Oesophageal Cancer
Squamous cell carcinoma arises from chronic mucosal irritation of the upper/mid oesophagus, while adenocarcinoma arises from Barrett's metaplasia driven by chronic acid reflux in the lower oesophagus, and both narrow the lumen from within to produce progressive dysphagia, solids before liquids.
In a nutshell
Squamous cell carcinoma follows chronic mucosal irritation of the upper/mid oesophagus; adenocarcinoma follows Barrett's metaplasia from chronic reflux in the lower oesophagus. Both narrow the lumen progressively, which is why dysphagia moves from solids to liquids and why any dysphagia triggers urgent same-pathway investigation.
Classic presentation
Progressive dysphagia, first for solids then liquids, with unintentional weight loss, in a patient with longstanding reflux or a smoking and alcohol history.
Key points
- Squamous cell carcinoma arises from direct mucosal irritation (smoking, alcohol); adenocarcinoma arises from Barrett's metaplasia driven by chronic GORD.
- Progressive solids-then-liquids dysphagia reflects worsening mechanical luminal narrowing, unlike motility disorders which affect both from the start.
- Absence of a serosal layer and a rich submucosal lymphatic network mean early local invasion and nodal spread, so disease is often advanced at diagnosis.
- Any dysphagia warrants urgent two-week-wait referral for OGD, regardless of other features.
- EUS refines T and N staging beyond CT; PET-CT/staging laparoscopy excludes occult metastases before committing to surgery.
First-line investigation
Urgent upper GI endoscopy (OGD) with biopsy to visualise the tumour and confirm histological subtype.
First-line management
Urgent two-week-wait referral for OGD, then full staging and MDT-guided neoadjuvant therapy plus oesophagectomy if resectable, or palliative treatment if not.
Exam traps
- Do not attribute new dysphagia to reflux or anxiety without endoscopy: any dysphagia meets 2ww criteria.
- Solids-before-liquids progression points to a mechanical cause; both-from-the-start dysphagia suggests a motility disorder instead.
- Barrett's oesophagus is a risk factor for adenocarcinoma specifically, not squamous cell carcinoma. Do not conflate the two mechanisms.
Educational content pending clinical review. Not medical advice.