Esophageal Cancer

Aka: Esophageal Cancer

1. Epidemiology
   1. Incidence in U.S. (2005): 14,520 diagnosed
2. Pathophysiology
3. Types
   1. Squamous Cell Carcinoma of the esophagus
      1. Typical: 60 to 70 year old black male
      2. Habits associated with cancer development
         1. Tobacco smoking
         2. Alcohol Abuse
         3. Diet low in vegetables and fruits
      3. Conditions predisposing to cancer development
         1. Achalasia
         2. Plummer-Vinson surgery
         3. Other head and neck surgery or radiation
   2. Adenocarcinoma of the esophagus
      1. Typical: 50 to 60 year old white male
      2. Habits associated with cancer development
         1. Obesity
      3. Conditions predisposing to cancer development
         1. Barrett's Esophagus
         2. Gastroesophageal Reflux
         3. Hiatal Hernia
         4. Scleroderma
         5. Zollinger-Ellison syndrome
         6. Achalasia history with status-post myotomy
4. Symptoms
   1. Presentation
      1. Progressive Dysphagia or odynaphagia for months
      2. Unintentional Weight Loss (10% over <6 months)
   2. Later
      1. Trunk pain
         1. Initially swallowing-induced (constant later)
         2. Location of pain
            1. Chest and upper back: Upper 2/3 of esophagus
            2. Abdomen and low back: Lower third of esophagus
      2. Halitosis
      3. Clubbing
5. Signs: Suggesting local tumor spread
   1. Hoarseness (Recurrent laryngeal nerve involvment)
   2. Horner Syndrome
   3. Lymphadenopathy (Lymphadenopathy)
   4. Peristent Hiccups (diaphragm association)
6. Evaluation
   1. Step 1: Double contrast barium esophagram
      1. If abnormal or symptoms persist, go to step 2
   2. Step 2: Upper endoscopy with biopsies and brushings
      1. If cancer present, go to step 3a
   3. Step 3a: Evaluate for metastases
      1. CT Chest
      2. CT Abdomen
      3. Liver Function Tests
      4. Alkaline Phosphatase
   4. Step 3b: Are distant metastases present?
      1. Distant Metastases: Palliative Care
      2. No distant metastases: Step 4a
   5. Step 4a: Preoperative Staging
      1. Lesions in upper two thirds of esophagus
         1. Chest CT (if not already done)
         2. Endoscopic Ultrasound
         3. Consider bronchoscopy or thoracoscopy
      2. Lesions in lower third of esophagus
         1. Abdominal CT (if not already done)
         2. Consider laparoscopy
   6. Step 4b: Are there small distant metastases?
      1. Examples: Peritoneal seeding or small liver lesions
      2. Metastases: Palliative Care
      3. No metastases: Go to Step 5
   7. Step 5: Treatment
      1. See Chemoradiation and Surgery below
7. Staging
   1. Stage 0: Carcinoma in-situ
   2. Stage I: (T1-N0-M0)
      1. Tumor invades to lamina propria or submucosa
   3. Stage IIA: (T2-N0-M0) or (T3-N0-M0)
      1. Tumor invades to muscularis propria or adventitia
   4. Stage 1IB: (T1-N1-M0) or (T1-N1-M0)
      1. Regional lymph node spread
   5. Stage 1II: (T3-N1-M0) or (T4-N1-M0)
      1. Local invasion to at least adventitia and
      2. Regional lymph node spread
   6. Stage 1V: Distant Metastases
8. Management: Treatment (used in combination)
   1. Radiation: Indicated for some squamous cell cancers
   2. Chemotherapy: Cisplatin and Fluorouracil
   3. Surgical tumor resection: Total esophagectomy
9. Management: Palliative Care
   1. Brachytherapy
   2. Chemoradiation
   3. Esophageal dilation
   4. Surgical resection
   5. Laser fulguration
10. Prevention
    1. Tobacco Cessation
    2. Decrease Alcohol and Caffeine
    3. Increase vegetables and fruits in diet
    4. Manage achalasia and strictures
    5. Control Gastroesophageal Reflux
11. References
    1. Layke (2006) Am Fam Physician 73(12):2187-94
    2. Wang (2004) Curr Opin Gastroenterol 20:381-5