Esophageal Cancer
44 ESOPHAGEAL CANCER
Casey M. Calkins M.D.
1. What are the risk factors for developing esophageal cancer?
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Both alcohol and tobacco increase the risk of carcinoma of the esophagus by a factor of 10. Additional risk factors include Barrett’s esophagus with dysplasia, carcinogen exposures (e.g., nitrosamines in the Eastern world), vitamin and trace element deficiencies, and Plummer-Vinson syndrome.
2. What is the epidemiology of carcinoma of the esophagus?
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Esophageal cancer accounts for 1% of all cancers and 2% of cancer-related deaths. Generally, it is three times more common in men and occurs most commonly in the seventh decade of life. Worldwide, 95% of all esophageal cancers are of squamous cell origin; however, in the Western world, the relative incidence of adenocarcinoma has increased dramatically over the past 20 years because of the comparable increase in the incidence of Barrett’s esophagus.
3. What is Barrett’s esophagus, and how does it relate to esophageal cancer?
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Chronic reflux of gastric contents into the esophagus may lead to Barrett’s esophagus, which is characterized by replacement of the normal squamous esophageal mucosa with a glandular columnar mucosa resembling the stomach. This is also called intestinal metaplasia. If Barrett’s esophagus progresses to high-grade dysplasia, patients have a fortyfold increased risk of esophageal adenocarcinoma. Patients with high-grade dysplasia are traditionally treated by esophagectomy; however, photodynamic therapy (PDT) may eliminate dysplastic Barrett’s mucosa, obviating surgical resection. PDT remains unapproved and experimental.
4. What are the most common presenting symptoms of esophageal cancer?
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Dysphagia occurs in 85% of patients. Others symptoms include weight loss (60%), chest or epigastric pain (25%), regurgitation of undigested food (25%), hoarseness caused by recurrent laryngeal nerve involvement (5%), cough or dyspnea (3%), and hematemesis (2%).
5. What is the diagnostic work-up for patients presenting with these symptoms?
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1. History and physical examination
2. Upper gastrointestinal series (contrast study of the upper GI tract)
3. Upper endoscopy with biopsies of all concerning luminal structures
4. Computed tomography (CT) scan of chest and abdomen to define nodal and potential metastatic disease
5. Endoscopic ultrasound (EUS) to define the T stage (i.e., size) of the primary mass and regional lymph node involvement with possible fine-needle aspiration (FNA) biopsy
6. Positron emission tomography (PET) scan to define distant metastatic spread
6. What is the anatomic distribution of esophageal cancer?
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The esophagus is divided into three anatomic segments: upper, middle, and lower thirds. Fifteen percent of esophageal cancers arise in the upper third, 50% in the middle third, and 35% in the lower third.
KEY POINTS: ESOPHAGEAL CARCINOMA
1. Most common in older patients with dysphagia (85% of cases) and weight loss (60% of cases).
2. Major causative factors are alcohol and tobacco (10-fold increase in risk).
3. Diagnosis is made by upper GI endoscopy and biopsy.
4. Most common variant is adenocarcinoma; second most common is squamous cell cancer.
5. Radiographic work-up is necessary to stage disease.
7. What is neoadjuvant chemotherapy? What are its advantages and disadvantages?
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This is chemotherapy, radiation therapy, or both to the primary lesion before surgical resection.
The advantages include:
* Potential downstaging (to shrink the tumor or treat locoregional lymph node involvement)
* Early treatment of micrometastatic disease
* Treatment is better tolerated before surgical stress
* Calibrates the patient’s ability to tolerate major surgery
* Verification of primary tumor’s sensitivity to the chemotherapy or radiation therapy
The disadvantages include:
* Delay in treatment of the primary lesion, particularly when the primary tumor progresses despite neoadjuvant therapy
* Selection for chemoresistant cell lines
8. What are the surgical options for treatment of carcinoma of the esophagus?
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Surgery alone or combined with chemoradiotherapy offers the only hope for cure. The surgical approaches include: (1) transabdominal resection of lesions located at the gastroesophageal junction; (2) resection with intrathoracic anastomosis by left thoracoabdominal (Sweet procedure) or combined midline laparotomy and right thoracotomy (Ivor-Lewis procedure); and (3) transhiatal esophagectomy with cervical anastomosis. Laser therapy, esophageal stenting procedures, and dilatation are reserved for palliation.
9. What are the risks of surgery?
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* Death
* Hemorrhage
* Anastomotic leak
* Empyema and sepsis
* Anastomotic stricture
* Local recurrence of cancer
* Dysphagia
10. What is the natural history of esophageal cancer?
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In a collected series of almost 1000 untreated patients, the 1- and 2-year survival rates were 6.0% and 0.3%, respectively. Untreated patients typically succumb to progressive malnutrition complicated by aspiration pneumonia, sepsis, and death. Formation of a fistula between the aorta or pulmonary artery and the esophagus or pulmonary tree is a somewhat more dramatic (or perhaps merciful) mode of exit. Treated or untreated, esophageal cancer is a bad disease.
11. Describe the stages of esophageal cancer and the respective 5-year survival rate after esophagectomy.
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Stage I is cancer confined to the inner layer (muscularis mucosae or submucosa), and 5-year survival is as high as 80%. Stage II describes tumors that are confined to the layers outside the submucosa with local lymph node involvement, and 5-year survival can be as high as 35%. Stage III tumors have either invaded surrounding structures (lung, aorta, or trachea) irrespective of regional lymph node involvement or go through the wall of the esophagus with nodal involvement. The 5-year survival is typically < 10%. Stage IV esophageal cancer has spread to nonregional lymph nodes (supraclavicular or celiac nodes) or distant organs (lung, liver, bone). Essentially, all patients with stage IV disease die within 2 years of diagnosis.
12. What is an “R0″ (or “R zero”) resection, and how does it impact survival?
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All gross disease is removed, and microscopically, the margins of resection are negative for tumor. Achieving an R0 resection is the surgeon’s goal and is the most robust predictor of a favorable outcome after surgery for esophageal cancer. An R1 resection represents removal of all gross disease, yet resection margins are microscopically positive for tumor. The overall 5-year survival (any stage) for patients with microscopically positive margins decreases by an order of magnitude (e.g., 30% down to 3%).
References
WEB SITES
1. http://www.emedicine.com/med/topic741.htm
2. http://www.acssurgery.com/abstracts/acs/acs0309.htm
BIBLIOGRAPHY
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
