Esophageal carcinoma

Last revised by Mohammadtaghi Niknejad on 10 Mar 2024

Esophageal carcinoma is globally the 7th most common cancer and 6th most common cause of cancer-related death as per NCCN version 3.2023. It tends to present with increasing dysphagia, initially to solids and progressing to liquids as the tumor increases in size, obstructing the lumen of the esophagus.

Esophageal cancer is responsible for <1% of all cancers and 4-10% of all gastrointestinal malignancies. There is recognized male preponderance with the squamous cell subtype, M:F 4:1. 

The incidence of the subtypes has regional variation. The squamous cell subtype has the greatest worldwide incidence (~90%), but the adenocarcinoma subtype is more common in many parts of North America and Europe. In addition, there are certain regions where individuals are at particularly high risk of developing esophageal cancer, e.g. Iran, Malawi, Zimbabwe, Mongolia, Italy, and China.

Predisposing factors include 8:

  • alcohol and smoking: for squamous cell carcinoma and adenocarcinoma

  • achalasia

  • asbestosis

  • Barrett esophagus: for adenocarcinoma

  • celiac disease

  • ionizing radiation

  • caustic stricture/lye stricture

  • Plummer-Vinson syndrome

  • obesity: for adenocarcinoma

  • history of oral or pharyngeal cancer

  • human papillomavirus (HPV)

  • tylosis (Howel–Evans syndrome): a rare autosomal dominant disease with hyperkeratosis of the palms and soles with a high incidence of esophageal squamous cell carcinoma

  • Bloom syndrome: rare autosomal recessive disorder consisting of hematological malignancies Wilms tumor and solid tumors, including that of the esophagus

  • Fanconi anemia: a rare autosomal recessive disorder characterized by hematological malignancies, pancytopenia, congenital malformations and solid tumors (such as that of the esophagus)

Patients present with progressive dysphagiaweight loss, chronic worsening gastro-esophageal reflux and hoarseness, cough, vocal cord paralysis, or other signs and symptoms of mediastinal invasion.

* in the western world, adenocarcinoma is as common or even slightly more common than squamous cell carcinoma

  • polypoid/fungating (most common)

    • sessile/pedunculated tumor

    • lobulated surface protruding

    • irregular, polycyclic, overhanging, step-like "apple core" lesion

  • ulcerating: large ulcer niche within a bulging mass

  • infiltrating: gradual narrowing with a smooth transition

  • superficial spreading carcinoma

See the separate articles by histology:

  • lymphatic

    • anterior jugular chain and supraclavicular nodes (primary in upper 1/3)

    • para-esophageal and subdiaphragmatic nodes (primary in middle 1/3)

    • mediastinal and paracardiac and celiac trunk nodes (primary in lower 1/3)

  • hematogenous: lung, liver, adrenal glands

A combination of CT scan, transesophageal ultrasound, and PET-CT is used to stage the disease. CT is the best initial modality for detecting distant metastasis, gross direct invasion, and enlarged lymph nodes. Ultrasound is the most sensitive modality for assessment of the depth of invasion and regional enlarged lymph nodes. PET can be useful for restaging after the initial neoadjuvant therapy 7

Many indirect signs can be sought on a chest radiograph, and these include:

  • irregular stricture

  • prestricture dilatation with 'hold up'

  • shouldering of the stricture

The most accurate imaging modality for the T staging of esophageal cancer. It defines the layers of the esophageal wall hence can differentiate T1, T2, and T3 tumors.

The esophagus consists of five layers:

  1. first hyperechoic layer represents the interface between the balloon and the superficial mucosa

  2. second hypoechoic layer represents the lamina propria and muscularis mucosae

  3. a third hyperechoic layer represents the submucosa

  4. fourth hypoechoic layer represents the muscularis propria

  5. fifth layer represents the interface between the adventitia and surrounding tissues

  • eccentric or circumferential wall thickening >5 mm

  • periesophageal soft tissue and fat stranding

  • dilated fluid- and debris-filled esophageal lumen is proximal to an obstructing lesion

  • tracheobronchial invasion appears as a displacement of the airway (usually the trachea or left mainstem bronchus) as a result of the mass effect by the esophageal tumor

  • aortic invasion

FDG PET-CT is useful for detecting esophageal primary tumors. Yet, it has little role in helping determine the specific T classification because it provides limited information about the depth of tumor invasion.

PET-CT is also superior to CT for detecting lymph node metastases and can depict metastases in normal-sized lymph nodes through the uptake of FDG. 

PET-CT has a primary role in depicting distant sites of metastatic disease.

The bones and liver are the most common sites of distant metastases detected at PET (but frequently missed at CT). 

The 5-year mortality depends on the stage of the tumor. Unfortunately, most cases present with regional or distant metastatic disease (30% and 40%, respectively).

  • localized disease: ~40% 5-year survival

  • distant metastatic disease: ~5% 5-year survival

Endoscopic mucosal resection, without or with localized ablation, is an option for localized (T1a) disease. These epithelial tumors are usually <2 cm, asymptomatic, and noncircumferential.

For T1b tumors and above, surgical options are mostly limited to esophagectomy (including sometimes with palliative colonic interposition (see case 19)).

  • fistula formation to the trachea (5-10%), bronchi or mediastinum: can be either due to direct tumor progression or iatrogenic effects (e.g. radiation therapy) 

  • esophageal perforation

Imaging differential considerations include:

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