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A 60-year-old man presents with 4 months of progressive dysphagia (solids then liquids) and 10 kg weight loss. He has a long history of GORD. Endoscopy shows an ulcerated mass at 35 cm. Biopsy: adenocarcinoma. [1]
Questions
a) What is the diagnosis and what premalignant condition is likely responsible? (2 marks) [1]
Oesophageal adenocarcinoma at 35 cm (lower third). Premalignant condition: Barrett's oesophagus (intestinal metaplasia of distal oesophageal epithelium) secondary to chronic GORD. Barrett's increases adenocarcinoma risk 30-100x. [1]
b) Describe the complete staging workup. (4 marks) [1]
- Endoscopic ultrasound (EUS): T-stage (wall depth) and N-stage (regional nodes)
- CT chest/abdomen/pelvis: M-stage (distant metastases — liver, lung, bones)
- PET-CT: Occult metastases (changes management in 15%)
- Laparoscopy: For GOJ tumours — peritoneal seeding assessment
- Cardiopulmonary exercise testing (CPET): Fitness for oesophagectomy [1]
c) Assuming resectable disease (T3N1M0), what is the standard treatment? (3 marks) [1]
Neoadjuvant chemoradiotherapy (CROSS protocol) followed by surgery:
- Carboplatin (AUC 2) + paclitaxel (50 mg/m²) weekly x 5 weeks
- Concurrent radiotherapy 41.4 Gy in 23 fractions
- Ivor Lewis oesophagectomy 4-6 weeks after CRT completion
- 5-year survival: 47% (vs 34% surgery alone) [1]
d) What are the main complications of oesophagectomy? (1 mark) [1]
Anastomotic leak (5-15%), chylothorax (thoracic duct injury), recurrent laryngeal nerve palsy, gastric emptying delay, respiratory complications (atelectasis, pneumonia, ARDS). [1]
References1Show ledgerHide ledger
- [1]van Hagen P, Hulshof MC, van Lanschot JJ, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med, 2012.PMID 22646630