Carcinoma of the Esophagus
Essentials of Diagnosis • Progressive dysphagia, initially during ingestion of solid foods and later for liquids. • Progressive weight loss and inanition. • Classic radiographic outlines: irregular mucosal pattern with narrowing, with shelf-like upper border or concentrically narrowed esophageal lumen. • Definitive diagnosis established by endoscopic biopsy or cytology
General Considerations • Carcinoma of the esophagus constituted about 1% of all malignant lesions and 6% of those of the gastrointestinal tract in the USA. • Blacks have a fivefold higher incidence of squamous cell carcinoma than whites, but the incidence of adenocarcinoma among blacks is one-third that of whites. • Both lesions are more common among men, with a male-to-female ratio of 7:10 for adenocarcinoma and 3:4 for squamous cell tumors. • The peak incidence is between ages 50 and 60 years
• Estimated new cases and deaths from esophageal cancer in the United States in 2009: New cases: 16,470 Deaths: 14,530 - www.cancer.gov
Causes and risk factors Studies have found the following risk factors for esophageal cancer: • Age 65 or older: Age is the main risk factor for esophageal cancer. The chance of getting this disease goes up as you get older. In the United States, most people are 65 years of age or older when they are diagnosed with esophageal cancer. • Being male: In the United States, men are more than three times as likely as women to develop esophageal cancer. • Smoking: People who smoke are more likely than people who don't smoke to develop esophageal cancer. • Heavy drinking: People who have more than 3 alcoholic drinks each day are more likely than people who don't drink to develop squamous cell carcinoma of the esophagus. Heavy drinkers who smoke are at a much higher risk than heavy drinkers who don't smoke. In other words, these two factors act together to increase the risk even more
Causes and risk factors • Diet: Studies suggest that having a diet that's low in fruits and vegetables may increase the risk of esophageal cancer. However, results from diet studies don't always agree, and more research is needed to better understand how diet affects the risk of developing esophageal cancer. • Obesity: Being obese increases the risk of adenocarcinoma of the esophagus. • Acid reflux: Acid reflux is the abnormal backward flow of stomach acid into the esophagus. Reflux is very common. A symptom of reflux is heartburn, but some people don't have symptoms. The stomach acid can damage the tissue of the esophagus. After many years of reflux, this tissue damage may lead to adenocarcinoma of the esophagus in some people. • Barrett esophagus: Acid reflux may damage the esophagus and over time cause a condition known as Barrett esophagus. The cells in the lower part of the esophagus are abnormal. Most people who have Barrett esophagus don't know it. The presence of Barrett esophagus increases the risk of adenocarcinoma of the esophagus. It's a greater risk factor than acid reflux alone
• Heavy alcohol or tobacco use is thought to predispose to esophageal carcinoma in the USA. • Adenocarcinoma of the esophagus, primarily related to Barrett's epithelium, has been increasing in frequency in the USA and accounts for up to 40% of cases in some series. • Twenty percent of esophageal tumors occur in the upper third, 30% in the middle third, and 50% in the lower esophagus. • Squamous cell lesions predominate in the mid esophagus. • Adenocarcinomas are more common in the lower third
❑ Fungating-type: Predominantly intraluminal growth with surface ulceration and extreme friability. This type frequently invades mediastinal structures. It is present in 11 to 60% of cases. ❑Ulcerating-type: Characterized by a flat based ulcer with slightly raised edges; hemorragic and friable and surrounding induration and erythema. This is present in 25 to 63% of patients. ❑Infiltrating-type: A dense firm logitudinal and circumferential intramural growth pattern. The infiltrating type is found in 15 to 26% of squamous cell carcinoma tumors. ❑Annular: Annular carcinomas may be mistaken for benign strictures, especially if most of the growth is intramural Macroscopic Features