Oesophageal cancer — Rapid | Doctor’s Passport

Synopsis

Recognise progressive dysphagia early, obtain endoscopic histology, stage locoregional and distant disease accurately and coordinate endoscopic, surgical, chemoradiation, systemic, nutritional and symptom-directed treatment by histology and intent.

Progressive dysphagia and weight loss is oesophageal cancer until promptly investigated; urgent upper-GI endoscopy with multiple biopsies is the first diagnostic route.
Adenocarcinoma usually affects distal oesophagus or gastro-oesophageal junction and is associated with Barrett reflux and obesity; squamous cancer more often affects upper or mid oesophagus and tobacco–alcohol exposure.
The diagnostic reference standard is histology from endoscopic biopsy; repeat with deeper or image-guided sampling when visible or radiological suspicion remains despite non-diagnostic tissue.
After diagnosis, contrast CT chest and abdomen is the first staging overview, followed by PET-CT and endoscopic ultrasound when curative treatment remains plausible and each test will change management.
Use bronchoscopy for an upper or mid-oesophageal tumour abutting the tracheobronchial tree and staging laparoscopy for selected junctional or gastric-side adenocarcinoma at peritoneal risk.
Early mucosal neoplasia may be treated by endoscopic resection with eradication of remaining Barrett dysplasia, preserving the oesophagus.
Resectable adenocarcinoma commonly receives perioperative chemotherapy or neoadjuvant chemoradiation before oesophagectomy; anatomy, fitness and current MDT protocol determine the sequence.
Squamous cancer is often treated with definitive chemoradiotherapy, particularly cervically or when surgery would be highly morbid, with salvage surgery reserved for selected persistent or recurrent disease.
Advanced systemic treatment depends on squamous versus adenocarcinoma histology and HER2, PD-L1 and mismatch-repair or microsatellite status where relevant.
Nutrition is assessed at diagnosis. Use oral adaptation, dietetic supplements, enteral access or parenteral support according to obstruction, aspiration, treatment intent and anatomy.
For non-curative dysphagia, self-expanding metal stent gives rapid relief, whereas radiotherapy or brachytherapy may provide slower but more durable relief in a patient likely to live longer.
Do not place a stent reflexively before curative surgery or chemoradiation; migration, perforation and interference with later treatment can outweigh short-term benefit.
Palliative care addresses dysphagia, pain, saliva, aspiration, bleeding and family distress alongside active systemic or radiation treatment.

Key red flags

Progressive dysphagia, especially solids followed by liquids, requires urgent upper-GI endoscopy and biopsy rather than empirical reflux treatment.

Inability to swallow saliva, dehydration, aspiration or rapid nutritional decline requires same-day assessment and a safe route for fluids and nutrition.

Cough on swallowing, recurrent pneumonia, haemoptysis or air seen within tumour raises tracheo-oesophageal fistula.

Haematemesis, melaena, syncope or falling haemoglobin indicates tumour bleeding or another upper-GI haemorrhage.

Hoarseness, Horner syndrome, vertebral pain or airway stridor suggests recurrent-laryngeal, sympathetic, spinal or tracheobronchial invasion.

Severe chest pain, fever, subcutaneous emphysema or shock after endoscopy or stenting suggests perforation and mediastinal sepsis.

Advanced local invasion

Chest or back pain, hoarseness, stridor, cough on swallowing or haemoptysis suggests neural, airway or mediastinal extension.

Complete obstruction

Inability to swallow saliva, pooling secretions, dehydration and aspiration requires urgent airway, fluid, nutrition and endoscopic assessment.

Investigation priorities

First-line upper-GI endoscopy with biopsyFirst stepFirst line

Locate and characterise tumour, assess obstruction and obtain multiple tissue samples for definitive histology.

First-line contrast CT chest and abdomenFirst line

Assess local mediastinal relationships, regional nodes, liver, lung, adrenal and other distant disease and identify biopsy targets.

Management branches

DysphagiaObtain tissue before symptom-only treatment

An adult develops progressive dysphagia, food sticking, weight loss or another alarm upper-GI symptom.

Assess hydration, aspiration, ability to swallow saliva, bleeding and nutrition and arrange urgent endoscopy rather than a prolonged empirical acid-suppression trial.
Biopsy the lesion adequately and use targeted CT or ultrasound-guided sampling if endoscopic tissue is non-diagnostic or a metastatic site is safer.
Communicate histology promptly, obtain CT staging and refer to the specialist oesophago-gastric MDT with dietetic support from diagnosis.

Key medicines

Perioperative FLOT for eligible adenocarcinomaA common 14-day specialist cycle gives docetaxel 50 mg/m², oxaliplatin 85 mg/m² and leucovorin 200 mg/m² intravenously on day 1 followed by fluorouracil 2,600 mg/m² over 24 hours, usually four cycles before and four after surgery.Use the exact NHS protocol with DPD status, marrow, renal, liver, neuropathy, infection, mucositis, diarrhoea, thrombotic and nutritional monitoring and reassess postoperative fitness before resuming.

Weekly carboplatin and paclitaxel with radiotherapyA common neoadjuvant chemoradiation protocol gives carboplatin AUC 2 and paclitaxel 50 mg/m² intravenously once weekly for 5 weeks during 41.4 Gy radiotherapy, with exact dates and fields set by the specialist protocol.Monitor marrow, infection, neuropathy, hypersensitivity, swallowing, dehydration and radiation oesophagitis and avoid applying a neoadjuvant dose or field unchanged to a definitive-intent regimen.

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