Oesophageal Carcinama and its ManagementCarcinoma of the Oesophagus remains one of the major killers in KwaZulu-Natal. In the indigent population in some areas, particularly near the Transkei the incidence is over 100 per100, 000 per year. The commonest tumours are squamous cell carcinomas. Presentation is generally when the disease is very advanced. Patients usually present in an emaciated, poorly nourished state. Because of the poor social conditions of these patients our main aim of treatment is to get the patient to be able to swallow. Prior to referral the patient should be counselled in order to ensure that the patient is willing to undergo invasive investigation to avoid stress for the patient and wastage of resources.
Treatment is by means of surgical resection, brachytherapy, external beam radiation or insertion of oesophageal/oesophago-gastric tubes.
Providing there are no clinical contra-indications all patients are investigated after contrast swallow by bronchoscopy, oesophagoscopy and tumour biopsy. At bronchoscopy, upper and middle third tumours frequently show evidence of bronchial invasion which should not be biopsied on the tracheal side because of the risk of forming a tracheo-oesophageal fistula, but rather biopsied in the oesophageal side. Brush cytology can be obtained from either site. Tracheal invasion precludes both surgical resection and radiation as therapies.
All patients who have no clinical or radiological evidence of extra-oesophageal tumour spread are assessed for operability on general grounds including adequate pulmonary function, serum albumen of over 28gm/L and either abdominal ultrasound or CT chest and abdomen. Surgery in the individual patient is tailored to the position of the tumour.
Patients felt suitable for brachytherapy (endo-luminal radiation) are referred to the Dept. of Radiotherapy at Inkhosi Albert Luthuli Central Hospital. This is reserved for tumours in the upper two thirds of the oesophagus who have no evidence of endo-bronchial spread at bronchoscopy. All patients referred for radiotherapy are required to have positive histology and all have their tumour dilated the day before surgery to facilitate the passage of the intra-oesophageal radiation carrier.
Patients unsuitable or unwilling to undergo the above treatments may be palliated with an intra-luminal tube. We use a Proctor-Livingstone tube placed either using rigid oesophagoscopy or fibreoptic oesophagoscope with radiological screening. If the oral-transoesophageal route can not be used then a Celestin Tube is inserted via the oropharynx with an accompanying laparotomy.