Epidemiology and Etiology
Esophageal cancer is estimated to account for nearly 15,590 deaths in the United States in 2015. Esophageal cancer is three to four times more common in men than in women. Risk factors include tobacco, alcohol, obesity, gastroesophageal reflux disease, Barrett esophagus, achalasia, and caustic injury.
Adenocarcinomas are most common in the lower third of the esophagus and at the gastroesophageal junction and have had a sharp increase in incidence over the last few decades in the United States. Squamous cell carcinomas are more common in the upper and middle esophagus.
Patients usually present with progressive dysphagia and weight loss. Other symptoms include odynophagia, cough, regurgitation, and hoarseness.
- The diagnosis is usually established through upper endoscopy with biopsy.
- Staging workup includes CT of the chest and abdomen (with or without PET) to determine the presence of distant metastases. For patients without distant metastases, endoscopic ultrasonography (EUS) is required for the definition of tumor depth and lymph node status.
- Tumors located above the carina increase the risk of tracheoesophageal (TE) fistula formation and should be evaluated with bronchoscopy. Patients with TE fistulas often present with postprandial cough and aspiration pneumonias.
- Resectable disease: Patients with resectable disease are candidates for esophagectomy with or without preoperative chemotherapy and radiation (N Engl J Med 2012;366:2074 [PMID:22646630]), depending on the extent of disease.
- Unresectable primary disease: Patients diagnosed with locally advanced disease are usually managed by concurrent chemoradiation.
- Metastatic disease is treated with palliative chemotherapy, usually with regimens including 5FU, platinum, and a taxane or anthracycline agent. Ramucirumab, an antibody against vascular endothelial growth factor receptor-2 (VEGFR-2), is approved for use in the second-line setting in combination with paclitaxel or as a single agent (Lancet 2014;383:31 [PMID:24094768]).
- Trastuzumab can be used in combination with chemotherapy in patients with HER2-amplified esophageal or gastroesophageal junction metastatic adenocarcinomas.
- Chapter 22: Cancer
- Approach to the Cancer Patient
- Lung Cancer
- Breast Cancer
- Head and Neck Cancer
- Gastrointestinal Malignancies
- Genitourinary Malignancies
- Gynecologic Malignancies
- Hematologic Malignancies
- Oncologic Emergencies
- Management of Treatment Toxicities
- Supportive Care: Complications of Cancer
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