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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 ...

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