Esophageal Cancer

Most of the esophageal cancers are squamous cell (SCC) or adenocarcinomas. Worldwide, the most common cause of esophageal cancer is squamous cell carcinoma (SCC), but the most common in the USA is adenocarcinoma.

While the incidence of SCC is decreasing in the United States, the incidence of adenocarcinoma arising due to increase Barrett’s esophagus in the rise.

As we have mentioned earlier, there are generally 2 most common types of esophageal cancer: Squamous cell carcinoma (SCC) and Adenocarcinoma:

Squamous cell carcinoma:

This is the most common type in the world especially in Asian countries and african americans. They typicalu occur in the upper two-thirds of the esophagus (middle and upper). The most common cause of squamous cell carcinoma include

• Lifestyles/Diet – Smoking, Alcohol, Nitrite contaminate, hot liquid, pickled food.
• Esophageal disease – Achalasia (Chagas), Plummer-Vinson Syndrome, Zenker diverticulum, Chronic Esophagitis injury from hot beverage
• Genetic – Celiac Disease, Tylosis (ectodermal dysplasia)

3 different patterns like squamous cell carcinoma

• Polypoid exophytic: mass lesion most common, protrude to lumen need 2/3 obstruction to cause pain.
• Infiltrative: cause thickening and rigidity of the wall and narrowing the wall
• Ulcerative/Necrotizing/excavated: extend deeply possibly into aorta, respiratory tree etc.

Adenocarcinoma: (arise from glandular cells like columnar cells)

Most common type in the USA (more common in whites) and usually occur after 20 years of GERD. Occurs in the Lower esophagus associated with Barrett Esophagus and Dysplasia. The most common causes of Adenocarcinoma of esophagus include the following

• Chronic GERD causing metaplasia of cells near the gastroesophageal junction (GEJ) → Barrett’s Esophagus develops which is a precancerous lesion → dysplasia occurs and columnar cells transform into esophageal Carcinoma (Adenocarcinoma type);
• Fatty diet in the western world and obesity are strong risk factors for adenocarcinoma development.
• Other risk factors common to squamous cell carcinoma include: smoking, alcohol (although the cause of esophageal adenocarcinoma due to alcohol has raised controversy, it is best advised to avoid alcohol.

The same 3 pattern of tumor is present in adenocarcinoma like quamous cell carcinoma (SCC).

• Polypoid exophytic, Infiltrative, Ulcerative/necrotic/excavated

Other esophageal cancers from metastasis of non-esophageal primary tumors can also occur. Common primary tumors that can spread to the esophagus include:

• Lung cancer, breast Cancer and other Small cell variants and anaplastic types

Symptoms and Clinical Presentation for both SCC and Adenocarcinoma:

• Progressive dysphagia, weight loss, hematemesis that can be painful (2/3 lumen obstructed) or painless
• Squamous cell carcinoma: may present with hoarse voice (recurrent laryngeal nerve involvement) and cough (tracheal involvement)
• Dysphagia is progressive to solid first → liquid later.
• Heme positive stool or anemia

Diagnosis of esophageal cancer

• The best initial study for patient suspecting of dysphagia with possible esophageal pathology is Barium swallow.
• The most diagnostic and accurate test is upper endoscopy with biopsy. Patient usually present with dysphagia and hence Barium swallow is typically done first.

Staging:

• Once esophageal cancer is diagnosed, your doctor will stage the cancer with the following procedures: Endoscopic ultrasound (EUS)
• Bronchoscopy – to detect any spread to bronchi
• MRI or CT Scan to detects local or distant spread.

Spread of tumor to nearby lymph nodes (LNs)

• Upper 1/3 → Cervical nodes
• Middle 1/3 → Mediastinal or tracheobronchial nodes
• Lower 1/3 → Celiac and Gastric nodes.

Treatment and Management of Esophageal Cancer

• Localized esophageal cancer without local or distant spread are treated with surgical resection.
• Metastatic esophageal cancer are treated with 5FU-based Chemotherapy and Radiation.
• Unresectable lesion – stent placement to keep esophagus open (palliation and dysphagia).