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      Anonymous
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      Keith M Baldwin, DO Attending Surgical Oncologist, Roger Williams Medical Center, Boston University School of Medicine

      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 progressive increase in the incidence of esophageal adenocarcinoma, for which the most common predisposing factor is gastroesophageal reflux disease (GERD).

      Signs and symptoms
      Presenting signs and symptoms of esophageal cancer include the following:

      Dysphagia (most common); initially for solids, eventually progressing to include liquids
      Weight loss (second most common)
      Bleeding
      Epigastric or retrosternal pain
      Bone pain with metastatic disease
      Hoarseness
      Persistent cough
      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 Clinical Presentation for more detail.

      Diagnosis
      Laboratory studies focus principally on patient factors that may affect treatment (eg, nutritional status).

      Imaging studies used for diagnosis and staging include the following:

      Esophagogastroduodenoscopy (allows direct visualization and biopsies of the tumor)
      Endoscopic ultrasonography (EUS; most sensitive test for T and N staging)
      Computed tomography of the abdomen and chest (for assessing lung and liver metastasis and invasion of adjacent structures)
      Positron emission tomography (PET) scanning (for staging)
      Bronchoscopy (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)
      Current TNM classification is as follows (staging is detailed in Table 1, below):

      Tis – Carcinoma in situ/high-grade dysplasia
      T1 – Lamina propria or submucosa
      T1a – Lamina propria or muscularis mucosae
      T1b – Submucosa
      T2 – Muscularis propria
      T3 – Adventitia
      T4 – Adjacent structures
      T4a – Pleura, pericardium, diaphragm, or adjacent peritoneum
      T4b – Other adjacent structures (eg, aorta, vertebral body, trachea)
      N0 – No regional lymph node metastasis
      N1 – 1-2 regional lymph nodes (N1 is site dependent)
      N2 – 3-6 regional lymph nodes
      N3 – More than 6 regional lymph nodes
      M0 – No distant metastasis
      M1 – Distant metastasis (M1a and M1b are site dependent)
      Table 1. Staging Classification. (Open Table in a new window)

      Stage IA T1 N0 M0
      Stage IB T2 N0 M0
      Stage IIA T3 N0 M0
      Stage IIB T1,T2 N1 M0
      Stage IIIA T4a N0 M0
      T3 N1 M0
      T1,T2 N2 M0
      Stage IIIB T3 N2 M0
      Stage IIIC T4a N1,N2 M0
      T4b Any N M0
      Any T N3 M0
      Stage IV Any T Any N M1
      See Workup for more detail.

      Management Treatment of esophageal cancer varies by disease stage, as follows:
      Stage I – Consideration for endoscopic therapy (eg, mucosal resection or submucosal dissection), particularly for Tis and T1aN0 by EUS; consideration for initial surgery for T1b and any N
      Stages II-III – Consideration for chemoradiation followed by surgery (trimodality therapy)
      Stage IV – Chemotherapy or symptomatic and supportive care
      Indications for surgical treatment of esophageal cancer include the following:

      Diagnosis of 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 for surgical treatment include the following:

      Metastasis to N2 (celiac, cervical, supraclavicular) nodes or solid organs (eg, liver, lungs)
      Invasion of adjacent structures (eg, recurrent laryngeal nerve, tracheobronchial tree, aorta, pericardium)
      Severe associated comorbid conditions (eg, cardiovascular disease, respiratory disease)
      Impaired cardiac or respiratory function
      Surgical options include the following:

      Transhiatal esophagectomy (THE)
      Transthoracic esophagectomy (TTE)
      Minimally invasive esophagectomy
      Endoscopic mucosal resection (EMR)
      Neoadjuvant therapy for esophageal cancer is as follows:

      Combination of radiotherapy and chemotherapy
      Usually administered over a 45-day period, with esophageal resection after approximately 4 weeks
      Most chemotherapy agents for esophageal cancer are used off-label
      Palliative care options for patients who are not candidates for surgery are as follows:

      Chemotherapy
      Radiotherapy
      Laser therapy
      Stents

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