Esophageal Cancer

Esophageal cancer develops in the esophagus, the muscular tube connecting the throat to the stomach. It’s often diagnosed at advanced stages due to subtle early symptoms, leading to a poor prognosis.

Types:

1. Squamous Cell Carcinoma (SCC)
   • ~30% of cases. Arises from squamous cells lining the upper/mid esophagus.
   • Key risks: Smoking, alcohol, hot beverages, dietary nitrosamines (common in Asia/Africa).
2. Adenocarcinoma (AC)
   • ~60% in Western countries. Develops from glandular cells in the lower esophagus.
   • Key risks: Chronic gastroesophageal reflux disease (GERD), Barrett’s esophagus, obesity.
3. Rare Types: Small cell carcinoma, sarcoma, lymphoma.

Symptoms:

• Early: Often none or vague (heartburn, indigestion).
• Progressive:
  • Dysphagia (trouble swallowing solids → liquids), odynophagia (painful swallowing).
  • Weight loss (unintentional), chest pain, regurgitation.
• Advanced: Hoarseness (recurrent laryngeal nerve invasion), cough (tracheal fistula), vomiting blood.

🚨 Red Flag: Dysphagia warrants immediate endoscopy.

Risk Factors:

• SCC:
  • Tobacco (any form), heavy alcohol, combined use ↑ risk 100×.
  • Poor diet (low fruits/vegetables), hot beverages (>65°C), achalasia, caustic injury.
• AC:
  • GERD/Barrett’s esophagus (main precursor), obesity, hiatal hernia, high-fat diet.
• Shared: Age (>50 yrs), male sex (3–4× ↑ risk), radiation exposure, family history.

Diagnosis:

1. Endoscopy (+ Biopsy):
   • Gold standard. Visualizes tumors and biopsies tissue.
2. Imaging:
   • Barium Swallow: Identifies strictures/ulcers.
   • CT/PET-CT: Staging (lymph nodes, metastases).
   • Endoscopic Ultrasound (EUS): Determines tumor depth (T-stage) and nodal involvement.
3. Biomarkers: Limited role (e.g., HER2 for targeted therapy in AC).

Treatment:

Treatment depends heavily on stage, location, histology, and patient fitness.

1. Early-Stage (Tis, T1a):
   • Endoscopic Resection: For mucosal tumors (EMR/ESD).
   • Ablation: Radiofrequency ablation (RFA) for Barrett’s dysplasia.
2. Locally Advanced (Stages II–III):
   • SCC:
     • Chemoradiation (Definitive): Cisplatin + 5-FU + radiation (preferred for cervical/upper esophagus).
     • Surgery: Esophagectomy (Ivor Lewis/McKeown) after neoadjuvant chemoradiation.
   • AC:
     • Neoadjuvant Chemo/Chemoradiation → Surgery (CROSS regimen: carboplatin/paclitaxel + RT).
3. Metastatic (Stage IV):
   • Immunotherapy: 1st-line for PD-L1+ tumors (pembrolizumab ± chemo).
   • Targeted Therapy:
     • *HER2+ AC:* Trastuzumab + chemo.
     • VEGF Inhibitors: Ramucirumab (2nd-line).
   • Palliative Care: Stents/laser for dysphagia, nutrition support, pain management.

Prognosis:

• Overall, 5-Year Survival: ~20% (improving with multimodal therapy).
• Favorable Factors:
  • Early stage (T1), AC histology, response to neoadjuvant therapy, R0 resection.
• Poor Prognosis:
  • SCC, weight loss >10%, nodal/distant spread, poor differentiation.

Prevention & Screening

• High-Risk Groups (Barrett’s):
  • Regular surveillance endoscopy with biopsies.
• Lifestyle Modifications:
  • Quit smoking, limit alcohol, weight loss, treat GERD.
• Diet: Avoid very hot drinks; increase fruits/vegetables.

Critical Considerations

• Nutritional Support: Essential pre/post-treatment (feeding tubes often needed).
• Surgical Complications: Anastomotic leaks, vocal cord paralysis, dumping syndrome.
• Clinical Trials: Investigating immunotherapy combinations, biomarkers, and minimally invasive surgery.
• Quality of Life: Dysphagia management is prioritized (stents, dilation).

Multidisciplinary care (GI, oncology, surgery, nutrition) is crucial. Consult a gastrointestinal oncologist for personalized plans.