Esophageal Cancer

Snapshot

A 62-year-old man presents to the physician with complaint of fatigue and weight loss. His wife noted that he has looked thinner in the past few months, at which point he weighed himself and noted that he had unintentionally lost 10 pounds in the past few months. He has also had increased difficulty swallowing his food with occasionally choking. He has a history of alcohol use disorder and has smoked 1 pack of cigarettes daily for the past 40 years. An upper endoscopy is performed and demonstrates the finding seen in the image.

Introduction

Overview
- malignancy affecting the esophagus
  - most cases of esophageal malignant tumors are due to squamous cell carcinoma and adenocarcinoma
Epidemiology
- incidence
  - adenocarcinoma > squamous cell carcinoma in Western countries
    - adenocarcinoma accounts for > 60% of all esophageal cancers in the United States
  - squamous cell carcinoma is the predominant type of esophageal cancer worldwide
- demographics
  - most common > 50 years of age
  - men > women
- location
  - distal esophagus
    - adenocarcinoma
  - middle esophagus
    - squamous cell carcinoma
- risk factors
  - smoking
    - associated with squamous cell carcinoma
  - alcohol consumption
    - associated with squamous cell carcinoma
  - Barrett esophagus
    - associated with adenocarcinoma
  - gastroesophageal reflux disease
    - associated with adenocarcinoma
  - Plummer-Vinson syndrome
    - associated with squamous cell carcinoma
Prognosis
- negative factors
  - increased grade of tumor
metastasis to other areas of the body

Presentation

History
- patients often complain of difficulty swallowing solids that progresses to difficulty swallowing liquids
Symptoms
- progressive dysphagia
- unintentional weight loss
- bleeding
- epigastric or retrosternal pain
- hoarseness
- persistent cough
Physical exam
- typically normal exam unless the cancer has metastasized
cervical or supraclavicular lymphadenopathy (indicating metastasis)

Studies

Upper gastrointestinal endoscopy
- allows for direct visualization and biopsies if a tumor is present
Histology
- squamous cell carcinoma
  - keratinocyte-like cells with intercellular bridges or keratinization
- adenocarcinoma
well or moderately differentiated intestinal-type mucosa cells with well-formed tubular or papillary structures

Differential

Treatment

Medical
- chemoradiation
  - indication
    - stage I-III disease
- systemic chemotherapy with palliative care
  - indication
    - stage IV disease
    - patients who are not candidates for surgery
Surgical
- endoscopic mucosal resection
  - indication
    - stage I-III disease
- esophagectomy or esophagogastrectomy
  - indication
high-grade dysplasia in a patient with Barrett esophagus that cannot be adequately treated with endoscopic resection

Complications

Esophageal obstruction
Metastasis
- distant metastasis typically to the liver, lungs, and adrenal glands