1) Clinico-pathologic Considerations

The most common presenting symptom of esophageal cancer is dysphagia, often associated with weight loss. The initial investigation is usually a barium study, followed by endoscopy and biopsy.

Only a small proportion of patients with carcinomas of the esophagus or cardia will be cured and there is a significant morbidity with either radical surgery or radical chemotherapy and radiation. It is therefore important to detect metastatic or unresectable disease as early as possible. Occult asymptomatic metastases are often discovered on metastatic workup. A CT scan of the mediastinum and upper abdomen is needed to evaluate the primary tumour, the mediastinal and upper abdominal nodes and the liver. Techniques to improve evaluation of the primary tumour and regional lymph nodes such as endoscopic ultrasound, mediastinoscopy and laparoscopy are under study.

If the tumour is lying adjacent to the trachea or main bronchi, a bronchoscopy is required because direct endotracheal or endobronchial invasion may preclude radiotherapy or curative therapy.

Cancers originating above the carina are usually squamous cell carcinomas whereas those below may be either squamous or adenocarcinomas. There is some disagreement as to whether these histological subtypes should be treated differently. The overall survival does not appear to be different, although systemic metastases appear to be more common with adenocarcinomas. Although some patients present with symptomatic metastases, the majority have dysphagia of varying degree and the aim of most curative and palliative treatment is to relieve this symptom. Meaningful palliation of other symptomatic metastases is less consistent.

2) Diagnostic Pathology

The most common esophageal cancer is squamous cell cancer, comprising about 2/3 of all esophageal cancers. Extensive submucosal spread is common, as are skip areas of microscopic involvement. Diagnosis is by endoscopic biopsy. Special attention is paid to the level of the lesion in the esophagus.

During curative intent surgery, intraoperative frozen section may be useful in determining margins. The final pathology report should include information regarding the radial margins, as well as the mucosal margins and well detailed presence or absence of nodal involvement.