Esophageal Cancer: Current Diagnosis and Management

Other risk factors associated with esophageal SCC include poor oral hygiene, atrophic gastritis, caustic esophageal injuries, and achalasia (likely due to stasis of esophageal contents in the case of achalasia) [24–27].Dietary causes of esophageal SCC have also been implicated in many international studies. Foods containing N-nitroso compounds and diets with selenium and zinc mineral deficiencies have been found to be risk factors for esophageal SCC [20,28–30].Thermal injury to the esophageal mucosa caused by food and beverages served at high temperatures has been shown to increase the risk of esophageal cancer [31]. Also, as seen in esophageal adenocarcinoma, diets rich with vegetables and fruits have been associated with a reduced risk of esophageal SCC [32].

In a meta-analysis of 1813 esophageal cancer cases by Corley et al, the use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) was found to be protective against both esophageal SCC and esophageal adenocarcinoma [33]. The study found a dose-dependent effect in the protective association between aspirin/NSAID use and esophageal cancer. Frequent aspirin/NSAID use was associated with a 46% reduction of the odds for developing any esophageal cancer, whereas intermittent use provided an 18% reduction in the odds. However, any use of aspirin or NSAIDs offered some degree of protection against both esophageal SCC (OR, 0.58; 95% CI, 0.43 to 0.78) and esophageal adenocarcinoma (OR, 0.67; 95% CI, 0.51 to 0.87). The mechanism of the risk reduction with aspirin and NSAIDs is still unclear but may be associated with inhibition of the cyclooxygenase-2 enzyme and the reduction of inflammation [33–35].

Clinical Manifestations

Esophageal cancer commonly presents with dysphagia, weight loss, gastrointestinal reflux, and/or odynophagia. In a study by Daly et al, 74% of esophageal cancer patients reported dysphagia and 16.6% reported having odynophagia at the time of initial diagnosis [36]. Patients can have the sensation of food getting “stuck,” which initially can be overcome by careful chewing and/or dietary modification [37]. A history of trouble swallowing solid foods followed by difficulty with drinking liquids is frequently seen. Some patients complain of regurgitation of undigested foods, and approximately 20% of patients have reported having GERD symptoms [36,37]. Due to the complete or partial esophageal obstruction combined with tumor effects, patients with esophageal cancer often develop significant weight loss. In the study by Daly et al, 57.3% of patients reported weight loss at the time of their cancer diagnosis [36]. Weight loss of more than 10% body mass has been identified as an independent indicator for poor prognosis [36,38]. Pain, dyspnea, hoarseness, and cough occur less frequently but may reflect extensive cancer burden [39]. Some patients with advanced tumors have hematemesis from tumor erosion or have recurrent pneumonias due to tracheobronchial fistulas.

Hepatomegaly, pleural effusion, and lymphadenopathy, especially in Virchow’s node (left supraclavicular fossa), are physical examination findings suggestive of metastatic disease [39]. However, most patients with esophageal cancer will have unremarkable physical examination findings.

It should be noted that patients with early stage lesions (ie, stage T1 lesions) may have minimal or no symptoms, with lesions detected either incidentally or as part of endoscopic screening/surveillance programs.