscopy
• Insertion of a metal mesh (stent) to keep the oesophagus open
• Radiotherapy (from the outside or directly inside the oesophagus)
• Laser therapy (especially for short stenoses)

Sometimes several of these procedures are used at the same time. Another option for ensuring adequate nutrition is the insertion of a feeding tube (PEG tube), especially if there is a risk of an existing stricture worsening. This is also possible at the start of radiotherapy, for example, so that we often place such a tube as a preventive measure before the start of therapy. If the tube is no longer needed, it can be removed again

If a relapse (recurrence of the tumour in the former tumour area) occurs, treatment should be repeated, although in most cases a cure can no longer be achieved.