Pathophysiology
most common types by far are adenocarcinoma and squamous cell carcinoma
Signs and Symptoms
1) difficulty swallowing (dysphagia) – most common presenting symptom 2) pain on swallowing (odynophagia) 3) anorexia 4) cachexia 5) hoarseness (owing to compression of recurrent laryngeal nerve) 6) chronic cough (owing to tracheoesophageal fistula) 7) aspiration pneumonia 8) chest pain
Characteristic Test Findings
Laboratory – 1) hypercalcemia (even in absence of bone metastates) Endoscopy – 2) test of choice for obtaining tissue biopsy
Histology/Gross Pathology
1) occurs in polypoid, ulcerating, and infiltrative forms 2) spread is to regional lymph node basin, draining affected part of esophagus – cervical lymph nodes from upper third, mediastinal lymph nodes from middle third, and celiac and gastric lymph nodes from lower third 3) adenocarcinoma almost always arises from Barrett’s metaplasia 4) adenocarcinoma is located in lower third of esophagus 5) squamous cell carcinoma is more common in upper two thirds of esophagus
Associated Conditions
increased incidence with – 1) Plummer-Vinson syndrome 2) Barrett’s esophagus 3) heavy smoking and alcohol use (squamous carcinoma) 4) achalasia 5) chemical injury with stricture 6) presence of webs, rings, or diverticula 7) large amount of ingested nitrates 8) smoked opiates 9) deficiencies in dietary zinc, molybdenum, and vitamin A
Inheritance/Epidemiology
1) worldwide, squamous cell more common; in USA adenocarcinoma predominates 2) increased incidence in lower socioeconomic classes 3) esophageal cancer belt stretches across central Asia with incidence 300 times greater than areas of low incidence
Treatment
1) chemoradiation and surgery (if resectable) 2) anti-angiotenic drugs (endostatin, alpha-IFN) are being tried to stabilize disease 3) prognosis for adenocarcinoma is better than squamous, but overall 5 year survival is 5%
Tips for USMLE
1) if patient is a 56 year-old man with heavy alcohol and smoking history who develops weight loss and difficulty swallowing solids over a 3 month period, think esophageal cancer 2) if patient is a 67 year old man with a 25 year history of poorly controlled severe heartburn who has “pain in this throat” when he swallows, think esophageal cancer
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