Esophageal Cancer

For further information, see CMDT Part 39-09: Esophageal Cancer

Key Features

Essentials of Diagnosis

• Progressive dysphagia to solid food

• Weight loss

• Endoscopy with biopsy establishes diagnosis

General Considerations

• Two histologic types

  • Squamous cell carcinoma: occurs throughout esophagus; half occur in distal third

  • Adenocarcinoma: most arise near the gastroesophageal junction

• Squamous cell cancer risk factors

  • Chronic alcohol and tobacco use

  • Tylosis

  • Achalasia

  • Caustic-induced esophageal stricture

  • Other head and neck cancers

• Adenocarcinoma risk factors

  • Barrett metaplasia due to chronic gastroesophageal reflux

  • Obesity

Demographics

• Occurs usually in persons between 50 and 70 years of age

• Ratio of men to women is 3:1

• About 17,920 new cases of esophageal cancer were diagnosed in 2018

• Squamous cell carcinoma is common in Eastern Europe and Asia

• Adenocarcinoma is more common in North America and most Western European countries

Clinical Findings

Symptoms and Signs

• Solid food dysphagia (> 90%)

• Odynophagia

• Significant weight loss

• Coughing on swallowing or recurrent pneumonia suggests tracheoesophageal fistula from local tumor extension

• Chest or back pain suggest mediastinal extension

• Hoarseness suggests recurrent laryngeal nerve involvement

• Physical examination often unrevealing

• Supraclavicular or cervical lymphadenopathy or hepatomegaly suggests metastatic disease

Differential Diagnosis

• Peptic stricture

• Achalasia

• Adenocarcinoma of gastric cardia with esophageal involvement

• Esophageal web, ring (eg, Schatzki), or diverticulum

Diagnosis

Laboratory Tests

• Anemia related to chronic disease or occult blood loss

• Elevated aminotransferase or alkaline phosphatase suggest hepatic or bony metastases

• Hypoalbuminemia

Imaging Studies

• Chest radiographs may show adenopathy

• Barium esophagogram

• Contrast CT of the chest and abdomen to look for evidence of pulmonary or hepatic metastases, lymphadenopathy, and local tumor extension

• Positron emission tomography with fluorodeoxyglucose (FDG-PET) or integrated PET-CT imaging is indicated to look for regional or distant spread in patients thought to have localized disease after other diagnostic studies

Diagnostic Procedures

• Upper endoscopy with biopsy

• Endoscopic ultrasonography with guided fine-needle aspiration (FNA) of lymph nodes is superior to CT for evaluating local extension and lymph node involvement

• Bronchoscopy may be required to exclude tracheobronchial extension

• Laparoscopy to exclude occult peritoneal carcinomatosis should be considered in tumors at gastroesophageal junction

Treatment

Medications

• Chemotherapy (cisplatin and fluorouracil) plus radiation therapy for patients with “curable” disease who are poor surgical candidates

• Combination chemotherapy may be considered in those patients with metastatic disease who still have good functional status and expected survival of at least several months

  • For patients with poor functional status, single-agent therapy with a fluoropyrimidine, a taxane, or irinotecan may be used

  • Trastuzumab may be added to standard regimens when patients have metastatic distal esophageal and gastroesophageal junction adenocarcinomas positive for amplification ...