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Esophageal Cancer
Noah Kornblum
Questions and Answers
1. A 75-year-old male heavy smoker presents to your office
with complaints of progressive difficulty with swallowing
for the last 3 weeks. He is able to easily swallow liquids,
but feels that solid food “gets stuck in my chest.” He
believes he has lost about 15 lb over the last 6 weeks. The
best initial evaluation of this patient is:
A. Upper GI series/barium swallow
B. Contrast-enhanced chest CT scan
C. GI referral for upper endoscopy
D. 18-FDG PET/CT scan (skull base to mid-thigh)
Answer: C
Early symptoms of esophageal cancer include dysphasia,
initially primarily to solids, later progressing to liquids.
The patient’s clinical symptoms coupled with unintentional
weight loss should raise a high suspicion for esophageal
cancer. While barium contrast-enhanced radiography may
prove useful, ultimately the diagnosis is established through
endoscopic biopsy. Upper endoscopy detects early esophageal cancers, which may appear as superficial plaques,
nodules, or ulcerations. More advanced lesions appear as
strictures, ulcerated, circumferential, or large masses. CT
and PET/CT are useful for staging purposes, but are generally done after a pathological diagnosis is established.
2. Risk factors for esophageal carcinoma include all the following EXCEPT:
A. Tobacco use
B. Gastroesophageal reflux disease (GERD)
C. Achalasia
D. Female gender
Answer: D
Smoking increases the risk of both squamous cell carcinoma (SCC) and esophageal adenocarcinoma (EAC), the
latter particularly true with BE. In a large pooled data analysis from the International BEACON (Barrett’s Esophagus
and Esophageal Adenocarcinoma Consortium), smoking
was associated with a more than twofold increased risk of
adenocarcinoma compared to controls. Chronic GERD has
been identified as an important risk factor for the development of Barrett’s esophagus, a precursor to EAC. Underlying
anatomical abnormalities to the esophagus including achalasia and strictures (from caustic damage, lye, etc.) are
linked to the development of esophageal cancer. Esophageal
cancer trends reveal a distinct male predominance.
3. A 65-year-old male smoker presents with dysphagia to
solids and weight loss. EGD with biopsy reveals an invasive SCC in the mid-esophagus. Staging evaluation with
endoscopic ultrasound (EUS) and PET/CT is notable for
an ulcerating mid-esophageal mass invading the adventitia
with two enlarged regional lymph nodes. There is no evidence of distant metastatic disease (T3N1M0 Stage IIIA).
The patient has a good performance status with no major
comorbidities. The best initial therapy for this patient is:
A. Platinum-based combination systemic chemotherapy
B. Concurrent chemoradiotherapy
C. Chemotherapy followed by radiation
D. Brachytherapy
Answer: B
Management of patients diagnosed with locally advanced
cancers of the esophagus and GEJ is complicated by the
heterogeneous nature of this group. In general, a multimodality approach is required. Available management options
include systemic chemotherapy, radiotherapy (including
brachytherapy), and concurrent chemoradiotherapy. At
present, definitive concurrent chemoradiotherapy represents
the standard of care for fit patients with locoregional esophageal cancer, which may be followed by surgical resection.
Sequential treatment is inferior to concurrent therapy.
4. A 78-year-old patient presents with dysphagia to solids and
liquids, extensive weight loss, and abdominal pain. EDG
reveals a large mid-esophageal SCC. Comprehensive staging
evaluation reveals hepatic, pulmonary, and retroperitoneal
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology,
DOI 10.1007/978-1-4419-1623-5_61, © Springer Science+Business Media, LLC 2012
625
626
lymph node metastases. Palliative treatment options for this
patient include all the following EXCEPT:
A. Esophagectomy with gastric pull-up
B. Esophageal stent placement
C. Systemic chemotherapy
D. Radiation therapy
Answer: A
This patient is presenting with very advanced and symptomatic disease. The goals of care should be clearly outlined from the start and include symptom palliation and
prolonged survival if feasible. Systemic chemotherapy is
N. Kornblum
the mainstay treatment for advanced metastatic esophageal and gastroesophageal junction (GEJ) cancers.
Radiotherapy to the primary tumor can help palliate and
temporarily improve dysphagia in the metastatic setting,
but does not impact on overall survival. Esophageal stents
may help some patients. Surgical management of this
patient is totally inappropriate and is limited to those
patients with life-threatening bleeding or perforation. It is
associated with major mortality risk and would likely
only increase the patient’s suffering without impacting on
survival or improvements in quality of life.