Editing Oesophageal cancer (section)

== '''General stage-based approach''' ==

* As of 2024, no consensus on     whether to treat SCC and AC any differently
* '''Pre-treatment     optimisation is vital'''
** Nutritional assessment and      management, including enteral access if required - NGT through tumour on      diagnosis if unable to tolerate pureed/solids. 60% of newly-diagnosed      upper GI cancer have malnutrition.
** Management of other      comorbidities
* Mucosa-only cancer ('''TisN0M0''' and '''HGD''') - intensive surveillance vs     endoscopic ablation vs oesophagectomy
** See separate topic under      'Barrett's oesophagus'
** Current best option probably      endoscopic in the first instance
* '''T1aN0M0'''
** Only 2% lymph node mets (not      much lymphoid tissue in lamina propria/muscularis mucosae)
** Can usually be treated with      EMR
*** Better with lesions <2cm
*** Indicated in nodular or       raised Barrett's or other findings suspicious of superficial invasive       cancer
*** Resects down to submucosa
*** Does not address the       potential for nodal disease (need to assess risk of nodal mets using       nomogram above)
** Higher-risk T1a lesions      (larger tumours or lymphovascular invasion) or extensive multifocal      lesions/ulcerated tumours could be considered for oesophagectomy
* '''T1bN0M0''' - oesophagectomy generally     best due to abundance of lymphoid tissue in the submucosa
** Up to 20% lymph node      metastasis risk - probably should go back and do oesophagectomy if this      is the final EMR diagnosis
** However low-risk sm1 may be      able to have oesophagus-sparing therapy, with 84% five-year survival rate
*** Needs intense high-dose       PPI, H2 blockers, and sucralfat, with 3-monthly endoscopy for the first       year
** EMR not considered adequate      for sm2 and above due to risk of missing nodal mets
** Generally, give neoadjuvant      therapy
* '''T2-4a''', any N, M0 ('locally     advanced')
** Easy to get locoregional      control with oesophagectomy, but rates of death from distant recurrence      or metastasis continue to be high
** Neoadjuvant CTX followed by      surgery 5-7 weeks later is best strategy
** Restage with CT after CTX
** Clinical T2N0 is somewhat      controversial
*** Many have node-positive       disease in histopathology after oesophagectomy
*** One strategy is to       selectively offer neoadjuvant CTX based on the pretest probability of       upstaging (long tumours >3cm, presence of lymphovascular invasion,       and high-grade tumours indicate likely to upstage)
* '''T4b or any     M1''' - palliative     - consider palliative chemoradiotherapy
** Endoscopic palliation -      self-expanding stents