Esophageal Carcinoma

• • Progressive dysphagia, initially during ingestion of solid foods and later of liquids

  • Progressive weight loss and inanition

  • Classic radiographic outlines: Irregular mucosal pattern with narrowing, with shelf-like upper border or concentrically narrowed esophageal lumen

  • Definitive diagnosis established by endoscopic biopsy or cytologic studies

Epidemiology

• • 1% of all malignant lesions and 6% of GI tract cancers

  • More common among men

  • Associated with alcohol and tobacco use

  • Some adenocarcinomas are an upward extension of a gastric tumor but most are related to Barrett epithelium, which has been increasing in frequency

  • Squamous cell lesions predominate in the mid esophagus; adenocarcinomas are more common in the lower third

  • Direct intramural extension from the gross margin as great as 9 cm in 10% of cases

  • -In 15% of patients, there are additional islands of tumor within 5 cm of the gross margin of the lesion

  • Metastases to lymph nodes are present at the time of diagnosis in 80% of cases

  • Extramural extension is common

  • Lung, bone, liver, and adrenal glands are frequent sites of distant metastases

Symptoms and Signs

• • Dysphagia

  • Weight loss and weakness

  • Difficulty swallowing solid foods initially followed by both solids and liquids

  • Pain that may be related to swallowing

  • -If pain is constant, the tumor has probably invaded somatic structures

  • Regurgitation and aspiration

  • Coughing related to swallowing

  • Hoarseness most often reflects spread to the recurrent laryngeal nerves

Laboratory Findings

• • Anemia

Imaging Findings

• • Chest film: A column of air or air-fluid level in the esophageal lumen

  • Barium swallow

  • -Narrowing of the lumen at the site of the lesion and dilation proximally

    -Tumor appears as an irregular mass

  • Esophagoscopy with biopsy: Provides a tissue diagnosis in 95% of cases

  • Endoscopic US: Wall penetration and mediastinal invasion

  • CT scans: Distant mediastinal and celiac axis nodal metastases

  • Bronchoscopy: Distortion of the bronchial lumen, blunting of the carina, or intrabronchial tumor

• • Angulation of the axis of the esophagus above and below the tumor may be seen on barium swallow, a finding that strongly suggests spread of the lesion to extraesophageal sites

  • Because lesions of the upper and mid esophagus may invade the tracheobronchial tree, bronchoscopy is always indicated in the assessment of growths at these levels

  • Premalignant states

  • -Chronic iron deficiency

    -Esophageal stasis

    -Barrett esophagus

    -Reflux esophagitis

    -Congenital tylosis of the esophagus

  • Benign strictures

  • Benign papillomas, polyps, or granular cell tumors

• • Barium swallow

  • Esophagoscopy with biopsy

  • Endoscopic US

  • CT scan

  • Bronchoscopy

When to Admit

• • Severe pain or dysphagia

  • Inability to maintain adequate enteral nutrition

  • Severe pain

  • Respiratory distress

• • Preoperative radiation may convert ...