Key Clinical Updates in Esophageal Cancer
For patients who complete neoadjuvant chemoradiation and undergo a complete resection but are found to have residual cancer in the resection specimen, a year of adjuvant immunotherapy with nivolumab is recommended.
Ahmed O et al. Clin Gastroenterol Hepatol. [PMID: 33813072]
Esophageal cancer usually develops in persons between 50 and 70 years of age. There were an estimated 19,260 new cases and 15,530 deaths from esophageal cancer in the United States in 2021. The ratio for new cases in men versus women is approximately 4:1. (15,310 in men, 3,950 in women); and for deaths in men versus women is ~ 4:1 (12,410 in men, 3,120 in women). There are two histologic types: squamous cell carcinoma and adenocarcinoma, and their incidence has significant geographic variation. Squamous cell carcinoma is associated with low socioeconomic status; consumption of tobacco, alcohol, hot beverages, and nitrosamines; and poor nutritional status. It accounts for over 90% of cases of esophageal cancer in Eastern and Southeast Asia and sub-Saharan Africa. Adenocarcinoma is associated with age; obesity; smoking; and chronic GERD with Barrett metaplasia (eFigure 39–1). Adenocarcinomas make up most new cases of esophageal cancer in North America and Northern and Western Europe. Most (90%) squamous cell carcinomas occur in the upper and middle third of the esophagus (eFigure 39–2), whereas adenocarcinomas are more common in the distal esophagus and gastroesophageal junction. In the United States, squamous cell carcinoma is much more common in Black than White adults. Additionally, in countries with lower incidence of squamous cell carcinoma, it is estimated that up to 90% of cases are due to modifiable risk factors such as smoking, alcohol, and diets low in fruits and vegetables. 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. There are conflicting data about whether HPV may play a role in the pathogenesis of some squamous cell carcinomas.
An ulcerated mass with submucosal extension is visible in the mid-esophagus amidst columnar epithelium (Barrett esophagus). Biopsies confirmed adenocarcinoma. (Used, with permission, from Yao-Wen Cheng, MD.)
An exophytic mass in visualized in the distal esophagus. Biopsies confirmed poorly differentiated squamous cell carcinoma. (Used, with permission, from Yao-Wen Cheng, MD.)
Approximately 30-40% of patients with esophageal cancer present with stage IV, “incurable” disease. While early symptoms are nonspecific and subtle, over 90% eventually have ...