Esophageal cancer (EC) is the eighth most common type of cancer worldwide and affects men more than women (3:1 ratio). The two main forms are esophageal adenocarcinoma and squamous cell carcinoma. Esophageal adenocarcinomas are among the neoplasms with the fastest increasing incidence in northern and western Europe and North America, while squamous cell carcinoma is the most common form worldwide. Adenocarcinoma, which usually affects the lower third of the esophagus, may be preceded by gastroesophageal reflux disease and Barrett esophagus. Other risk factors include smoking and obesity. Risk factors for squamous cell carcinoma include carcinogen exposure (e.g., in the form of alcohol and tobacco) and a diet high in nitrosamines but low in fruits and vegetables. Locally advanced disease is common at the time of diagnosis because EC is typically asymptomatic early in the disease course. Symptomatic patients may experience weight loss, dyspepsia, progressive dysphagia, cervical adenopathy, hoarseness or persistent cough, and signs of upper gastrointestinal bleeding, such as hematemesis, melena, or anemia. Esophagogastroduodenoscopy (EGD) is used to directly visualize the lesion and obtain a biopsy sample for histopathological confirmation. Staging of the tumor involves CT scan of the chest and abdomen, a PET scan, and often transesophageal endoscopic ultrasound (EUS). Curative surgical resection may be considered for locally invasive cancers, but EC is unresectable in approximately 60% of patients at the time of diagnosis. For patients with unresectable disease, treatment options include chemotherapy, radiation, and palliative stenting. Prognosis is generally poor because of the aggressive nature of EC and oftentimes late diagnosis.
- Sex: ♂ > ♀ (3:1) 
- Incidence: an estimated 20,640 new cases of esophageal cancer will be diagnosed in 2022 in the United States 
- Median age of onset: : between 60 and 70 years of age
- Adenocarcinoma: : most common type of esophageal cancer in the US 
- Squamous cell carcinoma (SCC): most common type of esophageal cancer worldwide 
Adenocarcinoma is more common in the US of America.
Epidemiological data refers to the US, unless otherwise specified.
Exogenous risk factors
- Smoking (twofold risk)
Endogenous risk factors
- Male sex
- Older age (50–60 years)
- Gastroesophageal reflux
- Localization: mostly in the lower third of the esophagus
Squamous cell carcinoma (SCC) 
- Exogenous risk factors
Endogenous risk factors
- Male sex
- Older age (60–70 years)
- African American descent
- Diverticula (e.g., )
- Localization: : mostly in the upper two-thirds of the esophagus
Siewert classification of adenocarcinoma of the esophagogastric junction 
- Based on the location of the tumor in relation to the
- Siewert type I and II tumors are managed as esophageal cancer. 
|Overview of Siewert classification |
Siewert type I
|Siewert type II|
|Siewert type III|
Early stages 
- Often asymptomatic
- May manifest with dysphagia or retrosternal discomfort
Advanced stages 
- General signs
- Signs of advanced disease
- Signs of upper gastrointestinal bleeding
Initially, esophageal cancer is often asymptomatic. It typically becomes symptomatic at advanced stages.
- Patients with both clinical features and
Barium swallow 
- Characteristic stenosis and proximal dilatation (apple core lesion)
- Asymmetrical and irregular esophagal borders
Staging investigations 
Consider the following studies in consultation with a multidisciplinary team.
- Routine studies 
- Additional studies
Once the diagnosis is confirmed, EC should be staged to determine management. The American Joint Committee for Cancer (AJCC) TNM classification is currently the standard staging system used in clinical practice.
AJCC staging (8th Edition, 2017) 
- Carcinoma arises in context of Barrett esophagus (columnar epithelium with goblet cells) and high-grade dysplasia
- Gland-forming tumors with different possible growth patterns (tubular, papillary, tubulopapillary)
- Mucinous differentiation possible
- Breakdown of uniform tissue structure
- Squamous cell carcinoma clusters with circular keratinization
- Lymphocytic infiltration between the carcinoma clusters
- should be utilized if available.
- The treatment approach should be guided by shared decision-making and the patient's .
- Treatment goals 
- See “ .”
Surgical resection 
- Endoscopic submucosal resection for mucosal lesions 
Subtotal or total esophagectomy
- Indications: localized or resectable locally advanced disease
- Options include: gastric pull-through procedure, colonic interposition
- Neoadjuvant chemoradiotherapy
Chemoradiotherapy with or without targeted therapies
- Indication: unresectable or metastatic disease
- Common regimens
Other interventional therapy 
- Endoscopic placement of self-expanding metal stents for palliation of dysphagia and fistulae
- Gastrojejunostomy (GJ) tube for 
- Esophageal stenosis
- Tracheoesophageal fistula → passage of food and fluid into the respiratory tract → ↑ risk of aspiration pneumonia
- Metastasis, e.g.: 
- Surgical complications
- Functional gastrointestinal disorders
We list the most important complications. The selection is not exhaustive.
- Prognosis is generally poor due to an aggressive course (due to an absent serosa in the esophageal wall) and typically late diagnosis. 
- The Surveillance, Epidemiology, and End Results (SEER) database tracks survival rates for patients with EC in the United States.
|Estimated survival of patients diagnosed with EC between 2012–2018 |
|SEER stage||5-year relative survival rate|
|Combined (any stage)|| |