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Esophageal cancer is a difficult disease that reduces a patient's quality of life and is lethal in most cases.[1] There are two main histologic variants of esophageal cancer: squamous cell carcinoma (SCC) and adenocarcinoma. SCC can appear in any part of the esophagus but often originates in the upper half. Esophageal adenocarcinoma commonly arises in the lower half of the esophagus as a result of gastroesophageal reflux disease (GERD). Esophageal cancer affects more men than women and is one of the leading causes of cancer death in males. The image in the slide depicts the progression of events leading up to esophageal adenocarcinoma.
Barrett esophagus, a condition characterized by metaplastic columnar epithelium that takes over the squamous epithelium in the distal esophagus as a result of GERD, can lead to the development of esophageal adenocarcinoma.[2] An endoscopic examination is usually performed to diagnose this condition. Screening for Barrett esophagus is recommended primarily for patients who have a number of risk factors for esophageal cancer (eg, GERD).
Image courtesy of Medscape/ Science Source | Science Picture Co (background).
The image in the slide shows a late-stage squamous cell subtype of esophageal cancer in a 51-year-old male patient with a history of alcohol consumption.
Which of the following statements regarding esophageal cancer is not true?
Image courtesy of Wikimedia Commons.
Answer: F. Esophageal cancer is more common in women than in men.
Esophageal cancer has a 3:1 predilection for men over women. It has become the seventh leading cause of cancer death in males. The incidence of esophageal adenocarcinoma among white males is double that in Hispanic males and quadruple that in black and Asian males.[3]
The image in the slide shows a cancerous mass constricting the esophageal lumen.
Image courtesy of the National Library of Medicine.
The positron emission tomography (PET) scan in the slide depicts an esophageal cancer as a golden lesion in the chest.
A 59-year-old man, a former smoker who has a medical history of GERD, arthritis, and chronic obstructive pulmonary disease (COPD), is evaluated in the emergency department (ED). Initially, he had dysphagia to solids, but over the course of several months, the dysphagia progressed to liquids.
Which of the following is not a common potential complication of esophageal cancer?
Image courtesy of Medscape.
Answer: E. Bleeding from the tumor surface.
Bleeding from the tumor surface is a possible occurrence, but it is quite rare and is considerably less likely to happen than the other choices are. Answers A through D are all potential complications of esophageal cancer. The image in the slide is of a high-power hematoxylin-eosin (H&E) stain showing SCC in the esophagus. The differential features of this subtype of esophageal cancer are apparent, including keratinization and intercellular bridges.
Image courtesy of Medscape.
A 71-year-old woman presents with dysphagia to her primary care provider. She has a medical history significant for GERD, and she is an active smoker and a binge drinker. A barium swallow is completed and indicates a stricture at the distal esophagus (shown).
Which of the following is the most appropriate next step in management?
Image courtesy of Medscape.
Answer: C. Upper gastrointestinal (GI) endoscopy to obtain a biopsy, along with endoscopic ultrasonography (EUS).
The best next step would be to make a diagnosis and begin staging with EUS before initiating any further treatment.[4,5] The presence of esophageal cancer may be established by using barium studies, but assessment and characterization of the cancer are accomplished by means of endoscopic techniques. On endoscopy, esophageal cancer is initially noticeable as plaques, nodules, or ulcers; when it has progressed, it takes the form of strictures or large ulcerous masses. The images in the slide show a tumorous esophageal mass found during endoscopic biopsy (left) and EUS (right).
Images courtesy of Wikimedia Commons.
The contrast CT scan in the slide shows esophageal cancer, with the tumor circled in red.
A 74-year-old man with a medical history significant for atrial fibrillation, diabetes mellitus, and hypertension presents with a esophageal stricture noted on a barium swallow. EUS is planned.
Which of the following statements regarding EUS is not true?
Image courtesy of Wikimedia Commons.
The combined PET/CT scan in the slide shows adenocarcinoma in the distal esophagus.
A 73-year-old man presents with dysphagia to solids that has progressed over the past 9 months. He is an active smoker. He has a family history significant for an uncle with esophageal carcinoma who underwent esophagectomy at age 49 years. The patient is concerned about possible esophageal cancer and wants a full, expedited workup.
In this clinical scenario, which of the following measures is not indicated?
Image courtesy of Wikimedia Commons.
Answer: G. EUS if there is evidence of metastatic disease.
EUS is usually done if no distant metastatic disease is detected. It is utilized to image subtle mucosal changes in the vicinity of a target area. CT is commonly utilized to aid in the staging of distant metastases.[6] The image shows an endoscopic view of intraluminal esophageal cancer.
Image courtesy of Medscape.
The image in the slide shows a cancerous esophagus that has been surgically excised.
Esophagogastroduodenoscopy (EGD)/EUS is subsequently performed, and the patient is found to have a 1.5-cm mass 8 cm from the incisors that is invading the muscularis propria but has not penetrated the adventitia. Biopsy is performed, and the lesion is determined to be an adenocarcinoma. EUS identifies no suspicious enlarged lymph nodes. A PET/CT scan shows no distant metastases.
Which of the following is not a potential treatment that a multidisciplinary tumor board should consider for this patient?
Image courtesy of Wikimedia Commons.
Answer: A. Endoscopic mucosal resection (EMR).
According to National Comprehensive Cancer Network (NCCN) guidelines,[7] EMR is indicated only for Tis and T1 lesions. All of the other therapeutic measures are possible answers in this setting. These treatment options must be reviewed in a multidisciplinary conference, ideally including a pathologist, a general or thoracic surgeon, a radiation oncologist, and a medical oncologist. The image in the slide shows an esophageal resection with SCC protruding from the mucosal surface of the surgical specimen (left center).
Image courtesy of Medscape.
The 73-year-old patient from the preceding slides elects to delay his care. After 6 months, he expresses interest in having the tumor resected. He has an Eastern Cooperative Oncology Group (ECOG) Performance Status score[8] of 1 (shown) and would like to proceed immediately with surgery. Another PET/CT scan is obtained, which shows evidence of metastasis to the liver.
Which of the following agents is not actively used in the treatment of metastatic esophageal cancer?
Table adapted from ECOG-AGRIN Cancer Research Group.[8]
Answer: D. Lenalidomide.
Lenalidomide is an immunomodulatory drug used in the treatment of myelodysplastic syndrome (MDS) and multiple myeloma. The other agents can all be used to treat esophageal carcinoma, either singly or in combination. The high-magnification micrograph with H&E staining in the slide shows an esophageal adenocarcinoma. The adenocarcinoma is visible on the left of the image and is characterized by bundles of cancerous cells clustered together in glands.
Image courtesy of Wikimedia Commons.
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