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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: most (90%) occur in the distal two-thirds of the esophagus

    • Adenocarcinoma: most arise near the gastroesophageal junction

  • Squamous cell carcinoma is associated with

    • Smoking

    • Alcohol

    • Poor nutritional status

    • Drinking hot beverages

  • Risk of squamous cell cancer is also increased in patients with

    • Tylosis (rare disease manifested by hyperkeratosis of the palms and soles)

    • Achalasia

    • Caustic-induced esophageal stricture

    • Other head and neck cancers

  • Adenocarcinoma is associated with

    • Barrett metaplasia due to chronic gastroesophageal reflux

    • Obesity

    • Gastroesophageal reflux disease

Demographics

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

  • Ratio of men to women is 3:1

  • About 17,650 new cases of esophageal cancer were diagnosed in the United States in 2019

  • Squamous cell carcinoma accounts for over 90% of cases of esophageal cancer in Eastern and Southeast Asia and Sub-Saharan Africa

  • Adenocarcinoma is more common in North America and Northern and 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 ...

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