Clinical features

Progressive dysphagia and weight loss are the most frequently presented features of oesophageal carcinoma:

• progressive dysphagia is present in around 74% of patients
  • the patient may recount a short history of progressive dysphagia, initially affecting solids only, but gradually affecting the swallowing of fluids
  • the interruption of the passage of food may cause the individual to slowly alter the diet from solid to liquid nutrition; success with this approach may be at the expense of early medical self-referral
  • dysphagia can be graded as follows
    • grade 1 - able to swallow most foods
    • grade 2 - able to swallow soft foods only
    • grade 3 - able to swallow liquids only
    • grade 4 - unable to swallow anything
  • the level at which difficulty in swallowing is encountered may be identifiable by the patient
  • a short history of dysphagia in an elderly male is almost certainly carcinoma of the oesophagus or the cardia of the stomach
  • an infrequent presentation is of the obstruction of a large bolus of food with no prior history of dysphagia
• dysphagia is usually associated with vomiting of undigested food (1,2,3)

Other presentations include:

• pain on swallowing food and liquids - odynophagia
  • classically, retrosternally and in the interscapular region
• gastrointestinal bleeding
• non specific dyspeptic symptoms
• anorexia
• late symptoms
  • hoarseness - due to involvement of the recurrent laryngeal nerve
  • severe cough - linked with tumour fistula between the oesophagus and the respiratory tract
  • signs of metastatic disease e.g. - ascites or palpable lymph node metastases
  • oedema, due to a severe reduction in protein intake (1,2)

Secondary deposits occur in:

• lymph nodes
• in the liver causing jaundice

Note:

• an increasing number of asymptomatic oesophageal carcinoma patients are being recognised as part of screening and surveillance endoscopy
• typically, squamous cell carcinoma patients will have dysphagia associated with weight loss and a history of smoking and/or increased alcohol intake while patients with adenocarcinoma will be white males with a history of gastro-oesophageal reflux who had developed dysphagia (2,3)

Reference:

• (1) Lagergren J, Lagergren P. Oesophageal cancer. BMJ. 2010;341:c6280.
• (2) Rashid N et al. Current management of oesophageal cancer. BJMP 2015;8(1):a804
• (3) Pennathur A et al. Oesophageal carcinoma. Lancet. 2013;381(9864):400-12.