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INTRODUCTION

Epidemiology

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Epidemiology
Incidence:

16,940 (male: 13,360; female: 3580. Estimated new cases for 2017 in the United States)

8.1 per 100,000 male, 1.8 per 100,000 female

Deaths: Estimated 15,690 in 2014 (male: 12,720; female: 2970)
Median age at diagnosis: 67 years
Male to female ratio: 3:1 for squamous cell carcinoma and 7.5:1 for adenocarcinoma
Stage at presentation:

Locoregional disease: 52%

Distant metastasis: 48%

Zhang Y. World J Gastroenterol 2013;19:5598–5606

Mathieu LN. Dis Esophagus 2014;27:757–763

Siegel R et al. CA Cancer J Clin 2017;67:7–30

Surveillance, Epidemiology and End Results (SEER) Program, available from http://seer.cancer.gov [accessed 2017]

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 gastroesophageal junction (GEJ) 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 by 2004 the trend had changed further. 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

Brown LM et al. J Natl Cancer Inst 2008;100:1184–1187

Daly JM et al. Cancer 1996;78:1820–1828

Work-up

  1. H&P, esophagogastroduodenoscopy with biopsy, CBC, serum electrolytes, BUN, creatinine, LFTs and mineral panel, CT scan of chest and abdomen ± pelvis (if clinically indicated)

  2. In patients with locoregional cancer with no evidence of M1 disease, a PET scan and endoscopic ultrasound (EUS) should be performed

  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 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)

  6. If metastatic disease is documented or suspected, MSI or MMR deficiency should be tested. For metastatic adenocarcinoma, PD-L1 and HER2 expression should be tested

 

NCCN. Guidelines for Patients: Esophageal and Esophagogastric Junction Cancers. Version 4.2017

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, muscularis mucosae, or submucosa
T1a Tumor invades lamina propria or muscularis mucosae
T1b Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades adventitia
T4a Resectable cancer invades adjacent structures such as pleura, pericardium, diaphragm
T4b Unresectable cancer ...

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