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For further information, see CMDT Part 41-09: 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 occur in the upper and middle third of the esophagus

    • Adenocarcinoma: most arise in the distal esophagus and gastroesophageal junction

  • Squamous cell cancer risk factors

    • Low socioeconomic status

    • Consumption of tobacco, alcohol, hot beverages, and nitrosamines

    • Poor nutritional status

    • Tylosis

    • Achalasia

    • Caustic-induced esophageal stricture

    • Other head and neck cancers

  • Adenocarcinoma risk factors

    • Age

    • Obesity

    • Smoking

    • Chronic gastroesophageal reflux disease with Barrett metaplasia

Demographics

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

  • Ratio of men to women is ∼4:1

  • About 20,640 new cases of and 16,410 deaths from esophageal cancer in 2022

  • Adenocarcinomas make up the majority of new cases of esophageal cancer in North America as well as Northern and Western European countries

  • In the United States squamous cell carcinoma is much more common in Black than in White adults

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

DIAGNOSIS

Laboratory Tests

  • Anemia related to chronic disease or occult blood loss

  • Elevated aminotransferase or alkaline phosphatase suggest hepatic or bony metastases

  • Hypoalbuminemia may signal malnutrition

Imaging Studies

  • Chest radiographs may show

    • Adenopathy

    • Widened mediastinum

    • Pulmonary or bony metastases

    • Signs of trachea-esophageal fistula (eg, pneumonia)

  • Barium esophagogram

    • May be first study obtained to evaluate dysphagia

    • Appearance of a polypoid, obstructive, or ulcerative lesion suggests carcinoma and requires endoscopic evaluation

    • Even lesions believed to be benign by radiography warrant endoscopic evaluation

  • For disease staging after confirmation of the diagnosis of esophageal carcinoma

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

  • Endoscopy with biopsy

    • Establishes diagnosis of esophageal carcinoma

    • Significant submucosal spread of the tumor may yield nondiagnostic mucosal biopsies in some cases

    • Repeat biopsy may be necessary

  • Endoscopic ultrasonography with guided fine-needle biopsy of suspicious lymph nodes is superior to CT for ...

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