From the University of Utah School of Medicine, Salt Lake City, UT.
Abstract
Objective: To review the evaluation, diagnosis, and management of patients with esophageal cancer.
Methods: Review of the literature.
Results: Esophageal adenocarcinoma and esophageal squamous cell carcinoma (SCC) are aggressive cancers with a poor prognosis. GERD is the most common cause of esophageal adenocarcinoma, whereas increased alcohol consumption and tobacco commonly lead to esophageal SCC. Diagnosis is made via esophagogastroduodenoscopy and biopsies, and endoscopic ultrasound is typically used for locoregional staging. The endoscopic treatment of dysphagia is complex and several treatment options are available. Patients with locally advanced esophageal cancers are usually treated with neoadjuvant chemoradiation in combination with surgery. Improvement of quality of life is a major goal in patients with unresectable disease.
Conclusion: Esophageal cancer remains a commonly encountered clinical entity requiring multidisciplinary evaluation and treatment.
Esophageal cancer is an aggressive disease with an overall poor outcome. It is the eighth most common cancer and sixth most common cause of cancer-related death worldwide [1]. In 2012, there were an estimated 456,000 new diagnoses of esophageal cancer and 400,000 deaths worldwide [1]. In the United States alone, an estimated 18,170 cases of esophageal cancer will be diagnosed in 2014, with 15,450 expected deaths [2].
Esophageal cancer includes 2 distinct histologic diseases: esophageal adenocarcinoma and esophageal squamous cell carcinoma (SCC). Overall, esophageal adenocarcinoma has increased in incidence, while the incidence of SCC has decreased in the Western world due to long-term reductions in smoking and alcohol consumption and increased incidence of gastroesophageal reflux disease (GERD) and obesity [3,4]. Esophageal adenocarcinoma accounted for less than 15% of esophageal cancers in the early 1980s, but now represents more than 60% of all esophageal cancers in the United States [5]. Esophageal SCC is still more common in China, central Asia, sub-Saharan Africa, and India and among the African-American and Caucasian female population in the United States [3,5].
Etiology
Esophageal Adenocarcinoma
GERD leading to Barrett’s metaplasia is the most common risk factor for esophageal adenocarcinoma. Frequent reflux symptoms are strongly associated with the development of adenocarcinoma. A meta-analysis by Rubenstein and Taylor concluded that in patients with at least weekly symptoms of GERD, the odds of developing esophageal adenocarcinoma were increased fivefold, while daily symptoms increased the odds sevenfold [6]. A population-based cohort study by Lagergren and colleagues found that longstanding symptoms of reflux (more than 20 years), as well as more frequent and severe GERD, were associated with greater risk of esophageal adenocarcinoma [7]. In patients who had recurrent symptoms of GERD at least once a week versus those who did not, the odds ratio (OR) for the development of esophageal adenocarcinoma was 7.7 (95% confidence interval [CI], 5.3 to 11.4). Among patients with severe and longstanding symptoms of reflux, the OR was 43.5 (95% CI, 18.3 to 103.5). In a study by Pohl et al, hiatal hernia was identified as a risk factor strongly associated with the development of reflux and thus is a risk factor for esophageal adenocarcinoma [8]. Despite its strong association, it should be noted that Barrett’s esophagus develops among only a minority of patients with symptomatic GERD. Some cohort studies, including the Northern Ireland Barrett’s Esophagus Register, have convincingly demonstrated that the vast majority of cases of esophageal adenocarcinoma develop in individuals without a known preexisting diagnosis of Barrett’s esophagus [9]. While not easily supported by controlled trial data, proton pump inhibitor therapy may reduce the incidence of high-grade dysplasia and esophageal adenocarcinoma in patients with Barrett’s esophagus. Antireflux surgery has not been shown to prevent the development of esophageal adenocarcinoma and should not be considered a preventative therapy for esophageal adenocarcinoma ( Figure 1
