Esophageal cancer

INTRODUCTION

 The majority of esophageal cancers are squamous cell or adenocarcinoma.

Although the incidence of squamous cell carcinoma (SCC) is decreasing in the
United States, the incidence of adenocarcinoma arising out of Barrett’s
esophagus is rising dramatically
PATHOBIOLOGY
Squamous cell carcinoma

 The majority of SCCs are located in the midportion of the esophagus. SCC
arises from small polypoid excrescences, denuded epithelium, or plaques
 These early lesions are usually subtle, and can easily be missed on endoscopy.
In a series from Linxian China (where SCC is endemic), 25 of 31 patients had
biopsy specimens containing moderately dysplastic changes or cancer which
were obtained from sites classified as having either "friability, a focal red
area, erosion, plaque, or nodule"
 Furthermore, 15 of 16 patients (94 percent) with moderate dysplasia or
carcinoma would have been missed had biopsies been restricted to these
visibly abnormal areas
 Tissue staining with Lugol iodide solution during endoscopy (chromoendoscopy)
may facilitate diagnosis of early lesions, although the technique is uncommonly
used in clinical practice. Lugol solution is a compound iodine solution that stains
normal squamous epithelium containing glycogen. Malignant squamous cells do not
stain since they are usually devoid of glycogen
 More advanced lesions are characterized by infiltrating and ulcerated masses,
which may be circumferential. SCC invades the submucosa at an early stage, and
extends along the wall of the esophagus usually in a cephalad direction
 Local lymph node invasion occurs early and quickly because the lymphatics in the
esophagus are located in the lamina propria, in contrast to the rest of the
gastrointestinal tract, in which they are located beneath the muscularis mucosa.
The tumor spreads to regional lymph nodes along the esophagus, the celiac area,
and adjacent to the aorta
 Invasion of local structures may result in fistula formation such as to the trachea.
Erosion into the aorta can be associated with massive upper gastrointestinal
hemorrhage
 Distant metastases to the liver, bone, and lung are seen in nearly 30 percent of
patients. In addition, bone marrow invasion can be detected in 40 percent when
monoclonal antibodies are used to stain for malignant cells
Adenocarcinoma

 Much more is known about the early pathology of adenocarcinoma of the

esophagus because of recognition of early cancer during surveillance of patients
with Barrett's esophagus
 The majority of cases are located near the gastroesophageal junction and are
associated with endoscopic evidence of Barrett's esophagus. Adenocarcinoma
arising in Barrett's esophagus may present as an ulcer, a nodule, an altered
mucosal pattern, or no visible endoscopic abnormality
 Early adenocarcinoma not associated with Barrett's esophagus arises from an
ulcer, plaque, or nodule near the gastroesophageal junction
 Similar to SCC, lymph node metastases occur early to adjacent or regional lymph
nodes. Involvement of celiac and perihepatic nodes is more common with
adenocarcinoma because of the location of the tumor at the gastroesophageal
junction
ETIOLOGIC FACTORS

 Hereditary factors — Familial aggregation of esophageal cancer has been

described in regions with a high incidence of esophageal SCC, such as China
 Familial aggregation of Barrett's esophagus has also been described. Whether
this represents common environmental risk factors or inherited predisposition
is unknown. Discordant data regarding familial clustering have been published
in reports from other regions including Sweden and the United States
 Thus, the extent to which hereditary factors are involved in the pathogenesis
of esophageal cancer remains uncertain
 Squamous cell carcinoma — The incidence of esophageal SCC varies
considerably among geographic regions. The highest rates are found in Asia
(particularly in China and Singapore), Africa, and Iran (the so-called
“esophageal cancer belt”)
 Geographic variation has also been reported within individual countries.
Within China, for example, rates of esophageal cancer range from 1.4 to 140
per 100,000 in the Hebi and Hunyuan counties, respectively
 Demographic and socioeconomic factors — Worldwide differences in the rates
of SCC have provided insight into risk factors associated with the disease. The
importance of specific risk factors varies within different geographic regions:
In high incidence regions, the disease has no gender specificity. In contrast, SCC
is more common in men in low incidence regions.
The incidence is higher in urban areas (compared to rural areas) of the United
States, particularly among African-American men. In one report, the incidence
among African-American men in Washington D.C. was 28.6 per 100,000.
Lower socioeconomic status was associated with esophageal SCC in a large
population-based study
 Smoking and alcohol — In the United States, Western Europe and some other
regions of the world, cigarette smoking and alcohol consumption are major
risk factors for esophageal SCC. Cigarette smoking is also becoming a major
risk factor in Asia, as smoking is gaining in popularity
 An increase in risk of esophageal SCC has been associated with cigar and pipe
smoking, although the magnitude of risk appears to be less than with
cigarettes. Tobacco and alcohol may synergistically increase risk, as they do
in SCC of the head and neck
 The type and quantity of alcoholic beverages consumed may affect the risk of
esophageal SCC. Hard liquor may have a higher risk than wine or beer;
however, the cumulative amount of alcohol rather than the type is probably
more important
 Dietary factors — Several dietary associations with esophageal SCC have been
uncovered in Asia. Foods containing N-nitroso compounds have long been
implicated
 These compounds are carcinogens that may exert their mutagenic potential by
inducing alkyl adducts in DNA. Certain types of pickled vegetables and other food-
products consumed in high-risk endemic areas are rich in N-nitroso compounds
 Toxin-producing fungi have also been identified in food sources within endemic
areas and may, in part, exert their mutagenic potential by reducing nitrates to
nitroso compounds
 Chewing of areca nuts or betel quid (areca nuts wrapped in betel leaves), which is
widespread in certain regions of Asia, have been implicated in the development of
esophageal SCC. The mechanism may involve the release of copper with resulting
induction of collagen synthesis by fibroblasts
 High temperature beverages and foods may increase the risk of esophageal
cancer by causing thermal injury to the esophageal mucosa. In a systematic
review of 59 studies, more than 50 percent of the studies found that higher
temperatures of fluid intake were associated with a statistically significant
increase in the risk of esophageal cancer
 An association with drinking hot tea was noted in a case-control study from
northern Iran in which drinking hot tea (60 to 64 degrees C) or very hot tea (≥65
degrees C), and drinking tea within three minutes of its being poured was
significantly associated with an increased risk of esophageal SCC
 Several other dietary factors affect the risk of esophageal cancer; most of these
studies come from regions with a high frequency of SCC. These include:
A positive association between red meat intake and risk of esophageal SCC has been
described
Low selenium levels increase risk, while selenium supplementation has been
associated with reduced risk
Zinc deficiency, which may act by enhancing the carcinogenic effects of
nitrosamines and by overexpression of cyclooxygenase (COX)-2
A meta-analysis of epidemiologic studies suggested an association between increased
dietary folate and a reduced risk of esophageal cancer
 Underlying esophageal disease — The presence of specific preexisting
esophageal diseases (such as achalasia and caustic strictures) increases the
risk of esophageal SCC as illustrated by the following observations:
In a population-based study including 1062 patients with achalasia, the risk of
esophageal SCC was increased more than 16-fold during the first 1 to 24 years
following diagnosis; cancer was detected an average of 14 years after the
diagnosis of achalasia
In a review of 2414 patients with esophageal SCC, 63 had a history of caustic
esophageal injury due to ingestion of lye during childhood; the average time to
diagnosis of SCC was 41 years (range 13 to 71 years) following the ingestion
 Prior gastrectomy — Patients who have undergone a partial gastrectomy may
be at increased risk of esophageal SCC. This may represent common risk
factors for disorders predisposing to esophageal SCC and the need for partial
gastrectomy such as smoking or alcohol
 Atrophic gastritis — Atrophic gastritis and other conditions that cause gastric
atrophy are associated with an approximately twofold increased risk of
esophageal SCC (but not adenocarcinoma)
 Human papilloma virus — Certain infectious agents have been implicated in
the pathogenesis of esophageal SCC. Human papilloma virus (HPV, particularly
serotypes 16 and 18) has received the most scrutiny
 Arguments in support of an association include:
The detection of HPV DNA in esophageal SCCs
The proximity of the esophagus and oropharynx, and the histologic similarities
between esophageal and oral squamous epithelia; HPV associated oropharyngeal
SCC is a well-described entity
Evidence of an association between HPV and bovine esophageal SCC
 Tylosis — Tylosis is a rare disease associated with hyperkeratosis of the palms
of the hands and soles of the feet, and a high rate of esophageal SCC
 Bisphosphonates — Use of oral bisphosphonates has been linked to esophageal
adenocarcinoma and SCC in post-marketing surveillance. The finding of
crystalline material similar to alendronate in biopsies of patients with drug-
related erosive esophagitis, and the persistence of the abnormalities after
healing of the esophagitis suggested the potential for carcinogenicity
 Upper aerodigestive tract cancer — Several studies have described an
association between a current or past history of SCC of the head and neck ie,
oral cavity, oropharynx, hypopharynx, or larynx, lung or esophagus with
synchronous or metachronous SCC of the esophagus
 Gastroesophageal reflux disease — Most, if not all, esophageal
adenocarcinoma arises from a region of Barrett's metaplasia, which is due to
gastroesophageal reflux disease (GERD)
 Smoking — Smoking increases the risk of adenocarcinoma, particularly in patients with
Barrett's esophagus
 Obesity — Obesity has been linked to esophageal adenocarcinoma and adenocarcinoma
of the gastric cardia. Obesity appears to be an indirect risk factor for both esophageal
adenocarcinoma and Barrett's esophagus because it increases the risk of GERD
 Helicobacter pylori infection — The observation that Helicobacter pylori (H. pylori) can
colonize areas of gastric metaplasia in the esophagus suggested a potential role in the
pathogenesis of esophageal adenocarcinoma
 Increased esophageal acid exposure — Patients with acid hypersecretory states (such as
Zollinger-Ellison syndrome) or other conditions that are associated with
gastroesophageal reflux (such as surgical myotomy or balloon dilation of the lower
esophageal sphincter or scleroderma), may be at increased risk for esophageal
Adenocarcinoma
 Use of drugs that decrease lower esophageal sphincter pressure — The
association of chronic reflux with the development of esophageal
adenocarcinoma suggests that drugs known to decrease the pressure of the
lower esophageal sphincter (and hence predispose to reflux) may be a risk
factor for Barrett's esophagus and possibly adenocarcinoma
CLINICAL MANIFESTATIONS

 Both adenocarcinoma and SCC have similar clinical presentations except that
adenocarcinoma arises much more commonly in the distal esophagus/GEJ
 Among patients with locally advanced esophageal cancer, obstruction of the
esophagus by the tumor causes progressive solid food dysphagia often
accompanied by weight loss
 This usually occurs once the esophageal lumen diameter is less than 13 mm,
which indicates advanced disease. Weight loss is due to dysphagia, changes in
diet, and tumor-related anorexia
 Early symptoms of esophageal cancer are subtle and nonspecific. Transient
"sticking" of apples, meat, hard-boiled eggs, or bread, which can be easily
overcome by the patient with careful chewing, may precede frank dysphagia
 Patients may also notice retrosternal discomfort or a burning sensation
 Regurgitation of saliva or food uncontaminated by gastric secretions can also
occur in patients with advanced disease
 Aspiration pneumonia is infrequent
 Hoarseness may occur if the recurrent laryngeal nerve is invaded
 Chronic gastrointestinal blood loss from esophageal cancer is common and
may result in iron deficiency anemia. However, patients seldom notice
melena, hematemesis or blood in regurgitated food
 Similarly, acute upper gastrointestinal bleeding is rare and is a result of
tumor erosion into the aorta or pulmonary or bronchial arteries
 Tracheobronchial fistulas are a late complication of esophageal cancer. The
fistulas are caused by direct invasion through the esophageal wall and into
the main stem bronchus. Such patients often present with intractable
coughing or frequent pneumonias
 Life expectancy is less than four weeks following the development of this
complication
 Most early (superficial) esophageal cancers in the United States are detected
serendipitously or during screening for or surveillance of Barrett's esophagus.
Early intramucosal cancers are not specifically symptomatic
Diagnosis and staging of
esophageal cancer
DIAGNOSTIC TESTING

 Barium studies may suggest the presence of esophageal cancer, but the
diagnosis is established with endoscopic biopsy
 Early esophageal cancers appear endoscopically as superficial plaques,
nodules, or ulcerations. Advanced lesions appear as strictures, ulcerated
masses, circumferential masses, or large ulcerations
 Biopsy — While the endoscopic visualization of a large mucosal mass is nearly
pathognomonic of esophageal cancer, biopsy must be performed to confirm
the diagnosis. Early studies found that the greater the number of biopsies
taken (up to seven), the higher the diagnostic accuracy
 The addition of brush cytology specimens to seven biopsies increased the
accuracy to 100 percent. Seventeen percent of lesions thought to be benign
endoscopically were subsequently proven to be malignant
 In vivo staining of the esophageal mucosa (chromoendoscopy) can direct the
area of biopsy and determine the extent of disease. Lugol's iodide reacts with
the glycogen components of normal squamous mucosa to produce a greenish
brown color, while neoplastic tissue is depleted of glycogen and squamous
carcinoma remains unstained
Esophageal tumors seen during OGD
PREOPERATIVE STAGING EVALUATION

 TNM staging criteria — The TNM staging system of the American Joint
Committee on Cancer (AJCC) and the International Union Against Cancer
(UICC) for esophageal cancer is used universally. A major change between the
2002 and the 2010 editions was the development of separate stage groupings
according to histology
 In addition to the separate stage groupings for SCC and adenocarcinoma,
other major differences from the 2002 classification include:
A simplification of tumor location and inclusion of tumors at the esophagogastric
junction and proximal 5 cm of the stomach that extend into the EGJ or
esophagus as esophageal cancers
Redefinition of Tis as high-grade dysplasia, which includes all noninvasive
neoplastic epithelia that was formerly called "carcinoma in situ", a diagnosis that
is no longer used for columnar mucosa anywhere in the GI tract
Subclassification of T4 disease based upon potential resectability of adjacent
involved organs/structures
Subclassification of nodal (N) status according to the number of regional nodes
containing metastases
Reassignment of stage groupings using T, N, M categories as well as histologic
grade of differentiation (G), and for SCCs, tumor location
American Joint Committee on Cancer
(AJCC)-TNM Staging
Overview of the preoperative staging
evaluation
 Once the diagnosis of an esophageal cancer is established, staging usually
begins with a CT scan of the chest and upper abdomen to both evaluate the
region of the primary tumor and to search for distant metastatic disease
 However, CT is of limited value for locoregional tumor staging. Although it
can accurately show enlarged nodes, sensitivity for celiac axis nodal disease is
poor, and it is not consistently able to differentiate the depth of primary
tumor invasion
 Another disadvantage of CT is its limited sensitivity for small metastases
(particularly within the peritoneum). PET scans are more sensitive than CT for
detecting metastatic disease and are now widely used for preoperative
staging in patients who lack evidence of distant disease on CT
 Endoscopic ultrasound (EUS) uses a high frequency ultrasound transducer to
provide detailed images of esophageal masses and their relationship with the
five-layered structure of the esophageal wall
 EUS is the most accurate technique for locoregional staging of invasive
esophageal cancer, with an overall accuracy of EUS for tumor (T) and node
(N) staging of 80 to 90 percent. Staging accuracy may be less reliable in
patients with early superficial esophageal cancer than in those with more
advanced esophageal cancer
 Laparoscopy and thoracoscopy- In order to limit aggressive treatment to
patients with locally advanced disease, diagnostic laparoscopy is sometimes
performed to detect occult intraperitoneal metastases in patients with distal
esophageal and EGJ adenocarcinomas. Intraperitoneal metastases are
notoriously difficult to diagnose noninvasively by either CT or PET
 Thoracoscopic and laparoscopic staging procedures have also been examined
for their potential to more accurately stage regional lymph nodes
(particularly celiac and intrathoracic) as compared to EUS
 Bronchoscopy — Preoperative bronchoscopy with biopsy and brush cytology
has been advocated by some (including the NCCN) as the last investigation in
the staging workup for patients with locally advanced nonmetastatic tumors
that are located at or above the level of the carina
Localized cancers of the
esophagus management overview
THORACIC ESOPHAGUS TUMORS

 Surgery alone — Although only 30 to 40 percent of patients have potentially

resectable disease at presentation, surgery has been the standard treatment
for early stage esophageal cancer. Its utility as monotherapy has been
challenged. Poor long-term outcome has prompted an evaluation of
neoadjuvant (preoperative), adjuvant (postoperative), and nonoperative
strategies aimed at improving survival in patients with apparently localized
disease
 RT alone — Before the era of modern chemotherapy and combined
chemoradiotherapy, RT alone (60 to 66 Gy over a period of 6 to 6.6 weeks) was
associated with five-year survival rates of 5 to 20 percent, depending upon
tumor extent. Modern techniques (eg, three-dimensional conformal RT [3D-
CRT], intensity modulated RT [IMRT]) are associated with more favorable
toxicity profiles than those associated with the lower energy units used in
earlier years
 Chemoradiotherapy — Concurrent chemoradiotherapy permits maximal tumor
control because the combined local antitumor effect is more than additive (a
therapeutic advantage termed radiation sensitization), and chemotherapy
provides the opportunity for control of micrometastatic disease
 Postoperative adjuvant therapy- many patients with esophageal or
esophagogastric junction (EGJ) cancer are offered induction therapy with
chemotherapy or chemotherapy plus RT prior to attempted surgical resection.
Although this is a preferred approach for patients who present with clinically
node-positive or T3/4 disease, some patients will undergo surgery initially
 For patients who are found to have node-positive or T4 disease after
undergoing surgery alone, the addition of postoperative adjuvant therapy
(chemotherapy with or without RT) is reasonable in an effort to improve
outcomes
 POSTTREATMENT CANCER SURVEILLANCE- The majority of recurrences
develop within one year. In a series of 590 patients who underwent
esophagectomy for adenocarcinoma, the peak interval for recurrence after
esophagectomy alone was six to nine months, and more than 90 percent of
the disease recurrences occurred by three years
 In contrast, among patients treated with neoadjuvant chemoradiotherapy,
the peak time frame for recurrence was the first three months, and >90
percent of recurrences were evident by 21 months
 The pattern of recurrence was distant, locoregional, or both in 60, 30, and 10
percent of patients, respectively, and did not differ in patients treated with
induction chemoradiotherapy versus surgery alone
 Consensus-based guidelines from the National Comprehensive Cancer Network
(NCCN) suggest the following:
History and physical examination every three to six months for one to three
years, then every six months for years four and five, then annually
CBC and chemistry profile, as clinically indicated
Radiologic imaging and upper GI endoscopy, as clinically indicated
Dilation for anastomotic stenosis
Nutritional counseling
CERVICAL ESOPHAGUS TUMORS

 Squamous cell cancer (SCC) of the cervical esophagus presents a unique

management situation. If surgery is performed, it usually requires removal of
portions of the pharynx, the larynx, the thyroid gland, and portions of the
proximal esophagus
 In addition, radical neck dissections are usually carried out; as such, the
management is more closely related to SCC of the head and neck than for
malignancies involving the more distal portions of the esophagus
 In general, radiation therapy combined with chemotherapy is preferred over
surgery for these patients since survival appears to be the same and major
morbidity is avoided in most
Surgical oncologic principles for
management of resectable
esophageal cancer
Criteria for resection
 Esophagectomy as first line of therapy — The indications for an esophagectomy as the
initial therapeutic approach to the patient with an esophageal cancer include:
Patients with clinical T1N0M0 lesions
Patients with T2N0M0 lesions are candidates in many medical centers
 Esophagectomy post-adjuvant therapy — Patients who tolerate their induction well and
have a response by radiographic evaluation and endoscopy are generally candidates for a
surgical resection four to six weeks following completion of the chemotherapy or
chemoradiotherapy.The indications for induction therapy first, followed by an
esophagectomy include:
Patients with full-thickness (T3 or T4) involvement of the esophagus with/without nodal
disease
Patients with esophageal cancer invasion of local structures (pericardium, pleura, and/or
diaphragm only) that can be resected en bloc, without evidence of metastatic disease to
other organs (eg, liver, colon)
 Relative contraindications — The relative contraindications to an esophagectomy
include:
Advanced age
Comorbid illness
OPERATIVE PROCEDURES

 Cervical esophageal cancer resection — Carcinoma of the cervical esophagus

presents a unique management situation. Because most patients present with
advanced disease, a surgical resection usually requires removal of portions of
the pharynx, the larynx, the thyroid gland, and portions of the proximal
esophagus. Restoration of gastrointestinal tract continuity is accomplished
with a gastric pull-up and anastomosis to the pharynx
 Thoracic cancer resection — Patients with either adenocarcinoma or
squamous cell carcinoma involving the middle or lower third of the
esophagus, with the exception of gastroesophageal junction cancers,
generally require a total esophagectomy because of the risk of submucosal
skip lesions. Although the gastric interposition is most commonly used as a
conduit for reconstruction following esophagectomy, the jejunum or the colon
can also be used as the conduit
 Transhiatal esophagectomy — A transhiatal esophagectomy (THE) can be
performed to resect cervical, thoracic, and EGJ esophageal cancers; it is
performed through an upper midline laparotomy incision and a left neck
incision, typically without a thoracotomy. A cervical anastomosis is created
most often with a gastric pull-up approach
 Ivor-Lewis transthoracic esophagectomy — The Ivor-Lewis transthoracic
esophagectomy can be used to resect cancers in the lower third of the
esophagus but is not the optimal approach for cancers located in the middle
third because of the limited proximal margin that can be achieved. This
procedure combines a laparotomy with a right thoracotomy and an
intrathoracic esophagogastric anastomosis
Management of locally advanced
unresectable esophageal cancer
SURGICAL PALLIATION
 Palliative resection is usually not considered for patients with locally advanced
disease and distant metastases due to their short life expectancy (usually less than six
months)
 Palliative resection is also no longer considered a valid concept for patients with
locally advanced nonmetastatic esophageal cancer. Perioperative morbidity and
mortality rates are high, and the opportunity for potentially curative alternatives such
as definitive chemoradiotherapy may be lost
 Furthermore, although palliative resection can relieve dysphagia, restoration of the
ability to swallow can now be accomplished successfully nonsurgically in the majority
of patients and is most commonly achieved by the placement of an endoluminal stent
 Like palliative esophagectomy, surgical bypass provides limited benefit and is
associated with substantial morbidity in patients with clearly unresectable disease.
Although these palliative bypasses relieve symptoms, complication rates usually
exceed 50 to 60 percent, and mortality rates are between 5 and 10 percent. As a
result, these procedures are now rarely attempted
 Instead, the recommended treatment for inoperable patients with local tumor
invasion of the airway or aorta, or extraregional abdominal metastases, is endoscopic
therapy, stent placement, RT, or combined chemotherapy and radiation
ENDOSCOPIC INTERVENTIONS

 Endoscopic interventions may be appropriate for palliation of dysphagia in

patients who have advanced esophageal cancer in the following settings:
Patients for whom definitive management is planned, but who have severe
dysphagia at presentation, requiring intervention prior to therapy
Failure to achieve adequate palliation of dysphagia with initial therapy
Recurrent dysphagia due to locoregional failure
Recurrent dysphagia due to benign strictures in patients who are successfully
treated with RT
Patients are poor candidates for either chemotherapy or RT
 There are several endoscopic approaches to providing palliation from
malignant dysphagia:
Dilation
Laser therapy
Endoscopic injection therapies
Endoscopic mucosal resection
Photodynamic therapy
Placement of a prosthetic self expanding plastic (SEPS) or metal stent (SEMS)
Brachytherapy
 Stenting is preferred for patients with a malignant stricture and/or fistula
 TE fistula- For patients with persistent TE fistula after the completion of
treatment, options for symptomatic management include airway stents,
esophageal stents, or surgery. In most cases, symptomatic treatment and
closure of the fistula is achieved with stenting; dual stenting appears to work
better than single prosthesis both for palliation and safety
 Alternatives to stenting include esophageal exclusion with cervical
esophagostomy, gastrostomy, and placement of a jejunostomy feeding tube.
Esophageal bypass is rarely needed. Palliative esophageal resection with
repair of the fistula, tracheoesophageal reconstruction, or placement of a
gastrostomy tube is not warranted because it is extremely complicated and is
usually associated with high morbidity and mortality
Tracheoesophageal fistula and a
covered, self-expanding metal stent
Endoscopic images in esophageal cancer
EPIDEMIOLOGY

 In the United States, an estimated 17,990 cases of esophageal cancer will be

diagnosed in 2013, and 15,210 deaths are expected from the disease. Worldwide,
an estimated 482,300 new esophageal cancer cases and 406,800 deaths occurred
in 2008
 Incidence rates vary internationally by nearly 16-fold, with the highest rates found
in Southern and Eastern Africa and Eastern Asia, and the lowest rates in Western
and Middle Africa and Central America in both males and females
 In the highest-risk area, stretching from Northern Iran through the central Asian
republics to North-Central China (often referred to as the “esophageal cancer
belt”), 90 percent of cases are squamous cell carcinomas (SCC)
 Temporal trends in incidence vary for the two major histologic types of esophageal
cancer. Incidence rates for adenocarcinoma of the esophagus have been increasing
in several Western countries, in part due to increases in known risk factors such as
overweight and obesity
 In contrast, rates for SCC have been steadily decreasing in these same
countries because of long-term reductions in tobacco use and alcohol
consumption. However, SCC of the esophagus has been increasing in certain
Asian countries such as Taiwan, probably as a result of increases in tobacco
and alcohol consumption
The end

 Thank you all