Board Review

A 72-year-old man is evaluated for a 3-month history of difficulty swallowing solid foods. He has lost 4.5 kg (10.0 lb) over the last 2 months. He has a 10-year history of heartburn, which is controlled with omeprazole once daily. His other medical problems include obesity and a 35-pack-year history of cigarette smoking. His BMI before the onset of his symptoms was 30.

On physical examination, vital signs are normal; BMI is 29. The remainder of the physical examination is unremarkable.

Laboratory studies are normal.

Which of the following is the most appropriate next step in management?

A) CT of the chest

B) Esophageal manometry

C) pH study

D) Upper endoscopy

Answer: D - Upper endoscopy

Objective: Diagnose esophageal cancer with upper endoscopy.

Key Point

Upper endoscopy with biopsy is the preferred initial diagnostic test for suspected esophageal cancer.

The most appropriate next step in management is upper endoscopy. Progressive solid-food dysphagia is the most common presenting symptom of esophageal cancer. Associated weight loss (as a consequence of reduced oral intake), anorexia, and anemia (from gastrointestinal bleeding) may be present as well. Despite the association of gastroesophageal reflux disease (GERD) with adenocarcinoma, many patients do not have frequent or severe reflux symptoms. This may be because of decreased perception of acid reflux in these patients. Endoscopy is usually diagnostic. Upper endoscopy is the preferred test to assess for esophageal cancer, as it allows for tissue biopsy. Squamous cell carcinoma usually affects the proximal esophagus, whereas adenocarcinoma usually affects the distal esophagus. Risk factors for squamous cell carcinoma include long-term exposure to alcohol and tobacco, nitrosamine exposure, corrosive injury to the esophagus, dietary deficiencies (zinc, selenium), achalasia, tylosis (keratosis of the palms and soles), and human papillomavirus infection. In addition to GERD, risk factors for the development of adenocarcinoma include tobacco use, obesity (especially central obesity), and Barrett esophagus. Staging of the tumor is critical in determining therapy and prognosis. Staging is typically done with CT (to detect distant metastases), endoscopic ultrasound (for locoregional staging), and PET (to follow up on indeterminate lesions found with other staging modalities).

A CT of the chest could be used later to assess locoregional spread of esophageal cancer (such as lymph node involvement), but upper endoscopy should be performed first to assess for esophageal cancer.

Esophageal manometry is the test of choice to evaluate an underlying motility disorder. In this patient, the concern is for an esophageal mass, which does not require manometry.

A pH study would be useful to evaluate a patient with acid reflux whose symptoms are not responding to medical therapy. This test would not be appropriate to evaluate this patient's solid-food dysphagia, and his GERD symptoms have been controlled with omeprazole.

Varghese TK Jr, Hofstetter WL, Rizk NP, et al. The society of thoracic surgeons guidelines on the diagnosis and staging of patients with esophageal cancer. Ann Thorac Surg. 2013 Jul;96(1):346-56. Link Out