Esophageal cancer is a disease in epidemiologic transition. Until the 1970s, the most common type of esophageal cancer in the United States was squamous cell carcinoma, which has smoking and alcohol consumption as risk factors. Since then, there has been a steep increase in the incidence of esophageal adenocarcinoma, for which the most common predisposing factor is gastroesophageal reflux disease (GERD). See the image below.
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Cascade of events that lead from gastroesophageal reflux disease to adenocarcinoma.
Signs and symptoms
Presenting signs and symptoms of esophageal cancer include the following:
Dysphagia (most common); initially for solids, eventually progressing to include liquids (usually occurs when esophageal lumen < 13 mm)
Weight loss (second most common) due to dysphagia and tumor-related anorexia.
Bleeding (leading to iron deficiency anemia)
Epigastric or retrosternal pain
Bone pain with metastatic disease
Hoarseness (due to the involvement of the recurrent laryngeal nerve)
Persistent cough
Intractable coughing or frequent pneumonia (due to tracheobronchial fistulas caused by direct invasion of tumor through the esophageal wall and into the mainstem bronchus)
Physical findings include the following:
Typically, normal examination results unless the cancer has metastasized
Hepatomegaly (from hepatic metastases)
Lymphadenopathy in the laterocervical or supraclavicular areas (reflecting metastasis)
See Presentation for more detail.
Diagnosis
Laboratory studies such as complete blood count (CBC) and comprehensive metabolic panel (CMP) focus principally on patient factors that may affect treatment (eg, nutritional status, renal function).
Imaging studies used for diagnosis and staging include the following:
Esophagogastroduodenoscopy (EGD; allows direct visualization and biopsies of the tumor)
Endoscopic ultrasonography (EUS; most sensitive test for T and N staging ; used when no evidence of M1 disease)
Computed tomography (CT) of the abdomen and chest with contrast (for assessing lung and liver metastasis and invasion of adjacent structures)
Pelvic CT scan with contrast if clinically indicated
Bronchoscopy (if tumor is at or above the carina, to help exclude invasion of the trachea or bronchi)
Laparoscopy and thoracoscopy (for staging regional nodes)
Barium swallow (very sensitive for detecting strictures and intraluminal masses, but now rarely used)
For staging information, see Esophageal Cancer Staging.
See Workup for more detail.
Management
Treatment of esophageal cancer varies by disease stage, as follows:
Stage I-III (locoregional disease) - Available modalities are endoscopic therapies (eg, mucosal resection or ablation), esophagectomy, preoperative chemoradiation, and definitive chemoradiation.
Stage IV – Systemic chemotherapy with palliative/supportive care for patients with ECOG performance score of 2 or less and palliative/supportive care only for patients with ECOG performance score of 3 or more.
Indications for surgical treatment of esophageal cancer include the following:
Esophageal cancer in a patient who is a candidate for surgery (esophagectomy)
High-grade dysplasia in a patient with Barrett esophagus that cannot be adequately treated endoscopically[1, 2]
Contraindications for surgical treatment include the following:
Metastasis to N2 (celiac, cervical, supraclavicular) nodes or solid organs (eg, liver, lungs)
Esophageal cancer is a devastating disease. It is the 6th most common cause of cancer deaths worldwide.[3] Although some patients can be cured, the treatment for esophageal cancer is protracted, diminishes quality of life, and is lethal in a significant number of cases.
The principal histologic types of esophageal cancer are squamous cell carcinoma (SCC) and adenocarcinoma. Both are common in men. SCC is the most common histology in Eastern Europe and Asia, while adenocarcinoma is most common in North America and Western European countries.
Adenocarcinoma is diagnosed predominantly in white men and the incidence has risen more steeply in that population. However, adenocarcinoma is gradually increasing in men of all ethnic backgrounds and also in women.[4]
Squamous cells line the entire esophagus, so SCC can occur in any part of the esophagus, but it often arises in the upper half. Adenocarcinoma typically develops in specialized intestinal metaplasia (Barrett metaplasia) that develops as a result of gastroesophageal reflux disease (GERD); thus, adenocarcinoma typically arises in the lower half of the distal esophagus and often involves the esophagogastric junction.
Treatment history and controversy
Surgery has traditionally been the treatment for esophageal carcinoma. The first successful resection was performed in 1913 by Torek.[5] In the 1930s, Ohsawa in Japan and Marshall in the United States were the first to perform successful single-stage transthoracic esophagectomies with continent reconstruction.[6, 7] Nonoperative therapy is usually reserved for patients who are not candidates for surgery because of clinical conditions or advanced disease.
The ideal treatment for localized esophageal cancer is sometimes debated across practice cultures and subspecialties. Proponents of surgical treatment argue that resection is the only treatment modality to offer curative intent; proponents of the nonsurgical approach claim that esophagectomy has a prohibitive index of mortality and that esophageal cancer is an incurable disease.
Most recently, in a study of 12,298 patients with esophageal cancer, median survival in patients who underwent surgery was 35.6 months, versus 24.8 months in the 708 (6%) patients who were advised to have surgery but declined and chose other treatment modalities or no treatment.[8]
A propensity-matched analysis showed that 525 patients who had preoperative therapy followed by surgery had a median survival of 32.3 months, compared with 21.9 months in patients who refused surgery, In a multivariate analysis, refusal of surgery remained a strong predictor of poorer survival (odds ratio, 1.72; P< 0.001).[8]
The esophagus is a muscular tube that extends from the level of the 7th cervical vertebra to the 11th thoracic vertebra. The esophagus can be divided into the following anatomic parts:
Cervical esophagus
Thoracic esophagus
Abdominal esophagus
The blood supply of the cervical esophagus is derived from the inferior thyroid artery, while the blood supply for the thoracic esophagus comes from the bronchial arteries and the aorta. The abdominal esophagus is supplied by branches of the left gastric artery and inferior phrenic artery.
Venous drainage of the cervical esophagus is through the inferior thyroid vein, while the thoracic esophagus drains via the azygous vein, the hemiazygous vein, and the bronchial veins. The abdominal esophagus drains through the coronary vein.
The esophagus is characterized by a rich network of lymphatic channels in the submucosa that can facilitate the longitudinal spread of neoplastic cells along the esophageal wall. Lymphatic drainage is to the following node basins:
Major risk factors for SCC include alcohol consumption and tobacco use. Most studies have shown that alcohol is the primary risk factor but smoking in combination with alcohol consumption can have a synergistic effect.
Alcohol damages the cellular DNA by decreasing metabolic activity within the cell and therefore inhibits detoxification and promotes oxidation.[9] Alcohol is a solvent, specifically of fat-soluble compounds. Therefore, the carcinogens within tobacco are able to penetrate the esophageal epithelium more easily.
Some of the carcinogens in tobacco include the following:
Aromatic amines
Nitrosamines
Polycyclic aromatic hydrocarbons
Aldehydes
Phenols
Other carcinogens, such as nitrosamines found in certain salted vegetables and preserved fish, have also been implicated in esophageal SCC. The pathogenesis appears to be linked to inflammation of the squamous epithelium that leads to dysplasia and in situ malignant transformation.[10]
Adenocarcinoma of the esophagus most commonly occurs in the distal esophagus and has a distinct relationship to GERD. Untreated GERD can progress to Barrett esophagus (BE), in which the stratified squamous epithelium that normally lines the esophagus is replaced by a columnar epithelium.
The chronic reflux of gastric acid and bile at the gastroesophageal junction and the subsequent damage to the esophagus has been implicated in the pathogenesis of Barrett metaplasia. Diagnosis of Barrett esophagus can be confirmed by biopsies of the columnar mucosa during an upper endoscopy.
Barrett esophagus incidence increases with age. The disorder is uncommon in children. It is more common in men than women and more common in whites than in Asians or African Americans.[9]
The progression of Barrett metaplasia to adenocarcinoma is associated with several changes in gene structure, gene expression, and protein structure.[11, 12, 13] The oncosuppressor gene TP53 and various oncogenes, particularly erb-b2, have been studied as potential markers. Casson and colleagues identified mutations in the TP53 gene in patients with Barrett epithelium associated with adenocarcinoma.[14] In addition, alterations in p16 genes and cell cycle abnormalities or aneuploidy appear to be some of the most important and well-characterized molecular changes.
Obesity is another risk factor for esophageal adenocarcinoma, specifically in individuals with central fat distribution. Hypertrophied adipocytes and inflammatory cells within fat deposits create an environment of low-grade inflammation and promote tumor development through the release of adipokines and cytokines.[15] Adipocytes in the tumor microenvironment supply energy production and support tumor growth and progression.[16]
The etiology of esophageal carcinoma is thought to be related to exposure of the esophageal mucosa to noxious or toxic stimuli, resulting in a sequence of dysplasia to carcinoma in situ to carcinoma. In Western cultures, retrospective evidence has implicated cigarette smoking and chronic alcohol exposure as the most common etiologic factors for squamous cell carcinoma. High body mass index, GERD, and resultant Barrett esophagus are often the associated factors for esophageal adenocarcinoma.[17]
Certain factors can increase or decrease risk for both cancer types. A study by Steevens et al found that in current smokers, increased consumption of specific groups of vegetables and fruits were inversely associated with risk for esophageal SCC and adenocarcinoma.[18] Total vegetable consumption nonsignificantly reduced risk for both esophageal cancer types. Consumption of raw vegetables and of citrus fruits was inversely associated with risk for esophageal adenocarcinoma. The risk of both SCC and adenocarcinoma of the esophagus was increased in current smokers.[19]
Risk factors for esophageal squamous cell carcinoma
The risk factors and etiologic associations for SCC of the esophagus include the following:
Smoking and alcohol use
Diet
Certain infections
Tylosis
Smoking and alcohol use
The Netherlands Cohort Study, a prospective study in 120,852 participants, demonstrated the combined effects of smoking and alcohol consumption on risk of SCC of the esophagus.[19] In participants who drank 30 g or more of ethanol daily, the multivariable adjusted incidence rate ratio (RR) for esophageal SCC was 4.61 compared with abstainers. The RR for current smokers who consumed more than 15 g/day of ethanol was 8.05 when compared with nonsmokers who consumed less than 5 g/day of ethanol.
No associations were found between alcohol consumption and esophageal adenocarcinoma.
Dietary associations
Esophageal SCC has a wide variety of dietary associations, among them the following:
Foods products containing N-nitroso compounds increase the risk of esophageal SCC.[20]
Toxin-producing fungi (eg, aflatoxin) induce carcinogenesis by reducing nitrates to nitroso compounds.[21]
Areca nuts or betel quid (areca nuts wrapped in betel leaves) increase the risk through the release of copper, with resulting induction of collagen synthesis by fibroblasts[22]
Red meat consumption increases the risk [23]
Low selenium levels increase risk,[24] while selenium supplementation reduces the risk.[25]
Zinc deficiency[26] mediates carcinogenesis by enhancing the carcinogenic effects of nitrosamines[27] and also leads to overexpression of cyclooxygenase (COX)-2.[28]
Low dietary folate intake is associated with an increased risk of esophageal SCC.[29]
Higher intake of fruits and vegetables reduces the risk of esophageal SCC.[30]
A variety of other factors may promote esophageal SCC. These include the following:
Caustic stricture
Achalasia cardia
Prior gastrectomy
Use of oral bisphosphonates[31]
Drinking scalding-hot liquids (hotter than 65° C [149° F])
Poor oral hygiene
Plummer-Vinson syndrome
A Chinese study found that risk for esophageal cancer was five times higher in individuals who drank very hot tea and drank more than 15 g of alcohol every day compared with those who drank tea less than once a week and consumed fewer than 15 g of alcohol daily (hazard ratio [HR], 5.00). Risk was doubled in those who drank very hot tea daily and smoked tobacco, compared with nonsmokers who drank tea only occasionally (HR, 2.03). The analysis included 456,155 participants aged 30 to 79 years who did not have a prior history of cancer.[32, 33]
A genome-wide association study by Wu et al identified seven susceptibility loci on chromosomes 5q11, 6p21, 10q23, 12q24, and 21q22, suggesting the involvement of multiple genetic loci and gene-environment interaction in the development of esophageal SCC.[34]
Bisphosphonate use can result in esophagitis and has been suggested as a risk factor for esophageal carcinoma. However, a large study found no significant difference in the frequency of esophageal or gastric cancers between the bisphosphonate cohort and the control group.[35]
Infections
Human papillomavirus (HPV) infection has been recognized as a contributing factor to esophageal cancer. However, Sitas et al reported limited serologic evidence of an association between esophageal SCC and HPV in a study of more than 4000 subjects. The study could not exclude the possibility that certain HPV types may be involved in a small subset of cancers, although HPV does not appear to be an important risk factor.[36] . Helicobacter pylori infection, which can cause stomach cancer, has not been associated with esophageal cancer.
Tylosis
Tylosis is a rare autosomal dominant disease caused by a mutation in TEC (tylosis with esophageal cancer), a tumor suppressor gene located on chromosome 17q25. Tylosis is associated with hyperkeratosis of the palms and soles (see the images below) and a high rate of esophageal SCC (40% to 90% by the age of 70 years).[37] The inherited type of tylosis (Howell-Evans syndrome) has been most strongly linked to esophageal SCC.[38, 39] Surveillance by upper GI endoscopy is recommended for family members with tylosis after 20 years of age.[40]
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Palmoplantar keratoderma (Tylosis) of palms (A) and soles (B). Courtesy of The American Journal of Gastroenterology, Nature Publishing Group.
Risk factors for adenocarcinoma
The principal risk factors and etiologic associations for esophageal adenocarcinoma include the following:
GERD
Obesity and metabolic syndrome
Gastroesophageal reflux disease
GERD is the most common predisposing factor for adenocarcinoma of the esophagus. Adenocarcinoma may represent the last event of a sequence that starts with irritation caused by the reflux of acid and bile and progresses to specialized intestinal (Barrett) metaplasia, low-grade dysplasia, high-grade dysplasia, and finally adenocarcinoma see the image below). Approximately 10%-15% of patients who undergo endoscopy for evaluation of GERD symptoms are found to have Barrett epithelium.
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Cascade of events that lead from gastroesophageal reflux disease to adenocarcinoma.
In 1952, Morson and Belcher published the first description of a patient with adenocarcinoma of the esophagus arising in a columnar epithelium with goblet cells.[41] In 1975, Naef et al emphasized the malignant potential of Barrett esophagus.[42]
The risk of adenocarcinoma in patients with Barrett metaplasia has been estimated to be 30-60 times that of the general population. A nationwide population-based case-control study performed in Sweden found an odds ratio of 7.7 for adenocarcinoma in persons with recurrent symptoms of reflux, as compared with persons without such symptoms, and an odds ratio of 43.5 in patients with long-standing and severe symptoms of reflux.[17]
Although the annual risk of developing esophageal adenocarcinoma in people with GERD has been reported at 0.5%, some studies have found lower risk. Data from the Northern Ireland Barrett Esophagus Register, which is one of the largest population-based registries in the world, found that malignant progression in patients with Barrett esophagus was 0.22% per year. This suggests that current surveillance approaches may not be cost effective.[43]
A study by Hvid-Jensen et al examined a large Danish registry (11,028 patients over a median of 5.2 years) and found the incidence of esophageal adenocarcinoma to be 1.2 cases per 1000 person-years (or 0.12% annual risk). Low-grade dysplasia detected on index endoscopy was associated with an incidence rate of 5.1 cases per 1000 person-years, compared with 1 per 1000 person-years in those without dysplasia.[44]
Additional factors that increase the risk for esophageal adenocarcinoma, particularly in patients with Barrett esophagus, include cigarette smoking[45] and certain polymorphisms of the epidermal growth factor gene that have been associated with higher serum levels of epidermal growth factor.[46] Freedman et al suggested a possible association between cholecystectomy and esophageal adenocarcinoma, likely due to the toxic effect of refluxed duodenal juice containing bile on esophageal mucosa [47]
Obesity and metabolic syndrome
Obesity has been linked to a higher risk for Barrett esophagus and esophageal adenocarcinoma.[48, 49] Individuals in the highest quartile for body mass index (BMI) have a 7.6-fold higher risk of developing esophageal adenocarcinoma compared with those in the lowest quartile. A meta-analysis of case control and cohort studies revealed a relative risk for esophageal adenocarcinoma of 1.71 (95% confidence index [CI] 1.5-1.96) for BMI between 25 and 30 kg/m2, and 2.34 (95% CI 1.95-2.81) for BMI ≥30 kg/m2.[50] Obesity does not appear to increase the risk of esophageal SCC.[51]
Obesity increases the risk of GERD and subsequently of esophageal adenocarcinoma by a "mechanical" process that consists of an amplification of intragastric pressure, disruption of normal esophageal sphincter function, and increased risk of a hiatal hernia.[52] Obesity also has an inflammatory effect mediated by the release of various proinflammatory cytokines, which can lead to metabolic syndrome, a constellation of metabolic disorders that includes obesity, impaired fasting glucose, high blood pressure, and dyslipidemia. Like obesity, metabolic syndrome is also linked with the risk of esophageal adenocarcinoma.[53]
The American Cancer Society estimates that 17,650 new cases of esophageal cancer (13,750 in men and 3,900 in women) will occur in the United States in 2019, and that 16,080 persons (13, 020 men and 3,060 women) will die of the disease.[54] Esophageal cancer is the seventh most common cause of cancer death in males.[54] The 5-year survival rate from 2007 to 2013 was 18.8%.[55]
The incidence of esophageal carcinoma is approximately 3-6 cases per 100,000 population, although certain endemic areas appear to have higher per-capita rates. The age-adjusted annual incidence is 4.3 cases per 100,000 population.[55]
The epidemiology of esophageal carcinoma has changed markedly over the past several decades in the United States.[56] Until the 1970s, squamous cell carcinoma was the most common type of esophageal cancer (90-95%). It was typically located in the thoracic esophagus and most frequently affected African-American men with a long history of smoking and alcohol consumption.
Subsequently, rates of esophageal adenocarcinoma rose markedly, particularliy in whites. In white men, the incidence rate of esophageal adenocarcinoma exceeded that of squamous cell carcinoma around 1990, while in white women aged 45–59 years, adenocarcinoma overtook squamous cell carcinoma in 2006–2010.[57]
From 1973 to 1996, the incidence of esophageal adenocarcinoma increased by 8.2% annually. From 1996 to 2006, the rate of increase fell to 1.3% annually, principally because of a plateau in the incidence of early-stage disease. Prior to 1996, early-stage cases increased by 10% annually; subsequently, they declined by 1.6% annually.[58] From 2004 to 2014, incidence rates of esophageal adenocarcinoma in the United States fell on average 1.4% each year.[55]
International statistics
Esophageal cancer is the ninth most common cancer and the sixth most common cause of cancer deaths worldwide.[59] It is endemic in many parts of the world, particularly in the third world countries, where it is the fourth most common cause of cancer deaths.[59] Incidence rates are variable worldwide, with the highest rates found in southern and eastern Africa and eastern Asia and the lowest rates in western and central Africa and Central America in both men amd women.[59]
In some regions, such as areas of northern Iran, some areas of southern Russia, and northern China (sometimes called an "esophageal cancer belt"), the incidence of esophageal carcinoma may be as high as 800 cases per 100,000 population. Major risk factors in these areas are not well known but are probably related to the poor nutritional status, including low intake of fruits and vegetables and drinking very hot beverages. Unlike in the United States, squamous cell carcinoma is responsible for 95% of all esophageal cancers worldwide.
Sex- and age-related demographics
Esophageal cancer is more common in men than in women. The male-to-female ratio is 3-4:1.
Esophageal cancer occurs most commonly during the sixth and seventh decades of life. The disease becomes more common with advancing age; it is about 20 times more common in persons older than 65 years than it is in individuals below that age. Median age at diagnosis is 68 years.[55]
Survival in patients with esophageal cancer depends on the stage of the disease. Squamous cell carcinoma and adenocarcinoma, stage-by-stage, appear to have equivalent survival rates.
Lymph node or solid organ metastases are associated with low survival rates. In 2009-2015, the overall 5-year survival rate for esophageal cancer was 19.9%.[55] Patients without lymph node involvement have a significantly better prognosis and 5-year survival rate than patients with involved lymph nodes. Stage IV lesions with distant metastasis are associated with a 5-year survival rate of around 5%. (See the table below.)
Table 2. Five-year esophageal cancer survival rates by stage at diagnosis in the US, 2009-2015[55]
View Table
See Table
The 5-year survival rate in 2015 was 21.5% in whites and 13.5% in blacks.[60] A report of 1085 patients who underwent transhiatal esophagectomy for cancer showed that the operation was associated with a 4% operative mortality rate and a 23% 5-year survival rate. A better 5-year survival rate (48%) was identified in a subgroup of patients who had a complete response (ie, disappearance of the tumor) following preoperative radiation and chemotherapy (ie, neoadjuvant therapy).[61]
Transhiatal and transthoracic esophagectomies have equivalent long-term survival rates.[62, 63]
Imaging and prognosis
Suzuki et al found that a higher initial standardized uptake value on positron emission tomography (PET) scanning is associated with poorer overall survival in patients with esophageal or gastroesophageal carcinoma receiving chemoradiation. The authors suggested that PET scanning may become useful for individualizing therapy.[64]
A study by Gillies et al also found that PET–computed tomography (CT) scanning can be used to predict survival; in this study, the presence of fluorodeoxyglucose (FDG)-avid lymph nodes was an independent adverse prognostic factor.[65]
HER-2 and prognosis
A study by Prins et al of human epidermal growth factor 2 (HER-2) protein overexpression and HER-2 gene amplification in esophageal carcinomas found that HER-2 positivity and gene amplification are independently associated with poor survival. In their study, which involved 154 patients with esophageal adenocarcinoma, HER-2 positivity was seen in 12% of these patients and overexpression was seen in 14% of them.[66]
Dysphagia, the most common presenting symptom of esophageal cancer, is initially experienced for solids but eventually progresses to include liquids. It usually occurs when esophageal lumen diameter is under 13 mm and indicates locally advanced disease. A complaint of dysphagia in an adult should always prompt an endoscopy to help rule out the presence of esophageal cancer. A barium swallow study is also indicated in these cases.
Other symptoms include the following:
Weight loss - This is the second most common symptom, occurring in more than 50% of people with esophageal carcinoma. It is caused by dysphagia and tumor-related anorexia.
Bleeding - Patients may experience bleeding from the tumor leading to iron deficiency anemia.
Pain - Pain may be felt in the epigastric or retrosternal area; pain over bony structures indicates metastatic disease.
Hoarseness - This is caused by invasion of the recurrent laryngeal nerve; it is a sign that the cancer has progressed beyond the point at which surgical resection remains possible.
Persistent cough
Respiratory symptoms (persistent cough and recurrent pneumonia) - These can be caused by aspiration of undigested food or by direct invasion of the tracheobronchial tree by the tumor (tracheobronchial fistula); the latter is also a sign of unresectabiliy.
Physical examination findings in patients with esophageal cancer are typically normal, unless the cancer has metastasized to neck nodes or the liver. Lymphadenopathy in the laterocervical or supraclavicular area or the presence of hepatomegaly often indicates unresectable disease.
In 2013, the Society of Thoracic Surgeons released clinical practice guidelines to assist in the diagnosis and treatment of localized esophageal cancer. Their recommendations for diagnosis include the following[67] :
Flexible endoscopy with biopsy is the primary method for diagnosis of esophageal cancer.
Computed tomography (CT) of the chest and abdomen is an optional test for staging of early-stage esophageal cancer, and a recommended test for staging of locoregionalized esophageal cancer.
Positron emisison tomography (PET) is an optional test for staging of early-stage esophageal cancer, and a recommended test for staging of locoregionalized esophageal cancer.
In patients without metastatic disease, endoscopic ultrasonography is recommended to improve the accuracy of staging
In patients with small, discrete nodules or areas of dysplasia in whom disease appears limited to the mucosa or submucosa as assessed by endoscopic ultrasonography, endoscopic mucosal resection should be considered as a diagnostic/staging tool.
In patients with locally advanced (T3/T4) adenocarcinoma of the esophagogastric junction infiltrating the anatomic cardia or Siewart type III esophagogastric tumors, laparoscopy is recommended to improve the accuracy of staging.
Imaging studies used in the diagnosis and staging of esophageal cancer include the following:
CT scanning
PET scanning
Endoscopic ultrasound (EUS)
Bronchoscopy
Barium swallow
Computed tomography
Abdominal and chest computed tomography (CT) scans are useful for helping to exclude the presence of metastases (M staging) to the lungs and liver and may be useful for helping to determine whether adjacent structures have been invaded.[68] (See the image below.)
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Chest CT scan showing invasion of the trachea by esophageal cancer.
Positron emission tomography
PET scanning is also a useful baseline imaging technique and is increasingly becoming standard in the staging of esophageal cancer. It may be particularly useful in detecting occult distant lymph node metastases and bone spread. In addition, the intensity of radiopharmaceutical uptake on PET scans may reflect the biology of the cancer and thus may have prognostic significance.[64]
Endoscopic ultrasound
EUS is the most sensitive test for determining the depth of tumor penetration (T staging) and the presence of enlarged periesophageal lymph nodes (N staging).[69, 70]
Following are the characteristic features of malignant or inflammatory lymph nodes detected on EUS:
Enlarged in size
Hypoechoic (dark)
Homogeneous
Well circumscribed and rounded
The accuracy of diagnosing nodal disease is significantly increased with the combination of above-mentioned features, but also is confirmed with the use of fine needle aspiration (FNA) biopsy for cytology assessment.[71] The combined use of EUS and FNA (EUS-FNA) has a greater accuracy than EUS alone in the evaluation of lymph node metastasis.[72] In a study that compared the role of CT, EUS, and EUS-FNA for preoperative nodal staging in 125 patients with esophageal cancer, EUS-FNA was more sensitive than CT (83% vs. 29%) and more accurate than CT (87% vs. 51%) or EUS (87% vs. 74%) for nodal staging.[73]
Patients with obstructing tumors are at increased risk for perforation during staging EUS. The risk of perforation can be reduced with the use of wire-guided or mini-EUS probes. In certain cases, the malignant stricture is dilated prior to the staging EUS.The review of CT and PET scans prior to EUS is recommended to evaluate the nodal distribution for a possible FNA biopsy.
Bronchoscopy
Bronchoscopy is indicated for cancers of the middle and upper third of the thoracic esophagus (tumor at or above carina) to help exclude invasion of the trachea or bronchi. It should be performed only if the patient shows no evidence of M1 disease. Laparoscopy and thoracoscopy have a greater than 92% accuracy in staging regional nodes.
Barium swallow
Barium swallow is very sensitive for detecting strictures (see the first image below) and intraluminal masses (see the second image below) but does not allow staging and biopsy. It is now rarely used, but it may be helpful for studying the distal anatomy in obstructive tumors that are inaccessible by endoscopy.
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Barium swallow demonstrating stricture due to cancer.
View Image
Barium swallow demonstrating an endoluminal mass in the mid esophagus.
For more information, see the Medscape article Esophageal Carcinoma Imaging.
Esophageal cancer staging follows the tumor-node-metastasis (TNM) classification of the American Joint Cancer Committee/Union for International Cancer Control/ (AJCC/UICC).[74]
No completely satisfactory method is available to clinically stage esophageal cancer. The difficulty of clinically assessing the disease is reflected by changes over time in the AJCC staging system. The 1983 system was based on the length of the intraluminal esophageal tumor, the presence of esophageal obstruction, and the involvement of palpable lymph nodes. This clinical staging system proved to have limited value.
The 1988 revision defined a clinical and pathologic staging system based entirely on the depth of esophageal wall invasion and the presence or absence of local nodal involvement. Neither of those parameters is assessed easily on a clinical basis. Hofstetter et al therefore proposed incorporating the number of involved lymph nodes with regional and nonregional node location.[75] This modification, which seemed to be simpler and to better predict long-term survival, was adopted into the revised system.
The revised 2010 AJCC staging classification was based on the risk-adjusted random forest analysis of the data generated by the Worldwide Esophageal Cancer Collaboration (WECC) for 4627 patients who were treated with primary esophagectomy without preoperative or postoperative therapy.[76] In the data reported by the WECC, survival decreased with increasing depth of tumor invasion (T), presence of regional lymph node metastases (N), and the presence of distant metastases (M).[77]
The 2017 TNM classification for esophageal cancer is shown below (staging is detailed in Tables 2-4, below. T staging is illustrated in the image below). For more information, see Esophageal Cancer Staging.
TNM staging is as follows:
Tis - High-grade dysplasia (malignant cells confined to the epithelium by the basement membrane)
T1 - Tumor invades the lamina propria, muscularis mucosae, or submucosa
T1a - Tumor invades the lamina propria or muscularis mucosae
T1b - Tumor invades the submucosae
T2 - Tumor invades the muscularis propria
T3 - Tumor inades adventitia
T4 - Tumor invades adjacent structures
T4a -Tumor invading into pleura, pericardium, azygos vein, diaphragm, or peritoneum
All esophageal tumors, as well as tumors with epicenters within 5 cm of the esophagogastric junction that also extend into the esophagus, are classified and staged according to the AJCC/UICC esophageal scheme. Tumors with an epicenter in the stomach that are more than 5 cm from the esophagogastric junction or those within 5 cm of the esophagogastric junction without extension into the esophagus are staged using the gastric carcinoma scheme.
However, this classification may not work well for patients who have received preoperative therapy. Some other shortcomings associated with the current staging classification are as follows:
Inclusion of proximal 5 cm of the stomach
Lack of guidance for regional resectable and unresectable cancer
Emphasis on the number of nodes rather than their size and anatomic locations/significance.
Other classifications—such as that of the Japanese Society for Esophageal Diseases, which is widely used in Asia—differ from that of the AJCC/UICC, especially regarding lymph node distribution and nomenclature.[78]
Laboratory studies in patients with esophageal cancer focus principally on patient factors that may affect treatment. These include complete blood count (CBC) and comprehensive metabolic panel (CMP). Nutritional status should be evaluated in patients with dysphagia; liver function studies should be performed in patients who abuse alcohol.
Endoscopy is a very important tool in the diagnosis, staging, and surveillance of patients with esophageal cancer. Most endoscopy procedures are performed under conscious sedation. Patients who are at risk of aspiration during endoscopy may require general anesthesia.
Diagnostic endoscopies are performed to determine the following:
Detection of esophageal tumor
Biopsy of any suspicious lesions
Location of the tumor relative to the teeth and esophagogastric junction
Tumor length
Degree of obstruction
Esophageal tumor length, as assessed by preoperative endoscopy, has been identified as an independent predictor of long-term survival in patients with adenocarcinoma of the esophagus.[79] The 5-year survival rate was significantly higher for patients with a tumor length of 2 cm or less (78% vs 29% for those with a tumor length of more than 2 cm).
Endoscopic resection
Endoscopic resection (ER) of focal nodules should be performed in the setting of early-stage disease (T1a or T1b) to provide accurate assessment of depth of invasion, degree of differentiation, and the presence of lymphovascular invasion.[80] Thus, ER is an essential procedure for the accurate staging of early-stage cancer especially in patients with small nodular lesions (≤2 cm).[81] ER can become a therapeutic procedure if a small lesion (under 2 cm) is fully removed and histopathology reveals that the lesion is well differentiated, with penetration limited to submucosa, absence of lymphovascular invasion, and clear margins.[82]
Histologically, esophageal squamous cell carcinoma is characterized microscopically by keratinocyte-like cells with intercellular bridges or keratinization. Adenocarcinomas that arise from Barrett esophagus mucosa are typically well- or moderately differentiated and have well-formed tubular or papillary structures. In poorly differentiated adenocarcinomas, glandular structures are only sloightly formed; in undifferentiated adenocarcinomas, glandular structures are absent. See the images below.
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Micrograph of squamous cell carcinoma of the esophagus (H&E Stain). Courtesy of Wikimedia Commons.
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Low magnification micrograph of an intramucosal esophageal adenocarcinoma (H&E stain). Endoscopic mucosal resection specimen. Courtesy of Wikimedia Co....
Treatment of esophageal cancer varies according to stage—locoregional (stages I-III) versus metastatic cancer (stage IV)—and histologic subtype—squamous cell carcinoma (SCC) versus adenocarcinoma.
National Comprehensive Cancer Network (NCCN) treatment recommendations for esophageal cancer include the following[83] :
Endoscopic therapy (endoscopic mucosal resection, endoscopic submucosal dissection and/or ablation) is preferred for high-grade dysplasia (HGD) or T1a tumors ≤2 cm; ablation alone is a primary treatment option for patients with HGD.
Select pT1a or pT1b tumors can be treated with endoscopic resection (ER); ablation of residual Barrett esophagus should follow ER.
Additional ablation may be needed after ER if multifocal HGD is present elsewhere in the esophagus but may not be needed for tumors that are completely resected.
Esophagectomy is indicated for patients with extensive HGD or pT1a adenocarcinoma with nodular disease that is not adequately controlled by ER with or without ablation; a transhiatal or transthoracic, or minimally invasive approach may be used; gastric reconstruction preferred; for postoperative nutritional support, feeding jejunostomy is preferred to gastrostomy.
Primary treatment options for patients with SCC T1b, N+ tumors and locally advanced resectable tumors (T2-T4a, any regional N) include preoperative chemoradiation (for non-cervical esophagus tumors), definitive chemoradiation (recommended for cervical esophagus tumors) or esophagectomy (for non-cervical esophagus tumors).
For patients with adenocarcinoma T1b, N+ tumors and locally advanced resectable tumors (T2-T4a, any regional N) preoperative chemoradiation is preferred; definitive chemoradiation is indicated only for non-surgical patients; esophagectomy is an option for patients with low-risk, < 2 cm, well-differentiated lesions.
Tumors in the submucosa (T1b) or deeper may be treated with esophagectomy.
For patients with SCC, no postoperative treatment is indicated if no residual disease is present at surgical margins (R0 resection).
For patients with adenocarcinoma who have not received preoperative therapy, postoperative fluoropyrimidine-based chemoradiation (following R0 resection) is indicated for all patients with Tis, T3-T4 tumors, node-positive T1-T2 tumors, and selected patients with T2, N0 tumors with high-risk features.
Chemotherapy following R0 resection is indicated for all patients with adenocarcinoma, irrespective of the nodal status.
Chemoradiation may be offered to all patients with residual disease at surgical margins (R1 and R2 resections).
Definitive chemoradiation is preferred for all T4b (unresectable) tumors.
Fluoropyrimidine- or taxane-based regimens are indicated for preoperative and definitive chemoradiation.
Two-drug cytotoxic regimens are preferred for patients with advanced disease because of lower toxicity.
Trastuzumab should be added to first-line chemotherapy (category 1 for combination with cisplatin and fluoropyrimidine; category 2B for combination with other chemotherapy agents) for patients with HER2-overexpressing advanced or metastatic adenocarcinoma (a tumor immunohistochemistry [IHC] score of 3+ or 2+ with the evidence of HER2 amplification by fluorescent in situ hybridization [FISH]).[84]
Ramucirumab, either as a single agent or in combination with paclitaxel, was approved in 2014 by the US Food and Drug Administration (FDA) for the treatment of patients with advanced esophagogastric junction (EGJ) adenocarcinoma refractory to or progressive following first-line therapy with platinum- or fluoropyrimidine-based chemotherapy.
Surgery remains the cornerstone of treatment for esophageal cancer. Indications for surgery include the following:
Esophageal cancer in a patient who is a candidate for surgery
High-grade dysplasia in a patient with Barrett esophagus that cannot be adequately treated endoscopically[1, 2]
Contraindications to surgery include the following:
Metastasis to N2 nodes (ie, cervical or supraclavicular lymph nodes) or solid organs (eg, liver, lungs); the treatment of patients with celiac lymph node involvement remains controversial[85]
Invasion of adjacent structures (eg, the recurrent laryngeal nerve, tracheobronchial tree, aorta, pericardium)
In addition, the presence of severe, associated comorbid conditions (eg, cardiovascular disease, respiratory disease) can decrease a patient's chances of surviving an esophageal resection. Consequently, cardiac and respiratory function must be carefully evaluated preoperatively. A forced expiratory volume in 1 second of less than 1.2 L and a left ventricular ejection fraction of less than 0.4 are relative contraindications to the operation.
Esophageal resection (esophagectomy) remains a critical component of multimodality therapy for patients with tumors of any stage. Endoscopic mucosal resection is an experimental approach to patients with T1a disease or high-grade dysplasia that is limited to certain centers and performed only under protocol. Esophagectomy is no longer is used for palliation of symptoms because other treatment modalities have become available for relieving dysphagia.
An esophagectomy can be performed by using an abdominal and a cervical incision with blunt mediastinal dissection through the esophageal hiatus (ie, transhiatal esophagectomy [THE]) or by using an abdominal and a right thoracic incision (ie, transthoracic esophagectomy [TTE]).
THE offers the advantage of avoiding a chest incision, which can cause prolonged discomfort and can further aggravate the condition of patients with compromised respiratory function. After removal of the esophagus, continuity of the gastrointestinal tract is usually reestablished using the stomach.
Some authors have questioned the validity of THE as a cancer operation because part of the operation is not performed under direct vision and fewer lymph nodes are removed than with TTE. However, many retrospective studies and 2 prospective ones have shown no difference in survival between the operations, suggesting that the factor influencing survival is not the type of operation but, rather, the stage of the cancer at the time the operation is performed.[62, 63, 86, 87, 88, 89]
Morbidity and mortality
Complications from esophagectomy occur in approximately 40% of patients. The morbidity associated with the surgery consists mostly of respiratory, cardiac, and septic complications, including the following:
Respiratory complications (15-20%) - Include atelectasis, pleural effusion, and pneumonia
Cardiac complications (15-20%) - Include cardiac arrhythmias and myocardial infarction
Septic complications (10%) - Include wound infection, anastomotic leak (breakdown of the new connection between the stomach and esophagus), and pneumonia
Anastomotic leaks and stricture may require dilatation (20%). Leaks may be treated with endoscopic placement of self-expanding, removable plastic stents.[90]
Leak rates vary depending on whether the anastomosis is in the chest (3%-12%) or the neck (10%-25%).[91] The choice of location for the anastomosis is based mostly on the location of the tumor and the surgeon’s assessment of the risks and benefits of a thoracic anastomosis. Such anastomoses have a lower leak rate, but an intrathoracic leak following esophagectomy can lead to sepsis and death.
A retrospective review of 1223 esophagectomies for cancer found that surgical management of intrathoracic leaks did not increase the patient mortality rate or effect long-term survival.[91]
As with other complex operations (eg, cardiac operations, resection of the pancreas or liver), the lowest mortality rate with esophagectomy is achieved when the procedure is performed in high-volume centers by high-volume surgeons. In California from 1990-1994, for instance, 5 high-volume centers had a mortality rate of 5% or less for esophageal resection for cancer, while the state’s average mortality rate for this surgery was approximately 18%.[92]
The better results in high-volume centers are due to a team approach. In these facilities, expert surgeons work with intensivists, cardiologists, pulmonologists, radiologists, and nurses who have experience and expertise.
Transthoracic esophagectomy
There are two types of TTE, as follows:
Ivor Lewis esophagectomy (right thoracotomy and laparotomy)
McKeown esophagectomy (right thoracotomy followed by laparotomy and cervical anastomosis)
For TTE, the patient is placed supine on the operating room table. An arterial line, a central venous catheter, a Foley catheter, and a dual-lumen endotracheal tube are placed. Preoperative antibiotics are administered. An upper midline incision is made.
After exploring the peritoneal cavity for metastatic disease (if metastases are found, the operation is not continued), the stomach is mobilized. The right gastric and the right gastroepiploic arteries are preserved, while the short gastric vessels and the left gastric artery are divided.
Next, the gastroesophageal junction is mobilized, and the esophageal hiatus is enlarged. A pyloromyotomy is performed, and a feeding jejunostomy is placed for postoperative nutritional support.
After closure of the abdominal incision, the patient is repositioned in the left lateral decubitus position and a right posterolateral thoracotomy is performed in the fifth intercostal space.
The azygos vein is divided to allow full mobilization of the esophagus. The stomach is delivered into the chest through the hiatus and is then divided approximately 5 cm below the gastroesophageal junction.
An anastomosis (hand-sewn or stapled) is performed between the esophagus and the stomach at the apex of the right chest cavity. Then, the chest incision is closed.
McKeown esophagectomy, with an anastomosis in the cervical region, is similar in conduct, but with the advantage of being applicable for tumors in the upper, middle, and lower thoracic esophagus.
Transhiatal esophagectomy
For THE, the preoperative details are similar to those of TTE, except that a single-lumen, rather than a double-lumen, endotracheal tube is used. The neck is prepared in the operative field.
The abdominal part of the operation is identical to the TTE; however, dissection of the esophagus is performed through the enlarged esophageal hiatus without opening the right chest. The esophagus is mobilized in this fashion all the way to the thoracic inlet.
Then, a 6-cm incision is made in the left side of the neck. The internal jugular vein and carotid artery are retracted laterally, and the esophagus is identified and isolated posterior to the airway. To prevent injury to the left recurrent laryngeal nerve, no mechanical retractors are used to retract the trachea.
Next, after resection of the proximal stomach and thoracic esophagus, the remaining stomach is pulled up through the posterior mediastinum until it reaches the remaining esophagus at the cervical level. Then, a hand-sewn anastomosis is performed, and a small drain is placed in the neck alongside the anastomosis. The abdominal and neck incisions are closed. (See the image below.)
View Image
Transhiatal esophagectomy in which (a) is the abdominal incision, (b) is the cervical incision, and (c) is the stomach stretching from abdomen to the ....
Minimally invasive esophagectomy
The use of laparoscopic and thoracoscopic techniques has revolutionized the treatment of benign esophageal disorders such as achalasia and gastroesophageal reflux disease (GERD). Advantages of minimally invasive surgery include a shorter hospital stay, less postoperative discomfort, and much faster recovery time than with open surgery. Minimally invasive esophagectomy (MIE) is finding a place in the treatment of esophageal cancer.[93]
In a study of MIE (mainly using thoracoscopic mobilization) in 222 patients, the mortality rate was only 1.4% and hospital stay was only 7 days, which is less than with most open procedures; only 16 patients (7.2%) required conversion to an open procedure.[94] A report by Luketich et al involving 56 patients also showed that MIE was comparable to open esophagectomy but the use of neoadjuvant treatment slightly increased the surgical mortality from 1.5% to 1.8%.[94]
In a randomized French study that compared transthoracic open esophagectomy (n=104) with MIE (hybrid procedure; n=103), .Mariette et al reported that the incidence of intraoperative and postoperative major complications, specifically pulmonary complications, was 69% lower with the hybrid procedure, while 3- and 5-year overall survival and disease-free survival were noninferior. For the hybrid procedure, the abdominal portion of the operation was performed through five small incisions, rather than the long abdominal incision used in TTE.[95, 96]
Video-assisted thoracoscopy (VATS) is being used in many centers for the thoracic mobilization of the esophagus, reducing the size of the chest incision. In addition, laparoscopy can be used to mobilize the gastric conduit in the abdomen, reducing abdominal incision size as well.
A study by Uenosono et al found that sentinel node mapping can be applied to patients with clinical T1 and N0 esophageal cancer. Use of this technique may facilitate less invasive surgery, with reduction of lymphadenectomy.[97]
Endoscopic mucosal resection (EMR) is a modern, attractive option for the treatment of superficial esophageal cancers. High-grade dysplasia and mucosa-limited neoplasms are candidates for EMR, because of the low risk of node metastasis in these cases. A population-based study of 1618 patients with grade Tis, T1a, or T1b esophageal cancer found that overall survival times and esophageal-cancer-specific survival times with endoscopic therapy were similar to those with surgery, after adjustment for patient and tumor factors.[98, 99]
Salvage endoscopic resection
In patients with local failure after definitive chemoradiotherapy (CRT) for esophageal squamous cell carcinoma (SCC), salvage endoscopic treatment (SET) may be a viable option, according to a study reported at the 2014 Gastrointestinal Cancers Symposium.[100] The study included 716 esophageal SCC patients treated with CRT, 417 of whom experienced local failure (incomplete response or local recurrence); of these 417 patients, 164 underwent SET (either photodynamic therapy or endoscopic resection).
Curative resection was achieved in 88% of the patients who underwent endoscopic resection, and a complete response was achieved in 57.5% of those who underwent photodynamic therapy.[100] Overall survival and relapse-free survival rates at 5 years were 38.6% and 28%, respectively. The factors most strongly predictive of improved survival were (1) an absence of lymph node metastasis before CRT and (2) an elapsed time of 6 months or longer between the initiation of CRT and the performance of SET.[100]
Chemotherapy and radiotherapy for esophageal cancer are delivered preoperatively. No survival benefit is obtained when radiation and chemotherapy are administered postoperatively; however, postoperative continuance of chemotherapy started preoperatively may be beneficial.[101] The aims of preoperative (neoadjuvant) chemotherapy and radiotherapy are to reduce the bulk of the primary tumor before surgery to facilitate higher curative resection rates and to eliminate or delay the appearance of distant metastases.
Most chemotherapy that is currently used for the treatment of esophageal cancer, including alkylating, antimetabolite, anthracycline, and antimicrotubular agents, are not approved for this indication by the US Food and Drug Administration (FDA). Chemotherapy for squamous cell esophageal carcinoma, as with squamous cell carcinomas in general, is based on cisplatin, while chemotherapy for esophageal adenocarcinoma has been extrapolated from experience in patients with adenocarcinoma of the stomach.
Neoadjuvant chemotherapy alone appears to offer a limited benefit at best. A North American randomized trial found that preoperative chemotherapy with a combination of cisplatin and fluorouracil did not improve overall survival among patients with squamous cell cancer or adenocarcinoma of the esophagus. In a larger trial, British investigators found that preoperative chemotherapy with those 2 agents resulted in a 5-year survival rate of 23.0%, compared with 17.1% for surgery alone.[102]
In contrast, the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) demonstrated considerable benefit from preoperative chemoradiation over surgery alone in selected patients with esophageal or esophagogastric junction cancer (tumor stage T1N1 or T2–T3 with any N).[103] Median overall survival with chemoradiation therapy followed by surgery was 49.4 months, compared with 24.0 months with surgery alone.
An analysis of data from CROSS I and II showed that preoperative chemoradiotherapy (CRT) plus surgery was superior to surgery alone in preventing local, regional, and distant recurrence, particularly hematogenous metastasis and peritoneal carcinomatosis.[104, 105, 106] Overall recurrence rates were 35% for CRT plus surgery and 58% for surgery alone. The rates of locoregional recurrence, peritoneal carcinomatosis, and hematogenous dissemination were all lower for the former as well (14% vs 34%, 4% vs 14%, and 29% vs 35%, respectively).
Neoadjuvant therapy consists of a combination of radiotherapy (approximately 45 Gy) and chemotherapy with cisplatin and 5-fluorouracil. While the radiotherapy acts locally at the tumor site, the chemotherapy acts on tumor cells that have already spread. This combination therapy is usually administered over a 45-day period; esophageal resection is performed after an interval of approximately 4 weeks.
In a study of patients with distal esophageal carcinoma, Franko and colleagues reported that a longer interval between neoadjuvant chemoradiation and esophagectomy was significantly associated with worse outcomes. The median interval between radiation therapy and esophagectomy was 7.1 weeks; when the delay was 9 weeks or more, perioperative mortality was increased and overall survival decreased.[107]
Rohatgi et al reported that the response to preoperative chemoradiotherapy correlated strongly with overall survival and disease-free survival in patients with esophageal cancer. In their review of 235 cases, survival decreased progressively between patients who achieved a pathologic complete response, those who had a partial response (1-50% residual carcinoma in the resected specimen), and those with no response (greater than 50% residual carcinoma).[108]
A study by Rao et al identified groups of esophageal tumors with distinct gene expression profiles, which in future may allow for tailored treatment protocols.[109] Similarly, Alexander et al identified DNA-repair biomarkers that predict response to neoadjuvant chemotherapy.[110]
A trial involving 111 patients undergoing chemoradiotherapy for head-and-neck or esophageal cancer indicated that enteral nutrition enriched with n-3 fatty acids helps to preserve body mass and improve nutritional and functional status parameters during chemoradiotherapy.[111, 112]
Pembrolizumab
In July 2019, the FDA approved pembrolizumab (Keytruda) for patients with recurrent, locally advanced or metastatic, squamous cell carcinoma of the esophagus (ESCC) whose tumors express PD-L1 (Combined Positive Score [CPS] ≥10), as determined by an FDA-approved test, with disease progression after ≥1 prior lines of systemic therapy.[113]
Efficacy was observed in two clinical trials, KEYNOTE‑181 and KEYNOTE‑180. KEYNOTE-181 (n=628) was a phase 3 randomized, open-label, active-controlled trial that enrolled patients with recurrent locally advanced or metastatic esophageal cancer who progressed on or after one prior line of systemic treatment for advanced or metastatic disease. Patients were randomized to receive either pembrolizumab or the investigator’s choice of a paclitaxel, docetaxel, or irinotecan regimen as a control arm. The median overall survival was 9.3 months and 6.7 months in the pembrolizumab and control arms, respectively.[114]
KEYNOTE‑180 was a single arm, open-label trial that enrolled patients with locally advanced or metastatic esophageal cancer who progressed on or after at least 2 prior systemic treatments for advanced disease. In the patients with ESCC expressing PD-L1 CPS ≥10, ORR was 20% and response durations ranged from 4.2 to 25.1+ months, with 71% having responses of 6 months or longer and 57% having responses of 12 months or longer.[115]
Tipiracil/trifluridine
The FDA approved tipiracil/trifluridine in February 2019 for metastatic gastric or gastroesophageal junction (GEJ) adenocarcinoma previously treated with at least 2 prior lines of chemotherapy that included a fluoropyrimidine, a platinum, either a taxane or irinotecan, and if appropriate, HER2/neu-targeted therapy.
Approval of tipiracil/trifluridine was based on the phase 3 TAGS (TAS-102 Gastric Study) clinical trial (n=507). Patients in the tipiracil/trifluridine group had a median overall survival 5.7 months compared with 3.6 months in the placebo group (one-sided P=0·00029, two-sided P=0·00058).[116]
In patients who are not candidates for surgery, because of their clinical condition or advanced disease, treatment focuses on control of dysphagia. The goal of palliative care is to prevent and relieve suffering and improve quality of life for patients and their caregivers regardless of the disease stage. In patients with unresectable or locally advanced cancer, palliative interventions provide symptomatic relief and may result in significant prolongation of life, improvement in nutritional status, the sensation of well-being, and overall quality of life.
Although various treatment options are available for the management of dysphagia, optimal treatment is still debated. A multimodality interdisciplinary approach is strongly encouraged.
Dysphagia is the most common symptom in patients with esophageal cancer. Assessing the severity of the condition and swallowing impairment is essential to initiate appropriate interventions for long-term palliation of dysphagia in patients with esophageal cancer.
Available palliative methods for the management of dysphagia include the following:
Endoscopic lumen restoration or enhancement
Temporary self-expanding metal stents (SEMS)
External beam radiation therapy (EBRT)
Brachytherapy
Chemotherapy
Laser
Surgery
National Comprehensive Cancer Network guidelines for best supportive/palliative care
For patients with complete esophageal obstruction, the NCCN guidelines[83] recommend the following:
Endoscopic lumen restoration
EBRT
Chemotherapy
Surgery
Surgical or radiologic placement of jejunostomy or gastronomy tubes may be necessary to provide adequate hydration and nutrition, if endoscopic lumen restoration is not undertaken or is unsuccessful. Brachytherapy may be considered instead of EBRT if lumen can be restored using appropriate applicators during the delivery of brachytherapy to avoid an excessive dose on mucosal surfaces. In a multicenter randomized trial, single-dose brachytherapy was associated with fewer complications and better long-term relief of dysphagia compared with metal stents.[117]
For patients with severe esophageal obstruction (those able to swallow liquids only), some additional options include endoscopic lumen enhancement (wire-guided or balloon dilation) and endoscopy or fluoroscopy-guided placement of covered expandable metal stents. While some data suggest a lower migration and re-obstruction rate with the larger-diameter covered expandable metal stents, there may be a higher risk of stent-related complications[118]
Stents
Long-term palliation of dysphagia can be achieved with endoscopic, radiographic-assisted insertion of expandable metal or plastic stents.[119, 120] Temporary placement of self-expanding metal stents (SEMS) with concurrent EBRT was found to increase survival rates compared with permanent stent placement.[121] SEMS is the preferred treatment for patients with tracheoesophageal fistula and those who are not candidates for chemoradiation or who failed to achieve adequate palliation with such therapy.[122] Membrane-covered stents have significantly better palliation than conventional bare metal stents because of a lower rate of tumor ingrowth.[120]
Radiotherapy
Radiation therapy is successful in relieving dysphagia in approximately 50% of patients. In patients with advanced esophageal cancer, the preoperative combination of chemotherapy and radiotherapy has shown good results.
In a large, multicenter study, Herskovic and colleagues reported a 2-year survival rate of 38%, with a median survival period of 12.5 months, for patients treated with radiotherapy in combination with chemotherapy (fluorouracil and cisplatin), compared with a 2-year-survival rate of 10% and a median survival period of 8.5 months in patients treated with radiotherapy alone.[123, 124]
Folkert et al found that high-dose-rate (HDR) endoluminal brachytherapy was well tolerated in medically inoperable patients with superficial primary or recurrent esophageal cancer. Over the course of 3 years, 14 patients were treated with HDR intraluminal brachytherapy; 10 had recurrent esophageal cancer and 4 had previously unirradiated lesions. The overall freedom from failure (OFFF) and the overall survival (OS) rate at 18 months were 30.8% and 72.7%, respectively. Patients with recurrent disease had an 11.1% OFFF and a 55.6% OS rate at 18 months. For patients with previously unirradiated disease, the OFFF was 75% and the OS rate was 100%.[125]
Chemotherapy
Chemotherapy as a single modality has limited use. Only a few patients achieve a modest and short-lived response.
A phase 3 study from the United Kingdom suggests that docetaxel may be useful as a second-line treatment for patients with esophageal cancer who have progressed after first-line chemotherapy.[126, 127] Median overall survival was significantly better in patients treated with docetaxel than in those managed with active symptom control (5.2 versus 3.6 months, respectively).
Because survival in these patients is measured in months, quality of life is an important consideration. In the UK study, quality-of-life questionnaires demonstrated no differences between the 2 groups on global and functioning scores but did indicate an improvement in symptom scores, with the docetaxel group reporting less pain.[126, 127]
In 2006, a Cochrane review tried to assess the effectiveness of chemotherapy versus best supportive care, as well as that of different chemotherapy regimens against each other, in metastatic esophageal carcinoma. The authors found that no consistent benefit with any specific chemotherapy regimen.[128] Cisplatin, 5-fluorouracil (5-FU), paclitaxel, and anthracyclines had promising response rates and tolerable toxicity.
Laser therapy
Laser therapy (Nd:YAG laser) can help to achieve temporary relief of dysphagia in as many as 70% of patients. Multiple sessions are usually required to keep the esophageal lumen patent.
The photosensitizer porfimer (Photofrin) is FDA approved for palliation of patients with completely obstructing esophageal cancer or partially obstructing cancer that cannot be satisfactorily treated with Nd:YAG laser therapy. Intravenous injection of porfimer is followed 40–50 hours later with delivery of 630 nm wavelength laser light; a second laser light treatment may be given 96–120 hours after the injection. Photodynamic therapy (PDT) with porfimer sodium has overall equal efficacy to Nd:YAG laser thermal ablation for palliation of dysphagia in esophageal cancer, and equal or better objective tumor response rate. Temporary photosensitivity is a limitation, but PDT is carried out with greater ease and is associated with fewer acute perforations than Nd:YAG laser therapy[119] .
The average length of postoperative hospital stay for patients with esophageal cancer is 9-14 days. Patients usually spend the first postoperative night in the intensive care unit (ICU).
Patients can be extubated immediately after the operation, but mechanical ventilation should be continued if any concerns about the respiratory status are present. Respiratory complications (eg, atelectasis, pleural effusion, pneumonia) and cardiac complications (eg, cardiac arrhythmias) usually occur in the first postoperative days. Patients leave the ICU and are transferred to the surgical ward only when their respiratory status and cardiac status are satisfactory.
Feeding through the feeding jejunostomy begins on postoperative day 1. On postoperative day 6, a swallow study is performed to check for anastomotic leakage. If no leak is present, patients start oral feedings. If a leak is present, the drainage tubes are left in place and nutrition is provided entirely through the feeding jejunostomy until the leak closes spontaneously.
Approximately 85%-90% of patients go home after discharge. The remaining patients may need additional time in a skilled nursing facility if they live alone and if they cannot take care of themselves.
Patients are seen by the responsible surgeon at 2 weeks and 4 weeks after discharge from the hospital and subsequently every 6 months by an oncologist. Most patients return to their regular level of activities within 2 months.
For squamous cell carcinoma, prevention consists of smoking cessation, efforts to reduce alcohol abuse, and consumption of a diet containing an adequate amount of fruits, vegetables, and vitamins. Both the National Comprehensive Cancer Network (NCCN) guidelines and the National Cancer Institute (NCI) cancer information summary for esophageal cancer prevention conclude that smoking cessation decreases the risk of squamous cell carcinoma.[83, 129]
For esophageal adenocarcinoma, prevention involves stopping the sequence of events leading from gastroesophageal reflux disease (GERD) to Barrett esophagus to adenocarcinoma. Better control of gastroesophageal reflux can prevent the development of Barrett metaplasia in patients with GERD and can discourage the development of high-grade dysplasia in patients with metaplasia. Endoscopic follow-up evaluations should be performed at 1- to 2-year interval to detect the presence of dysplasia, allowing intervention before cancer develops
Hereditary Cancer Predisposition Syndromes Associated with an Increased Risk for Esophageal and EGJ Cancers
Surveillance upper endoscopy with biopsy (see the table below) should be considered for patients who have one of the following hereditary cancer predisposition syndromes:
Tylosis (non-epidermolytic palmoplantar keratosis [PPK] or Howel Evans Syndrome)
Familial Barrett esophagus (FBE)
Bloom syndrome
Fanconi anemia (FA)
Table 5. Hereditary Cancer Predisposition Syndromes Associated with an Increased Risk for Esophageal Cancers.
Recommendations for screening and surveillance of patients with GERD and/or Barrett esophagus have been issued by the following organizations:
American Society for Gastrointestinal Endoscopy (ASGE)
American Gastroenterological Association (AGA)
American College of Gastroenterology (ACG)
American College of Physicians (ACP)
None of the organizations recommend endoscopic screening of the general population with GERD. There is general agreement among the guidelines that patients with chronic GERD and multiple other risk factors associated with esophageal adenocarcinoma should undergo upper gastrointestinal endoscopy to screen for Barrett esophagus or esophageal adenocarcinoma.[137, 138, 139, 140, 141] Those additional risk factors include the following:
Male sex
Age 50 years or older
White race
Hiatal hernia
Obesity
The 2015 American Society for Gatrointestinal Endoscopy (ASGE) guidelines for the use of endoscopy in the management of GERD recommends endoscopic screening in select patients with multiple risk factors for Barrett esophagus be considered, but also advises that patients be informed that there is insufficient evidence that this practice prevents cancer or prolongs survival.[141]
The American College of Physicians' (ACP) best practice advice, issued in 2012, offers the following recommendations for upper endoscopy for GERD[140] :
Screening endoscopy is not recommended for women of any age or men younger than 50, regardless of other risk factors, because of the low incidence of cancer in these populations
Screening is recommended in both men and women with GERD symptoms despite medical treatment, and especially in those with GERD and dysphagia, bleeding, anemia, weight loss, or recurrent vomiting
No further surveillance is recommended if endoscopy shows negative results for Barrett esophagus
In patients with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals of 3 to 5 years; shorter intervals are indicated in patients with Barrett esophagus and dysplasia
The American College of Gastroenterology (ACG) guidelines for the surveillance and therapy of Barrett esophagus[139] are listed in the table below.
Table 6. ACG Recommendations on surveillance of Barrett esophagus
View Table
See Table
The ACG recommends that endoscopic ablative therapies should not be routinely used in patients with nondysplastic Barrett esophagus, because of their low risk of progression to esophageal adenocarcinoma (strong recommendation, very low level of evidence). However, endoscopic eradication therapy is the procedure of choice for patients with confirmed dysplasia, whether low or high grade.
The ACG advises that antireflux surgery should not be used as an antineoplastic measure.[139] Endoscopic resection (ER) and mucosal radiofrequency ablation (RFA) has become the preferred treatment for most patients with Barrett esophagus and HGD. Alternative strategies include cryoablation or photodynamic therapy (PDT)[142, 143] . Surgical resection is reserved for patients with HGD and characteristics that are unfavorable for non-surgical therapy, such as nodularity or long-segment involvement. For patients with metaplasia or LGD, gastroesophageal reflux is controlled with histamine receptor antagonists or proton pump inhibitors.
Radiofrequency ablation
RFA has been gaining popularity as a treatment for Barrett esophagus with dysplasia. Shaheen et al reported complete eradication of all dysplasia 2 years after RFA in 101 of 106 patients (95%). After 3 years, dysplasia remained eradicated in more than 85% of patients, without maintenance RFA. The rate of serious adverse events was 3.4%, and the rate of esophageal stricture was 7.6%.[144]
Photodynamic therapy
PDT involves the administration of photosensitizing chromophores, which are selectively retained by dysplastic malignant tissue. Light is then delivered in the area. The photosensitizer absorbs photons, becomes photoexcited, and transfers its energy to a chemical substrate that causes biologic damage to the abnormal tissue. A drawback of PDT is the formation of esophageal strictures in 34% of patients. The photosensitizer porfimer is FDA approved for ablation of high-grade dysplasia in Barrett esophagus.
Surveillance of Esophageal Cancer
Surveillance strategies after successful local therapy of esophageal cancers remain controversial since very limited prospective data is available on effective surveillance strategies.
In general, for asymptomatic patients, follow-up should include a complete history and physical examination every 3 to 6 months for 1 to 2 years, then every 6 to 12 months for 3 to 5 years, and annually thereafter. CBC, comprehensive serum chemistry evaluation, upper GI endoscopy with biopsy, and imaging studies should be obtained as clinically indicated. In addition, some patients may require dilatation of an anastomotic or a chemoradiation-induced stricture. Nutritional assessment and counseling may be extremely valuable.
The stage-specific recommendations for surveillance included in the NCCN Guidelines are based on the available evidence from retrospective studies[145, 146] and the expertise of the panel members.
Stage (0-I / Tis, T1a, T1b): Evidence-based guidelines have not been established for all stages of completely treated early stage esophageal cancer. The recommendations outlined in the guidelines are based on available evidence from clinical trials and current practice. Endoscopic surveillance with upper GI endoscopy (EGD) is recommended for patients with Tis, T1a and T1b tumors, after completion of endoscopic therapy. It is recommended to perform EGD every 3 months for the first year, every 4-6 months for the second year, and annually for 3 more years. In patients with T1b tumors treated with esophagectomy, endoscopic surveillance with EGD should be done as clinically indicated based on the symptoms and radiographic findings. Routine imaging studies are not recommended for patients with Tis and T1a tumors.
Stage (II-III / T2-T4, N0-N+, T4b): Locoregional recurrences are common after bimodality therapy. Therefore, EGD is a valuable surveillance tool following bimodality therapy. In patients treated with bimodality therapy, the majority of recurrences (95%) occur within 24 months. Thus, surveillance for at least 24 months is recommended following bimodality therapy[147]
Locoregional relpases are uncommon following trimodality therapy.[148] Therfore, EGD for surveillance is not recommended after trimodality therapy. Other imaging modalities (e.g., PET/CT or CT chest/abdomen with contrast) are used for most luminal recurrences. In patients treated with trimodality therapy, the majority of recurrences (90%) occur within 36 months of surgery. Therefore, surveillance for at least 36 months is recommended following trimodality therapy.
In 2013, the Society of Thoracic Surgeons released clinical practice guidelines to assist in the diagnosis and treatment of localized esophageal cancer. Their recommendations include the following[67] :
For the diagnosis of esophageal cancer, flexible endoscopy with biopsy is the primary method
For early-stage esophageal cancer, CT of the chest and abdomen is an optional test for staging; for locoregionalized esophageal cancer, CT of the chest and abdomen is a recommended test for staging
For early-stage esophageal cancer, PET is an optional test for staging. For locoregionalized esophageal cancer, PET is a recommended test for staging
In patients without metastatic disease, endoscopic ultrasonography is recommended to improve the accuracy of staging
In patients with small, discrete nodules or areas of dysplasia in whom disease appears limited to the mucosa or submucosa as assessed by endoscopic ultrasonography, endoscopic mucosal resection should be considered as a diagnostic/staging tool
In patients with locally advanced (T3/T4) adenocarcinoma of the esophagogastric junction infiltrating the anatomic cardia or Siewart type III esophagogastric tumors, laparoscopy is recommended to improve accuracy of staging.
The 2013 American Society for Gastrointestinal Endoscopy (ASGE) guidelines for use of endoscopy in the assessment and treatment of esophageal cancer make the following recommendations for accurate staging[149] :
Endoscopic ultrasound and fine needle aspiration (FNA), when indicated, in conjunction with cross-sectional imaging is preferred over CT
Endoscopic mucosal or submucosal dissection is indicated for the treatment and staging of nodular Barrett esophagus and suspected squamous cell carcinoma and adenocarcinoma
Guidelines from the College of American Pathologists, American Society for Clinical Pathology, and American Society of Clinical Oncology, issued in 2016, include the following recommendations for clinicians[150] :
Request HER2 testing on tumor tissue in patients with advanced esophageal adenocarcinoma who are potential candidates for HER2-targeted therapy.
Request HER2 testing on tumor tissue in the biopsy or resection specimens (primary or metastasis), preferably before starting trastuzumab therapy, if such specimens are available and adequate; an acceptable alternative is HER2 testing on fine-needle aspiration specimens.
National Comprehensive Cancer Network (NCCN) guidelines for workup include the following[83] :
HER2 testing is recommended for all patients with esophageal or esophagogastric junction (EGJ) cancer at the time of diagnosis.
Microsatellite instability–high (MSI-H), deficient mismatch repair (dMMR), and programmed death ligand 1 (PD-L1) testing is recommended in all patients with esophageal or esophagogastric junction (EGJ) adenocarcinoma if metastatic disease is documented or suspected.
American College of Gastroenterology (ACG) recommendations regarding endoscopic treatment of Barrett esophagus include the following[139] :
In patients with T1a esophageal adenocarcinoma, endoscopic therapy is the preferred therapeutic approach (strong recommendation, moderate level of evidence)
In patients with T1b esophageal adenocarcinoma, consultation with multidisciplinary surgical oncology team should occur before embarking on endoscopic therapy; in such patients, endoscopic therapy may be an alternative strategy to esophagectomy, especially in those with superficial (sm1) disease with a well-differentiated neoplasm lacking lymphovascular invasion, as well as those who are poor surgical candidates (strong recommendation, low level of evidence)
In patients with known T1b disease, EUS may have a role in assessing and sampling regional lymph nodes, given the increased prevalence of lymph node involvement in these patients compared with less advanced disease (strong recommendation, moderate level of evidence)
In patients with dysplastic Barrett esophagus who are to undergo endoscopic ablative therapy for nonnodular disease, radiofrequency ablation is currently the preferred endoscopic ablative therapy (strong recommendation, moderate level of evidence).
National Comprehensive Cancer Network (NCCN) treatment recommendations for esophageal cancer include the following[83] :
Medically fit patients with locoregional SCC stage Tis (in situ) and T1a are treated with endoscopic therapies such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) with or without ablation. For stage T1b, N0 tumors, esophagectomy is the recommended primary treatment option[82] . Primary treatment options for patients with T1b,N+ and locally advanced resectable tumors (T2-T4a with any N) include preoperative chemoradiation (for non-cervical esophagus), definitive chemoradiation (for cervical esophagus) or esophagectomy (for non-cervical esophagus)[151, 152, 153] . Definitive chemoradiation is the preferred treatment modality for stage T4b (unresectable) tumors.[154]
Medically fit patients with locoregional adenocarcinoma stage Tis (in situ), T1a or T1b,N0 are treated with similar modalities as for SCC. Primary treatment options for patients with T1b,N+ and locally advanced resectable tumors (T2-T4a with any N) include preoperative chemoradiation (preferred)[155] , definitive chemoradiation (for patients who refuse surgery)[152, 153] , perioperative chemotherapy[156] or esophagectomy (for low risk patients with well differentiated lesions under 2 cm).
Chemoradiation followed by surgery is supported by strong level 1 evidence.[157, 158, 159, 160, 161, 162] In fact, 15%-30% of patients undergoing neoadjuvant chemoradiation will have a complete pathologic response (pCR), meaning that the tumor will have completely disappeared when the esophagus is examined after surgery. Patients with a pCR have a 3-year survival rate of approximately 50%, as opposed to 27% for those without a pCR.[163] Fluoropyrimidine- or taxane-based regimens are recommended for preoperative and definitive chemoradiation.
Definitive chemoradiation is the preferred treatment modality for stage T4b (unresectable) tumors.[154]
Preoperative chemotherapy followed by surgery is another option. However, the evidence for this approach is weak; the chance of increase in 2-year overall survival is less than 6%, compared with approximately 13% with trimodality therapy.
Postoperative treatment is based on the surgical margins, nodal status, and histology. The efficacy of postoperative treatment has not been established in randomized trials for patients with esophageal cancer. Available evidence for the use of postoperative chemoradiation (only for patients who have not received preoperative therapy) and perioperative chemotherapy for patients with adenocarcinoma of the distal esophagus or EGJ comes from prospective randomized clinical trials involving patients with gastric cancer that have included patients with adenocarcinoma of the distal esophagus or EGJ.[156, 164]
For patients with SCC who have not received preoperative therapy, no further treatment is necessary (irrespective of their nodal status) if there is no residual disease at surgical margins (R0 resection). Patients with microscopic (R1 resection) or macroscopic (R2 resection) residual disease should be treated with fluoropyrimidine-based chemoradiation. Palliative therapy is an alternative option for patients with macroscopic residual disease.
For patients with adenocarcinoma who have not received preoperative therapy, no further treatment is necessary for patients with Tis and T1, N0 tumors, if there is no residual disease at surgical margins (R0 resection). Based on the results of the INT-0116 trial, postoperative fluoropyrimidine-based chemoradiation (following R0 resection) is recommended for all patients with T3-T4 tumors, node-positive T1-T2 tumors, and selected patients with T2, N0 tumors with high-risk features (poorly differentiated or higher grade cancer, lymphovascular invasion, neural invasion, or age younger than 50 years).[164]
Perioperative chemotherapy is recommended following R0 resection for all patients with adenocarcinoma, irrespective of the nodal status (category 1). Patients with microscopic (R1 resection) or macroscopic residual disease with no distant metastatic disease (R2 resection) should be treated with fluoropyrimidine-based chemoradiation. Palliative therapy is an alternative option for patients with macroscopic residual disease.
For the management of locally advanced locoregional cancer (T2-T4a, any regional N) in non-surgical candidates, fluoropyrimidine-based or taxane-based definitive chemoradiation is the preferred treatment option. Alternatively, these patients can also be treated with chemotherapy or radiation therapy (RT) or supportive care. Palliative RT or supportive care are the appropriate options for non-surgical candidates who are unable to tolerate chemotherapy or chemoradiation (patients with poor performance status).
Based on the results of the ToGA trial, trastuzumab should be added to first-line chemotherapy (category 1 for combination with cisplatin and fluoropyrimidine; category 2B for combination with other chemotherapy agents) for patients with HER2- overexpressing advanced or metastatic adenocarcinoma (a tumor Immunohistochemistry (IHC) score of 3+ or 2+ with the evidence of HER2 amplification by FISH).[84]
Ramucirumab, a VEGFR-2 antibody, has shown promising results in the treatment of patients with previously treated advanced or metastatic gastric or EGJ cancers in phase III clinical trials.[165, 166] An international, randomized, multicenter, placebo-controlled, phase III trial (REGARD trial) demonstrated a survival benefit for ramucirumab for patients with advanced gastric or EGJ adenocarcinoma progressing after first-line chemotherapy[165] . In a more recent international phase III randomized trial (RAINBOW trial) that evaluated paclitaxel with or without ramucirumab in patients with metastatic gastric or EGJ adenocarcinoma progressing on first-line chemotherapy, the combination of paclitaxel with ramucirumab resulted in significantly higher survival rate[166] . Based on the results of these two studies, ramucirumab either as a single agent or in combination with paclitaxel was recently approved by the FDA for the treatment for patients with advanced EGJ adenocarcinoma refractory to or progressive following first-line therapy with platinum- or fluoropyrimidine-based chemotherapy.
Stage IV disease is treated with chemotherapy or symptomatic and supportive care, as indicated. There are two scoring methods commonly used by Oncologists to assess performace status in cancer patients: Karnofsky Performance Score (KPS) and Eastern Cooperative Oncology Group performance score (ECOG PS). For patients with poor performance status (ie, KPS score < 60 and ECOG PS score >2) or with advanced disease, curative treatment is not an option and the goal of therapy is palliation of dysphagia, so that these patients can eat. No single method of palliation is best for every situation. Most patients require more than 1 kind of palliative treatment to sustain esophageal patency during the course of their disease.
NCCN guidelines for surgical therapy of esophageal cancer are as follows[83] :
Prior to surgery, clinical staging should be performed to assess resectability with CT scan of the chest and abdomen, whole-body PET and endoscopic ultrasound (EUS).
Prior to starting therapy, all patients should should be be assessed for by an esophageal surgeon for physiologic ability to undergo esophageal resection. Esophageal resection should be considered for all physiologically fit patients with resectable esophageal cancer (ie, >5 cm from cricopharyngeus).
Siewert Siewert Classification tumor type should be assessed in all patients with adenocarcinomas involving the EGJ. Siewert Type I is adenocarcinoma of the lower esophagus with the center located within 1 cm to 5 cm above the anatomic EGJ. Siewert Type II is true carcinoma of the cardia with the tumor center within 1 cm above and 2 cm below the EGJ. Siewert Type III is subcardial carcinoma with the tumor center 2 to 5 cm below the EGJ that infiltrates the EGJ and lower esophagus from below.
Laparoscopy may be useful in select patients in detecting radiographically occult metastatic disease, especially in patients with Siewert II and III tumors.
Positive peritoneal cytology (performed in the absence of visible peritoneal implants) is associated with poor prognosis and is defined as M1 disease. In patients with advanced tumors, clinical T3 or N+ disease should be considered for laparoscopic staging with peritoneal washings.
Cervical or cervicothoracic esophageal carcinomas < 5 cm from the cricopharyngeus should be treated with definitive chemoradiation.
Resectable esophageal or EGJ cancer: T1a tumors, defined as tumors involving the mucosa but not invading the submucosa, may be considered for EMR + ablation or esophagectomy in experienced centers.Tumors in the submucosa (T1b) or deeper may be treated with esophagectomy. T1-T3 tumors are resectable even with regional nodal metastases (N+), although bulky; multi-station lymphatic involvement is a relative contraindication to surgery, to be considered in conjunction with age and performance status. T4a tumors with involvement of pericardium, pleura, or diaphragm are resectable.
Unresectable esophageal cancer: T4b tumors with involvement of the heart, great vessels, trachea, or adjacent organs including liver, pancreas, lung, and spleen are unresectable. Most patients with multi-station, bulky lymphadenopathy should be considered unresectable, although lymph node involvement should be considered in conjunction with other factors, including age and performance status and response to therapy.
Disease in patients with EGJ and supraclavicular lymph node involvement should be considered unresectable.
Esophageal cancers in patients with distant (including nonregional lymph nodes) metastases (stage IV) are unresectable.
The type of esophageal resection is dictated by the location of the tumor and the available choices for conduit, as well as by the surgeon's experience and preference and the patient's preference.
In patients who are unable to swallow well enough to maintain nutrition during induction therapy, esophageal dilatation or a feeding jejunostomy tube are preferred to a gastrostomy (which may compromise the integrity of gastric conduit for reconstruction).
Acceptable operative approaches for resectable esophageal or EGJ cancer: Ivor Lewis esophagogastrectomy (laparotomy + right thoracotomy; McKeown esophagogastrectomy (right thoracotomy + laparotomy + cervical anastomosis); minimally invasive Ivor Lewis esophagogastrectomy (laparoscopic approach); minimally invasive McKeown esophagogastrectomy (laparoscopic approach); robotic minimally invasive esophagogastrectomy; transhiatal esophagectomy (THE); and transthoracic/transabdominal esophagectomy with anastomosis in chest or neck.
Acceptable conduits: gastric (preferred), colon, and jejunum.
Acceptable lymph node dissections: standard and extended (en bloc)
In patients undergoing esophagectomy without induction chemoradiation, at least 15 lymph nodes should be removed to achieve adequate nodal staging. The optimum number of nodes to remove after preoperative chemoradiation is unknown, although similar lymph node resection is recommended.
Patients who develop localized, resectable esophageal cancer after defintive chemoradiation can be considered for esophagectomy if they do not have distant recurrence.
Patients with potentially resectable esophageal cancer should undergo multidisciplinary review. Esophageal resection, EMR, and other ablative techniques should be performed in high-volume esophageal centers by experienced surgeons and endoscopists.
NCCN recommendations for first-line systemic therapy of advanced or metastatic disease are as follows[83] :
First-line systemic therapy regimens with 2 cytotoxic drugs are preferred for treatment of advanced disease because of their lower toxicity.
Three-drug cytotoxic regimens should be reserved for medically fit patients with good performance status and access to frequent toxicity evaluation.
The preferred regimens for first-line systemic therapy include a fluoropyrimidine (fluorouracil or capecitabine) combined with either oxaliplatin or cisplatin.
In patients with HER2-positive metastatic adenocarcinoma, trastuzumab should be added to first-line chemotherapy (category 1 for combination with cisplatin and fluoropyrimidine).
NCCN recommendations for second-line and subsequent systemic therapy of advanced or metastatic disease are as follows[83] :
The selection of regimens for second-line or subsequent therapy depends on prior therapy and performance status.
Category 1 preferred options for second-line or subsequent therapy include single-agent docetaxel, paclitaxel, and irinotecan.
Pembrolizumab is a preferred second-line or subsequent therapy option for MSI-H/dMMR tumors; a second-line therapy option for esophageal cancers with PD-L1 expression levels (by combined positive score [CPS]) of ≥10 (category 2B); and a third-line or subsequent therapy option for esophageal and EGJ adenocarcinomas with PD-L1 expression levels by CPS of ≥1.
FOLFIRI is a preferred second-line treatment option if it was not used in first-line therapy.
Other recommended combined regimens for second-line therapy include irinotecan and cisplatin, and irinotecan and docetaxel (category 2B).
NCCN recommendations for targeted therapy are as follows[83] :
Trastuzumab combined with mFOLFOX6 is an effective regimen with an acceptable safety profile and warrants further study in patients with HER2+ gastroesophageal cancers.
Ramucirumab, as a single agent or in combination with paclitaxel, and pembrolizumab (for MSI-H/dMMR tumors) are options for second-line or subsequent therapy for patients with metastatic disease.
In 2014, the Society of Thoracic Surgeons (STS) released clinical practice guidelines for multimodal treatment of esophageal cancer with the following recommendations[167] :
Locally advanced disease should be treated in a multidisciplinary setting
Restaging should be performed after neoadjuvant therapy and before surgery
Endoscopic ultrasound restaging for residual local disease is inaccurate and can be omitted
A PET scan should be used for restaging after neoadjuvant therapy to detect interval development of distant metastatic disease
Neoadjuvant chemoradiation therapy should be used for locally advanced squamous cell cancer and either neoadjuvant chemotherapy or chemoradiation therapy for locally advanced adenocarcinoma; multimodality therapy has advantages over surgical resection alone
For patients with adenocarcinoma who have not received neoadjuvant therapy, adjuvant chemoradiotherapy is an option for regional lymph node disease.
The 2013 American Society for Gastrointestinal Endoscopy (ASGE) guidelines note that argon plasma coagulation (APC), heater probe, cryotherapy, or radiofrequency ablation should not be used as monotherapy with curative intent for T1a tumors. However, those techniques may have a role in ablation of remaining high-risk tissue following resection[149] .
NCCN guidelines recommend the following for palliative/best supportive care[83] ::
Palliative care is indicated for medically unfit patients, or those with unresectable or metastatic recurrence.
First-line therapy with two-drug chemotherapy regimens is preferred for advanced or metastatic disease.
Patients with complete esophageal obstruction can be treated with endoscopic lumen restoration, external beam radiation therapy (EBRT), chemotherapy, or surgery.
Surgical or radiologic placement of jejunostomy or gastronomy tubes may be necessary to provide adequate hydration and nutrition, if endoscopic lumen restoration is not undertaken or is unsuccessful.
Brachytherapy may be considered instead of EBRT, if lumen can be restored using appropriate applicators during the delivery of brachytherapy to avoid excessive dose on mucosal surfaces. In a multicenter randomized trial, single-dose brachytherapy was associated with fewer complications and better long-term relief of dysphagia compared with metal stents.[117]
For patients with severe esophageal obstruction (those able to swallow liquids only), some additional options include endoscopic lumen enhancement (wire-guided or balloon dilation) and endoscopy or fluoroscopy-guided placement of covered expandable metal stents. While some data suggest a lower migration and re-obstruction rate with the larger-diameter covered expandable metal stents, there may be a higher risk of stent-related complications.[118]
The 2013 American Society for Gastrointestinal Endoscopy (ASGE) guidelines have following recommendations for palliative care[149] :
Esophageal stent placement is the preferred method for palliation of dysphagia and fistulae.
Patient preferences, quality of life, and prognosis should be addressed with the patient and family before initiating endoscopic palliation.
Most of the chemotherapy regimens currently used for the treatment of esophageal cancer, including alkylating, antimetabolite, anthracycline, and antimicrotubular agents, have not been approved by the US Food and Drug Administration (FDA). Following are the recommended regimens for the treatment of esophageal cancer. These are based on extrapolations from the published literature and clinical practice.
For preoperative chemoradiation, preferred regimens (category 1) are as follows:
Paclitaxel and carboplatin
Fluorouracil and cisplatin
Fluorouracil and oxaliplatin
Other preoperative chemoradiation regimens (category 2B) are as follows:
Irinotecan and cisplatin
Paclitaxel and fluoropyrimidine (fluorouracil or capecitabine)
For definitive chemoradiation, preferred regimens are as follows:
Fluorouracil and cisplatin (category 1)
Fluorouracil and oxaliplatin (category 1)
Paclitaxel and carboplatin
Other definitive chemoradiation regimens are as follows:
Cisplatin with docetaxel or paclitaxel
Irinotecan and cisplatin (category 2B)
Paclitaxel and fluoropyrimidine (fluorouracil or capecitabine) (category 2B)
Perioperative chemotherapy is used only for adenocarcinoma of the thoracic esophagus. Three preoperative cycles and posteroperative cycles of the following may be given:
Preoperative chemotherapy is used only for adenocarcinoma of the thoracic esophagus. A total of two cycles of fluorouracil and cisplatin (category 2B) is given.
With postoperative chemoradiation, fluoropyrimidine (infusional fluorouracil or capecitabine) is given before and after fluoropyrimidine-based chemoradiation.
For postoperative chemotherapy, capecitabine plus oxaliplatin is used.
Clinical Context:
Fluorouracil is a pyrimidine antimetabolite. Several mechanisms of action have been proposed, including inhibition of thymidylate synthase and inhibition of RNA synthesis. This agent is also a potent radiosensitizer.
Clinical Context:
Capecitabine is a pyrimidine antimetabolite and a prodrug of fluorouracil. It forms the active moiety, fluorouracil, by undergoing hydrolysis in the liver and tissues. Capecitabine is used for the treatment of esophageal cancer, which is an off-label indication.
Clinical Context:
Intrastrand cross-linking of DNA and inhibition of DNA precursors are among the proposed mechanisms of action for cisplatin. This agent is used in combination with radiation therapy. Cisplatin has black box warnings for adverse reactions, including anaphylactic-like reactions, ototoxicity, and renal toxicity.
Clinical Context:
Carboplatin is a platinum alkylating agent that interferes with the function of DNA by producing interstrand DNA cross-links. It can be used in combination with paclitaxel for the treatment of esophageal cancer, which is an off-label indication. Carboplatin has black box warnings including bone marrow suppression, anaphylactic reactions, and vomiting.
Clinical Context:
Oxaliplatin is a platinum alkylating agent that inhibits DNA replication and transcription, resulting in cell death. It can be used in combination chemotherapy for the treatment of esophageal cancer, which is an off-label indication. It has a black box warning for anaphylactic reactions, which can be managed with epinephrine, corticosteroids, and antihistamines.
These agents inhibit cell growth and proliferation, interfering with DNA synthesis by the formation of DNA cross-links. Alkylating agents can have serious adverse effects such as bone marrow suppression, anaphylactic-like reactions, ototoxicity, renal toxicity, and vomiting.
Clinical Context:
Docetaxel inhibits the depolymerization of tubulin, which inhibits DNA, RNA, and protein synthesis. It can be used in combination with cisplatin and fluorouracil for the treatment of esophageal cancer, which is an off-label indication. It has several black box warnings such as bone marrow suppression, fluid retention, and hypersensitivity reactions.
Use of docetaxel is not recommended in certain patients with hepatic impairment. Patients receiving treatment with docetaxel should be premedicated with corticosteroids the day before administration to help reduce fluid retention and hypersensitivity reactions.
Clinical Context:
Paclitaxel promotes microtubule assembly, interferes with the G2 mitotic phase, and inhibits cell replication. Although not FDA approved, it has been used in combination chemotherapy for the treatment of esophageal cancer. Paclitaxel has an off-label indication for the treatment of adenocarcinoma. Black box warnings for this drug include bone marrow suppression and hypersensitivity reactions.
These agents prevent cell growth and proliferation. They work by enhancing tubulin dimers, stabilizing existing microtubules, and inhibiting microtubule disassembly.
Clinical Context:
Epirubicin inhibits DNA and RNA synthesis. It can be used off label as part of a combination chemotherapy regimen for the treatment of esophageal cancer. It has several black box warnings, including bone marrow suppression, extravasation, myocardial toxicity, and secondary malignancy. Dosage reduction is recommended in patients with mild to moderate hepatic impairment.
Anthracycline antineoplastics inhibit DNA and RNA synthesis by steric obstruction. They intercalate between DNA base pairs and trigger DNA cleavage by topoisomerase II.
Clinical Context:
Irinotecan binds reversibly to the topoisomerase I–DNA complex and prevents the ligation of the cleaved DNA strand. It can be used as part of combination chemotherapy for the treatment of esophageal cancer, which is an off-label indication. Black box warnings for irinotecan include bone marrow suppression and diarrhea.
Clinical Context:
Tipiracil is a thymidine phosphorylase inhibitor that increases trifluridine exposure by inhibiting its metabolism. Trifluridine is a thymidine-based nucleoside analog that incorporates into DNA, interferes with DNA synthesis, and inhibits cell proliferation. It is indicated for metastatic gastric or gastroesophageal junction (GEJ) adenocarcinoma previously treated with at least 2 prior lines of chemotherapy that included a fluoropyrimidine, a platinum, either a taxane or irinotecan, and if appropriate, HER2/neu-targeted therapy.
Clinical Context:
Porfimer is a photodynamic therapy that causes cytotoxic activity by producing oxygen free-radicals in the presence of laser light. It also can release thromboxane A2, leading to necrosis and vascular occlusion. It is indicated for palliation in patients with partially or completely obstructing esophageal cancer.
What is esophageal cancer?What are the signs and symptoms of esophageal cancer?Which physical findings suggest esophageal cancer?What is the role of lab tests in the evaluation of esophageal cancer?What is the role of imaging studies in the evaluation of esophageal cancer?What are the treatment options for esophageal cancer?When is surgery indicated for esophageal cancer?What are the contraindications for surgery for esophageal cancer?What are surgical options for the treatment of esophageal cancer?What are palliative care options for esophageal cancer?What are patient education resources for esophageal cancer?How common is esophageal cancer?What are the principal histologic types of esophageal cancer?Who is at highest risk for adenocarcinoma esophageal cancer?Where in the esophagogastric junction do squamous cell carcinoma (SCC) and adenocarcinoma typically occur?What is preferred treatment for esophageal cancer?What is the anatomy of the esophagus?From which artery is the blood supply for the esophagus derived?How does venous drainage of the esophagus occur?What are the lymphatic channels in the esophagus that facilitate esophageal cancer?What are the major risk factors for SCC esophageal cancer?What is the role of alcohol in the pathophysiology of esophageal cancer?Which tobacco carcinogens have a role in the pathogenesis of esophageal cancer?What is the role of carcinogens in the pathogenesis of SCC esophageal cancer?What is the pathophysiology of adenocarcinoma esophageal cancer?What is the role of Barrett metaplasia in esophageal adenocarcinoma?What is the role of obesity in the pathogenesis of esophageal adenocarcinoma?What is the role of tylosis in the pathogenesis of SCC esophageal cancer?What is the etiology of esophageal cancer?What are the risk factors for esophageal cancer?What are the risk factors for SCC esophageal cancer?How much does smoking and alcohol consumption increase the risk of SCC esophageal cancer?Which dietary factors increase or decrease the risk of SCC esophageal cancer?Which genetic factors may increase the risk of SCC esophageal cancer?Which infections may be etiological factors in esophageal cancer?What are the principal etiologic factors for esophageal adenocarcinoma?What is the most common predisposing factor for esophageal adenocarcinoma?What is the risk of esophageal adenocarcinoma in patients with Barrett metaplasia?What is the risk of developing esophageal adenocarcinoma in patients with gastroesophageal reflux disease (GERD)?What are risk factors for esophageal adenocarcinoma?How does obesity affect the risk for esophageal adenocarcinoma?What is the incidence of esophageal cancer in the US?What is the global incidence of esophageal cancer?How does the incidence of esophageal cancer vary by sex?How does the incidence of esophageal cancer vary by age?What is the survival rate for esophageal cancer?Which PET scan finding suggests poorer overall survival in patients with esophageal cancer?What can be used to predict survival in esophageal cancer?Which genetic mutation is a negative prognostic indicator in esophageal cancer?What is the most common presenting symptom of esophageal cancer?What are the signs and symptoms of esophageal cancer?Which physical findings suggest patients with esophageal cancer?Which esophageal lesions should be included in the differential diagnosis of esophageal cancer?How is achalasia differentiated from esophageal cancer?How is esophageal stricture differentiated from esophageal cancer?What are the differential diagnoses for Esophageal Cancer?What are the Society of Thoracic Surgeons recommendations for the diagnosis of esophageal cancer?Which imaging studies are performed in the diagnosis and staging of esophageal cancer?What is the role of a barium swallow in the diagnosis and staging of esophageal cancer?What is the role of CT scanning in the diagnosis of esophageal cancer?What is the role of PET scanning in the evaluation of esophageal cancer?What is the role of EUS in the evaluation of esophageal cancer?Which EUS findings are characteristic of esophageal cancer?What is the accuracy of EUS for the diagnosis of esophageal cancer?What are the risks of EUS for staging esophageal cancer?What is the role of bronchoscopy in the evaluation of esophageal cancer?What classification systems are used outside the US for staging esophageal cancer?Which staging system is used for esophageal cancer?How is esophageal cancer staging evolved?What is the 2017 AJCC/UICC TNM classification for esophageal cancer?What are the limitations of the AJCC/UICC TNM staging system for esophageal cancer?What is the role of lab testing in the evaluation of esophageal cancer?What is the role of upper GI endoscopy in the evaluation and management of esophageal cancer?What do diagnostic endoscopies for esophageal cancer determine?How does tumor length predict long-term survival in esophageal adenocarcinoma?What is the role of endoscopic resection (ER) of focal nodules is the staging of esophageal cancer?Which histologic findings are characteristic of esophageal cancer?Which factors impact the choice of treatment for esophageal cancer?What are the NCCN treatment recommendations for esophageal cancer?What are the indications for surgery for esophageal cancer?What are the contraindications for surgery of esophageal cancer?Which comorbidities decrease survival rates from esophageal resection of esophageal cancer?When is esophageal resection (esophagectomy) indicated in the treatment of esophageal cancer?How is esophageal resection (esophagectomy) performed in the treatment of esophageal cancer?What are complications of esophageal resection (esophagectomy) in esophageal cancer?What is the treatment for anastomotic leaks from esophageal resection (esophagectomy)?How do leak rates vary by location in an esophageal resection (esophagectomy) for esophageal cancer?What has been shown to decrease the mortality rate of esophageal resection (esophagectomy) for esophageal cancer?What are the benefits of a team approach to surgery of esophageal cancer?What are the types of transthoracic esophagectomy (TTE) used for the treatment of esophageal cancer?How is a transthoracic esophagectomy (TTE) performed in esophageal cancer?How is a transhiatal esophagectomy (THE) performed in esophageal cancer?What are the advantages of minimally invasive surgery for the treatment of esophageal cancer?What is the role of video-assisted thoracoscopy (VATS) in the treatment of esophageal cancer?What is the role of sentinel node mapping for the treatment of esophageal cancer?What is the role of endoscopic mucosal resection (EMR) in the treatment of esophageal cancer?What is the indication for a salvage endoscopic therapy (SET) in esophageal cancer and what is its efficacy?What is the role of CRT in the treatment of esophageal cancer?What is the role of neoadjuvant chemotherapy for esophageal cancer?What is the benefit of preoperative CRT for the treatment of esophageal cancer?What is neoadjuvant therapy for esophageal cancer and what is its efficacy?What is the response rate to preoperative CRT for esophageal cancer and how affect survival rates?What is the role of biomarkers in the treatment of esophageal cancer?What is the role of enteral nutrition in the treatment of esophageal cancer?What is the efficacy of laser therapy for palliative treatment of esophageal cancer?What is the goal of palliative care for esophageal cancer?How does dysphagia affect palliative care selection for esophageal cancer?What palliative care options for the management of dysphagia in esophageal cancer?What are the NCCN recommendations for palliative care of complete esophageal obstruction in esophageal cancer?What is the role of stents in the palliation of dysphagia in esophageal cancer?What is the efficacy of radiotherapy for palliative treatment of esophageal cancer?What is the efficacy of chemotherapy for palliative treatment of esophageal cancer?What is the typical length of hospitalization for esophageal cancer treatment?When are patients extubated after surgery to treat esophageal cancer?When does postoperative feeding through the jejunostomy begin in esophageal cancer?How frequently do patients return home after surgery for esophageal cancer?What postoperative follow-up for esophageal cancer is required?How can esophageal cancer be prevented?What is the indication for surveillance upper endoscopy with biopsy for esophageal cancer?What are the ACP recommendations for upper endoscopy for gastroesophageal reflux disease (GERD)?Which organizations have released screening guidelines for GERD) and/or Barrett esophagus?What are the recommendation for screening for Barrett esophagus or esophageal adenocarcinoma?What are the ASGE guidelines for the use of endoscopy in the management of gastroesophageal reflux disease (GERD)?What are the ACG guidelines for the surveillance and therapy of Barrett esophagus?What is the indication for radiofrequency ablation (RFA) for the treatment of Barrett esophagus with dysplasia?What is PDT for the treatment of Barrett esophagus?How do surveillance strategies for esophageal cancer vary by disease stage?What are the STS recommendations for diagnosis and treatment of localized esophageal cancer?What are the ASGE recommendations for the use of endoscopy in the assessment and treatment of esophageal cancer?What are the CAP-ASCP-ASCO recommendations for HER2 testing in esophageal cancer?What are the NCCN guidelines for HER-2 testing in the evaluation for esophageal cancer?What are the ACG recommendations for endoscopic treatment of Barrett esophagus in esophageal cancer?What are the NCCN treatment recommendations for esophageal cancer?What are the NCCN guidelines for surgical therapy of esophageal cancer?What are the NCCN treatment guidelines for metastatic or recurrent esophageal cancer?What are the STS recommendations for multimodal treatment of esophageal cancer?What are the NCCN guidelines for palliative care for esophageal cancer?What are the ASGE recommendations for palliative care for esophageal cancer?Which chemotherapy regimens have been approved by the FDA for the treatment of esophageal cancer?Which preoperative chemoradiation regimens are used in the treatment of esophageal cancer?What are the definitive chemoradiation regimens used in esophageal cancer?When is perioperative chemotherapy used for the treatment of esophageal cancer?When is preoperative chemotherapy used for the treatment of esophageal cancer?Which regimen is used for preoperative and postoperative chemotherapy for esophageal cancer?Which medications in the drug class Thymidine Analog are used in the treatment of Esophageal Cancer?Which medications in the drug class Antineoplastics, Topoisomerase Inhibitors are used in the treatment of Esophageal Cancer?Which medications in the drug class Antineoplastics, Anthracycline are used in the treatment of Esophageal Cancer?Which medications in the drug class Antineoplastics, Antimicrotubular are used in the treatment of Esophageal Cancer?Which medications in the drug class Antineoplastics, Alkylating are used in the treatment of Esophageal Cancer?Which medications in the drug class Antineoplastics, Antimetabolite are used in the treatment of Esophageal Cancer?Which medications in the drug class Antineoplastics, Other are used in the treatment of Esophageal Cancer?
Muhammad Masab, MD, Resident Physician, Department of Internal Medicine, Einstein Medical Center
Disclosure: Nothing to disclose.
Coauthor(s)
Claudia Mattos da Costa Dourado, MD, Clinical Assistant Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University; Associate Program Director, Hematology and Medical Oncology Fellowship Program, Attending Physician, Division of Hematology and Medical Oncology, Department of Medicine, Einstein Medical Center
Disclosure: Nothing to disclose.
Chief Editor
N Joseph Espat, MD, MS, FACS, Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, Roger Williams Medical Center
Disclosure: Nothing to disclose.
Additional Contributors
Fernando AM Herbella, MD, PhD, TCBC, Affiliate Professor, Attending Surgeon in Gastrointestinal Surgery, Esophagus and Stomach Division, Department of Surgery, Federal University of Sao Paulo Medical School; Private Practice; Medical Examiner, Sao Paulo's Medical Examiner's Office Headquarters, Brazil
Disclosure: Nothing to disclose.
Keith M Baldwin, DO, IMPH, Assistant Professor of Surgery, Boston University School of Medicine; Endocrine and Surgical Oncologist, Department of General Surgery, Roger Williams Cancer Center
Disclosure: Nothing to disclose.
Marco G Patti, MD, Surgeon, UNC Hospitals Multispecialty Surgery Clinic
Disclosure: Nothing to disclose.
Acknowledgements
Philip Schulman, MD Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center
Philip Schulman, MD, is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, and Medical Society of the State of New York
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Torek F. The first successful resection of the thoracic portion of the esophagus for carcinoma. Surg Gynecol Obstet. 1913. 16:614-17.
Ohsawa T. Surgery of the esophagus. Arch Jpn Chir. 1933. 10:605-8.
Marshall SF. Carcinoma of the esophagus: successful resection of lower end of esophagus with reestablishment of esophageal gastric continuity. Surg Clin North Amer. 1938. 18:643.
Brooks M. 'Striking' Survival Benefit With Surgery for Esophageal Cancer. Available at https://www.medscape.com/viewarticle/892133. February 2, 2018; Accessed: February 7, 2018.
Lu SH, Montesano R, Zhang MS, et al. Relevance of N-nitrosamines to esophageal cancer in China. J Cell Physiol Suppl 1986; 4:51.
Chu FS, Li GY. Simultaneous occurrence of fumonisin B1 and other mycotoxins in moldy corn collected from the People's Republic of China in regions with high incidences of esophageal cancer. Appl Environ Microbiol 1994; 60:847.
Trivedy C, Baldwin D, Warnakulasuriya S, et al. Copper content in Areca catechu (betel nut) products and oral submucous fibrosis. Lancet 1997; 349:1447.
Mark SD, Qiao YL, Dawsey SM, et al. Prospective study of serum selenium levels and incident esophageal and gastric cancers. J Natl Cancer Inst 2000; 92:1753.
Li B, Taylor PR, Li JY, et al. Linxian nutrition intervention trials. Design, methods, participant characteristics, and compliance. Ann Epidemiol 1993; 3:577.
Abnet CC, Lai B, Qiao YL, et al. Zinc concentration in esophageal biopsy specimens measured by x-ray fluorescence and esophageal cancer risk. J Natl Cancer Inst 2005; 97:301.
Fong LY, Sivak A, Newberne PM. Zinc deficiency and methylbenzylnitrosamine-induced esophageal cancer in rats. J Natl Cancer Inst 1978; 61:145.
Fong LY, Zhang L, Jiang Y, Farber JL. Dietary zinc modulation of COX-2 expression and lingual and esophageal carcinogenesis in rats. J Natl Cancer Inst 2005; 97:40.
Larsson SC, Giovannucci E, Wolk A. Folate intake, MTHFR polymorphisms, and risk of esophageal, gastric, and pancreatic cancer: a meta-analysis. Gastroenterology 2006; 131:1271.
Jenkins K. Hot Tea and Increased Risk for Esophageal Cancer. Medscape Medical News. Available at https://www.medscape.com/viewarticle/892285. February 5, 2018; Accessed: February 7, 2018.
Ellis A, Field JK, Field EA, Friedmann PS, Fryer A, Howard P, Leigh IM, Risk J, Shaw JM, Whittaker J. Tylosis associated with carcinoma of the oesophagus and oral leukoplakia in a large Liverpool family—a review of six generations. European Journal of Cancer Part B: Oral Oncology. 1994 Dec 31;30(2):102-12.
Stevens HP, Kelsell DP, Bryant SP, et al. Linkage of an American pedigree with palmoplantar keratoderma and malignancy (palmoplantar ectodermal dysplasia type III) to 17q24. Literature survey and proposed updated classification of the keratodermas. Arch Dermatol 1996; 132:640.
Iwaya T, Maesawa C, Ogasawara S, Tamura G. Tylosis esophageal cancer locus on chromosome 17q25.1 is commonly deleted in sporadic human esophageal cancer. Gastroenterology 1998; 114:1206.
Lindor NM, Greene MH. The concise handbook of family cancer syndromes. Journal of the National Cancer Institute. 1998 Jul 15;90(14):1039-71.
Cook MB, Kamangar F, Whiteman DC, et al. Cigarette smoking and adenocarcinomas of the esophagus and esophagogastric junction: a pooled analysis from the international BEACON consortium. J Natl Cancer Inst 2010; 102:1344.
Turati F, Tramacere I, La Vecchia C, Negri E. A meta-analysis of body mass index and esophageal and gastric cardia adenocarcinoma. Ann Oncol 2013; 24:609.
Lagergren J, Bergström R, Nyrén O. Association between body mass and adenocarcinoma of the esophagus and gastric cardia. Ann Intern Med 1999; 130:883.
Cook MB, Greenwood DC, Hardie LJ, et al. A systematic review and meta-analysis of the risk of increasing adiposity on Barrett's esophagus. Am J Gastroenterol 2008; 103:292.
Drahos J, Ricker W, Pfeiffer RM, Cook MB. Metabolic syndrome and risk of esophageal adenocarcinoma in elderly patients in the United States: An analysis of SEER-Medicare data. Cancer 2017; 123:657.
Cancer Facts & Figures 2019. American Cancer Society. Available at https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf. Accessed: January 14, 2019.
Cancer Stat Facts: Esophageal Cancer. National Cancer Institute. Available at https://seer.cancer.gov/statfacts/html/esoph.html. Accessed: August 5, 2019.
Howlader N, Noone AM, Krapcho M, Miller D, Brest A, Yu M, et al. SEER Cancer Statistics Review (CSR) 1975-2016. National Cancer Institute: Surveillance, Epidemiology, and End Results Program. Available at https://seer.cancer.gov/csr/1975_2016/. April 15, 2019; Accessed: August 5, 2019.
Gillies RS, Middleton MR, Han C, et al. Role of positron emission tomography–computed tomography in predicting survival after neoadjuvant chemotherapy and surgery for oesophageal adenocarcinoma. Brit J Surg. Feb 2012. 99(2):239-45.
Barbour AP, Rizk NP, Gerdes H, Bains MS, Rusch VW, Brennan MF, Coit DG. Endoscopic ultrasound predicts outcomes for patients with adenocarcinoma of the gastroesophageal junction. Journal of the American College of Surgeons. 2007 Oct 31;205(4):593-601.
Keswani RN, Early DS, Edmundowicz SA, Meyers BF, Sharma A, Govindan R, Chen J, Kohlmeier C, Azar RR. Routine positron emission tomography does not alter nodal staging in patients undergoing EUS-guided FNA for esophageal cancer. Gastrointestinal endoscopy. 2009 Jun 30;69(7):1210-7.
Vazquez-Sequeiros E, Norton ID, Clain JE, Wang KK, Affi A, Allen M, Deschamps C, Miller D, Salomao D, Wiersema MJ. Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma. Gastrointestinal endoscopy. 2001 Jun 30;53(7):751-7.
Vazquez-Sequeiros E, Wiersema MJ, Clain JE, Norton ID, Levy MJ, Romero Y, Salomao D, Dierkhising R, Zinsmeister AR. Impact of lymph node staging on therapy of esophageal carcinoma. Gastroenterology. 2003 Dec 31;125(6):1626-35.
[Guideline] NCCN Clinical Practice Guidelines in Oncology: Esophageal and Esophagogastric Junction Cancers. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/pdf/esophageal.pdf. Version 2.2019 — May 29, 2019; Accessed: August 5, 2019.
Castellino AM. Should Minimally Invasive Esophagectomy Now Be Standard?. Medscape Medical News. Available at https://www.medscape.com/viewarticle/907435. January 09, 2019; Accessed: January 14, 2019.
Brooks M. Endoscopic Therapy a Good Option in Early Esophageal Cancer. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/814817. Accessed: November 25, 2013.
Novak B. Salvage endoscopy viable for some esophageal cancers. Medscape Medical News. January 29, 2014.
Tailored Enteral Formula During Chemoradiotherapy Curbs Body Mass Loss. Medscape. Jun 21 2013.
Zosia Chustecka. First Approval for Immunotherapy for Esophageal Cancer. Medscape Medical News. Available at https://www.medscape.com/viewarticle/916257. Jul 31, 2019; Accessed: August 1, 2019.
Kojima T, et al. Pembrolizumab versus chemotherapy as second-line therapy for advanced esophageal cancer: Phase III KEYNOTE-181 study. Presented at the Gastrointestinal Cancers Symposium 2019. Journal of Clinical Oncology. February 1, 2019. 37 (4):2-2.
Homs MY, Steyerberg EW, Eijkenboom WM, Tilanus HW, Stalpers LJ, Bartelsman JF, van Lanschot JJ, Wijrdeman HK, Mulder CJ, Reinders JG, Boot H. Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. The Lancet. 2004 Oct 29;364(9444):1497-504.
Verschuur EM, Steyerberg EW, Kuipers EJ, Siersema PD. Effect of stent size on complications and recurrent dysphagia in patients with esophageal or gastric cardia cancer. Gastrointestinal endoscopy. 2007 Apr 30;65(4):592-601.
Lightdale CJ, Heier SK, Marcon NE, McCaughan JS, Gerdes H, Overholt BF, Sivak MV, Stiegmann GV, Nava HR. Photodynamic therapy with porfimer sodium versus thermal ablation therapy with Nd: YAG laser for palliation of esophageal cancer: a multicenter randomized trial. Gastrointestinal endoscopy. 1995 Dec 31;42(6):507-12.
Vakil N, Morris AI, Marcon N, Segalin A, Peracchia A, Bethge N, Zuccaro G, Bosco JJ, Jones WF. A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction. The American journal of gastroenterology. 2001 Jun 1;96(6):1791-6.
Shin JH, Song HY, Kim JH, Kim SB, Lee GH, Park SI, Han YM, Kang W. Comparison of temporary and permanent stent placement with concurrent radiation therapy in patients with esophageal carcinoma. Journal of vascular and interventional radiology. 2005 Jan 31;16(1):67-74.
Ross WA, Alkassab F, Lynch PM, Ayers GD, Ajani J, Lee JH, Bismar M. Evolving role of self-expanding metal stents in the treatment of malignant dysphagia and fistulas. Gastrointestinal endoscopy. 2007 Jan 31;65(1):70-6.
Chustecka Z. Second-line docetaxel affirmed for esophagogastric cancer. Medscape Medical News. Jan 23, 2013. Available at http://www.medscape.com/viewarticle/778031. Accessed: January 28, 2013.
Ford H, Marshall A, Wadsley J, et al. Cougar-02: a randomized phase III study of docetaxel versus active symptom control in advanced esophagogastric adenocarcinoma. J Clin Oncol. 2012. 30:(suppl 34 abstr LBA4).
Bethesda, MD: National Cancer Institute. National Cancer Institute: PDQ® Esophageal Cancer Prevention. Available at http://www.cancer.gov/cancertopics/pdq/prevention/esophageal/HealthProfessional. February 11, 2016; Accessed: August 7, 2016.
Romero YV, Cameron AJ, Locke G3, Schaid DJ, Slezak JM, Branch CD, Melton LJ. Familial aggregation of gastroesophageal reflux in patients with Barrett's esophagus and esophageal adenocarcinoma. Gastroenterology. 1997 Nov 1;113(5):1449-56.
Verbeek RE, Spittuler LF, Peute A, van Oijen MG, Fiebo J, Vermeijden JR, Oberndorff A, van Baal JW, Siersema PD. Familial clustering of Barrett's esophagus and esophageal adenocarcinoma in a European cohort. Clinical Gastroenterology and Hepatology. 2014 Oct 31;12(10):1656-63.
Ellis NA, German J. Molecular genetics of Bloom's syndrome. Human molecular genetics. 1996 Sep 1;5(Supplement 1):1457-63.
de Winter JP, Joenje H. The genetic and molecular basis of Fanconi anemia. Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis. 2009 Jul 31;668(1):11-9.
Rosenberg PS, Alter BP, Ebell W. Cancer risks in Fanconi anemia: findings from the German Fanconi Anemia Registry. Haematologica. 2008 Apr 1;93(4):511-7.
van Zeeburg HJ, Snijders PJ, Wu T, Gluckman E, Soulier J, Surralles J, Castella M, van der Wal JE, Wennerberg J, Califano J, Velleuer E. Clinical and molecular characteristics of squamous cell carcinomas from Fanconi anemia patients. Journal of the National Cancer Institute. 2008 Nov 19;100(22):1649-53.
Oostra AB, Nieuwint AW, Joenje H, De Winter JP. Diagnosis of fanconi anemia: chromosomal breakage analysis. Anemia. 2012 May 24;2012.
Chennat J, Waxman I. Endoscopic treatment of Barrett’s esophagus: From metaplasia to intramucosal carcinoma. World J Gastroenterol. 2010 Aug 14;16(30):3780-5.
Nealis TB, Washington K, Keswani RN. Endoscopic therapy of esophageal premalignancy and early malignancy. Journal of the National Comprehensive Cancer Network. 2011 Aug 1;9(8):890-9.
Oppedijk V, van der Gaast A, van Lanschot JJ, van Hagen P, van Os R, van Rij CM, van der Sangen MJ, Beukema JC, Rütten H, Spruit PH, Reinders JG. Patterns of recurrence after surgery alone versus preoperative chemoradiotherapy and surgery in the CROSS trials. Journal of Clinical Oncology. 2014 Jan 13;32(5):385-91.
Lou F, Sima CS, Adusumilli PS, Bains MS, Sarkaria IS, Rusch VW, Rizk NP. Esophageal cancer recurrence patterns and implications for surveillance. Journal of Thoracic Oncology. 2013 Dec 31;8(12):1558-62.
Sudo K, Xiao L, Wadhwa R, Shiozaki H, Elimova E, Taketa T, Blum MA, Lee JH, Bhutani MS, Weston B, Ross WA. Importance of surveillance and success of salvage strategies after definitive chemoradiation in patients with esophageal cancer. Journal of Clinical Oncology. 2014 Sep 15;32(30):3400-5.
Dorth JA, Pura JA, Palta M, Willett CG, Uronis HE, D'amico TA, Czito BG. Patterns of recurrence after trimodality therapy for esophageal cancer. Cancer. 2014 Jul 15;120(14):2099-105.
Stahl M, Walz MK, Stuschke M, Lehmann N, Meyer HJ, Riera-Knorrenschild J, Langer P, Engenhart-Cabillic R, Bitzer M, Königsrainer A, Budach W. Phase III comparison of preoperative chemotherapy compared with chemoradiotherapy in patients with locally advanced adenocarcinoma of the esophagogastric junction. Journal of Clinical Oncology. 2009 Jan 12;27(6):851-6.
Minsky BD, Pajak TF, Ginsberg RJ, Pisansky TM, Martenson J, Komaki R, Okawara G, Rosenthal SA, Kelsen DP. INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combined-modality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy. Journal of clinical oncology. 2002 Mar 1;20(5):1167-74.
Cooper JS, Guo MD, Herskovic A, Macdonald JS, Martenson Jr JA, Al-Sarraf M, Byhardt R, Russell AH, Beitler JJ, Spencer S, Asbell SO. Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85-01). Jama. 1999 May 5;281(17):1623-7.
Meerten EV, van Rij C, Tesselaar ME, Neelis K, Richel D, Hulshof M, Gaast AV. Definitive concurrent chemoradiation (CRT) with weekly paclitaxel and carboplatin for patients (pts) with irresectable esophageal cancer: A phase II study. Journal of Clinical Oncology. 2010 May 20;28(15_suppl):e14508-.
Bartley AN, Washington MK, Colasacco C, Ventura CB, Ismaila N, Benson III AB, Carrato A, Gulley ML, Jain D, Kakar S, Mackay HJ. HER2 Testing and Clinical Decision Making in Gastroesophageal Adenocarcinoma: Guideline From the College of American Pathologists, American Society for Clinical Pathology, and the American Society of Clinical Oncology. Journal of Clinical Oncology. 2016 Nov 14:JCO-2016.
PDQ® Adult Treatment Editorial Board. PDQ Esophageal Cancer Treatment. National Cancer Institute. Available at http://www.cancer.gov/types/esophageal/hp/esophageal-treatment-pdq. February 4, 2016; Accessed: August 8, 2016.
Micrograph of squamous cell carcinoma of the esophagus (H&E Stain). Courtesy of Wikimedia Commons.
Low magnification micrograph of an intramucosal esophageal adenocarcinoma (H&E stain). Endoscopic mucosal resection specimen. Courtesy of Wikimedia Commons.
Transhiatal esophagectomy in which (a) is the abdominal incision, (b) is the cervical incision, and (c) is the stomach stretching from abdomen to the neck.
Cascade of events that lead from gastroesophageal reflux disease to adenocarcinoma.
Barium swallow demonstrating stricture due to cancer.
Barium swallow demonstrating an endoluminal mass in the mid esophagus.
Chest CT scan showing invasion of the trachea by esophageal cancer.
Transhiatal esophagectomy in which (a) is the abdominal incision, (b) is the cervical incision, and (c) is the stomach stretching from abdomen to the neck.
Five-year survival for esophageal cancer based on TNM stage.
H and E, high power, showing junction of benign glands in the lower right, Barrett's columnar cell metaplasia with a large goblet cell containing blue mucin in the lower center and adenocarcinoma on the left.
Macroscopic image of a resection of the gastroesophageal junction. On the right is non-neoplastic esophagus, consisting of tan, smooth mucosa. On the left is the non-neoplastic rugal folds of the stomach. In the center of the picture is an ulcer with a yellow-green fibrinous exudate surrounded by irregular, heaped-up margins with almost a cobblestone appearance. The latter represents mucosal adenocarcinoma with probably some Barrett's metaplasia in the background.
H and E, high power, demonstrating invasive esophageal squamous cell carcinoma. This carcinoma does not form glands and instead shows features of squamous differentiation, including keratinization and intercellular bridges.
Macroscopic image of an esophageal resection. A polypoid squamous cell carcinoma is visible protruding from the esophageal mucosal surface (left center of specimen).
On this positron emission computed tomography (PET) scan, esophageal cancer is evident as a golden lesion in the chest.
Palmoplantar keratoderma (Tylosis) of palms (A) and soles (B). Courtesy of The American Journal of Gastroenterology, Nature Publishing Group.
Diagram showing T1,T2 and T3 stages of esophageal cancer. Courtesy of Cancer Research UK and Wikimedia Commons.
Micrograph of squamous cell carcinoma of the esophagus (H&E Stain). Courtesy of Wikimedia Commons.
Low magnification micrograph of an intramucosal esophageal adenocarcinoma (H&E stain). Endoscopic mucosal resection specimen. Courtesy of Wikimedia Commons.
Stage
Survival Rate (%)
Localized
46.7
Regional
25.1
Distant
4.8
All Stages
19.9
Stage 0
Tis
N0
M0
Stage I
T1
N0-1
M0
Stage II
T2
N0
M0
T3
N0
M0
Stage III
T3
N1
M0
T1-3
N2
M0
Stage IVA
T4
N0-2
M0
Any T
N3
M0
Stage IVB
Any T
Any N
M1
Stage 0
Tis
N0
M0
Stage I
T1
N0
M0
Stage IIA
T1
N1
M0
Stage IIB
T2
N0
M0
Stage III
T2
N1
M0
T3
N0-1
M0
T4a
N0-1
M0
Stage IVA
T1-4a
N2
M0
T4b
N0-2
M0
Any T
N3
M0
Stage IVB
Any T
Any N
M1
Syndrome
Gene(s)
Inheritance Pattern
Clinical Manifestation
Surveillance Recommendations
Tylosis (non-Epidermolytic palmoplantar keratosis (PPK) or Howel Evans syndrome)
RHBDF2
Autosomal dominant
Skin thickening of palms and soles. Non-epidermolytic PPK is associated with high risk of developing SCC of esophagus (40-90% by age of 70 years)[40, 37]
Surveillance by upper GI endoscopy is recommended for family members with tylosis after 20 years of age[40]
Familial Barrett esophagus (FBE)
Genes not identified
Autosomal dominant
Familial aggregation of Barrett esophagus, adenocarcinoma of the esophagus and EGJ[130, 131]
Potential family history of Barrett esophagus, and adenocarcinoma of the esophagus,should be determined for patients presenting with GERD, especially white men older than 40 years of age.
Bloom syndrome
BLM/RECQL3
Autosomal recessive
Increased predisposition to a wide variety of malignancies[132] . Acute myeloid leukemia, acute lymphoblastic leukemia, lymphoid neoplasms, and Wilms tumor are the predominant cancers diagnosed before 25 years of age, whereas carcinomas of different anatomic sites including SCC of the esophagus are diagnosed after 20 years of age. Chromosomal quadraradials with breakage may be used for the diagnosis of BS [40]
Screening for GERD with or without endoscopy after 20 years of age may be considered to detect cancer early.
Fanconi anemia (FA)
FANC[133]
Autosomal recessive
Characterized by congenital malformations, progressive pancytopenia, easy bruising, chromosomal breakage and an increased predisposition to the development of hematologic malignancies as well as solid tumors[40] . AML is the most common cancer type in patients with FA. However, patients with FA are also at an increased risk of developing SCC of head, neck and esophagus, cervical cancer, and brain tumors.[40, 134, 135] Enhanced mitomycin C–induced chromosomal breakage analysis can help in diagnosis.[136]
Endoscopy of the esophagus may be considered as a surveillance strategy in individuals identified with FA.
Biopsy Finding
Recommended Surveillance/Intervention
Barrett Esophagus (BE) without dysplasia
Endoscopic surveillance every 3 years for patients with BE without dysplasia on 2 consecutive endoscopies with biopsies within a year.
BE with low-grade dysplasia (LGD)
For patients with confirmed low-grade dysplasia and without life-limiting comorbidity, endoscopic therapy is considered as the preferred treatment modality, although endoscopic surveillance is an acceptable alternative (Endoscopy within 6 months is warranted to ensure that no HGD is present in the esophagus. Follow-up endoscopy is recommended annually until no dysplasia is detected on 2 consecutive endoscopies with biopsies)
BE with high- grade dysplasia (HGD)
Patients with confirmed high-grade dysplasia should be managed with endoscopic therapy. In case of life-limiting comorbidity endoscopy within 3 months is recommended to rule out adenocarcinoma of the esophagus. Follow-up endoscopy every 3 months is recommended thereafter.
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