Epidemiology
Approximately 4000 people die each year from oesophageal cancer, making it the ninth most common cancer in adults in the UK. There are very few cases in people under the age of 45 and the incidence increases eightfold between 45–54 and 65–74 years. It has a sevenfold higher incidence in men than women. It is 20–30 times more common in China than in the USA.
Aetiology and pathophysiology
One-third of oesophageal cancers are adenocarcinoma, mostly found in the distal oesophagus. Two-thirds are squamous cell cancers with 15% in upper, 45% in mid and 40% in lower portions of the oesophagus.
Squamous cell cancer of the oesophagus is associated with chronic irritation, possibly caused by alcohol, caustic injury, radiotherapy or achalasia. The Plummer–Vinson syndrome (sideroblastic anaemia, glossitis, oesophagitis), chronic iron deficiency anaemia and dysphagia are associated with squamous cell cancers, particularly in impoverished populations. Hereditary tylosis, an autosomal dominant trait which causes palmar-plantar hyperkeratosis, carries a 95% risk of squamous cell cancer by the age of 70.
Adenocarcinoma is associated with gastro-oesophageal reflux, hiatus hernia, obesity and frequent antacid or histamine H2 blocker use. Barrett’s oesophagus develops in 8% of patients with reflux, leading to metaplasia of the normal squamous epithelium of the lower oesophagus to columnar epithelium, which may be dysplastic, and the annual transformation to adenocarcinoma is 0.5%.
In recent years there has been a shift of diagnosis from squamous to adenocarcinoma, perhaps reflecting the changing patterns of smoking, obesity and nutrition of patients.
Rare tumours of the oesophagus include small cell carcinoma, mucoepidermoid carcinoma, sarcoma, adenoid cystic carcinoma and primary lymphoma.
Clinical presentation
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