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Esophageal cancer

Last updated: March 20, 2020

Summary

Esophageal cancer typically assumes the form of adenocarcinoma or squamous cell carcinoma, although there are some rarer tumors. Adenocarcinomas are considered the fastest-growing neoplasia in Western countries, while squamous cell carcinoma is still most common in the developing world. Adenocarcinoma, which usually affects the lower third of the esophagus, may be preceded by Barrett's esophagus, a complication of gastroesophageal reflux disease (GERD). In addition to GERD, other risk factors include obesity and smoking. Squamous cell carcinomas mostly occur in the upper two-thirds of the esophagus. Known risk factors for squamous cell carcinoma include carcinogen exposure from alcohol and tobacco consumption, and dietary factors (e.g., diet low in fruits and vegetables). Esophageal cancers are often asymptomatic in early stages of the disease. Locally advanced disease is common at presentation, progressive dysphagia being the primary symptom. Hoarseness, weight loss, and hematemesis may also be present. Endoscopy is the primary diagnostic test, enabling direct visualization and biopsy of the lesion for histopathological confirmation. Curative surgical resection may be considered for locally invasive cancers. Esophageal cancer is unresectable at presentation in about 60% of patients. Chemotherapy, radiation, and palliative stenting play a role in the management of unresectable disease.

Epidemiology

Adenocarcinoma is more common in the US of America.

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Adenocarcinoma

Squamous cell carcinoma (SCC)

The primary risk factors for squamous cell esophageal cancer are alcohol consumption, smoking, and dietary factors (e.g., diet low in fruits and vegetables)!

References:[4][6]

Clinical features

  • Early stages: Often asymptomatic but may present with swallowing difficulties or retrosternal discomfort
  • Late stages

Esophageal cancer is a "silent" disease and typically becomes symptomatic at advanced stages!

References:[3][6][7][8]

Diagnostics

References:[2][3][8][9]

Pathology

Adenocarcinoma

Squamous cell carcinoma

Treatment

Curative

Palliative

  • Indication: patients with advanced disease (majority of patients)
  • Methods:

References:[1][3][9][10][11][12][13]

Complications

References:[6][9][13][14]

We list the most important complications. The selection is not exhaustive.

Prognosis

  • Generally poor prognosis due to an aggressive course (due to an absent serosa in the esophageal wall) and typically late diagnosis [1][8]
  • The more distal the tumor, the better the prognosis

Esophageal cancer has an aggressive course and metastasizes early because of the absence of serosa in parts of the esophagus!References:[1][8]

References

  1. Berry MF. Esophageal cancer: staging system and guidelines for staging and treatment. Journal of Thoracic Disease. 2014; 6 (Suppl 3): p.S289-97.
  2. Saltzman JR, Gibson MK. Diagnosis and staging of esophageal cancer. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/diagnosis-and-staging-of-esophageal-cancer.Last updated: January 9, 2014. Accessed: January 3, 2017.
  3. Baldwin KM. Esophageal Cancer. In: Espat NJ, Esophageal Cancer. New York, NY: WebMD. http://emedicine.medscape.com/article/277930. Updated: December 11, 2016. Accessed: January 3, 2017.
  4. Gibson MK. Epidemiology, pathobiology, and clinical manifestations of esophageal cancer. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/epidemiology-pathobiology-and-clinical-manifestations-of-esophageal-cancer.Last updated: September 9, 2016. Accessed: January 3, 2017.
  5. Ribeiro U, Posner MC, Safatle-ribeiro AV, Reynolds JC. Risk factors for squamous cell carcinoma of the oesophagus. British Journal of Surgery . 1996; 83 (9): p.1174-85.
  6. Straif K, Weiland SK, Bungers M et al. Exposure to high concentrations of nitrosamines and cancer mortality among a cohort of rubber workers. Occupational and Environmental Medicine. 2000; 57 (3): p.180-187. doi: 10.1136/oem.57.3.180 . | Open in Read by QxMD
  7. Layke JC, Lopez PP. Esophageal Cancer: A Review and Update. Am Fam Physician. 2006; 73 (12): p.2187-2194.
  8. Varghese TK, Hofstetter WL, Rizk NP et al. The society of thoracic surgeons guidelines on the diagnosis and staging of patients with esophageal cancer. The Annals of Thoracic Surgery. 2013; 96 (1): p.346-56. doi: 10.1016/j.athoracsur.2013.02.069 . | Open in Read by QxMD
  9. Heron DE, Gibson MK. Management of locally advanced unresectable and inoperable esophageal cancer. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/management-of-locally-advanced-unresectable-and-inoperable-esophageal-cancer.Last updated: September 16, 2016. Accessed: January 4, 2017.
  10. Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015; 47 (9): p.829-54. doi: 10.1055/s-0034-1392882 . | Open in Read by QxMD
  11. Holzheimer RG, Mannick JA, Sayek I, Onat D, Lerut T. Surgical Treatment: Evidence-Based and Problem-Oriented. W. Zuckschwerdt Verlag GmbH. ; 2001
  12. Maple JT, Abu Dayyeh BK, Chauhan SS, et al. Endoscopic submucosal dissection: Technology Status Evaluation Report . Gastrointestinal Endoscopy. 2015; 81 (6): p.1311-1325. doi: 10.1016/j.gie.2014.12.010 . | Open in Read by QxMD
  13. Enzinger PC, Mayer RJ. Esophageal Cancer. The New England Journal of Medicine. 2003; 349 (23): p.2241-2252. doi: 10.1056/NEJMra035010 . | Open in Read by QxMD
  14. Baron TH, Law R. Use of expandable stents in the esophagus. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/use-of-expandable-stents-in-the-esophagus.Last updated: December 15, 2016. Accessed: January 4, 2017.
  15. Raymond DP. Complications of esophageal resection. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/complications-of-esophageal-resection.Last updated: January 19, 2016. Accessed: January 4, 2017.