Esophageal Cancer
Most common in males older than age 60, esophageal cancer is nearly always fatal. The disease occurs worldwide, but incidence varies geographically. It’s most commonly found in Japan, Russia, China, the Middle East, and the Transkei region of South Africa.
Esophageal tumors are usually fungating and infiltrating. In most cases, the tumor partially constricts the lumen of the esophagus. Regional metastasis occurs early by way of submucosal lymphatics, often fatally invading adjacent vital intrathoracic organs. If the patient survives primary extension, the liver and lungs are the usual sites of distant metastases. Unusual sites of metastasis include the bone, kidneys, and adrenal glands.
Most cases (98%) arise in squamous cell epithelium, although a few are adenocarcinomas and, fewer still, melanomas and sarcomas. About half the squamous cell cancers occur in the lower portion of the esophagus, 40% in the midportion, and the remaining 10% in the upper or cervical esophagus. Regardless of cell type, the prognosis for esophageal cancer is grim: 5-year survival rates are less than 5%, and most patients die within 6 months of diagnosis.
Causes
Although the cause of esophageal cancer is unknown, several predisposing factors have been identified. These include chronic irritation from heavy smoking or excessive use of alcohol; stasis-induced inflammation, as in achalasia or stricture; previous head and neck tumors; and nutritional deficiency, as in untreated celiac disease and Plummer-Vinson syndrome.
Complications
Direct invasion of adjoining structures may lead to severe complications, such as mediastinitis, tracheoesophageal or bronchoesophageal fistula (causing an overwhelming cough when swallowing liquids), and aortic perforation with sudden exsanguination.
Other complications include inability to control secretions, obstruction of the esophagus, and loss of lower esophageal sphincter control, which can result in aspiration pneumonia.
Assessment
Early in the disease, the patient may report a feeling of fullness, pressure, indigestion, or substernal burning. He may also tell you he uses antacids to relieve GI upset. Later, he may complain of dysphagia and weight loss. The degree of dysphagia varies, depending on the extent of disease. At first, dysphagia is mild, occurring only after the patient eats solid foods, especially meat. Later, the patient has difficulty swallowing coarse foods and, in some cases, liquids.
The patient may complain of hoarseness (from laryngeal nerve involvement), chronic cough (possibly from aspiration), anorexia, vomiting, and regurgitation of food. This results from the tumor size exceeding the limits of the esophagus. He may also complain of pain on swallowing or pain that radiates to his back.
If you observe the patient in the late stages of the disease, he appears very thin, cachectic, and dehydrated.
Diagnostic tests
X-rays of the esophagus, with barium swallow and motility studies, delineate structural and filling defects and reduced peristalsis.
Chest X-rays or esophagography may reveal pneumonitis.
Esophagoscopy, punch and brush biopsies, and exfoliative cytologic tests confirm esophageal tumors.
