PassFinals
Upper GI & Hepatobiliary Surgery

Oesophageal Cancer

Progressive dysphagia is an urgent cancer symptom: confirm oesophageal cancer with endoscopy and biopsy, stage it with CT and selected PET-CT, EUS or laparoscopy, then use histology, stage, fitness and MDT review to guide curative or palliative treatment.

In a nutshell

Progressive dysphagia is an urgent oesophageal-cancer symptom. Confirm with OGD and biopsy, stage with CT and selected PET-CT, EUS or laparoscopy, then use histology, stage, fitness, nutrition, biomarkers and MDT review to choose endoscopic, curative or palliative treatment.

Classic presentation

Progressive dysphagia, initially to solids and later liquids, with weight loss, food sticking or regurgitation and risk factors for reflux-related adenocarcinoma or tobacco/alcohol-related squamous carcinoma.

Key points

  • Dysphagia of any degree meets NICE suspected-cancer referral criteria; do not delay investigation for empirical reflux treatment.
  • Solids-before-liquids suggests progressive mechanical narrowing; dysphagia to solids and liquids from onset suggests a motility disorder.
  • OGD with biopsy confirms the lesion and histological subtype; CT stages the chest, abdomen and pelvis.
  • Offer PET-CT for people suitable for radical treatment except T1a disease; use EUS or staging laparoscopy only when the result changes management.
  • Selected T1a adenocarcinoma can be treated endoscopically; localised disease beyond T1N0 often needs perioperative chemotherapy or preoperative chemoradiotherapy plus specialist resection.
  • Palliative dysphagia may need immediate stenting, radiotherapy or systemic treatment, with nutrition, specialist palliative care and current biomarker-dependent NICE options considered alongside goals.

First-line investigation

Urgent OGD with biopsy after suspected-cancer referral, followed by CT staging and specialist MDT-directed PET-CT, EUS or laparoscopy where indicated.

Management

Refer dysphagia urgently

  • Use the suspected-cancer pathway for dysphagia of any degree and arrange urgent assessment sooner if fluids cannot pass, aspiration, bleeding or severe malnutrition is present.4,3

Confirm with OGD and biopsy

  • Arrange upper gastrointestinal endoscopy with biopsy to confirm malignancy, histological subtype, location and the degree of obstruction; do not delay for empirical reflux treatment.4,3

Stage and plan in MDT

  • Use CT and then PET-CT, EUS or staging laparoscopy according to radical-treatment suitability and whether the result changes management; bring the case to the specialist oesophago-gastric MDT.1

Match treatment to stage and subtype

  • Use endoscopic treatment for selected early disease, perioperative or preoperative treatment plus specialist resection for appropriate localised disease, and current NICE biomarker-guided systemic options or symptom-directed palliation for advanced disease.1,2

Protect nutrition and quality of life

  • Provide dietetic, clinical nurse specialist, psychosocial and palliative support throughout; relieve severe malignant dysphagia with a stent or radiotherapy according to urgency, impact, fitness and prognosis.1,3

Use symptom-led recurrence access

  • After curative treatment, explain recurrence symptoms and provide rapid MDT access if they occur; do not arrange routine clinical or radiological surveillance solely for recurrence in asymptomatic people without residual disease.1,2

Exam traps

  • Any dysphagia warrants a suspected-cancer pathway referral, even without weight loss or bleeding.
  • Barrett's oesophagus is linked to adenocarcinoma, whereas smoking and alcohol are classic squamous-cell risk factors; do not merge the two pathways.
  • EUS is not requested simply to distinguish T2 from T3 disease; it is used only if it will guide management.
  • For suspected T1a adenocarcinoma, NICE NG231 advises endoscopic resection for staging and does not advise CT or EUS before resection as routine staging steps.
  • Do not routinely give external-beam radiotherapy after a palliative stent; NICE limits consideration to selected bleeding contexts.
  • Asymptomatic patients with no evidence of residual disease after curative treatment should not have routine clinical or radiological surveillance solely to detect recurrence under NG83.

Illustrations

Obstructing oesophageal cancer on endoscopyEndoscopic view of an irregular ulcerated exophytic oesophageal carcinoma narrowing the lumen.Samir, Wikimedia Commons · CC-BY-SA-3.0
Staging CT showing distal oesophageal wall thickening (outlined) in oesophageal cancerCross-sectional CT and endoscopic ultrasound images demonstrating oesophageal wall thickening and locoregional lymph nodes used for staging.Tdvorak, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. NICE NG83: Oesophago-gastric cancer: assessment and management in adults (Current NICE guidance for staging, radical and palliative treatment, biomarker testing, nutritional support and follow-up; last updated 4 July 2023 and last reviewed 13 May 2026.)
  2. NICE NG231: Barrett's oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management (Current guidance for Barrett's surveillance and endoscopic staging and treatment of stage 1 oesophageal adenocarcinoma; last reviewed 1 May 2026, with surveillance recommendations under update review.)
  3. NHS: Oesophageal cancer (Current NHS information on symptoms, diagnostic tests, treatment choices, supportive care and follow-up for oesophageal cancer.)
  4. NICE NG12: Suspected cancer: recognition and referral (Current upper-GI referral criteria: suspected-cancer pathway for dysphagia of any degree, and for age 55 or over with weight loss plus upper abdominal pain, reflux or dyspepsia; recommendation amended 2025.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.