Neoplastic Conditions

Benign tumours: these are rare in surgical material, e.g., squamous papilloma, leiomyoma or granular cell tumour.

Oesophageal carcinoma: predisposing conditions to oesophageal cancer include diverticula, achalasia and Plummer-Vinson syndrome (elderly females, iron-deficiency anaemia, upper oesophageal web). Predisposing lesions to oesophageal cancer are squamous cell dysplasia and Barrett's metaplasia/dysplasia.

Squamous cell dysplasia/carcinoma in-situ: macroscopically inapparent but seen histologically adjacent to, overlying, or distant from squamous cell carcinoma.

Barrett's metaplasia or columnar epithelium lined lower oesophagus (CLO): seen in about 10% of patients with hiatus hernia and/or GOR. It arises from erosion with differentiation of multipotential stem cells to metaplastic small intestinal or gastric glandular epithelia. The Barrett's segment appears as a velvety area proximal to the OG junction surrounded by pale squamous mucosa. It can be multifocal or continuous. The segment is either classical/long (> 3 cm), short (< 3 cm ), or ultra-short (junctional). About 10% of Barrett's cases develop mucosal dysplasia and/or adenocarcinoma, representing an increased risk of 30-40 times that of the general population. Barrett's metaplasia positive for mucosal dysplasia is classified as either low-grade or high-grade. The latter has a strong (40-60%) association with concurrent or subsequent adenocarcinoma, indicating the need for immediate clinicopathological reassessment and consideration of surgery. The appearances of Barrett's metaplasia can also be altered by its treatment with antacid medication, laser ablation or photodynamic therapy.

Squamous cell carcinoma: forms 30-40% of oesophageal cancers and is typically seen in the mid-oesophagus of elderly patients. It is usually moderately differentiated and keratinising, ulcerates or strictures with rolled, irregular margins, involves a long segment of oesophagus and has spread through the full thickness of the wall at presentation. Palliation can be achieved by radiotherapy, ablative laser therapy or the insertion of an expanding metal stent or tube to relieve obstruction. Primary surgical resection is the treatment of choice in a medically fit patient with a locally confined lesion < 5 cm in length. If more extensive than this, resection can be facilitated by preoperative radio-/chemotherapy which produces signs of tumour regression (degeneration, necrosis, fibrosis, keratin granulomas) in some 50-60% of cases, but often makes identification of tumour on gross inspection of the specimen difficult. Perforation with potentially fatal medi-astinitis is a possible complication of preoperative therapy and endoscopy of malignant strictures. Bronchoscopy is also done to exclude the possibility of a primary lung cancer invading the oesophagus which would preclude primary resection as do haematogenous and distant nodal metastases or invasion of mediastinal vessels and main structures.

Variants of squamous carcinoma are: verrucous carcinoma (warty, slow growth), basaloid carcinoma (aggressive) and spindle cell/polypoid carcinoma (carcinosarcoma - intermediate prognosis).

Adenocarcinoma: forms 50-60% of oesophageal cancers and arises in the distal oesophagus/OG junction often secondary to intestinal-type Barrett's metaplasia and dysplasia. The incidence of this tumour has greatly increased in the last twenty years due in part to antibiotic eradication of helicobacter pylorii with loss of its gastric acid suppressor effect resulting in more GOR disease. As well as extensive radial spread through the wall out to the CRM it can spread upwards undermining the oesophageal squamous mucosa and downwards to the proximal stomach where clear distinction from a primary gastric carcinoma can be difficult. Clues as to site of origin are both anatomical (oesophageal if > 50% of the tumour is above the OG junction) and histological in the adjacent mucosa (oesophagus - Barrett's metaplasia/dysplasia; stomach - gastric mucosal dysplasia). Adenocarcinoma is usually ulcerated with irregular rolled margins or polypoid, and histologically tubular or papillary with an intestinal glandular pattern, but sometimes of diffuse signet ring cell type. Treatment of choice for locally confined disease is primary surgical resection supplemented by chemotherapy if indicated by subsequent pathological staging of the resection specimen. Current clinical trials are examining whether preoperative chemotherapy has any role to play.

Other features: oesophageal cancer tends to show multifocality (15-20%). Examination of specimen proximal and distal surgical margins is therefore important. "Early" or superficial squamous carcinoma is confined to the mucosa or submucosa with or without regional lymph node involvement and is of better prognosis than "advanced" or deep muscle invasive carcinoma. Involvement of the perioesophageal CRM is partly dependent on individual patient anatomy but is also an indicator of extent of tumour spread, adequacy of surgical resection and potential local recurrence due to residual mediastinal disease.

Other cancers: rare but can include small cell carcinoma, malignant melanoma, leukaemia/ malignant lymphoma, metastatic cancer (e.g., lung or breast), leiomyosarcoma, and Kaposi's sarcoma (AIDS).

Prognosis: prognosis of oesophageal cancer is poor (five-year survival 5-15%) relating mainly to depth of spread and lymph node involvement, i.e., tumour stage, and involvement of longitudinal and circumferential excision margins. Early or superficial carcinoma does significantly better - 55% ^ 88% five-year survival depending on the depth of mucous membrane invasion.

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