Carcinoma of The Esophagus

In the USA, carcinoma of the esophagus is predominantly a disease of men in the fifth to eighth decades. It usually arises from squamous epithelium. Stasis induced inflammation such as is seen in achalasia or esophageal stricture and chronic irritation induced by excessive use of alcohol seemingly are etiologically important in the development of this neoplasm. Malignant tumors of the distal esophagus are frequently adenocarcinomas, which originate in the stomach and spread cephalad to the gullet. Conversely, squamous cell carcinoma of the esophagus rarely invades the stomach. Primary adenocarcinoma of the esophagus is rare and probably arises in Barrett's epithelium. An even more unusual lesion is esophageal carcinosarcoma. Regardless of cell type, the prognosis for malignancy of the esophagus is usually poor.

Clinical Findings

A. Symptoms and Signs:

Dysphagia, which is progressive and ultimately prevents swallowing of even liquids, is the principal symptom. Anterior or posterior chest pain which is unrelated to eating implies local extension of the tumor, whereas significant weight loss over a short period is an ominous sign. Swallowing times are abnormally prolonged or absent.

B. X-Ray Findings:

Barium swallow is positive for an irregular, frequently annular, space occupying lesion, usually localized to the midesophagus.

C. Special Examinations:

Esophagoscopy, biopsy, and cytologic examination confirm the diagnosis.

Differential Diagnosis

Achalasia can be differentiated by endoscopy, esophageal manometry (with or without methacholine), and cinefluorography. Since there is a significant association of stricture with malignancy, any compromise of the esophageal lumen should be evalu-ated by esophagoscopy and biopsy.

Treatment & Prognosis

Although once considered a hopeless disease, dramatic improvements during the last 2 decades in anesthesia, surgical technics, and radiation therapy have substantially improved survival of patients with esophageal carcinoma. Irradiation generally is the best form of therapy, particularly for lesions in the proximal half of the gullet. When there is no evidence of metastases, tumors of the lower half of the esophagus may be treated by resection and esophagogastrostomy or jejunocolonic interpositions.

After dilatation of tumor-bearing portions of the esophagus, effective palliation can often be accomplished by the use of prosthetic tubes which are implanted either surgically or through the mouth, thereby enabling better deglutition of food and liquids.

Gastrostomy is supposed to improve nutrition and prolong survival, but the inability of patients to swallow even saliva makes those benefits of questionable value and existence intolerable.

The use of chemotherapeutic agents in the management of esophageal carcinoma is currently also unsatisfactory.

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• Disease and Treatment