Esophageal Cancer

Esophageal cancer is rising in incidence worldwide and carries poor prognosis. Squamous cell carcinoma (SCC) and adenocarcinoma (ADC), the two most common types, differ in their epidemiology, pathogenesis and management. Smoking and alcohol along with betel quid chewing and poor nutritional status have been implicated in carcinogenesis of SCC; whereas for ADC, gastroesophageal reflux disease (GERD) and obesity are the major risk factors. Eastern Asia and India have a higher incidence of SCC, while ADC is the commoner subtype in the west. Most patients present in locally advanced stage, and multidisciplinary approach is recommended. Diagnostic workup includes an upper gastrointestinal endoscopy, contrast-enhanced CT scan and positron emission tomography, with endoscopic ultrasound being useful in specific situations. Surgery remains the mainstay of the multimodal approach integrating chemotherapy and/or radiation depending on the stage and location of the disease. A small proportion of early cancers with no nodal involvement can undergo endoscopic treatment. Neoadjuvant therapy (chemotherapy or chemoradiation) followed by surgery is the standard of care for locally advanced operable esophageal cancers. Minimally invasive esophagectomy is being increasingly adopted in recent times due to favorable short-term outcomes of postoperative morbidity. Patients unfit for surgery and locally advanced inoperable disease are managed with definitive chemoradiation. Metastatic esophageal cancers have limited options of palliative radiotherapy, esophageal stenting or chemotherapy. Despite advances in treatment modalities, esophageal cancer carries a dismal prognosis with 5-year survival varying between 5% and 30%. Multidisciplinary team management with future research into earlier diagnosis and treatment modalities is the way forward. This chapter provides a brief overview of the approach toward management of esophageal cancers.