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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 1/3rd
- 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)
- Blood Spread
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
