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Stem
A 64-year-old overweight man presents with three months of progressive dysphagia — initially to solids and now to liquids — with odynophagia, regurgitation and 9 kg weight loss. He has a 25-year history of GORD and a 40-pack-year smoking history. On examination he is cachectic with no palpable lymphadenopathy. OGD shows an ulcerated, circumferential tumour at 38 cm (distal oesophagus); biopsy confirms moderately differentiated adenocarcinoma. CT chest/abdomen/pelvis shows a thickened distal oesophageal wall, no enlarged nodes, and no distant metastases.
Questions
a) What is the most likely diagnosis, what precursor lesion underlies it, and what is the next essential staging investigation? (2 marks)
Diagnosis: oesophageal adenocarcinoma (Siewert I) arising at the distal oesophagus / gastro-oesophageal junction. The underlying precursor lesion is Barrett's intestinal metaplasia (columnar reprogramming of the squamous mucosa, driven by CDX1/CDX2 in response to chronic acid reflux), progressing through low-grade and high-grade dysplasia to invasive adenocarcinoma. The next essential staging investigation is endoscopic ultrasound (EUS) to determine the depth of wall invasion (T-stage) and assess regional lymph nodes (N-stage) before deciding on neoadjuvant therapy.
b) Outline the complete staging pathway and what each modality contributes. (3 marks)
- OGD with biopsy — confirms diagnosis and histology.
- CT chest/abdomen/pelvis (contrast) — distant metastases (liver, lung), local invasion, M-staging.
- Endoscopic ultrasound (EUS) — T-stage (depth of wall invasion) and N-stage (regional nodes); critical before neoadjuvant therapy.
- PET-CT (18-FDG) — detects occult distant metastases missed by CT and aids response assessment.
- Staging laparoscopy with peritoneal washout — mandatory for gastric/GOJ adenocarcinoma; detects occult peritoneal disease missed on CT in 10 to 30 percent of patients. Positive cytology = M1.
c) Describe the standard neoadjuvant regimen (the CROSS trial) and the subsequent surgery. (2 marks)
The CROSS regimen (van Hagen, NEJM 2012) consists of weekly carboplatin (AUC 2) and paclitaxel (50 mg/m²) for 5 weeks with concurrent radiotherapy of 41.4 Gy in 23 fractions, followed by oesophagectomy at 6 to 8 weeks. CROSS improved R0 resection (92 percent vs 69 percent) and median overall survival (49 vs 24 months), with benefit in both squamous and adenocarcinoma histologies. The standard surgical approach is an Ivor Lewis (two-phase) oesophagectomy — laparotomy with gastric conduit formation, then right thoracotomy with intrathoracic anastomosis; minimally invasive (thoracoscopic/laparoscopic/robotic) approaches are now standard in many centres.
d) List the early and long-term complications of an oesophagectomy. (2 marks)
Early: anastomotic leak (5 to 15 percent), anastomotic stricture, gastric conduit necrosis (catastrophic), chylothorax (thoracic duct injury), recurrent laryngeal nerve palsy (hoarseness, aspiration), atrial fibrillation, and respiratory complications (atelectasis, pneumonia — the commonest cause of early mortality).
Long-term: reflux, dumping syndrome (early vasomotor, late hypoglycaemic), early satiety, and post-oesophagectomy malnutrition.
e) What is the significance of a Barrett's oesophagus surveillance programme, and how is high-grade dysplasia managed? (1 mark)
Barrett's surveillance (using the Prague C and M criteria to document extent) aims to detect dysplasia and early adenocarcinoma while still curable endoscopically. High-grade dysplasia and T1a adenocarcinoma are managed by endoscopic mucosal resection (EMR) of visible lesions plus radiofrequency ablation (RFA) of the residual Barrett's segment — achieving over 95 percent 5-year survival and obviating oesophagectomy for most mucosal disease.