Diagnosis

Esophageal cancer

Etiology

Cause [b4o]

• Squamous cell carcinoma

• Adenocarcinoma

• Secondary cancer:

  • Sarcomas

  • Small cell carcinomas

  • Lymphomas

  • Melanomas

Pathophysiology [b4o]

1. In squamous cell carcinoma:

   • Genetic, environmental, and lifestyle factors (smoking, alcohol, hot beverages, and poor nutrition)

2. In adenocarcinoma:

   • Repeated exposure to stomach acid --> replacement of the normal squamous epithelium with metaplastic columnar epithelium (Barrett esophagus)

3. Chronic irritation/inflammation + exposure to carcinogens

4. Genetic alterations --> mutations in tumor suppressor genes (p53) and oncogenes

5. Disruption of normal cell cycle regulation --> promoting uncontrolled cell growth

6. Dysplasia --> carcinoma in situ (cancer cells are confined to the epithelial layer)

7. Cancer cells breach the basement membrane and invade the submucosa and muscularis propria --> Cancer

8. Cancer cells enter the lymphatic system or bloodstream --> metastasis to lymph nodes, the liver, lungs, and bones

Risk factors [b4o]

• Squamous cell carcinoma:

  • Smoking

  • Alcohol

  • A diet low in fruits and vegetables

  • Hot beverages (thermic damage --> inflammation)

  • Human papillomavirus

  • Genetic syndromes (tylosis, Bloom syndrome, and Fanconi anemia)

• Adenocarcinoma:

  • Barrett esophagus

  • Smoking

  • High body mass index

  • Gastroesophageal reflux disease

Complications [b4o]

• Malnutrition: Dysphagia, anorexia, cachexia

• Obstruction

• Aspiration

• Bleeding

• Fistula Formation

• Perforation

• Metastatis

• Treatment-Related Complications:

  • Chemotherapy: infection, anemia, bleeding, nausea/vomiting, diarrhea, neuropathy

  • Radiation therapy: esophagitis, strictures, perforation, fistula

  • Surgery: anastomotic leak, pulmonary complications, arrhythmia, chylothorax

Epidemiology

Incidence per 100.000 [akg]

Approach

• Barium enema

• Gastroscopy + Biopsy

• CT scan

TNM-classification

• Tumor:

  • Tis: High-grade dysplasia

  • T1: Tumor invades the lamina propria, muscularis mucosae, or submucosa

    • T1a: Tumor invades the lamina propria or muscularis mucosae

    • T1b: Tumor invades the submucosa

  • T2: Tumor invades the muscularis propria

  • T3: Tumor invades the adventitia

  • T4: Tumor invades adjacent structures

    • T4a: Invades the pleura, pericardium, azygos vein, diaphragm, or peritoneum

    • T4b: Invades other adjacent structures: aorta, vertebral body, or trachea

• Node:

  • N0: No regional lymph node metastasis

  • N1: Metastasis in 1-2 regional lymph nodes

  • N2: Metastasis in 3-6 regional lymph nodes

  • N3: Metastasis in 7 or more regional lymph nodes

• Metastasis:

  • M0: No distant metastasis

  • M1: Distant metastasis

Treatment

1. Early-stage: T1a or superficial cT1b [b4o]

   • Endoscopic resection

2. Mid-stage: lesions penetrating the submucosa with negative lymph nodes (<3 cm)

   • Esophagectomy with lymphadenectomy

3. Local lymph node-positive:

   • Esophagectomy + neoadjuvant chemo(radio)therapy

4. Advanced: T4a or T4b

   • Definitive chemoradiation

5. Palliative stage:

   • Chemotherapy

   • Radiotherapy

   • Brachytherapy

   • Stents (treatment of dysphagia)

Differential diagnoses

Achalasia, Eosinophilic esophagitis, Esophageal diverticula, Esophageal perforation, Esophageal spasm, Esophageal stricture, Gastric cancer, Gastroesophageal reflux disease, Lipoleiomyoma, Myasthenia gravis, Pneumonia, Systemic sclerosis, Tuberculosis