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  • Progressive dysphagia to solid food.

  • Weight loss common.

  • Endoscopy with biopsy establishes diagnosis.


Esophageal cancer usually develops in persons between 50 and 70 years of age. There were an estimated 20,640 new cases and 16,410 deaths from esophageal cancer in the United States in 2022. The ratio for new cases in men versus women is approximately 4:1 (16,510 in men, 4130 in women); for deaths in men versus women it is ∼ 4:1 (13,250 in men, 3160 in women). There are two histologic types: squamous cell carcinoma and adenocarcinoma, and their incidence has significant geographic variation. Squamous cell carcinoma (SCC) 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 41–1). 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 41–2), 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.

eFigure 41–1.

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.)

eFigure 41–2.

An exophytic mass in visualized in the distal esophagus. Biopsies confirmed poorly differentiated squamous cell carcinoma. (Used, with permission, from Yao-Wen Cheng, MD.)


A. Symptoms and Signs

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 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 tracheoesophageal fistula, characterized by coughing on swallowing or by pneumonia. Chest or back ...

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