ESOPHAGEAL CANCER

Etiology
Adenocarcinoma [4]

● Exogenous risk factors

o Smoking (twofold risk)
o Obesity
● Endogenous risk factors
o Male sex
o Older age (50–60 years)
o Gastroesophageal reflux
o Barrett esophagus
● Localization: mostly in the lower third of the esophagus
The most important risk factors for
esophageal adenocarcinoma are gastroesophageal reflux and associated Barrett
esophagus.

Squamous cell carcinoma (SCC) [4][5]

● Exogenous risk factors

o Alcohol consumption
o Smoking (ninefold risk)
o Diet low in fruits and vegetables
o Hot beverages
o Nitrosamines exposure (e.g., cured meat, fish, bacon) [6]
o Caustic strictures
o HPV
o Helicobacter pylori infection
o Radiotherapy
o Betel or areca nut chewing
o Esophageal candidiasis [8][9]
● Endogenous risk factors
o Male sex
o Older age (60–70 years)
o African American descent
o Plummer-Vinson syndrome
o Achalasia
o Diverticula (e.g., Zenker diverticulum)
o Tylosis
● Localization: mostly in the upper two-thirds of the esophagus
The primary risk factors for squamous cell esophageal cancer
are alcohol consumption, smoking, and dietary factors (e.g., diet low in fruits and
vegetables).

Clinical features
Early stages [4]

● Often asymptomatic
● May manifest with dysphagia or retrosternal discomfort

Advanced stages [4]

● General signs
o Unintentional weight loss
o Dyspepsia
o Signs of anemia
● Signs of advanced disease
o Progressive structural dysphagia (from solids to liquids) with
possible odynophagia
o Retrosternal chest or back pain
o Cervical adenopathy
o Hoarseness and/or persistent cough
o Horner syndrome
● Signs of upper gastrointestinal bleeding
o Hematemesis
o Melena
Initially, esophageal cancer is often asymptomatic. It typically becomes symptomatic
at advanced stages.

SPREAD
1. Local Spread
● When the trachea is involved, trachea-oesophageal fistula develops
from carcinoma upper 1/3rd of esophagus
● Broncho-oesopahgeal fistula from carcinoma middle 1/3 rd
2. Lymphatic Spread
● Patients having metastasis to 5 or fewer lymph nodes have a better
outcome
● Palpable left supraclavicular nodes indicate advanced disease (trosier’s
sign)
3. Blood Spread
 ● It results in secondaries in the liver, which clinically appear as nodular
enlarged liver
● Later, ascites and retro vesical deposits occur

Diagnostics
Esophagogastroduodenoscopy (EGD) with biopsy is the best initial and confirmatory
test in patients with suspected esophageal cancer. [12][13]

EGD [14]

● Indications
o Red flags for dysphagia
o Patients with both clinical features and risk factors for EC
● Uses
o Direct visualization of the tumor
o Biopsy of any suspicious lesions

Barium swallow [12]

● Indications
o Severe esophageal strictures
o Suspected tracheoesophageal fistula
● Findings
o Characteristic stenosis and proximal dilatation (apple core lesion)
o Asymmetrical and irregular esophagal borders

Staging investigations [12]

● Routine studies [15]

o CT chest and abdomen with IV contrast
o FDG-PET/CT
o Transesophageal EUS with fine-needle aspiration biopsy
● Additional studies
o Bronchoscopy: for lesions at or above the tracheal carina to rule
out airway involvement
o Laparoscopy: to increase staging accuracy in adenocarcinoma of
the gastroesophageal junction
AJCC staging (8th
Edition)
Pathology

Adenocarcinoma
● 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

Squamous cell carcinoma [17]

● Breakdown of uniform tissue structure

● Squamous cell carcinoma clusters with circular keratinization
● Lymphocytic infiltration between the carcinoma clusters

Treatment
General principles
● Treatment goals [4]
o Curative for patients with:
▪ High-grade metaplasia in Barrett esophagus
▪ Localized lesions that have not infiltrated surrounding
structures
o Palliative for patients with unresectable locally advanced
or metastatic cancer
● See “Principles of cancer care.”

Surgical resection [18]

● Endoscopic submucosal resection for mucosal lesions [19]

● Subtotal or total esophagectomy
o Indications: localized or resectable locally advanced disease
o Options include: gastric pull-through
procedure, colonic interposition
Chemoradiotherapy [18][20]

● Neoadjuvant chemoradiotherapy
● Chemoradiotherapy with or without targeted therapies

Other interventional therapy [13]

● Endoscopic placement of self-expanding metal stents for palliation

of dysphagia and fistulae
● Gastrojejunostomy (GJ) tube for specialized nutrition support

Complications
Cancer-associated complications
● Esophageal stenosis
● Tracheoesophageal fistula → passage of food and fluid into the
respiratory tract → ↑ risk of aspiration pneumonia
● Metastasis, e.g.: [13]
o Squamous cell carcinoma → lungs and thorax
o Adenocarcinoma → liver, peritoneum, bones

Treatment-associated complications
● Surgical complications
o Anastomotic leak or stricture
o Recurrent laryngeal nerve injury
● Functional gastrointestinal disorders
o Dysphagia
o Reflux
o Dumping syndrome

PROGNOSIS

It is generally poor due to an aggressive course and typically late diagnosis

⮚ LOCALIZED to esophagus – 5yr survival rate(47%)

⮚ REGIONAL lymph nodes – 5yr survival rate(26%)
⮚ DISTANT organs/lymph nodes – 5yr survival rate(6%)