01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Squamous and glandular cancers both narrow the oesophagus, so symptoms do not identify histology. A proximal squamous lesion may cause cervical sticking, aspiration or recurrent laryngeal nerve palsy; distal adenocarcinoma often presents with progressive solids-first dysphagia after reflux or Barrett history. Neither risk profile is diagnostic, and absence of classic exposures cannot exclude either tumour.
Biopsy defines morphology and biomarker work-up. Whole-body CT maps gross regional and distant disease once cancer is established. NICE adds PET-CT before radical treatment for oesophageal or junctional cancer except T1a; EUS is selective and must answer a management question, not be used solely to distinguish T2 from T3. In suspected T1N0 adenocarcinoma, endoscopic resection provides pathological stage before routine CT or EUS is used merely to separate T1a from T1b. Bronchoscopy is reserved for a tumour threatening the central airway.
Treatment integrates cancer control with fitness and histology. Surgery removes oesophagus and regional nodes; definitive chemoradiotherapy is a curative option for squamous disease and selected non-operative patients. NICE branches are specific: untreated HER2-negative advanced or metastatic oesophageal adenocarcinoma with PD-L1 CPS 5 or more can receive nivolumab with platinum- and fluoropyrimidine-based chemotherapy, while completely resected oesophageal or junctional cancer with residual disease after neoadjuvant chemoradiotherapy can receive adjuvant nivolumab. Severe malignant dysphagia may still need prompt stenting or radiotherapy irrespective of systemic eligibility.
Key points
- Squamous carcinoma predominates in the upper and mid oesophagus and is associated with tobacco, alcohol, chronic mucosal injury and some nutritional exposures.
- Adenocarcinoma usually arises distally or at the junction, commonly through Barrett metaplasia linked to reflux, central adiposity and smoking.
- Histology matters because tumour distribution, nodal fields and the balance between surgery and definitive chemoradiotherapy differ.
- For an advanced oesophageal cancer take at least eight viable biopsies. If a lesion may be endoscopically resectable, limit diagnostic sampling to one or two targeted biopsies and let expert endoscopic resection establish stage.
- Potentially curable disease is discussed for oesophagectomy, perioperative chemotherapy or chemoradiotherapy according to histology, site, stage and fitness.
- Palliative care actively treats dysphagia, nutrition, pain, bleeding and psychological distress; a self-expanding stent is used when immediate luminal relief is needed.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Squamous carcinogenesis
Tobacco, alcohol and repeated squamous injury promote cumulative epithelial mutations, dysplasia and ultimately invasive squamous carcinoma within the oesophageal lining.
Barrett sequence
Chronic gastro-oesophageal reflux can produce Barrett columnar metaplasia, sequential dysplasia and distal gland-forming adenocarcinoma arising near the gastro-oesophageal junction.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Wall invasion
Tumour progresses from mucosa through submucosa and muscular wall, gaining access to lymphatic channels and increasing the probability of regional nodal spread.
- 2Longitudinal lymphatics
Longitudinal oesophageal submucosal lymphatic channels permit regional nodal dissemination both above and below the visible primary lesion early during invasion.
- 3Luminal compromise
Circumferential malignant growth progressively narrows the oesophageal lumen, producing retained food, solids-first dysphagia, later liquid obstruction, regurgitation and aspiration.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Difficulty with solids that advances to soft food and liquids is typical of an enlarging oesophageal lesion.
Upper or middle lesions and tobacco plus alcohol exposure increase squamous probability but require histological confirmation.
Distal disease with Barrett history, chronic reflux or central adiposity suggests glandular origin.
Cough on swallowing, haemoptysis, hoarseness or recurrent pneumonia can signal invasion or fistulation.
Liver lesions, supraclavicular nodes, bone pain or declining performance status may shift treatment toward symptom control.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Endoscopy with diagnosis-appropriate samplingFirst step - Why
- Locate the tumour, assess obstruction and establish histology.
- Interpretation and limitations
- Record extent and junctional relation. Obtain at least eight viable biopsies from an advanced cancer, but only one or two targeted biopsies from a potentially resectable superficial lesion before expert endoscopic resection.
- 02
Staging CT - Why
- Detect distant spread, adjacent-organ invasion and gross nodal disease.
- Interpretation and limitations
- Whole-body CT is the systemic anatomical map after histological confirmation; it does not replace endoscopic resection as the initial staging test for suspected T1N0 disease.
- 03
FDG PET-CT - Why
- Seek occult metastases before radical treatment of oesophageal or junctional cancer, except T1a disease.
- Interpretation and limitations
- Inflammation can be avid and small-volume disease can be missed; suspicious distant foci need confirmation when management would change.
- 04
Endoscopic ultrasound - Why
- Refine depth or regional nodes only when the result will alter management.
- Interpretation and limitations
- Do not use EUS solely to distinguish T2 from T3, and do not force an echoendoscope across a tight cancer. Suspected T1N0 disease is staged by endoscopic resection.
- 05
Bronchoscopy - Why
- Assess tracheobronchial invasion or fistula in selected upper or mid lesions.
- Interpretation and limitations
- Airway involvement changes resectability, airway protection and stenting strategy.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Benign peptic stricture
Chronic reflux injury can heal as a distal fibrotic stricture, but progressive symptoms and irregular mucosa still require adequate biopsy to exclude carcinoma.
Achalasia or pseudoachalasia
Achalasia causes motor outflow failure affecting liquids and solids, while an infiltrating junctional cancer can imitate both its symptoms and manometric pattern.
Extrinsic compression
Mediastinal lymphadenopathy, lung cancer or vascular abnormality can compress the oesophagus externally while the overlying mucosa and routine forceps biopsies remain normal.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Radical assessmentBuild one stageFirst stepBiopsy confirms distal oesophageal adenocarcinoma and CT shows no metastases in a fit patient.+
- 1Complete PET-CT and selective EUS according to the specialist staging question.
- 2Review histology, junctional classification, nutrition, cardiopulmonary reserve and frailty at the MDT.
- 3Choose multimodality therapy and resection only after the patient understands survival and functional trade-offs.
- 4DefinitiveConfirm restaging and operative or definitive-treatment ownership after neoadjuvant therapy.
02Airway complicationCoordinate two lumensA mid-oesophageal squamous cancer causes coughing whenever liquid is swallowed and CT suggests a tracheal communication.+
- 1Stop oral intake that is unsafe for the airway, protect oxygenation and ventilation, treat aspiration or sepsis, and arrange a specialist-selected enteral or parenteral feeding route while the fistula anatomy is defined.
- 2Involve respiratory, upper-GI endoscopy, oncology and nutrition specialists urgently.
- 3Sequence airway and oesophageal interventions to avoid worsening compression or fistula.
- 4Verify cough control, oxygenation and a workable feeding route before discharge.
03Palliative dysphagiaMatch relief to prognosisMetastatic cancer causes severe dysphagia and rapid nutritional decline.+
- 1Clarify performance status, expected systemic treatment and how quickly swallowing must improve.
- 2Offer a self-expanding stent when immediate relief is needed, or radiotherapy when a slower durable response better fits.
- 3Provide specialist dietetic and palliative symptom support alongside tumour treatment.
- 4Review stent migration, pain, reflux, bleeding and recurrent obstruction rather than treating placement as completion.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Malignant fistula
Direct tumour invasion can connect oesophagus with trachea or bronchus, causing coughing during swallowing, recurrent aspiration pneumonia and respiratory sepsis.
Haemorrhage
Ulceration erodes friable tumour vessels and may produce slow occult iron loss, overt haematemesis, melaena or occasionally life-threatening haemorrhage.
Malnutrition
Mechanical restriction of intake and systemic cancer catabolism combine to produce progressive weight loss, sarcopenia, micronutrient deficiency and reduced treatment tolerance.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Measure swallowing grade, weight, sarcopenia, intake and aspiration throughout treatment.
- Reassess pulmonary and nutritional fitness after neoadjuvant therapy before oesophagectomy.
- Track pathology, biomarkers and staging results through one named MDT plan.
- After stenting, review chest pain, reflux, migration, bleeding and food obstruction.
- Provide rapid access for new airway symptoms, haemorrhage or complete dysphagia.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Histology changes the map
Squamous and adenocarcinoma share dysphagia but differ in typical site, precursor pathway and treatment emphasis.
A PET focus is a question
Unexpected avidity should be confirmed when it would deny curative treatment.
The airway may be the limiting organ
Upper and mid tumours can invade the tracheobronchial tree even when swallowing dominates the history.
Palliation requires timing
A stent relieves rapidly; radiotherapy may provide slower control with a different adverse-effect profile.
11Common pitfallsFrequent interpretation and management errors.
- 01
Assigning histology from risk factors without biopsy.
- 02
Passing an EUS instrument through a very tight tumour merely to complete a staging checklist.
- 03
Planning oesophagectomy without nutritional and cardiopulmonary assessment.
- 04
Offering a dysphagia intervention without explaining reflux, migration, pain and reintervention.