Esophageal Malignancy

I

Esophageal Anatomy

• 1.

  The esophagus is a muscular pump bordered by two sphincters, the upper esophageal sphincter (UES) and lower esophageal sphincter (LES). Its function is to transport food and liquids in a unidirectional movement, and it possesses no endocrine, exocrine, immunologic, digestive, absorptive, or secretory functions.

• 2.

  In contrast to the rest of the gastrointestinal (GI) tract, the esophagus has no serosa, thus reducing the resistance to local spread of invasive cancer cells.

II

Epidemiology

• 1.

  Cancers of the esophagus are 1% of newly diagnosed malignancies in the United States.

• 2.

  The median age of diagnosis in the United States is 67 years old.

• 3.

  Most patients present with advanced disease, and their survival remains poor (5-year survival rate of 18.4%).

• 4.

  In the United States, squamous cell carcinoma is declining in incidence and adenocarcinoma is increasing in incidence.

• 5.

  In the United States, adenocarcinoma is the most common esophageal cancer (70%–75% of esophageal cancers).

  • a.

    Incidence has increased by approximately 10% per year and is now 10 times what it was in 1976.

• 6.

  Worldwide, the incidence of squamous cell carcinoma is most common.

  • a.

    Endemic areas—northern China, South Africa, Iran, Russia, and India.

III

Histology and Risk Factors

• 1.

  Squamous cell carcinoma typically affects the proximal and mid esophagus, whereas adenocarcinoma typically affects the lower esophagus and gastroesophageal junction.

• 2.

  Adenocarcinoma is caused by chronic gastroesophageal reflux disease (GERD).

  • a.

    Barrett esophagus (intestinal metaplasia) is main risk factor for adenocarcinoma.

  • b.

    Barrett develops from GERD, which can lead to low-grade dysplasia (LGD), which can develop into high-grade dysplasia (HGD) and then invasive cancer.

  • c.

    Barrett esophagus portends a 50 times increased risk of cancer. Surveillance esophagogastroduodenoscopy (EGD) is recommended every 3–5 years after diagnosis .

  • d.

    LGD can regress with GERD treatment or can progress to HGD/cancer. Surveillance EGD is recommended every 6 months following diagnosis.

  • e.

    HGD—Treatment is recommended because 80% of patients will develop invasive cancer at 5 years. If surveillance is chosen, EGD is recommended every 3 months after diagnosis.

• 3.

  Risk factors for esophageal cancer ( Table 35.1 )

  TABLE 35.1

  Epidemiology of Esophageal Malignancy

  Data from Zhang Y. Epidemiology of esophageal cancer. World J Gastroenterol . 2013;19:5598–5606.

  Risk Factors	Squamous Cell Carcinoma	Adenocarcinoma
  First- or secondhand smoke	+++	++
  Alcohol consumption	+++	−
  Red meat consumption	+	+
  Barrett esophagus	−	++++
  Reflux symptoms	−	+++
  BMI >25	−	++
  Caustic injury	++++	−
  Head and neck CA history	++++	−
  Radiation history	+++	+++
  Hot beverage consumption	+	−

  −, No effect; +, suspicious effect; ++, positive effect; +++ and ++++, strong positive effect.

  BMI, Body mass index; CA, cancer.

IV

Diagnosis and Staging

• 1.

  Symptoms—Note that early cancers are generally asymptomatic.

  • a.

    Dysphagia (most common and classically described as progressing from solids to liquids)

  • b.

    Odynophagia/chest pain

  • c.

    Weight loss

  • d.

    Hematemesis

  • e.

    Dyspnea, cough, hoarseness, pain, and neurologic symptoms suggest advanced disease.

• 2.

  Diagnosis

  • a.

    Barium upper GI study

    • (1)

      Delineate the degree of esophageal compromise.

    • (2)

      Classic findings include polypoid tumors, strictures with mucosal irregularity, and “apple core” narrowing.

    • (3)

      Can identify tracheoesophageal fistulas

  • b.

    Flexible endoscopy (EGD) with biopsy is the primary method for the diagnosis of esophageal carcinoma.

    • (1)

      This determines location, degree of obstruction, and length and extent of circumferential involvement of the tumor.

    • (2)

      Multiple biopsies (6–8) should be performed on primary mass, as well as any additional suspicious lesions (submucosal spread or skip lesions can be present).

• 3.

  Staging—essential in choosing appropriate treatment plan

  • a.

    Use computed tomography (CT) of the chest and abdomen to evaluate for metastases/disseminated disease.

    • (1)

      If metastatic disease is present, treat nonoperatively with definitive chemoradiation therapy.

  • b.

    Positron emission tomography (PET) evaluates for occult metastatic disease.

  • c.

    Endoscopic ultrasonography (EUS) is used to determine depth of invasion (T stage).

    • (1)

      Local nodal involvement (N stage) can also be evaluated by EUS.

    • (2)

      EUS-directed needle biopsy of suspicious lymph nodes can be performed (EBUS = endobronchial ultrasound).

    • (3)

      Tumor depth helps to predict the probability of nodal involvement, which influences decision making for treatment approach . With increasing depth (T stage), the risk of regional lymph node involvement increases.

V