Esophageal cancer: Clinical sciences

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Introduction0:00–0:36

Esophageal cancer is a malignant tumor of the esophagus or esophagogastric junction. Two main pathologic types of esophageal cancer include squamous cell carcinoma and adenocarcinoma.
Esophageal cancer is associated with high morbidity and mortality as more than 50% of patients present with advanced disease.
However, even with early diagnosis and treatment, esophageal cancers have very poor long-term outcomes. When a patient presents with chief concern suggestive of esophageal cancer, the first step is to obtain a focused history and physical, and labs including CBC and CMP.

H&P and Labs0:36–1:51

Although most patients are asymptomatic, some might report dysphagia, odynophagia, epigastric or retrosternal pain, regurgitation of food or saliva, cough, and hoarseness.
They might also have associated anemia or weight loss. Additionally, history might reveal risk factors, such as tobacco or alcohol use, high BMI, gastroesophageal reflux disease or Barrett's esophagus, as well as a family history of esophageal cancer, or genetic conditions like Fanconi Anemia or Bloom Syndrome.
The physical exam is typically unremarkable, but might reveal cachexia, and sometimes lymphadenopathy and hepatomegaly if the disease has metastasized.
Finally, labs typically show anemia, electrolyte abnormalities, or elevated liver enzymes. So, if you see these findings, suspect esophageal cancer.Your next step is to obtain imaging.

Imaging1:51–3:08

The first choice is an upper endoscopy with biopsy and an endoscopic ultrasound with fine-needle aspiration if there are any suspicious lymph nodes.
However, bronchoscopy can be performed if you suspect a tumor above the carina. Endoscopy allows us to see macroscopic features, such as strictures, ulcerations, or an exophytic, fungating, or circumferential mass.
Biopsy of these suspicious features will likely show invasive adenocarcinoma or squamous cell carcinoma, also known as SCC.Here’s a clinical pearl!
Imaging can be done, where upper GI fluoroscopy can show a classic apple core lesion, or CT imaging can be done, which would show circumferential thickening of the esophagus.
In addition, you can expect the ultrasound to show the invasion of the mucosa, submucosa, or even beyond such as full-thickness invasion of the esophageal wall.
The ultrasound can also show any locoregional lymphadenopathy that might be present. The combination of these findings confirms the diagnosis of esophageal cancer.
Okay, back to our biopsy, if it shows squamous cell carcinoma, that’s your diagnosis! The next step in your workup is to stage the cancer using the TNM staging system by evaluating the size of the lesion, lymph node involvement, and the presence of metastatic disease.

Squamous cell carcinoma3:08–3:51

Since you were able to determine the size of the tumor and locoregional lymph node involvement using endoscopy and ultrasound, you’ll need to evaluate for involvement of distant lymph nodes or metastatic disease by ordering a CT of the chest and abdomen.
Sometimes, you might need additional imaging like a CT of the pelvis or a PET scan.If endoscopy reveals a tumor that’s less than 2 cm, and ultrasound and biopsy show no invasion of deep submucosa in addition to no signs of lymphadenopathy or distant metastasis on CT, you have stage 1A esophageal cancer.

Stage IA3:51–4:56

This is a favorable diagnosis, and the treatment of choice is endoscopic resection. A complete resection confirmed through pathological assessment is regarded as curative, and can be followed only by surveillance.
Surveillance includes a history and physical every 3 to 6 months for years 1 and 2, then every 6 to 12 months for years 3 to 5, and annually thereafter.
Esophagogastroduodenoscopy or EGD is performed every 6 months during year 1, and then annually up to year 5. On the other hand, if you have an incomplete resection, your next step is to obtain a surgical consultation for an esophagectomy to achieve complete resection of the tumor.

Stage IB-II4:56–5:43

Now let’s go back and talk about a more advanced disease. On endoscopy, these lesions are typically greater than 2 cm, and ultrasound shows invasion of the submucosa.
If no distant metastasis is present, staging is based on specific tumor characteristics. Stage 1B to 2 disease means that the tumor has low-risk features.
This means a size less than 3 cm and well-differentiated with no lymphovascular invasion on histopathology. The treatment for these patients mainly involves surgical consultation for esophagectomy.
Once complete resection of the tumor has been achieved, the patient can go into surveillance. On the other hand, tumors with high-risk features, including deep level of tissue invasion, or lymph node involvement are considered to be Stage 2, 3, or 4A.

Stage II to IVA5:43–7:37

Stage 2 with high-risk features means that the tumor is greater than 3 cm, poorly differentiated, and invades through the muscularis propria with lymphovascular invasion.
Stages 3 and 4A imply full-thickness invasion with nodal involvement. Because the likelihood for locoregional metastasis for Stages 3 and 4A is high, you need to assess for spread beyond the esophagus with a staging laparoscopy and peritoneal cytology washings.
This is done to evaluate for peritoneal dissemination of disease, which is typically not seen on CT. Keep in mind that Stage 2 high-risk tumors do not need staging laparoscopy, since the tumor has not invaded through the entire wall of the esophagus.
f there’s no locoregional metastatic disease on CT, laparoscopy, or peritoneal cytology, treatment involves neoadjuvant chemoradiation, restaging with PET CT or a CT to assess for treatment response, and surgical consultation for esophagectomy if the tumor positively responded to chemoradiation and adjuvant immunotherapy.
For patients who respond well to treatment, you can continue with the surveillance. However, if patients decline surgery, chemotherapy with radiation is an appropriate option for treatment.
On the other hand, if there is evidence of locoregional metastasis on CT, laparoscopy, or peritoneal cytology, the patient is upstaged to Stage 4B disease.Okay, let’s go back to TNM staging and talk about Stage 4 patients a bit more.

Stage IVB - TNM: Metastasis7:37–8:43

If there’s any evidence of distant metastasis on TNM staging, the patient has Stage 4B disease, which is considered to be unresectable.
In these cases, surgical resection is not recommended, so treatment includes chemotherapy with radiation and immunotherapy for those with Her-2 or PDL-1 positive tumors.
The prognosis is very poor, so consider offering palliative and supportive care. Here’s a couple of clinical pearls!
Radiation is contraindicated if there’s invasion of the trachea, great vessels, vertebral body, or heart. Now, sometimes the tumor might cause esophageal obstruction.
Even though surgery is not recommended for stage 4 disease, in this case, an endoscopic stent can be placed to allow for oral intake and saliva to pass through the esophagus.Alright, time to go back to the biopsy and talk about adenocarcinoma.

Adenocarcinoma8:43–9:01

As before, start with staging, so obtain CT of the chest and abdomen. You can also obtain a CT of the pelvis and a PET scan if indicated.
Similarly to SCC, adenocarcinomas less than 2 cm on endoscopy with invasion into the submucosa on ultrasound and no lymphadenopathy and no metastasis on CT are considered Stage 1A.

Stage IA9:01–9:36

These tumors can be treated with endoscopic resection. Complete pathologic resection is considered curative, so only surveillance is recommended afterwards.
However, patients with incomplete endoscopic resections need surgical consultation for esophagectomy. Now, let’s take a look at advanced tumors.

Stage IB - II low risk9:36–10:31

These are greater than 2 cm on endoscopy and show invasion of the submucosa or deeper on ultrasound. If no distant metastasis is present, for low risk features there is stage 1B and II, but if the tumor has high-risk features, it would be classified into stage II, III, or 4A.
Tumors are then staged by limited depth of invasion, local nodes, and invasion of adjacent organs.For stages 1B and 2 with low-risk features like well-differentiated with no lymphovascular invasion, treatment includes surgical consultation for esophagectomy and adjuvant chemoradiation for node-positive disease.
Once therapy is complete, the patient can be followed up with surveillance. Alright, patients with Stage 3 or 4A, or any stage with lymph node-positive disease need to be assessed for locoregional metastasis with staging laparoscopy and peritoneal cytology washings.

Stage II high risk, Stage III - IVA10:31–11:08

If there is no locoregional metastasis, you can treat the patient with neoadjuvant chemoradiation followed by restaging to determine treatment response, then surgical consultation for esophagectomy.
After surgery, offer adjuvant therapy and then surveillance if the patient responds well to the treatment. Now, if your patient had locoregional metastasis, they are upstaged to Stage 4B disease.

Stage IVB - TNM: Metastasis11:08–11:45

Speaking of which, if you found distant metastasis on TNM staging, that’s also stage 4B.The treatment here includes chemoradiation and immunotherapy for Her-2 or PDL-1 positive tumors.
Although surgical resection is generally not recommended, candidacy for esophagectomy is evaluated on a case-by-case basis.
Regardless, the prognosis is poor, so be sure to offer palliative and supportive care. Alright, as a quick recap… The two main types of esophageal cancers are squamous cell carcinoma and adenocarcinoma.

Review11:45–12:10

Diagnostic workup usually begins with an upper endoscopy with a biopsy to visualize the mass and confirm tissue diagnosis.
Once the diagnosis is made, stage the cancer using the TNM system. The treatment is based on the stage.