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Clinical Findings
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A Symptoms and Signs
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Most patients with esophageal cancer present with advanced, incurable disease Over 90% have solid food dysphagia, which progresses over weeks to months Odynophagia is sometimes present Significant weight loss is common Local tumor extension into the tracheobronchial tree may result in a tracheoesophageal fistula, characterized by coughing on swallowing or pneumonia Chest or back pain suggests mediastinal extension Recurrent laryngeal involvement may produce hoarseness Physical examination is often unrevealing The presence of supraclavicular or cervical lymphadenopathy or of hepatomegaly implies metastatic disease
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Prognosis
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Most patients die of respiratory failure and complications of local extension Median survival time from onset of symptoms ranges from 4 months in extensive disease to 16 months in localized disease Five-year survival is less than 5%
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Robinson BW et al Advances in malignant mesothelioma N Engl J Med 2005 Oct 13;353(15):1591 603 [PMID: 16221782] West SD et al Management of malignant pleural mesothelioma Clin Chest Med 2006 Jun;27(2):335 54 [PMID: 16716822]
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B Laboratory Findings
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Laboratory findings are nonspecific Anemia related to chronic disease or occult blood loss is common Elevated aminotransferase or alkaline phosphatase concentrations suggest hepatic or bony metastases Hypoalbuminemia may result from malnutrition
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ALIMENTARY TRACT CANCERS
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ESOPHAGEAL CANCER
C Imaging
Chest radiographs may show adenopathy, a widened mediastinum, pulmonary or bony metastases, or signs of tracheoesophageal fistula such as pneumonia A barium esophagogram is obtained as the first study to evaluate dysphagia The appearance of a polypoid, infiltrative, or ulcerative lesion is suggestive of carcinoma and requires endoscopic evaluation However,
ESSENTIALS OF DIAGNOSIS
Progressive solid food dysphagia
Cancer
even lesions felt to be benign by radiography warrant endoscopic evaluation
CMDT 2008
D Upper Endoscopy
Endoscopy with biopsy establishes the diagnosis of esophageal carcinoma with a high degree of reliability In some cases, significant submucosal spread of the tumor may yield nondiagnostic mucosal biopsies Repeated biopsy may be necessary
1 Radiation or chemoradiation therapy Combined radiation therapy and chemotherapy may achieve palliation in two-thirds of patients but is associated with significant side effects It should be considered for patients with a good functional status without other significant medical problems Radiation therapy alone may afford significant short-term relief of pain and dysphagia and may be suitable for patients with poor functional status or underlying medical problems During therapy, esophagitis may lead to worsening of dysphagia and odynophagia 2 Local antitumor therapy Patients with advanced esophageal cancer may have a poor functional and nutritional status and an average survival of less than 12 weeks from diagnosis Radiation or chemoradiation is poorly tolerated Rapid palliation of dysphagia may be achieved by peroral placement of permanent expandable wire stents, application of endoscopic laser therapy, or photodynamic therapy Although dysphagia and quality of life are improved significantly, patients can seldom eat normally Complications of stents occur in 20 40% and include perforation, migration, and tumor ingrowth These are most suitable for patients with a short life expectancy, patients with tracheoesophageal fistula, patients who have failed radiation therapy, or patients in locations where optimal surgical or radiation modalities are not available Laser therapy (Nd:YAG laser) maintains luminal patency in up to 90% of patients but involves multiple treatment sessions and can be difficult to administer Photodynamic therapy has been shown to be superior to laser therapy A photosensitizing agent (porfimer sodium) in combination with a low-power 630-nm laser results in significant tumor necrosis Side effects include sun sensitivity of the skin for 4 6 weeks and the development of esophageal stricture Both laser therapy and photodynamic therapy require expensive equipment that is not available at many institutions
Differential Diagnosis
Esophageal carcinoma must be distinguished from other causes of progressive dysphagia, including peptic stricture, achalasia, and adenocarcinoma of the gastric cardia with esophageal involvement Benign-appearing peptic strictures should be biopsied at presentation to exclude occult malignancy
Staging of Disease
After confirmation of the diagnosis of esophageal carcinoma, the stage of the disease should be determined since doing so influences the choice of therapy Patients should undergo evaluation with CT of the chest and liver to look for evidence of pulmonary or hepatic metastases, lymphadenopathy, and local tumor extension If there is no evidence of distant metastases or extensive local spread on CT, endoscopic ultrasonography with guided FNA biopsy of lymph nodes should be performed, which is superior to CT in demonstrating the level of local mediastinal extension and local lymph node involvement Positron emission tomography (PET) with fluorodeoxyglucose is used increasingly to look for regional or distant spread in patients thought to have localized disease after other diagnostic studies Bronchoscopy is sometimes required in proximal esophageal cancer to exclude tracheobronchial extension Apart from distant metastasis, the two most important predictors of poor survival are lymph node involvement and adjacent mediastinal spread See Additional Reading at the end of the chapter
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