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Snapshot
  • A 62-year-old man presents to the physician with complaint of fatigue and weight loss. His wife noted that he has looked thinner in the past few months, at which point he weighed himself and noted that he had unintentionally lost 10 pounds in the past few months. He has also had increased difficulty swallowing his food with occasionally choking. He has a history of alcohol use disorder and has smoked 1 pack of cigarettes daily for the past 40 years. An upper endoscopy is performed and demonstrates the finding seen in the image.
Introduction
  • Overview
    • malignancy affecting the esophagus
      • most cases of esophageal malignant tumors are due to squamous cell carcinoma and adenocarcinoma
  • Epidemiology
    • incidence
      • adenocarcinoma > squamous cell carcinoma in Western countries
        • adenocarcinoma accounts for > 60% of all esophageal cancers in the United States
      • squamous cell carcinoma is the predominant type of esophageal cancer worldwide
    • demographics
      • most common > 50 years of age
      • men > women
    • location
      • distal esophagus
        • adenocarcinoma
      • middle esophagus
        • squamous cell carcinoma
    • risk factors
      • smoking 
        • associated with squamous cell carcinoma
      • alcohol consumption 
        • associated with squamous cell carcinoma
      • Barrett esophagus
        • associated with adenocarcinoma
      • gastroesophageal reflux disease
        • associated with adenocarcinoma
      • Plummer-Vinson syndrome
        • associated with squamous cell carcinoma
  • Prognosis
    • negative factors
      • increased grade of tumor
      • metastasis to other areas of the body
Presentation
  • History
    • patients often complain of difficulty swallowing solids that progresses to difficulty swallowing liquids
  • Symptoms
    • progressive dysphagia
    • unintentional weight loss
    • bleeding
    • epigastric or retrosternal pain
    • hoarseness
    • persistent cough
  • Physical exam
    • typically normal exam unless the cancer has metastasized
      • cervical or supraclavicular lymphadenopathy (indicating metastasis)
Studies
  • Upper gastrointestinal endoscopy
    • allows for direct visualization and biopsies if a tumor is present
  • Histology
    • squamous cell carcinoma
      • keratinocyte-like cells with intercellular bridges or keratinization
    • adenocarcinoma
      • well or moderately differentiated intestinal-type mucosa cells with well-formed tubular or papillary structures
Differential
  • Gastroesophageal reflux disease (GERD)
    • differentiating factor
      • absence of malignancy on esophageal biopsy
Treatment
  • Medical
    • chemoradiation
      • indication
        • stage I-III disease
    • systemic chemotherapy with palliative care
      • indication
        • stage IV disease
        • patients who are not candidates for surgery
  • Surgical
    • endoscopic mucosal resection
      • indication
        • stage I-III disease
    • esophagectomy or esophagogastrectomy
      • indication
        • high-grade dysplasia in a patient with Barrett esophagus that cannot be adequately treated with endoscopic resection
Complications
  • Esophageal obstruction
  • Metastasis
    • distant metastasis typically to the liver, lungs, and adrenal glands

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(M1.ON.13.31) A 45-year-old African American male presents to his primary care physician complaining of difficulty swallowing that was initially limited to solids but has now progressed to liquids. Biopsy of the esophagus reveals dysplastic cells, but does not show evidence of glands or increased mucin. Which of the following patient behaviors most contributed to his condition?

QID: 101088
1

Obesity

0%

(0/31)

2

Smoking

58%

(18/31)

3

Drinking extremely hot beverages

3%

(1/31)

4

Gastroesophageal reflux disease

35%

(11/31)

5

Radiation exposure in the past 6 months

3%

(1/31)

M 2 E

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