Cancer of the Esophagus

Published on 04/03/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 04/03/2015

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Chapter 74

Cancer of the Esophagus

Summary of Key Points

Pathogenesis

• Exact etiology is unknown.

• The data support the hypothesis that epithelial tumors arise as a result of chronic irritation from a wide variety of sources, including gastric contents in chronic reflux and known carcinogens.

• A strong association of Barrett esophagus and adenocarcinoma is seen, but a benefit to screening endoscopy for those at risk for or with known Barrett esophagus is unknown as the overall risk of cancer-related mortality is low. Studies with longer-term follow-up are needed to clarify this issue. Other identified risk factors are gastroesophageal reflux disease (GERD), obesity, and smoking.

• Squamous cell carcinoma is associated with smoking as well as alcohol use, and the declining incidence has paralleled the decline in smoking.

• Point mutations, increased copy number, and promotor region hypermethylation all appear important in the progression to malignancy.

Diagnosis and Staging

• Symptoms and demographics will strongly suggest the diagnosis.

• Endoscopy is the best screening examination but esophagram may also be used.

• Diagnosis is made by endoscopy with cytology and biopsy of tumor.

• Transesophageal ultrasound should be used to assess T and N stage to guide optimal definitive therapy.

• Computed tomography (CT) of chest and abdomen is useful in screening for metastatic disease.

• Positron emission tomographic (PET) scan is useful to detect additional cases of metastatic disease before costly and toxic definitive therapy. It may be superior to endoscopic ultrasound (EUS) in detecting intraabdominal lymph nodes, but not periesophageal nodes adjacent to the primary tumor.

• Additional studies include laparoscopy, thoracoscopy, bone scan, and CT of the brain when indicated by clinical circumstances.

• The new AJCC/UICC 7 staging system contains important changes: adenocarcinoma and squamous cell carcinoma are separate; grade of histology is incorporated; the gastroesophageal junction is defined; nodal staging is based on number of involved nodes, similar to gastric cancer; Tis includes high graded dysplasia; and T4 is subcategorized by features suggestive of resectability.

• Staging is based on pathological findings at the time of resection, but therapy is often guided by staging estimated by clinical testing.