Surgery Gastrointestinal Surgery

Esophageal cancer

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11 أقسام

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Background

  • Esophageal cancer is a malignancy that arises in the esophagus
  • Most cases of esophageal malignant tumors are due to squamous cell carcinoma and adenocarcinoma
  • Patients usually present with progressive dysphagia (first solids then subsequently liquids) and weight loss
  • This cancer is very aggressive due to the lack of serosa in esophageal wall (allows for rapid extension)
Esophageal Cancer
Subtypes
  • Adenocarcinoma (Distal Esophagus; Arises from Barrett’s Esophagus)
  • Squamous Cell Carcinoma (Anywhere in the Esophagus)
Risk Factors
  • Acid Reflux, Obesity (Adenocarcinoma)
  • Smoking, Alcohol, Caustic Injury (Squamous Cell Carcinoma)
Symptoms
  • Chest Pain
  • Weight Loss
  • Dysphagia (Solid)
Diagnosis
  • Endoscopy with Biopsy
  • CT (PET/CT) For Staging
Treatment
  • Chemoradiation
  • Surgery

 

Cancer Location Risk Factors Prevalence
Squamous Cell Carcinoma Upper 2/3 Alcohol, Hot Liquids, Caustic Strictures, Smoking, Achalasia, Nitrosamine-Rich Foods More Common Worldwide
Adenocarcinoma Lower 1/3 Chronic GERD, Barrett Esophagus, Obesity, Tobacco Smoking More Common in America

 

 

 

Version 2

  • Definition: Esophageal cancer is a malignant neoplasm arising from the epithelial lining of the esophagus
  • ★ Most common histologic types:
    • Adenocarcinoma (60-70% in US) - Most common in Western countries
    • Squamous cell carcinoma (30-40% in US) - Most common worldwide
  • Epidemiology:
    • 8th most common cancer worldwide
    • Male:Female ratio = 3:1
    • Median age: 60-70 years
    • Incidence: ~20,640 new cases/year in US (2022)
  • ⚠️ Key Point: Very aggressive cancer due to lack of serosa in esophageal wall → rapid local extension and early metastasis

🎯 HIGH-YIELD FACT

Progressive dysphagia (solids → liquids) + weight loss in older patient = Esophageal cancer until proven otherwise

Types and Classification

Feature Adenocarcinoma ★ Squamous Cell Carcinoma
Location Distal 1/3 of esophagus
Gastroesophageal junction		 Upper 2/3 of esophagus
Middle > upper > lower
★ Most Common in Western countries (US, Europe) Worldwide (Asia, Africa)
★ Key Risk Factors
  • Barrett esophagus (most important)
  • Chronic GERD
  • Obesity
  • Tobacco smoking
  • Alcohol + Tobacco (synergistic)
  • Hot liquids/beverages
  • Caustic injury
  • Achalasia
  • Nitrosamine-rich foods
  • Plummer-Vinson syndrome
Pathogenesis Normal squamous → Metaplasia (Barrett) → Dysplasia → Adenocarcinoma Normal squamous → Dysplasia → Carcinoma
Demographics White males > others African Americans > whites

💡 MEMORY AID

"ABCDEF" for Adenocarcinoma risk factors:

  • Acid reflux (GERD)
  • Barrett esophagus
  • Cigarettes
  • Diet (processed foods)
  • Excess weight (obesity)
  • Fat (central adiposity)

 

 

 

 

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Clinical presentation

  • Symptom
    • Progressive dysphagia
    • Unintentional weight loss
    • Epigastric or retrosternal pain
    • Hoarseness

 

 

Version 2

 

 

★ CLASSIC PRESENTATION

Elderly male (60-70 years) with:

  1. Progressive dysphagia (solids → liquids) - Most common symptom
  2. Unintentional weight loss - Second most common
  3. Odynophagia (painful swallowing)

Additional Clinical Features:

  • Local symptoms:
    • Retrosternal chest pain/burning
    • Regurgitation of undigested food
    • Halitosis
  • Advanced disease:
    • Hoarseness - recurrent laryngeal nerve involvement
    • Chronic cough - tracheoesophageal fistula
    • Hematemesis/melena - tumor bleeding
    • Iron deficiency anemia - chronic blood loss
    • Horner syndrome - sympathetic chain involvement
    • Cervical lymphadenopathy - metastatic disease

 

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Diagnosis

  • Upper gastrointestinal endoscopy (to allow for direct visualisation)

 

Version 2

 

 

 

🔍 DIAGNOSTIC APPROACH

  1. ★ Best initial test: Upper endoscopy (EGD) with biopsy
    • Direct visualization
    • Tissue diagnosis (gold standard)
    • Can assess for Barrett esophagus
  2. Staging workup (if cancer confirmed):
    • CT chest/abdomen - distant metastases
    • ★ Endoscopic ultrasound (EUS) - Most accurate for T and N staging
    • PET/CT - detect occult metastases
    • Bronchoscopy - if upper third tumor (rule out tracheal invasion)

Alternative Initial Tests (if endoscopy unavailable):

  • Barium swallow: Shows "apple core" lesion or irregular filling defect
  • CT scan: Can show esophageal wall thickening

Histopathology:

Type Microscopic Features
Adenocarcinoma
  • Malignant glandular structures
  • Mucin-producing cells
  • May see intestinal metaplasia (Barrett)
Squamous Cell
  • Keratin pearls
  • Intercellular bridges
  • Eosinophilic cytoplasm

 

 

 

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Differential diagnosis

  • Gastrointestinal reflux disease (GERD)

 

 

Version 2

 

 

 

Condition Key Distinguishing Features Test to Differentiate
GERD Heartburn, no dysphagia to solids, responds to PPI Trial of PPI, endoscopy if refractory
Achalasia Dysphagia to solids AND liquids from onset, regurgitation Esophageal manometry (absent peristalsis)
Esophageal stricture History of GERD/caustic ingestion, gradual onset Barium swallow, endoscopy
Esophageal web/ring Intermittent dysphagia, especially with meat Barium swallow, endoscopy
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Treatment

  • Medical management
    • Chemoradiation
  • Surgical management
    • Endoscopic mucosal resection (stage 1-2-3)
    • Esophagectomy or esphagogastrectomy (in case of high-grade dysplasia that cannot be adequately treated with endoscopic resection)

 

 

Version 2

 

 

⚕️ TREATMENT ALGORITHM

Based on staging:

  1. Early disease (T1a, mucosal only):
    • ★ Endoscopic mucosal resection (EMR)
    • Endoscopic submucosal dissection (ESD)
  2. Localized disease (T1b-T3, N0-1):
    • ★ Neoadjuvant chemoradiation → Esophagectomy (preferred)
    • Alternative: Primary esophagectomy → adjuvant therapy
  3. Locally advanced (T4 or N2-3):
    • ★ Definitive chemoradiation
    • Consider surgery if good response
  4. Metastatic disease:
    • Palliative chemotherapy
    • Esophageal stenting for obstruction
    • Radiation for bleeding/pain
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Complication

  • Esophageal obstruction

 

 

Version 2

 

 

  • ★ Most common complication: Esophageal obstruction
    • Progressive dysphagia
    • Malnutrition
    • Aspiration pneumonia
  • Local invasion complications:
    • Tracheoesophageal fistula - coughing with swallowing
    • Aortoesophageal fistula - massive hematemesis (fatal)
    • Pericardial effusion - cardiac tamponade
  • Treatment complications:
    • Post-esophagectomy: Anastomotic leak (most feared), stricture, dumping syndrome
    • Radiation: Esophagitis, stricture, pneumonitis

⚠️ WARNING - RED FLAGS

  • Coughing with swallowing → Suspect tracheoesophageal fistula
  • Massive hematemesis in esophageal cancer patient → Aortoesophageal fistula (surgical emergency)
  • New hoarseness → Recurrent laryngeal nerve involvement
سجل دخولك لإضافة ملاحظات خاصة لكل قسم  · اشترك الآن

Prevention and Screening - was not included in the first version

🛡️ PREVENTION STRATEGIES

  • Primary prevention:
    • Smoking cessation
    • Limit alcohol consumption
    • Weight loss if obese
    • GERD management with PPIs
  • ★ Screening recommendations:
    • Barrett esophagus surveillance:
      • No dysplasia: Every 3-5 years
      • Low-grade dysplasia: Every 6-12 months
      • High-grade dysplasia: Every 3 months or treat
    • Consider screening in: White males >50 with chronic GERD (>5 years) + ≥2 risk factors
سجل دخولك لإضافة ملاحظات خاصة لكل قسم  · اشترك الآن

Quick Review Box - was not included in the first version

📚 MUST-KNOW FACTS FOR EXAMS

  1. ★ Most common type in US: Adenocarcinoma (lower 1/3)
  2. ★ Most common type worldwide: Squamous cell carcinoma (upper 2/3)
  3. ★ Classic presentation: Progressive dysphagia (solids → liquids) + weight loss
  4. ★ Most important risk factor for adenocarcinoma: Barrett esophagus
  5. ★ Most important risk factors for SCC: Alcohol + tobacco (synergistic)
  6. ★ Best initial test: Upper endoscopy with biopsy
  7. ★ Most accurate staging test: Endoscopic ultrasound (EUS)
  8. ★ Treatment of choice for resectable disease: Neoadjuvant chemoRT → surgery
  9. ★ Why aggressive spread? Lack of serosa in esophageal wall
  10. ★ Prognosis: Poor (5-year survival ~20%)
سجل دخولك لإضافة ملاحظات خاصة لكل قسم  · اشترك الآن

Clinical Pearls - was not included in the first version

💎 CLINICAL PEARLS

  • Dysphagia patterns:
    • Mechanical obstruction (cancer): Solids → liquids
    • Motility disorder (achalasia): Solids AND liquids from start
  • Barrett esophagus: Increases adenocarcinoma risk 30-40x (0.5% annual risk)
  • Alcohol + tobacco: Multiplicative (not additive) risk for SCC
  • "Hot dog dysphagia": Think esophageal web/ring, not cancer
  • Iron deficiency anemia in elderly male: Always rule out GI malignancy
سجل دخولك لإضافة ملاحظات خاصة لكل قسم  · اشترك الآن

Common Exam Questions - was not included in the first version

📝 EXAM QUESTION PATTERNS

  • Classic vignette #1: "65-year-old man with 30-year history of GERD presents with progressive dysphagia and 20-lb weight loss" → Adenocarcinoma
  • Classic vignette #2: "55-year-old man with history of heavy alcohol and tobacco use presents with dysphagia and hoarseness" → Squamous cell carcinoma
  • Next best step questions:
    • Dysphagia + weight loss → Upper endoscopy with biopsy
    • Confirmed cancer → CT chest/abdomen for staging
    • Resectable tumor → Neoadjuvant therapy
  • Risk factor associations:
    • Barrett → Adenocarcinoma
    • Achalasia → Squamous cell
    • Plummer-Vinson → Squamous cell
    • Caustic injury → Squamous cell
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