esophageal cancer
Jump to navigation
Jump to search
Etiology
- squamous cell carcinoma
- most cases can be attributed to smoking or excess alcohol or both
- other risk factors:
- Plummer Vinson syndrome
- tylosis
- achalasia
- lye stricture
- human papilloma virus
- high fat, low protein, & low calorie diets increase risk
- nitrosamines (nitrates, nitrites) may be common etiology
- fungal toxins in pickled vegetables
- radiation-induced stricture
- zinc-deficiency may be risk
- hot or burning hot tea daily + smoking &/or drinking (see Camellia sinensis)[11]
- adenocarcinoma risk factors
- Barrett's esophagus (BE) & risk factors for BE
- gastroesophageal reflux
- smoking
- central obesity
- Causasian race
- age > 50 years
Epidemiology
- estimated 14,55 cases/year (2006)
- 7th leading cause of death from cancer in U.S.[3]
- 2.7 times more common in men than women
- adenocarcinoma 50%
- more frequent in US than squamous cell carcinoma with greatest frequency in males age 40-50
- more common in whites
- male/female ratio 7:1, black/white ratio 1:4
- squamous cell carcinoma 50%
- incidence increased with age & peaks in 7th decade
- more common in blacks
- most prominant histologic type world-wide
- male/female ratio 3:1, black/white ratio 6:1
- incidence 20-30 times higher in China than US
Pathology
- adenocarcinoma
- distal 1/3 of esophagus is most common site
- incidence of adenocarcinoma involving gastroesophageal (GE)-junction is increasing
- generally occurs on a background of Barrett's esophagus
- squamous cell carcinoma
- most often in proximal 2/3 of esophagus
- 10% may have malignant neoplasms of the oral cavity, pharynx, larynx or lung
- other types:
- metastatic spread
- regional lymph nodes
- lungs
- liver
- bone
- adrenal glands
- diaphragm
- adenocarcinoma may metastasize to brain
Genetics
- abnormal transcripts of FHIT found in ~50%
- downregulation of NMES1, DEC1
- upregulation of RABGAP1L (SCC), TNFRSF6B
- defects in DLEC1 are a cause of esophageal cancer
- DLEC1 silencing due to promoter methylation & aberrant transcription are implicated in the development of esophageal cancer
- other implicated genes
Clinical manifestations
- progressive solid food dysphagia is the most common presenting symptom[3]
- dysphagia is not noted until esophageal lumen is narrowed to 1/2 to 1/3 of its normal diameter because of its elasticity
- weight loss is common
- cough is suggestive of local extension into the trachea with tracheal esophageal fistula
- pain may radiate to back
- hoarseness may be a sign of recurrent laryngeal nerve involvement
- metastatic disease may result in:
- pleural effusion
- ascites
- bone involvement may result in pain &/or hypercalcemia
Laboratory
Diagnostic procedures
- endoscopy for visualization & esophageal biopsy
- endoscopic ultrasound (EUS) for staging
- bronchoscopy to detect tracheal invasion except for adeno- carcinoma of the distal 1/3 of the esophagus
Radiology
- CT of thorax, abdomen & pelvis to look for metastases
- PET scan for staging to look for metastases[3][9] (covered by Medicare)
- bone scan if patient has bone pain or elevated serum alkaline phosphatase
- barium swallow
Staging
see staging of esophageal cancer
Complications
- most cases are diagnosed at advanced stages after onset of symptoms
Differential diagnosis
- Schatzky ring: thin, smooth benign ring of mucosa proximal to the gastroesophageal junction
Management
- recommendations from[3]
- surgery (esophagectomy)
- in patients with metastatic regional lymphadenopathy, neoadjuvant chemotherapy followed by surgery confers a modest survival benefit relative to surgery alone[3]
- recommendations from[5]
- Stage 0 (Tis N0 M0), carcinoma in situ
- radiation followed by surgery (esophagectomy)
- > 90% 5 yr survival
- Stage 1 (T1 N0 M0)
- chemoradiation* followed by surgery (esophagectomy)
- > 50% 5 yr survival
- Stage 2a (T2-3 N0 M0)
- chemoradiation* followed by surgery (esophagectomy)
- 15-30% 5 yr survival
- Stage 2b (T1-2 N1 M0)
- chemoradiation* followed by surgery
- 10-30% 5 yr survival
- Stage 3 (T3 N1 M0 or T4 any N M0)
- chemoradiation*, palliative resection of T3a tumors
- <10% 5 yr survival
- Stage IV (any T any N M1)
- radiation therapy +/- intraluminal dilation & chemotherapy
- 5 yr survival is rare
- 30-40% of total surgically resectable
- Stage 0 (Tis N0 M0), carcinoma in situ
- add trastuzumab to chemotherapy if HER2 positive
- adjuvant nivolumab improves disease-free survival[12]
- prognosis: 5 year survival is 15-25%[3]
- prevention
- regular NSAID use may reduce risk of esophageal adenocarcinoma[10]
* chemoradiation: two courses of 5-fluorouracil & cisplatin (Platinol) plus 40 Gy of radiation in 15 sessions over 3 weeks
* chemoradiation with fluoropyrimidine S-1 enhanced anticancer activity & reduced toxicity vs 5-fluorouracil & cisplatin in the elderly[13]
* epirubicin, cisplatin & 5-fluorouracil for 3 months before & 3 months after surgery (no radiation therapy)[3]
* cisplatin based therapy or cisplatin-based therapy + trastuzumab in patients with HER2 tumor expression[3]
More general terms
Additional terms
References
- ↑ Bonin et al, Cancer Management: A Multidisciplinary Approach, Chapter 5, 1999
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 281
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2021.
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 568-69
- ↑ 5.0 5.1 Cunningham D, Allum WH, Stenning SP et al Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006 Jul 6;355(1):11-20. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16822992
- ↑ Kleinberg L, Forastiere AA. Chemoradiation in the management of esophageal cancer. J Clin Oncol. 2007 Sep 10;25(26):4110-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17827461
- ↑ Wang KK, Wongkeesong M, Buttar NS. American Gastroenterological Association technical review on the role of the gastroenterologist in the management of esophageal carcinoma. Gastroenterology. 2005 May;128(5):1471-505 PMID: https://www.ncbi.nlm.nih.gov/pubmed/15887129
- ↑ Varghese TK Jr, Hofstetter WL, Rizk NP et al The society of thoracic surgeons guidelines on the diagnosis and staging of patients with esophageal cancer. Ann Thorac Surg. 2013 Jul;96(1):346-56. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23752201
- ↑ 9.0 9.1 Healy MA, Yin H, Reddy RM, Wong SL. Use of positron emission tomography to detect recurrence and associations with survival in patients with lung and esophageal cancers. J Natl Cancer Inst 2016 Feb 22; 108:djv429 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26903519
- ↑ 10.0 10.1 Bjorkman DJ NSAIDs Do Not Reduce Risk for Barrett Esophagus. Physician's First Watch, Sept 21, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
Thrift AP et al. Nonsteroidal anti-inflammatory drug use is not associated with reduced risk of Barrett's esophagus. Am J Gastroenterol 2016 Aug 30 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27575711 - ↑ 11.0 11.1 Yu C, Tang H, Guo Y et al Effect of Hot Tea Consumption and Its Interactions With Alcohol and Tobacco Use on the Risk for Esophageal Cancer: A Population-Based Cohort Study. Ann Intern Med. 2018. Feb 6. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29404576 <Internet> http://annals.org/aim/article-abstract/2671921/effect-hot-tea-consumption-its-interactions-alcohol-tobacco-use-risk
Kamangar F, Freedman ND Hot Tea and Esophageal Cancer. Ann Intern Med. 2018. Feb 6. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29404600 <Internet> http://annals.org/aim/article-abstract/2671922/hot-tea-esophageal-cancer - ↑ 12.0 12.1 Kelly RJ, Ajani JA, Kuzdzal J et al Adjuvant Nivolumab in Resected Esophageal or Gastroesophageal Junction Cancer. N Engl J Med 2021; 384:1191-1203. April 1. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33789008 https://www.nejm.org/doi/full/10.1056/NEJMoa2032125
- ↑ 13.0 13.1 Ji Y, Du X, Zhu W et al Efficacy of Concurrent Chemoradiotherapy With S-1 vs Radiotherapy Alone for Older Patients With Esophageal Cancer. A Multicenter Randomized Phase 3 Clinical Trial. JAMA Oncol. Published online August 5, 2021 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34351356 https://jamanetwork.com/journals/jamaoncology/fullarticle/2782741
Eads JR, Haller DG Primary Chemoradiotherapy for Older Patients With Esophageal Cancer. JAMA Oncol. Published online August 5, 2021 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34351378 https://jamanetwork.com/journals/jamaoncology/fullarticle/2782745 - ↑ National Cancer Institute Esophageal Cancer - Health Professional version https://www.cancer.gov/types/esophageal/hp
Patient information
esophageal cancer patient information