Esophageal Cancer
A 62-year-old man comes
for evaluation of progressive “difficulty swallowing solids and, recently, semisolids” for 4 months.
He has noticed
a 20-lb weight
loss. His past medical history is significant for reflux esophagitis for 15 years and
a 40-pack-year smoking history. On the
physical examination, a 1.5-cm, left supraclavicular lymph node is found. The remainder of the physical
examination is unremarkable.
Pathogenesis. Esophageal cancer is linked to the synergistic, carcinogenic effect of alcohol and tobacco use for cases of squamous
cell cancer in the proximal two-thirds of the esophagus. Adenocarcinoma is found in the distal
third of the esophagus and is associated with long-stand- ing
gastroesophageal reflux disease and Barrett esophagus. The rate of development
of cancer from Barrett esophagus is between 0.4 and 0.8% per year. Squamous and adenocarcinoma are now
of equal frequency.
Clinical Presentation. Esophageal cancer presents
with progressive dysphagia
first for solid food, then for liquids. Weight loss is prominent. Rarely, halitosis, regurgitation, and
hoarseness occur. Hypercalcemia may
arise, as it can with most cancers.
Diagnosis. Although
a barium swallow can be done first, endoscopy is mandatory because this is a
diagnosis that requires a tissue biopsy. CT
scanning detects the degree of local spread, and bronchoscopy detects
asymptomatic spread into the bronchi. Endoscopic ultrasound is performed for staging.
Treatment. The only truly effective
therapy for esophageal carcinoma is surgical resection if the disease is sufficiently localized to the esophagus. Only 25% of patients are found to be oper- able. A total of 10 to 20% will die from the surgery.
Five-year survival is between 5 and 20%. Chemotherapy with a 5-fluorouracil-based
chemotherapy is combined with
radiation to control locally
metastatic disease.
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