The most common malignant esophageal neoplasms are squamous cell carcinoma and adenocarcinoma, the latter typically arising in Barrett epithelium. Although esophageal squamous cell carcinoma is the more common of the two worldwide, adenocarcinoma is more frequent in the United States. Frequent symptoms resulting from masses include dysphagia, odynophagia, loss of appetite, nausea and vomiting, and weight loss, which require diagnosis by means of upper endoscopy with biopsy. On establishment of diagnosis, preoperative staging is needed before selection of therapy.

Esophageal squamous cell carcinoma occurs predominantly in lower socioeconomic groups within the United States, with a predilection for African American males. Risk factors include tobacco and alcohol use, although in high‐incidence areas of the world (northern China, India, Iran, southern Russia, South Africa, and some parts of South America) other factors appear more critical, such as exposure to nitrosamines and concomitant nutritional (minerals and vitamins) deficiencies. Clinical suspicion of squamous cell carcinoma may merit initial performance of a barium esophagography but definitively upper endoscopy. This may reveal an early cancer that manifests as a plaque‐like lesion (Figure 13.1) or, alternatively, advanced cancer with an ulcerated polypoid lesion (Figure 13.2) or a circumferential annular lesion (Figures 13.3 and 13.4). Endoscopy with biopsies may demonstrate various stages: dysplasia, carcinoma in situ, or carcinoma (Figure 13.5). Preoperative staging is necessary, with endoscopic ultrasound to determine esophageal wall invasion and lymph node involvement (Figure 13.6), assuming no distant metastasis. A computed tomography (CT) scan will exclude regional and distant metastases. Although surgical resection with esophagectomy and gastric interposition is preferred for cure of patients who are appropriate candidates, neoadjuvant therapy with chemotherapy and radiation therapy followed by surgery is typically pursued. Currently, immunotherapy has been integrated into the treatment of metastatic esophageal squamous cell carcinoma. Palliation is needed for patients who cannot undergo potentially curative therapy (Figure 13.7).

Esophageal adenocarcinoma invariably develops in the setting of Barrett esophagus (Figure 13.8). An important factor in the development of Barrett esophagus is gastroesophageal reflux, although other unidentified factors may be important, such as central obesity. Because Barrett esophagus may progress from metaplasia to low‐ and high‐grade dysplasia with eventual adenocarcinoma, endoscopic surveillance with a systematic protocol for biopsies is warranted. Initial suspicion and diagnosis of Barrett dysplasia and esophageal adenocarcinoma may require barium esophagography (Figure 13.9) but definitely upper endoscopy (Figure 13.10). Pathology may reveal Barrett esophagus with varying degrees of dysplasia (Figure 13.11a,b) and adenocarcinoma (Figure 13.11c). As with squamous cell carcinoma, preoperative staging entails endoscopic ultrasound (Figure 13.12) and CT. Therapy may be surgical or multimodal (neoadjuvant chemotherapy and radiation therapy followed by surgery) if the patient is an appropriate candidate. Immunotherapy may be integrated in patients with metastatic disease. Otherwise, palliative therapy is provided. It should be noted that both esophageal neoplasms could have associated complications, such as fistula formation (Figure 13.13).

There are many other epithelial and nonepithelial esophageal neoplasms, both benign and malignant, but they are generally quite rare. An example of a benign nonepithelial tumor is leiomyoma, which is typically silent and patients are generally asymptomatic (Figure 13.14). Rare malignant esophageal neoplasms include carcinosarcoma, metastatic cancer (melanoma, breast cancer), neuroendocrine tumors, and various sarcomas (Figure 13.15).

Related posts:

3: Small intestine 49: Chronic hepatitis C 21: Dysmotility of the small intestine and colon 28: Miscellaneous diseases of the small intestine 70: Parasitic diseases: helminths 87: Abdominal sonography

Stay updated, free articles. Join our Telegram channel

Join