Esophageal Cancer Overview

Esophageal Cancer

• Common Types: Squamous cell carcinoma and adenocarcinoma. Adenocarcinoma is the fifth most common gastrointestinal malignancy. Incidence has risen exponentially in recent decades.
• Epidemiology (Historical): Before the 1970s, squamous cell carcinoma was the most common type, linked to smoking and alcohol.
• Epidemiology (Modern): The incidence of esophageal adenocarcinoma has increased significantly in the last 20 years.
• Incidence (US): Squamous cell carcinoma has an incidence of 2.6 cases per 100,000 people per year in the United States.
• Incidence (International): In China and Iran, squamous cell carcinoma is even higher, at 132 cases per 100,000 people per year.
• Prognosis: Esophageal cancers have a poor prognosis. The 5-year survival rate is between 2-26%, depending on the stage at diagnosis.

Risk Factors for Squamous Cell Carcinoma

• Environmental: Tobacco use, alcohol consumption, nitrosamines (e.g., from grilling meat), hot liquids, caustic substances, and chronic esophageal stasis (achalasia).
• Nutritional Deficiencies: Deficiency in vitamin C.
• Other: Previous radiation exposure.

Risk Factors for Adenocarcinoma

• Barrett Esophagus: A pre-cancerous condition where the lining of the esophagus changes due to chronic acid reflux.
• Age: Advancing age.
• Sex: Male sex.
• Chronic Reflux: Chronic reflux of gastric contents into the tubular esophagus.
• Ethnicity: White ethnicity.
• Obesity: Obesity.

Risk Factors - Progression Model

• Gastroesophageal Reflux: Initiates the process.
• Metaplasia: A change in the esophageal cell type as a result of the chronic reflux.
• Low Grade Dysplasia: A pre-cancerous change in the esophageal cells.
• High Grade Dysplasia: More severe pre-cancerous changes.
• Adenocarcinoma: The development of cancer.

Signs and Symptoms of Esophageal Cancer

• Dysphagia: Difficulty swallowing, progressing rapidly. Lumen diameter under 13mm indicates advanced disease.
• Odynophagia: Painful swallowing
• Unintentional Weight Loss: Commonly seen in later-stage disease.
• Bleeding: Leading to iron-deficiency anemia.
• Pain: Epigastric or retrosternal pain. Pain over bones suggests metastatic disease.
• Hoarseness: Due to recurrent laryngeal nerve involvement.
• Persistent Cough:
• Respiratory Symptoms: Possible from aspiration.

Physical Examination

• Normal Findings: Most patients have normal physical examination findings.
• Late-Stage Indications/Palpation: In late stages or proximal esophageal disease, supraclavicular lymphadenopathy might be palpable.

Imaging Studies

• Upper GI Endoscopy: Visual inspection of the upper digestive tract.
• CT Scanning: Cross-sectional imaging to assess the extent of disease.
• PET Scanning: For staging and detecting potential distant metastasis.
• Endoscopic Ultrasound (EUS): Provides detailed images of the esophageal wall.
• Bronchoscopy: Examines the airway and esophagus.
• Barium Swallow: Fluoroscopic imaging to visualize the esophagus.

Approach Considerations/Diagnosis

• Flexible endoscopy with biopsy: Crucial for initial diagnosis and tumor sampling.
• Computed Tomography (CT): Of the chest and abdomen is pivotal for staging.
• Positron Emission Tomography (PET): Optional for early-stage disease and recommended for locoregional esophageal cancer staging
• Endoscopic Ultrasound (EUS): Recommended for patients without metastasis for improved staging accuracy.

Consultations

• Multidisciplinary approach: The patient's condition and stage of disease need evaluation involving gastroenterologist, medical oncologist, radiation oncologist and thoracic surgeon.
• Performance Status: Patient's physical condition is vital
• Adequate Surgical Candidate: Determining the patient's ability to withstand surgery.
• Comorbid conditions: Any existing medical issues influencing surgical planning.

Treatment

• Staging-Dependent: Locoregional vs Metastatic
• Histology-Dependent: Squamous cell carcinoma vs Adenocarcinoma
• Available Treatments: Endoscopic therapy (endoscopic mucosal resection, endoscopic submucosal dissection, ablation), and esophagectomy.
• Chemoradiation Therapy: Before surgery for advanced stages, to achieve complete tumor response in the specimen.

Treatment Strategy

• Multimodality Approach: T2 stage and beyond benefit.
• Neoadjuvant Therapy: Chemoradiation before surgery in advanced cases sometimes results in a complete response.
• Tumor Response Rates: A significant number of patients achieve complete pathologic response after surgery, resulting in a higher 3 year survival rate. (15-30%).

Staging and Treatment Options

• Table 1: Shows treatment options based on disease extent, stage, and survival rates.

Esophageal Stent

• Indication: For relief of esophageal obstruction due to cancer.

Motility Disorders of the Esophagus

• Manometry: Used to diagnose esophageal motility disorders.
• Achalasia: A primary motility disorder resulting from inadequate relaxation of the lower esophageal sphincter and absent peristalsis.

Achalasia - Pathophysiology

• Hallmark: Reduced number of inhibitory ganglion cells.
• Cause: Unknown. Possible factors: infection (varicella-zoster virus), Chagas’ disease, and possible genetic component.

Achalasia - Clinical Presentation

• Dysphagia: Difficulty swallowing for both solids and liquids. Symptoms are often intermittent.
• Chest Pain Common
• Regurgitation: Occurs in a substantial number of patients.
• Heartburn and Weight loss: Less frequent, but possible.

Achalasia - Diagnosis

• Barium Swallow: Useful to detect the classic bird's beak appearance and dilated esophagus.
• Esophageal Manometry: The gold standard, demonstrating incomplete LES relaxation, high resting LES pressure, and absent esophageal peristalsis upon swallowing.
• Esophagogastroduodenoscopy: Helps rule out cancer.

Achalasia - Differential Diagnoses

• Pseudoachalsia: A condition that mimics achalasia but is caused by another disease (malignancy, sarcoidosis, amyloidosis, etc.).

Achalasia - Management

• Treatment options: Drugs, Botulinum Toxin (Botox), Pneumatic Dilatation, Surgical Myotomy.

Detailed Treatment Options

• Drugs: Used to relax the lower esophageal sphincter. Limited effectiveness. Examples include Nifedapine, isosoribide dinitrate.
• Botulinum Toxin (Botox): Injected to weaken the lower esophageal sphincter. Good results initially, but relapses are common and antibodies can lead to decreased efficacy.
• Pneumatic Dilatation: Using a balloon to open the constricted esophageal opening. Can be effective, but has a risk of perforation.
• Surgical Myotomy: Involves cutting a portion of the muscle to improve relaxation. This is a definitive treatment for many.