Category: Medicine | Discipline: Gastroenterology | Setting: Outpatient Clinic
Case
Mr. David Thompson, a 68-year-old retired builder, presents to the gastroenterology outpatient clinic with a 3-month history of progressive dysphagia. He describes initial difficulty swallowing solid foods, which has now progressed to include soft foods and liquids. He has lost 8 kg during this period and reports a feeling of food "sticking" in his chest. He has a 45-pack-year smoking history and drinks 2-3 standard drinks daily. He has also noticed regurgitation of undigested food and occasional chest discomfort unrelated to exertion.
Vital signs: BP 135/80 mmHg, HR 78 bpm, RR 16/min, Temp 36.8°C, SpO2 98% on room air. BMI 21 (previously 24 three months ago)
Questions
1. What are the key red flag features in Mr. Thompson's presentation that warrant urgent investigation?
Red flag features present in this case include:
Progressive dysphagia: Starting with solids and progressing to liquids suggests mechanical obstruction
Significant unintentional weight loss: Loss of 8kg over 3 months is substantial and concerning for malignancy
Age >55 years: Increased risk of upper GI malignancy
Smoking history: Major risk factor for oesophageal carcinoma, particularly squamous cell carcinoma
Alcohol consumption: Synergistic effect with smoking in increasing cancer risk
The combination of progressive dysphagia with weight loss in a patient with significant risk factors requires urgent investigation, typically with upper GI endoscopy within 2 weeks (urgent cancer pathway).
2. What are the two main histological types of oesophageal carcinoma, and how do their epidemiology and risk factors differ?
Squamous Cell Carcinoma (SCC):
Historically the most common type worldwide, though incidence is decreasing in Western countries
Typically occurs in the upper and middle third of the oesophagus
Major risk factors: smoking, alcohol, achalasia, caustic injury, Plummer-Vinson syndrome
More common in lower socioeconomic groups
Higher incidence in certain geographical areas (e.g., parts of Asia, Iran, South Africa)
Adenocarcinoma:
Rapidly increasing incidence in Western countries, now the most common type in developed nations
Typically arises in the lower third of the oesophagus
Major risk factors: Barrett's oesophagus (the main precursor), chronic gastro-oesophageal reflux disease (GORD), obesity, smoking
More common in Caucasian males
Associated with metabolic syndrome
Mr. Thompson's smoking and alcohol history places him at risk for both types, though his symptoms and risk factors are compatible with either histology.
3. What is Barrett's oesophagus and why is it clinically significant?
Barrett's oesophagus is a condition where the normal stratified squamous epithelium of the lower oesophagus is replaced by metaplastic columnar epithelium, typically containing goblet cells (intestinal metaplasia).
Pathophysiology:
Develops as a response to chronic acid exposure from GORD
The columnar epithelium is more resistant to acid than squamous epithelium
Represents an adaptive but pre-malignant change
Clinical Significance:
Main precursor lesion for oesophageal adenocarcinoma
Risk of malignant transformation approximately 0.2-0.5% per year
Dysplasia in Barrett's significantly increases cancer risk:
Low-grade dysplasia: 0.5-1% annual cancer risk
High-grade dysplasia: 7-10% annual cancer risk
Requires surveillance endoscopy with systematic biopsies
Surveillance intervals depend on length of Barrett's segment and presence of dysplasia
Management:
PPI therapy to control acid reflux
Regular surveillance endoscopy (intervals based on dysplasia grade and segment length)
Endoscopic intervention (ablation or resection) for dysplasia
Minimally invasive oesophagectomy increasingly used
Significant morbidity and mortality (perioperative mortality ~3-5%)
Requires adequate cardiopulmonary reserve
3. Neoadjuvant Therapy:
Neoadjuvant chemotherapy: Used for adenocarcinoma (typically ECF or FLOT regimen)
Neoadjuvant chemoradiotherapy: May be used for squamous cell carcinoma
Improves survival compared to surgery alone
Allows downstaging of tumour
Given for locally advanced resectable disease (typically T2-3, N0-1)
4. Definitive Chemoradiotherapy:
For patients unfit for surgery
Particularly for squamous cell carcinoma
May achieve cure in selected cases
Palliative Treatment Options:
Palliative chemotherapy: For metastatic disease in fit patients
Palliative radiotherapy: For bleeding, pain, or obstruction
Oesophageal stenting: For dysphagia relief
Nutritional support:
Dietary modification
Enteral feeding (nasogastric, nasojejunal, or gastrostomy)
Parenteral nutrition if required
Best supportive care: Including pain management and psychological support
Treatment Decision Factors:
Tumour stage (most important)
Patient performance status and comorbidities
Nutritional status
Patient preference
Tumour location and histology
7. Mr. Thompson is diagnosed with T3N1M0 adenocarcinoma of the lower oesophagus. What specific nutritional concerns would you address, and what supportive measures might be needed during his treatment?
Nutritional Concerns:
Pre-existing malnutrition: Already lost 8kg (significant weight loss)
Detailed dietary history and nutritional screening (e.g., MUST score)
Biochemical markers: albumin, prealbumin (though affected by inflammatory response)
Body composition assessment
Swallowing assessment
Nutritional Support Strategies:
Pre-treatment optimization:
Dietitian review and individualized nutritional plan
High-calorie, high-protein diet modifications:
Small, frequent meals
Soft, moist foods
Food fortification
Oral nutritional supplements
Consider early enteral feeding if inadequate oral intake:
Nasogastric or nasojejunal feeding
Radiologically inserted gastrostomy (RIG) or jejunostomy if prolonged support anticipated
During treatment:
Continue nutritional support
Manage treatment side effects affecting nutrition
Regular weight and nutritional status monitoring
Feeding jejunostomy often placed at time of oesophagectomy for post-operative nutrition
Other Supportive Measures:
Smoking cessation: Critical for surgical outcomes and overall prognosis
Alcohol reduction: Cessation support if needed
Psychological support: Diagnosis of cancer and major surgery
Clinical psychology/psychiatry referral
Support groups
Information provision
Symptom management:
Dysphagia management strategies
Pain control
Anti-emetics for chemotherapy
PPI therapy for reflux symptoms
Prehabilitation program:
Exercise program to improve fitness
Respiratory physiotherapy
Optimisation of comorbidities
Dental assessment: Prior to radiotherapy
Clinical nurse specialist support: Coordination of care and patient support
A multidisciplinary approach involving surgeons, oncologists, dietitians, specialist nurses, physiotherapists, and other allied health professionals is essential for optimal outcomes.