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ESSENTIALS OF DIAGNOSIS

  • Progressive dysphagia to solid food.

  • Weight loss common.

  • Endoscopy with biopsy establishes diagnosis.

GENERAL CONSIDERATIONS

Esophageal cancer usually develops in persons between 50 and 70 years of age. There were an estimated 17,920 new cases of esophageal cancer in 2018. The overall ratio of men to women is 3:1. There are two histologic types: squamous cell carcinoma and adenocarcinoma (eFigure 39–1). Squamous cell carcinoma is common in Eastern Europe and Asia while adenocarcinoma is more common in North America and most Western European countries. In the United States, squamous cell carcinoma is much more common in blacks than in whites. Most (90%) squamous cell carcinomas occur in the distal two-thirds of the esophagus. Chronic alcohol and tobacco use are strongly associated with an increased risk of squamous cell carcinoma. The risk of squamous cell cancer is also increased in patients with tylosis (a rare disease transmitted by autosomal dominant inheritance and manifested by hyperkeratosis of the palms and soles), achalasia, caustic-induced esophageal stricture, and other head and neck cancers. Adenocarcinoma is more common in whites. Its incidence is increasing dramatically, and it is now more common than squamous cell carcinoma in the United States. The majority of adenocarcinomas develop as a complication of Barrett metaplasia due to chronic gastroesophageal reflux. Thus, most adenocarcinomas arise near the gastroesophageal junction. Obesity also is strongly associated with adenocarcinoma, even after controlling for gastroesophageal reflux.

eFigure 39–1.

Esophageal adenocarcinoma: Note the ulcerated mass with fungating heaped up borders in this esophageal mass seen in the lower end of the esophagus. (Used with permission from Michelle Nazareth, MD.)

CLINICAL FINDINGS

A. Symptoms and Signs

The majority (50–60%) of patients with esophageal cancer present with advanced, incurable disease. While early symptoms are nonspecific and subtle, over 90% eventually have solid food dysphagia, which progresses over weeks to months. Odynophagia is sometimes present. Significant weight loss is common. Local tumor extension into the tracheobronchial tree may result in a tracheo-esophageal fistula, characterized by coughing on swallowing or by pneumonia. Chest or back pain suggests mediastinal extension. Recurrent laryngeal nerve involvement may produce hoarseness. Physical examination is often unrevealing. The presence of supraclavicular or cervical lymphadenopathy or of hepatomegaly implies metastatic disease.

B. Laboratory Findings

Laboratory findings are nonspecific. Anemia related to chronic disease or occult blood loss is common. Elevated aminotransferase or alkaline phosphatase concentrations suggest hepatic or bony metastases. Hypoalbuminemia may result from malnutrition.

C. Imaging

A barium esophagogram may be the first study obtained to evaluate dysphagia. The appearance of a polypoid, obstructive, or ulcerative lesion is suggestive of carcinoma and requires endoscopic evaluation. However, even lesions believed to be benign by radiography warrant endoscopic evaluation. Chest radiographs may show ...

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