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INTRODUCTION

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Epidemiology

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Epidemiology
Incidence:

18,170 (male: 14,660; female: 3,510. Estimated new cases for 2014 in the United States)

7.7 per 100,000 male, 1.8 per 100,000 female

Deaths: Estimated 15,450 in 2014 (male: 12,450; female: 3,000)
Median age at diagnosis:

Squamous cell esophageal carcinoma: 53.4 years

Adenocarcinoma of the esophagus: 62.6 years

Male to female ratio: 3:1 for squamous cell carcinoma and 7:1 for adenocarcinoma
Stage at presentation:

Locoregional disease: 50%

Distant metastasis: 50%

Kelsen DP et al. Textbook of Gastrointestinal Oncology: Principles and Practice. Lippincott Williams & Williams, 2001

Siegel R et al. CA Cancer J Clin 2014;64:9–29

Surveillance, Epidemiology and End Results (SEER) Program, available from http://seer.cancer.gov (accessed in 2013)

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Pathology

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Pathology
Upper to midthoracic esophagus: Predominantly squamous cell carcinoma
Distal esophagus and GE junction: Predominantly adenocarcinoma
Other rare pathology: Basaloid-squamous carcinoma (1.9%) or small cell carcinomas

Especially in white men, the incidence of adenocarcinoma of the GE junction has risen significantly in the United States, whereas that of squamous cell carcinoma has slightly decreased. In the 1960s, squamous cell cancer accounted for 90% or more of esophageal cancer. Data from 1996 suggested that they occur with equal frequency, and in 2004 the trend has changed further so that adenocarcinoma now accounts for at least 75% of esophageal cancers. This is thought to be related to increase in body mass index and Barrett esophagus

Abe K et al. Am J Surg Pathol 1996;20:453–461

Daly JM et al. National Cancer Data Base Report on Esophageal Carcinoma. Cancer 1996;78:1820–1828

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Work-up

  1. H&P, esophagogastroduodenoscopy, CBC, serum electrolytes, BUN, creatinine, LFTs and mineral panel, PET scan ± CT scan, of chest and abdomen

  2. Endoscopic ultrasound is highly recommended if there is no evidence of distant metastases, with FNA if indicated

  3. For locoregional cancer at or above the carina, a bronchoscopy must be considered

  4. In selected patients with local-regional GE junction cancer, a laparoscopic staging of the peritoneal cavity may be warranted

  5. In patients with locoregional cancer, PET/CT scan is strongly recommended. Suspicious metastatic cancer should be confirmed

  6. In addition, for patients with locoregional cancer (stages I–III), a multidisciplinary evaluation is required, including nutritional assessment. The need for supplementation depends on the severity of dysphagia, and the overall nutritional status (>10% weight loss). Enteral nutritional support is preferred (PEG is avoided if surgery is a consideration)

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Staging

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Staging

Primary Tumor (T)

TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis High-grade dysplasia
T1 Tumor invades lamina propria or submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades adventitia
T4a Resectable cancer invades adjacent structures such as pleura, pericardium, diaphragm
T4b Unresectable cancer invades adjacent structures such as aorta, vertebral body, trachea

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