Esophageal cancer

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Esophageal cancer



Esophageal cancer


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USMLE® Step 1 questions

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High Yield Notes

18 pages


Esophageal cancer

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USMLE® Step 1 style questions USMLE

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A 69-year-old man presents to the primary care physician with dysphagia. The patient reports progressive difficulty swallowing, now to the point where he has trouble tolerating liquids and sometimes vomits after eating. The patient has a significant history of alcohol abuse, 50-pack-year smoking history, as well as hypertension and hyperlipidemia. Temperature is 37°C (98.6°F), pulse is 68/min, respirations are 14/min and blood pressure is 130/82 mmHg. Physical exam shows a thin male with bitemporal wasting and non-tender anterior cervical lymphadenopathy. Oral and neck examination is unremarkable aside from poor dentition. Laboratory results are as follows:  
Laboratory value  Result 
CBC, Serum 
 Hemoglobin  11.2  g/dL 
 Hematocrit  33.6% 
 Leukocyte count  10,100 /mm3 
 Platelet count  149,000/mm3 
 MCV                        72 fL 
 RDW                    11.5-14.5% 
 Iron Studies, Serum  
          Serum Iron                     90 μg/dL  
             Ferritin            Ferritin 170 ng/mL  
 Total iron binding capacity                               220 μg/dL 
A barium swallow study reveals an esophageal mass that significantly narrows the lumen in the middle of the esophagus. Which of the following pathologic features is most likely to be found on upper endoscopy?  

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Achalasia p. 385

esophageal cancer and p. 387

Alcoholism p. 595

esophageal cancer p. 387

Esophageal cancer p. 387

achalasia and p. 385

Gastroesophageal reflux disease (GERD)

esophageal cancer and p. 387


esophageal cancer and p. 387


esophageal cancer and p. 387

Weight loss

esophageal cancer p. 387


Esophageal cancer is when malignant or cancerous cells arise in the esophagus. This cancer can appear in any segment of the esophagus and it’s further classified into squamous cell carcinoma and adenocarcinoma - depending on the type of cells it originates from. Squamous cell carcinoma, as you can tell by its name, arises from squamous epithelium. On the other hand, adeno- means gland. So, adenocarcinoma arises from columnar glandular epithelium. Esophageal cancer is generally considered a poor prognosis cancer, because it doesn't cause symptoms until later stages.

The esophagus is a long tube going from the pharynx to the stomach, and it’s connected to the pharynx through the upper esophageal sphincter, and to the stomach through the lower esophageal sphincter. Both relax during swallowing to allow the passage of food or liquids. Additionally, the lower esophageal sphincter is tightly closed between meals to prevent acid reflux. Now, the esophageal wall has four layers - from the outside in, these are the adventitia ; the muscular layer; the submucosa and the mucosa. The mucosa comes into direct contact with food, and it protects the esophageal wall from friction. The mucosa also has three layers of its own: a layer made of stratified squamous epithelium; a layer of connective tissue, called the lamina propria; and a layer of muscle cells, called the muscularis mucosae. Finally, at the lower esophageal sphincter, the squamous epithelium joins the columnar gastric epithelium to form the gastroesophageal junction.

Now, squamous cell carcinoma is the most common type of esophageal cancer worldwide, and it originates in the squamous epithelium of the esophagus, most often in the upper two thirds. When this epithelium is repeatedly exposed to risk factors like alcohol, cigarette smoke, or hot fluids, it gets damaged, so the squamous cells divide to replace the old damaged cells. With each division, there is a risk that a mutation can occur in the genes that are in charge of the cell cycle and cell division. Mutations can occur in tumor suppressor genes, which normally code for proteins that stop the cell cycle or promote apoptosis - so they’re the cell cycle’s very own brake pedal. Or they can occur in proto-oncogenes, which normally code for proteins that promote the cell cycle - so they’re the cell cycle’s accelerator pedal. When this happens, squamous cells start dividing uncontrollably, and more mutations accumulate with each division. So eventually, these mutations might make the cells malignant - meaning they gain the ability to invade neighboring tissues and spread to distant sites.


  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  4. "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
  5. "Multimodality Assessment of Esophageal Cancer: Preoperative Staging and Monitoring of Response to Therapy" RadioGraphics (2009)
  6. "Imaging the small bowel" Current Opinion in Gastroenterology (2014)
  7. "Oesophageal carcinoma" The Lancet (2013)

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