Oesophageal Disorders — Written Clinical Reasoning

Model answer — Part A: progressive dysphagia with alarm features

Frame it first. Progressive dysphagia that began with solids, with weight loss and iron-deficiency anaemia, is a mechanical obstruction from malignancy until endoscopy proves otherwise. This combination of alarm features bypasses any empirical PPI trial — the first test is an urgent upper gastrointestinal endoscopy with biopsy of any lesion ^[1].

Assessment establishes the trajectory and the host: tempo and direction of the dysphagia, regurgitation and aspiration symptoms, performance status and nutrition, cardiorespiratory comorbidity that will shape fitness for neoadjuvant therapy and oesophagectomy, and smoking/alcohol exposure that fits the squamous risk profile ^[1].

Investigation and staging proceed in layers once biopsy confirms cancer: CT of neck, chest and abdomen for gross spread; PET-CT to exclude occult distant metastases that would convert the intent from curative to palliative; and endoscopic ultrasound for T-depth and regional nodal status in patients who remain potentially resectable. Early intramucosal disease is treated endoscopically; locally advanced disease in a fit patient is not ^[2].

Curative-intent treatment for locally advanced oesophageal or junctional cancer is neoadjuvant therapy then surgery. The CROSS regimen — weekly carboplatin and paclitaxel for five weeks with 41.4 Gy of concurrent radiotherapy, followed by oesophagectomy — roughly doubled median overall survival (about 49 versus 24 months) against surgery alone, with benefit durable at ten-year follow-up in both squamous and adenocarcinoma histologies. The answer closes with the multidisciplinary frame: nutrition optimisation, smoking cessation, and explicit staging review before any knife ^{[2] [3]}.