Clinical Case: 67-year-old Man with Progressive Dysphagia and Weight Loss

2. Suspected Diagnosis

• Progressive dysphagia (initially solids, now liquids) — hallmark of mechanical obstruction
• Significant unintentional weight loss
• Older male patient

1. Further History and Signs to Elicit

Symptoms to Ask About

Signs to Elicit on Examination

3. Investigations

First-line

Panel A: Endoscopic view showing an irregular ulcerated mass narrowing the oesophageal lumen. Panel B: Barium swallow showing segmental mucosal irregularity and luminal narrowing with pre-stenotic dilatation — classic features of malignant infiltration.

Staging Investigations

4. Treatment Options (if Oesophageal Carcinoma Confirmed)

Curative Intent

Palliative/Non-Surgical Options

Summary Algorithm

Confirm diagnosis (OGD + biopsy)
        ↓
   Staging (CT + PET-CT + EUS)
        ↓
  ┌─────────────────┬──────────────────┐
Localised          Locally advanced    Metastatic/unfit
(T1–T2, N0)        (T3/T4, N+)
  ↓                    ↓                    ↓
Surgery or EMR   Neoadjuvant CRT     Palliative stent,
(early stage)    → surgery (if fit)   chemo, RT, immunotherapy
                 OR definitive CRT

Contraindications to Oesophagectomy

Oncological Contraindications (Unresectable Disease)

Patient-Related (Fitness) Contraindications

Contraindications Specific to Neoadjuvant Chemoradiotherapy

Practical Summary

1. Resectable tumour (T1–T3, no T4b, no M1) — AND
2. Adequate cardiopulmonary reserve (able to lose ~25% lung function post-operatively and survive a 4–8 hour operation)

Assessment of Your Management Plan

What to Add

• Neoadjuvant therapy (given before surgery) — this is now standard of care for locally advanced resectable disease, not just adjuvant (after surgery)
• Definitive chemoradiotherapy — for patients with resectable disease who are unfit for surgery, or cervical oesophageal tumours; can be curative on its own
• Endoscopic resection (EMR/ESD) — for very early stage (T1a) tumours only

• Nutritional support (nasogastric feeding, PEG tube)
• Best supportive care / hospice

Explanations of Each Treatment

CURABLE TREATMENTS

1. The Three Surgical Methods (Oesophagectomy)

Imagine the oesophagus is a blocked water pipe running from the basement (abdomen) through the walls (chest) to the top floor (neck). Ivor Lewis opens the basement and the wall. McKeown opens the basement, the wall, and the top floor. Transhiatal opens only the basement and top floor, reaching through without opening the wall.

2. Neoadjuvant Therapy (given BEFORE surgery)

• Shrink the tumour to make surgery easier and more likely to achieve clear margins
• Kill any microscopic spread early
• In some patients, the tumour completely disappears (pathological complete response) — these patients have the best outcomes

3. Adjuvant Therapy (given AFTER surgery)

4. Definitive Chemoradiotherapy (no surgery)

PALLIATIVE TREATMENTS (Incurable Disease)

5. Oesophageal Stenting (SEMS — Self-Expanding Metal Stent)

6. Palliative Chemotherapy

7. Palliative Radiotherapy

8. Laser Recanalisation

9. Nutritional Support

• Nasogastric (NG) tube — fine tube through the nose into the stomach
• PEG tube (Percutaneous Endoscopic Gastrostomy) — tube placed directly into the stomach through the skin
• Total parenteral nutrition (TPN) — feeding directly into a vein, bypassing the gut entirely

Revised Complete Management Framework

CONFIRMED OESOPHAGEAL CARCINOMA
           │
    ┌──────┴──────┐
 CURABLE        INCURABLE
(no metastases,  (M1, T4b, or
 resectable)      unfit)
    │                │
 FIT for surgery?   Palliative:
  ├── YES →          • Stenting
  │  Neoadjuvant     • Chemo/RT
  │  CRT → Surgery   • Laser
  │  (Ivor Lewis /   • Nutrition
  │  McKeown /       • Supportive
  │  Transhiatal)      care
  │  ± Adjuvant CRT
  │
  └── NO (poor fitness,
      cervical tumour) →
      Definitive CRT
      (curative intent)

What You Have — Assessment

What to Add or Improve

Under Curable — Section B (Adjuvant Therapy)

• Neoadjuvant therapy — given before surgery to shrink the tumour (this is now standard of care and arguably more important than adjuvant)
• Adjuvant therapy — given after surgery to eliminate residual disease

B) Neoadjuvant + Adjuvant Chemo/Radiotherapy

• Neoadjuvant CRT (chemo + radiotherapy given before surgery) — shrinks tumour, improves resectability, standard for locally advanced disease
• Adjuvant CRT (after surgery) — for high-risk histological findings post-operatively

Under Curable — Add Section C

• Definitive Chemoradiotherapy (no surgery) — for patients who are unfit for surgery or have cervical oesophageal tumours; given with curative intent, not just palliative

Under Palliative — Add These

• Palliative chemotherapy (systemic — slows disease progression)
• Palliative radiotherapy (shrinks tumour, relieves dysphagia/bleeding)
• Nutritional support — NG tube, PEG tube, or TPN (very important in practice)
• Best supportive care / hospice

Your Revised Complete Answer 4

• Modified Ivor Lewis
• McKeown (3-field oesophagectomy)
• Transhiatal oesophagectomy

• Metastasis to N2 nodes (coeliac, cervical, supraclavicular) or solid organs
• Invasion of adjacent structures (RLN, tracheobronchial tree, aorta, pericardium)
• Severe cardiovascular or respiratory comorbidities

• Shrinks tumour and improves surgical outcomes
• Standard for locally advanced resectable disease

• For high-risk features on post-operative pathology

• For patients unfit for surgery or cervical oesophageal tumours

• Intubation with Souttar tube or Celestin tube
• Expandable metal stents (SEMS)
• Endoscopic laser recanalisation
• Endoscopic bipolar diathermy
• Endoscopic argon-beam plasma coagulation
• Palliative chemotherapy
• Palliative radiotherapy
• Nutritional support (NG tube / PEG tube / TPN)
• Best supportive care