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Esophageal tumors
OVERVIEW: Carcinomas - begin in the esophagus (primary) and usually occur in the lower third. Types: Squamous cell carcinoma; adenocarcinoma (may now account for more than 25% of esophageal cancer). At the time of diagnosis, 80% have metastases to the lymph nodes.
• Benign neoplasms - rare. Types: Leiomyoma (most common), papilloma, and fibrovascular polyps.
System(s) affected: Gastrointestinal
Genetics: No known genetic pattern
Incidence/Prevalence in USA:
• Squamous cell: 3-15/100,000 males; 3-4/100,000 females (highest incidence in Blacks)
• Adenocarcinoma: Rising incidence (vast majority have Barrett's esophagus)
Predominant age: > 50 years (peak incidence 50-60)
Predominant sex: Male > Female (2.6:1)
SIGNS AND SYMPTOMS: • Progressive dysphagia for solids over weeks to months
• Progressive weight loss
• Regurgitation and aspiration are common (especially at night)
• Cachexia
• Supraclavicular lymphadenopathy
• Esophageal obstruction
• Hiccups
• Cough
• Hoarseness
• Gastrointestinal blood loss
CAUSES: Unknown. Most esophagus cancers are primary, but some spread from other body parts.
RISK FACTORS: • Smoking
• Excess alcohol consumption
• Head and neck tumors
• Nitrates in foods
• Lye stricture
• Achalasia
• Tylosis
• Plummer-Vinson syndrome (anemia and esophageal web)
• Coexisting primary oro-pharyngeal carcinoma
• Barrett's metaplasia (develops in 10-40% of patients with chronic gastroesophageal reflux)
DIAGNOSIS DIFFERENTIAL DIAGNOSIS: • Benign causes of dysphagia, achalasia
• Motility disorders of the esophagus
• Extrinsic esophageal compression secondary to mediastinal/pulmonary disease
LABORATORY: • Esophageal biopsy/brushing
• Anemia
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS: • Location - 20% in upper third, 30% in middle third, 50% in lower third
• Elevated plaques
• Ulceration
• Strictures
SPECIAL TESTS: Esophagoscopy
IMAGING: • Barium swallow - stenosing lesion
• CT scan - valuable for looking for metastases
• X-ray of the upper-intestinal tract may show pneumonitis, pleural effusion, lung abscess
• Endoscopic ultrasound - staging (most accurate)
DIAGNOSTIC PROCEDURES: • Esophagoscopy with biopsy
• Brush cytology (> 95% positive)
• Bronchoscopy - distortion of the bronchial lumen, blunting of the carina, or intrabronchial tumor
• Once tumor is identified, liver function studies and ultrasonography and/or CT scan for evidence of liver metastases
• Endoscopic ultrasound is most sensitive and specific test to determine local spread
TREATMENT APPROPRIATE HEALTH CARE: • Inpatient occasionally
• Home care or extended-care facility following definitive treatment
GENERAL MEASURES: • Palliative therapeutic options include: surgery, radiotherapy, chemotherapy, laser photocoagulation, photodynamic therapy, dilation, placement of endoluminal prosthesis (stent) or combination of these methods. The specific choice will depend on the extent of the tumor and symptoms and the individual patient's state of health.
SURGICAL MEASURES: • Majority of tumors are not resectable for cure at time of presentation
• Important to stage the lesion before determining treatment plan
• Strictures may be dilated for temporary relief
• Prior to surgery - average patient requires nutritional and pulmonary preparation, e.g., feeding tube with formula diet and respiratory therapy
• Endoluminal prosthesis may be attempted for patients who have failed other methods of palliation
ACTIVITY: Adjusted to patient's ability
DIET: • Soft to liquid
• High calorie supplements (usually liquid)
PATIENT EDUCATION: For patient education materials favorably reviewed on this topic, contact: National Cancer Institute, Dept. of Health And Human Services, Public Inquiries Section, Office of Cancer Communications, Building 31, Room 101-18, 9000 Rockville Pike, Bethesda, MD 20892, (301)496-5583
MEDICATIONS DRUG(S) OF CHOICE: • Chemotherapy in selected patients
• Analgesics
• Antacids, H2 receptor antagonist, or proton pump inhibitors when gastroesophageal reflux symptoms co-exist
• Metoclopramide if gastric emptying problems coexist (frequently paraneoplastic)
Contraindications: Refer to manufacturer's literature
Precautions: Refer to manufacturer's literature
Significant possible interactions: Refer to manufacturer's literature
ALTERNATIVE DRUGS: • Cisapride if gastric emptying problems coexist (frequently paraneoplastic) (not generally recommended)
FOLLOW UP PATIENT MONITORING: Individualized to follow results of preoperative and postoperative treatment
PREVENTION/AVOIDANCE: • Avoid tobacco, excess alcohol, corrosive chemicals
• Endoscopic surveillance of those at high risk (Barrett's, esophagus, head and neck cancer)
POSSIBLE COMPLICATIONS: • Metastases to anterior jugular, supraclavicular, subdiaphragmatic lymph nodes, liver, lungs
• Complications from surgical procedures (anastomotic leak or stricture, fistula formation, empyema, malnutrition)
• Radiation can cause esophageal perforation, stricture, fistula, esophagitis, pneumonitis, myelitis, and pulmonary fibrosis
• Toxicities of chemotherapy - nausea, vomiting, hair loss, gastroenteritis, hematopoietic and immune depression
• Tubes can become blocked or dislodged
• Aspiration from esophageal obstruction
EXPECTED COURSE AND PROGNOSIS: • Overall 5-year survival 5%; in squamous cell carcinoma with uninvolved lymph nodes 15-20%
• Death rate following resection or bypass is 10-15%
MISCELLANEOUS ASSOCIATED CONDITIONS: • Barrett's metaplasia
• Head and neck cancer
• Achalasia
AGE-RELATED FACTORS:
Pediatric: N/A
Geriatric: Most common in males over 60
Others:
• Uncommon under age 50
• Definitive treatment is standard regardless of age
• Symptomatic therapy requires dose adjustment for very old and very young
PREGNANCY: N/A
SYNONYMS: • Esophagus squamous cell carcinoma
• Esophagus adenocarcinoma
ICD-9-CM: 150 malignant neoplasm of esophagus
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