Esophagus
Carcinoma
General

Author: Elliot Weisenberg, M.D. (see Authors page)

Revised: 19 January 2018, last major update June 2013

Copyright: (c) 2003-2018, PathologyOutlines.com, Inc.

PubMed Search: Carcinoma esophagus[TIAB]

Cite this page: Weisenberg, E. Carcinoma - general. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/esophaguscarcinomageneral.html. Accessed February 18th, 2018.
Definition / general
Risk factors
  • In developed world, smoking and drinking are most important risk factors
  • Other risk factors are diet, especially some hot liquids, Plummer-Vinson syndrome, achalasia, stricture, webs, rings, diverticula
  • Higher incidence among African Americans, city dwellers, poor
  • "Esophageal carcinoma belt" extends from Northeast China to Middle East, with high incidence of squamous cell carcinoma
  • Adenocarcinoma associated with Barrett esophagus
Sites
  • Squamous cell carcinoma: 20% upper, 50% middle, 30% lower esophagus
  • Adenocarcinoma mostly in distal esophagus
  • Adenocarcinoma rarely arises in heterotopic gastric mucosa or submucosal glands
Pathophysiology
  • Adenocarcinoma: dysplasia - carcinoma sequence occurs in Barrett mucosa with stepwise accumulation of genetic mutations, especially p53, also HER2 / cERB-B2, cyclin D1, cyclin E, RB, p16
  • Squamous cell carcinoma: genetic alterations include p53, p16INK4a, amplification of cyclin D1, cMYC and EGFR; related to smoking, alcohol, diet, possible nutritional deficiency, genetic factors
Clinical features
  • Insidious onset, dysphagia to solids, followed by dysphagia to all food
  • Extreme weight loss due to loss of nutrition and tumor itself
  • Squamous cell carcinoma may erode through esophagus; invades respiratory tree with fistula formation and pneumonia; aorta with exsanguination; also invades mediastinum or pericardium
  • Metastasis generally occurs early even in superficial tumors due to extensive lymphatic network in esophagus that allows horizontal and longitudinal spread
  • Cancers of upper esophagus metastasize to cervical lymph nodes; of mid esophagus to mediastinal, paratracheal and tracheobronchial lymph nodes; of lower esophagus to gastric and celiac lymph nodes
  • Metastases to liver, lungs and pleura
  • Recurrences are common
Diagnosis
  • Endoscopic biopsy
  • Rarely identified during resection for achalasia or for lesions not amenable to biopsy
Radiology description
  • Stenosis or obstruction
  • Protruding mass may be detected
Overall 5 year survival
Case reports
Treatment
Gross description
  • Adenocarcinoma is located in distal esophagus and may involve gastric cardia (note: tumors in the proximal 5 cm of the stomach are regarded as esophageal carcinomas in Edge: AJCC Cancer Staging Manual, 7th Edition, 2011)
  • Flat or raised patches of intact mucosa develop into nodular masses
  • Squamous cell carcinoma begins as an in situ process
  • Generally starts as plaque-like lesions which grow to eventually encircle the lumen
  • Mostly form protruding cauliflower-like lesions (60%), may be flat (15%) or ulcerated
Gross images

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Adenocarcinoma

Squamous cell carcinoma

Microscopic (histologic) description
  • Overwhelming majority of carcinomas of esophagus are adenocarcinoma and squamous cell carcinoma
  • Diagnosis usually simple
  • Generally mucin secreting adenocarcinomas, less often signet ring carcinoma
  • Usually foci of dysplastic mucosa adjacent to cancer
  • Squamous cells carcinoma tends to be well or moderately differentiated; histologic variants include verrucous, spindle cell or basaloid
  • Other carcinomas are adenoid cystic carcinoma, adenosquamous carcinoma, mucoepidermoid carcinoma
  • Special stains only rarely needed for diagnosis
Microscopic (histologic) images

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Adenocarcinoma

Adenocarcinoma in lymphatics

Squamous cell carcinoma in situ

Differential diagnosis
  • Chemoradiation induced atypia: enlarged hyperchromatic nuclei with prominent mitotic figures but relatively mild pleomorphism in inflammatory background
  • Reparative processes: atypical cells in granulation tissue but with fine chromatin, few mitotic figures; cells mature at deeper levels, keratin negative