Chapter 8 - Esophagus

Summary

Introduction

Esophageal cancer incidence has risen in the last decade, accounting for 16,698 new cases of which 14,710 succumbed to the disease in 2011 (1–3). It is an uncommon tumor that accounts for approximately 7% of all gastrointestinal malignancies. The great majority of patients present with advanced disease. Squamous cell carcinoma was the most common histological type and has an association with tobacco and alcohol abuse. Recently adenocarcinoma associated with Barrett's metaplasia and seen almost exclusively in middle-aged white men with gastroesophageal reflux disease (GERD), has become the most predominant form, accounting for 60% of all esophageal cancers in 1994. Thus, the majority of adenocarcinomas affect the distal esophagus. Curative surgical resection is the treatment of choice; overall survival however is determined by the stage at initial diagnosis. Early esophageal cancer has 5-year survival ranging from 57%–78%, with locally advanced disease having a dismal prognosis despite aggressive therapy (3, 4). Therefore accurate pre-operative staging is crucial, as it helps guide management and avoids unnecessary surgery.

Computed tomography has been the first-line imaging modality for staging; however, endoscopic ultrasound and FDG-PET, each with their individual strengths, have improved pre-operative staging. The staging criteria in esophageal cancer comprise tumor size, depth of local invasion, nodal involvement, and distant metastases. The current work-up of newly diagnosed esophageal cancer is based on all three imaging modalities; hence familiarity with the strengths and weaknesses of each of these should prove helpful. Optimization of the utilization of the imaging results for the management of esophageal cancer patients requires an understanding of the epidemiology, patho-physiology, and patterns of metastases and recurrence.