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Esophageal cancer

Definition
Esophageal cancer refers to malignant disease arising from the esophageal epithelium, and principally comprises SCC and adenocarcinoma.
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Pathophysiology
Exposure to various carcinogens, genetic susceptibility, and repeated insults to the esophageal mucosa increase the risk of malignant transformation of esophageal epithelial cells, with the subsequent development of esophageal cancer.
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Epidemiology
The overall annual incidence of esophageal cancer in the US is 4.7 cases per 100,000 person-years.
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Disease course
Predominant changes in the squamous mucosa of the proximal esophagus predispose to esophageal SCC, while intestinal metaplasia of the mucosa of the distal esophagus predisposes to esophageal adenocarcinoma.
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Prognosis and risk of recurrence
The overall 5-year survival rate of patients with esophageal cancer is estimated at 15-20%.
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Key sources
The following summarized guidelines for the evaluation and management of esophageal cancer are prepared by our editorial team based on guidelines from the Society of Thoracic Surgeons (STS/ASTRO 2024), the Society for Immunotherapy of Cancer (SITC 2023), the Japan Endocrine Society (JES 2023), the American Society of Clinical Oncology (ASCO 2023; 2021; 2020), the European Society of Medical Oncology (ESMO 2022), the American College of Radiology (ACR 2022), the College of American Pathologists (CAP/AMP/FCC 2022), the Perioperative Quality Initiative (POQI/AUGIS 2022), the American Association for Thoracic Surgery (AATS/ESTS 2022), the American College of Gastroenterology (ACG 2022; 2016), the European Society of Gastrointestinal Endoscopy (ESGE 2021; 2017), the Canadian Task Force on Preventive Health Care (CTFPHC 2020), the American Society for Gastrointestinal Endoscopy (ASGE 2019; 2018; 2013), the British Society of Gastroenterology (BSG 2018), the American Society for Clinical Pathology (ASCP/CAP/ASCO 2017), the Society of Thoracic Surgeons (STS 2013), and the American Gastroenterological Association (AGA 2012).
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Guidelines

1.Screening and diagnosis

Indications for screening, GERD: do not screen adult patients with chronic GERD for esophageal adenocarcinoma or precursor conditions (Barrett's esophagus or dysplasia).
D
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  • Indications for screening (Barrett's esophagus, general principles)

  • Indications for screening (Barrett's esophagus, without dysplasia)

  • Indications for screening (Barrett's esophagus, with dysplasia)

  • Indications for screening (Barrett's esophagus, post-treatment)

2.Classification and risk stratification

Staging: as per ACR 2022 guidelines, obtain CT of the chest and abdomen with IV contrast or FDG-PET/CT of the skull base to mid-thigh for initial staging of patients with newly diagnosed esophageal cancer.
B

3.Diagnostic procedures

Upper gastrointestinal endoscopy: as per ESMO 2022 guidelines, perform upper gastrointestinal endoscopy in patients with new dysphagia, gastrointestinal bleeding, recurrent aspiration or emesis and weight loss and/or loss of appetite.
B

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  • Biopsy and histopathology

  • Ancillary testing (flow cytometry)

  • Ancillary testing (PD-L1 testing)

  • Ancillary testing (HER2 testing)

  • Ancillary testing (MMR/MSI)

  • Ancillary testing (tumor mutational burden)

  • Ancillary testing (genomic testing)

  • Ancillary testing (EBV testing)

4.Medical management

General principles: as per ESMO 2022 guidelines, ensure multidisciplinary assessment and planning before commencing any treatment.
B

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  • Management of locally advanced disease (chemoradiotherapy)

  • Management of locally advanced disease (surgery)

  • Management of locally advanced disease (immunotherapy)

  • Management of advanced/metastatic disease (immunotherapy/targeted therapy)

  • Management of advanced/metastatic disease (chemoradiotherapy)

  • Management of advanced/metastatic disease (surgery)

  • Palliative care

5.Nonpharmacologic interventions

Nutritional support: assess nutritional status and history of weight loss
B
and provide nutritional support as appropriate.
B

6.Perioperative care

Analgesia: perform either thoracic epidural or paravertebral blockade as the primary method of analgesia for esophagectomy to reduce pulmonary complications.
B

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  • Perioperative thromboprophylaxis

  • Perioperative supportive care

  • Perioperative nutrition

  • Postoperative rehabilitation

7.Surgical interventions

Technical considerations for surgery: as per ESMO 2022 guidelines, perform laparoscopy in patients with locally advanced (T3/T4) adenocarcinoma of the GEJ crossing the diaphragm to infiltrate the anatomical cardia.
B
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8.Patient education

General counseling: consider a variety of factors, including patient preferences, QoL, and prognosis with the patient and family before initiating endoscopic palliation for esophageal malignancy.
C

9.Follow-up and surveillance

Follow-up: as per ACR 2022 guidelines, obtain FDG-PET/CT of the skull base to mid-thigh for the evaluation of patients with esophageal cancer undergoing treatment.
B
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