Eduovisual
Gastrointestinal
Esophageal cancer: workup and staging overview
— Adenocarcinoma (EAC): dominant US subtype; distal esophagus/GEJ; arises from Barrett metaplasia
— Squamous cell carcinoma (SCC): mid/upper esophagus; dominant worldwide; declining in US
— Median age at diagnosis ~67; male predominance 4:1 (EAC) and 3:1 (SCC); Black patients have higher SCC incidence, White patients higher EAC incidence
— EAC: chronic GERD (>5 yr), Barrett esophagus, obesity (central adiposity), male sex, White race, smoking, hiatal hernia
— SCC: tobacco + alcohol (synergistic), achalasia, lye/caustic stricture, hot beverages, HPV (uncommon), tylosis, Plummer-Vinson syndrome, head/neck cancer history, low fruit/vegetable intake
— New progressive dysphagia (solids → liquids) in an adult >55
— Unintentional weight loss (>5% in 6 months) plus GI symptoms
— Iron deficiency anemia in a man or postmenopausal woman without other source
— Odynophagia, hematemesis, melena, hoarseness, or persistent retrosternal pain
— GERD patient with new alarm features (dysphagia, weight loss, anemia, vomiting, age >60 with new symptoms)
— Progressive dysphagia: ~70% of patients; solids first (meat, bread), later soft foods, finally liquids; often months of accommodation (chewing more, cutting smaller) before presentation
— Weight loss: ~50%; combination of mechanical obstruction + tumor cachexia; >10% body weight loss portends advanced disease
— Odynophagia: suggests ulcerated tumor or candidal superinfection in obstructed segment
— Retrosternal/epigastric pain, early satiety, regurgitation of undigested food
— Chronic occult blood loss → microcytic iron-deficiency anemia
— Frank hematemesis is uncommon; massive bleeding suggests aortoesophageal fistula (late, ominous)
— Hoarseness → recurrent laryngeal nerve invasion
— Persistent cough or aspiration with swallowing → tracheoesophageal fistula
— Horner syndrome → sympathetic chain invasion (upper thoracic)
— Chest/back pain → mediastinal invasion
— Hiccups → phrenic nerve
— Supraclavicular adenopathy (Virchow node), hepatomegaly/RUQ pain, bone pain, dyspnea from malignant effusion or lung mets
— Duration and trajectory of dysphagia (weeks vs months; progressive vs intermittent)
— Heartburn history: duration, frequency, PPI use, prior EGDs, known Barrett
— Tobacco (pack-years), alcohol (drinks/day × years)
— Caustic ingestion, prior radiation to chest/neck, head/neck cancer, achalasia
— Family history of GI cancers; tylosis (rare familial palmoplantar keratoderma → SCC)
— Medications: bisphosphonates, NSAIDs (pill esophagitis as differential)
— Functional status (ECOG) and weight trajectory — drives treatment eligibility
— Cachexia, temporal wasting, sarcopenia — strongly correlate with advanced stage and poor treatment tolerance
— Pallor (anemia), dry mucous membranes (volume depletion from poor PO intake)
— BMI trajectory matters more than absolute BMI; document baseline weight from prior visits
— Supraclavicular lymphadenopathy (Virchow/Troisier node, left) — implies M1 disease, generally precludes curative resection
— Cervical adenopathy — relevant for upper/mid esophageal SCC staging
— Oropharyngeal exam: synchronous head/neck SCC in ~3–5% of esophageal SCC patients (field cancerization)
— Hoarseness on voice assessment; laryngoscopy if upper esophageal lesion or vocal symptoms
— Lungs: focal dullness/decreased breath sounds → malignant pleural effusion or post-obstructive pneumonia from aspiration
— Hepatomegaly, nodular liver edge → hepatic metastases (most common visceral met site)
— Ascites: peritoneal carcinomatosis (more common in GEJ adenocarcinoma)
— Periumbilical (Sister Mary Joseph) nodule — rare but pathognomonic for intra-abdominal malignancy
— Tylosis (palmoplantar hyperkeratosis) — autosomal dominant, near-100% lifetime SCC risk
— Acanthosis nigricans (paraneoplastic, esp. GI adenocarcinoma)
— Bony tenderness → skeletal metastases
— Orthostatic vitals if poor PO intake; assess for dehydration
— Albumin, prealbumin, weight loss % as objective nutrition markers
— Performance status: ECOG 0–4 or Karnofsky — directly determines candidacy for trimodality therapy vs palliative-only approach
— Upper endoscopy is the gold-standard initial study — direct visualization plus tissue diagnosis in one procedure
— Obtain ≥6–8 biopsies from the mass; brush cytology adjunctively
— Document tumor location (cm from incisors), length, circumferential extent, GEJ involvement (Siewert classification I/II/III)
— Look for synchronous Barrett, second primaries, and exclude varices/peptic stricture mimics
— Adenocarcinoma vs SCC vs neuroendocrine
— HER2 (adenocarcinoma — drives trastuzumab eligibility in metastatic disease)
— PD-L1 CPS (immunotherapy eligibility, e.g., pembrolizumab/nivolumab)
— MMR/MSI status; claudin 18.2 (emerging biomarker for GEJ adenocarcinoma)
— CBC (iron-deficiency anemia from chronic blood loss)
— CMP (albumin as nutritional/prognostic marker; LFTs as low-sensitivity hepatic met screen)
— Coagulation studies (pre-procedural)
— Nutritional labs: prealbumin, vitamin D, B12, iron studies
— Tumor markers (CEA, CA 19-9) — not for diagnosis or screening; sometimes followed in metastatic adenocarcinoma
— CT chest/abdomen/pelvis with IV + oral contrast — assesses local extent, regional adenopathy, liver/lung/peritoneal metastases
— Chest CT also evaluates airway invasion and synchronous lung primary (smokers)
— Detects occult distant metastases in ~15–20% of patients deemed resectable by CT alone
— Useful for baseline SUV, response assessment after neoadjuvant therapy, and surveillance
— Limitations: false positives (inflammation, granulomas), poor for small peritoneal/liver mets <8 mm
— Order PET/CT before committing to curative-intent therapy
— Most accurate for T and N staging of locoregional disease (T accuracy ~85%, N ~75%)
— Assesses depth of invasion (mucosa → submucosa → muscularis propria → adventitia → adjacent structures)
— FNA of suspicious regional or celiac nodes changes stage and treatment
— Critical for T1a vs T1b distinction: T1a (intramucosal) candidates for endoscopic resection (EMR/ESD); T1b (submucosal) generally requires esophagectomy due to higher nodal risk
— Indicated for GEJ and gastric cardia adenocarcinomas (Siewert II/III) with T3/T4 or N+ disease
— Detects radiographically occult peritoneal carcinomatosis in 10–15%; converts to M1 (palliative)
— Not routine for purely thoracic esophageal SCC
— For upper or mid esophageal tumors at/above the carina to exclude tracheobronchial invasion or fistula before surgery or radiation
— T: depth of invasion (Tis/T1a/T1b/T2/T3/T4a/T4b)
— N: regional node count (N0–N3)
— M: distant mets (M0/M1)
— Clinical (c), pathologic (p), and post-neoadjuvant (yp) stage groupings differ — important for prognosis
— Tis / T1a N0 (intramucosal): Endoscopic resection (EMR or ESD) ± ablation (radiofrequency ablation for residual Barrett); organ-sparing, ~95% 5-yr survival when properly selected
— T1b N0 (submucosal): Esophagectomy preferred (15–25% nodal metastasis risk); selected superficial T1b sm1 with favorable features may get endoscopic therapy at expert centers
— T2N0 (limited): Upfront esophagectomy acceptable; many centers still offer neoadjuvant therapy for high-risk features (poor differentiation, LVI, large tumor)
— T3 or N+ (locally advanced, M0): Neoadjuvant chemoradiation followed by esophagectomy (CROSS regimen — carboplatin/paclitaxel + 41.4 Gy → surgery in 6–8 wk) is standard for both SCC and adenocarcinoma; alternatively perioperative FLOT chemotherapy for adenocarcinoma/GEJ
— Cervical esophageal SCC or unresectable locally advanced: Definitive chemoradiation (cisplatin/5-FU or carboplatin/paclitaxel + ~50 Gy); surgery avoided due to morbidity of pharyngolaryngectomy
— M1 (metastatic): Palliative systemic therapy + best supportive care; consider stenting/radiation for dysphagia
— Performance status (ECOG): 0–1 supports trimodality; 2 individualized; ≥3 palliative
— Cardiopulmonary reserve: PFTs, stress testing before esophagectomy; FEV1 <1.2 L or DLCO <40% predicted are red flags
— Nutrition: albumin <3.0, weight loss >10–15% → pre-treatment nutritional optimization (jejunostomy or NG feeding) before chemoradiation/surgery
— Frailty independent of age — quantitative frailty assessment (e.g., G8 in geriatric oncology)
— CROSS (preferred for resectable locally advanced, both histologies): Carboplatin AUC 2 + paclitaxel 50 mg/m² weekly × 5, with concurrent 41.4 Gy radiation in 23 fractions; surgery 6–8 weeks later
— Cisplatin + 5-FU + RT: older standard, more toxic; still used in definitive chemoradiation for cervical SCC or non-surgical candidates (~50–50.4 Gy)
— FOLFOX + RT: acceptable alternative
— FLOT: 5-FU + leucovorin + oxaliplatin + docetaxel — 4 cycles pre-op + 4 cycles post-op
— Replaced older ECF/MAGIC regimen; superior survival in FLOT4 trial
— Use when radiation is undesired or in bulky GEJ/gastric disease
— Nivolumab 240 mg q2wk or 480 mg q4wk × 1 year after R0 resection with residual pathologic disease post-neoadjuvant chemoradiation (CheckMate 577); doubled disease-free survival
— Adenocarcinoma / GEJ:
▸ FOLFOX or CAPOX + nivolumab (or pembrolizumab) — standard with PD-L1 CPS ≥5
▸ Add trastuzumab + pembrolizumab if HER2-positive (IHC 3+ or 2+/FISH+)
▸ Consider zolbetuximab if claudin 18.2-positive
— SCC:
▸ FOLFOX or cisplatin/5-FU + pembrolizumab (or nivolumab + ipilimumab) — chemoimmunotherapy is standard regardless of PD-L1 for many regimens, but benefit greatest at CPS ≥10
— Antiemetics: 5-HT3 antagonist (ondansetron) + dexamethasone + NK1 antagonist (aprepitant) for highly emetogenic regimens (cisplatin, oxaliplatin)
— G-CSF primary prophylaxis if febrile neutropenia risk >20% (e.g., FLOT)
— PPI for symptomatic reflux during and after treatment
— Nutritional support: consider jejunostomy before chemoradiation if poor PO intake
— Cisplatin: nephrotoxicity, ototoxicity, neuropathy → hydration, audiometry
— Oxaliplatin: cold-induced peripheral neuropathy, cumulative
— 5-FU: mucositis, diarrhea, coronary vasospasm/chest pain; check DPYD variants pre-treatment
— Paclitaxel: neuropathy, hypersensitivity (premedicate)
— Checkpoint inhibitors: immune-related colitis, pneumonitis, hepatitis, thyroiditis, hypophysitis
— EMR (endoscopic mucosal resection): lesions <2 cm, well/moderately differentiated, no LVI, T1a
— ESD (endoscopic submucosal dissection): larger or en-bloc resection; preferred for ≥2 cm or suspected superficial submucosal invasion
— Followed by radiofrequency ablation of residual Barrett to reduce metachronous neoplasia
— Surveillance EGD every 3 months × 1 yr, then taper
— Ivor Lewis (transthoracic): laparotomy + right thoracotomy, intrathoracic anastomosis — standard for middle/distal tumors
— McKeown (3-field): abdomen + right chest + left neck, cervical anastomosis — for more proximal tumors
— Transhiatal: abdomen + neck, no thoracotomy — lower pulmonary morbidity but limited mediastinal lymphadenectomy
— Minimally invasive/robotic esophagectomy increasingly used; equivalent oncologic outcomes, fewer pulmonary complications
— R0 resection (negative margins) is the goal; ≥15 lymph nodes for adequate staging
— Gastric conduit is the standard reconstruction; colon/jejunal interposition if stomach unavailable
— Routine feeding jejunostomy placed intraoperatively
— Anastomotic leak (10–15%) — most feared early complication; intrathoracic leak more lethal than cervical
— Chylothorax (thoracic duct injury), recurrent laryngeal nerve injury (hoarseness, aspiration), pneumonia, atrial fibrillation, ARDS
— 30-day mortality 2–5% at high-volume centers, >10% at low-volume centers — volume-outcome relationship is one of the strongest in surgery
— Self-expanding metal stent (SEMS): rapid dysphagia relief in M1 disease or unresectable patients; risks: migration, bleeding, perforation, food impaction; avoid if pre-stent chemoradiation planned for curative intent
— Brachytherapy or external beam radiation: more durable palliation than stenting in patients with longer life expectancy
— PEG/PEJ tubes for nutritional support; cricopharyngeal myotomy or laser ablation in selected cases
— Median age at diagnosis is ~67; many patients are 75+
— Chronologic age alone is not a contraindication to curative therapy — frailty and physiologic reserve matter more
— Use Comprehensive Geriatric Assessment (CGA) or screening tools (G8, VES-13) to identify vulnerable patients
— Domains: functional status, comorbidities, cognition, nutrition, polypharmacy, social support, depression
— Consider dose-attenuated chemotherapy (e.g., reduced platinum dose, single-agent if performance status borderline)
— Definitive chemoradiation may be preferred over esophagectomy in select older patients with locally advanced disease — comparable oncologic outcomes with lower perioperative mortality
— Aggressive prehabilitation (exercise, nutrition, smoking cessation) for 2–4 weeks before surgery improves outcomes
— Higher risk of postoperative delirium, pneumonia, AF, deconditioning
— Cisplatin requires CrCl ≥60 mL/min; below this, substitute carboplatin (AUC-dosed by Calvert formula using measured GFR)
— Aggressive pre- and post-cisplatin hydration (1–2 L NS), avoid concurrent nephrotoxins (NSAIDs, aminoglycosides, IV contrast same day)
— 5-FU and paclitaxel: primarily non-renal clearance; minimal adjustment
— Oxaliplatin: caution if CrCl <30; consider dose reduction
— Contrast considerations for staging CT: if eGFR <30, use non-contrast or weigh risk; PET/CT can substitute
— Paclitaxel and docetaxel: dose-reduce or avoid if bilirubin elevated (>1.5× ULN)
— Irinotecan (used in some salvage regimens): dose adjust for bilirubin and UGT1A1 polymorphism
— 5-FU: generally tolerated unless severe dysfunction
— Hepatic metastases impair clearance — monitor LFTs each cycle
— 5-FU and capecitabine can cause coronary vasospasm; baseline ECG; avoid in unstable CAD; if vasospasm occurs, switch to raltitrexed or oxaliplatin-based regimen
— Trastuzumab: baseline + serial LVEF; hold if LVEF drops >10 points or <50%
— Anthracyclines (rare in esophageal): cumulative cardiotoxicity
— Esophageal cancer in pregnancy is extraordinarily rare; case-by-case management
— Diagnostic EGD is safe with appropriate sedation (propofol or midazolam, anesthesia involvement) — generally deferred to second trimester when feasible
— Avoid PET/CT and abdominal CT in first trimester; MRI without gadolinium is preferred for staging
— Chemotherapy generally avoided in first trimester (teratogenicity); platinum-based regimens used after week 14 if needed
— Radiation to chest/abdomen contraindicated during pregnancy
— Multidisciplinary discussion including maternal-fetal medicine, ethics; balance maternal survival vs fetal viability/delivery timing
— Tylosis (RHBDF2 mutation): autosomal dominant palmoplantar hyperkeratosis; lifetime SCC risk ~95% by age 65 → annual EGD surveillance from age 30
— Plummer-Vinson syndrome: iron-deficiency anemia + esophageal webs + dysphagia (classically middle-aged women) → upper/cervical esophageal SCC risk; treat iron deficiency, surveil endoscopically
— Familial Barrett/EAC clusters: consider screening EGD in first-degree relatives of EAC patients with chronic GERD
— Fanconi anemia, dyskeratosis congenita: rare; increased upper aerodigestive SCC
— Higher incidence of HPV-associated SCC in some series; manage cancer therapy concurrently with antiretrovirals
— Watch drug interactions: protease inhibitors and CYP3A4-metabolized chemotherapy
— ~16-fold increased risk of esophageal SCC (and modest adenocarcinoma risk); long-standing food stasis → chronic inflammation
— No formal surveillance guideline but low threshold for EGD with any new symptom change
— Pseudoachalasia from tumor at the GEJ must always be excluded before treating presumed primary achalasia, especially short symptom duration in older adults
— Lye/acid strictures → ~1000× increased SCC risk, often 20–40 years after ingestion
— Surveillance EGD every 1–3 years starting ~10 years post-injury
— Sleeve gastrectomy may worsen GERD → potential long-term Barrett/EAC implications; emerging surveillance considerations
— Malignant dysphagia → aspiration pneumonia
▸ Recurrent, often polymicrobial, RLL predominant; treat with broad-spectrum coverage (e.g., ampicillin-sulbactam) and address obstruction (stent/radiation)
— Tracheoesophageal fistula (TEF): cough with swallowing, recurrent pneumonia, soilage of lungs; confirm with contrast esophagram (use water-soluble non-ionic contrast, not barium — barium triggers chemical pneumonitis if aspirated); manage with covered SEMS (dual airway + esophageal stenting often needed); precludes curative therapy
— Aortoesophageal fistula: sentinel hematemesis → exsanguinating hemorrhage; nearly uniformly fatal
— Bleeding: chronic occult → severe iron-deficiency anemia; rarely massive
— Mediastinitis, perforation from tumor necrosis or stent erosion
— Severe cachexia, sarcopenia, hypoalbuminemia → impaired wound healing, infections
— Refeeding syndrome when nutrition resumed after prolonged starvation — monitor phosphate, potassium, magnesium; thiamine before refeeding
— Dehydration, AKI from poor PO intake
— Chemoradiation: esophagitis, odynophagia (often requires NG/J-tube feeding mid-treatment), neutropenia, fatigue, radiation pneumonitis (8–12 wk post-RT, dry cough/dyspnea — steroids), pericarditis/cardiomyopathy (late)
— Esophagectomy: anastomotic leak, chylothorax, recurrent laryngeal nerve palsy, anastomotic stricture (20–40%, treated with serial endoscopic dilation), delayed gastric emptying from vagotomy, dumping syndrome, bile reflux, post-thoracotomy chronic pain
— Anastomotic stricture requiring repeated dilation
— Reflux and bile reflux — lifelong PPI; sleep with head elevated
— Dumping syndrome: early (osmotic, vasomotor) and late (reactive hypoglycemia); small frequent low-carb meals, separate liquids from solids
— Weight loss and nutritional deficiencies (B12, iron, vitamin D, calcium)
— Recurrence — most occur within 2–3 years; can be locoregional or distant
— Second primaries (head/neck, lung) — especially in SCC patients who continue tobacco/alcohol
— Massive hematemesis or hemodynamic instability from tumor or aortoesophageal fistula
— Acute airway compromise from tracheal compression, TEF, or massive aspiration
— Septic shock from aspiration pneumonia, anastomotic leak, or neutropenic sepsis
— Post-esophagectomy day 0–1: routine in many centers (especially open transthoracic); monitor for hemodynamic instability, arrhythmia, respiratory failure
— Severe febrile neutropenia with hemodynamic instability — broad-spectrum antibiotics within 1 hour, source control
— Gastroenterology: immediate for EGD at diagnosis; urgent for high-grade obstruction requiring stenting, dilation, or J-tube placement; urgent for upper GI bleeding
— Thoracic surgery: at diagnosis for all potentially resectable patients; emergent for perforation, anastomotic leak, or fistula
— Medical oncology: at diagnosis; before initiating any systemic therapy
— Radiation oncology: at diagnosis for chemoradiation candidates; urgently for palliation of dysphagia, pain, or bleeding
— Interventional radiology: for biliary or enteric access, bleeding embolization, drain placement
— Palliative care: early integration at diagnosis of advanced disease — improves quality of life and may improve survival (parallel to lung cancer data)
— Nutrition (RD): at diagnosis; coordinate jejunostomy if needed
— Speech-language pathology: swallowing evaluation if aspiration risk, post-RLN injury, or post-chemoradiation
— Genetics: if tylosis, strong family history, or syndromic features
— Admit for: severe dehydration/inability to swallow saliva, aspiration pneumonia, GI bleeding, suspected perforation/fistula, febrile neutropenia, intractable pain, refeeding syndrome management
— Outpatient management: most diagnostic workup, neoadjuvant chemoradiation (with close monitoring), surveillance
— Transfer to high-volume center for esophagectomy is a strong Step 3 systems answer
— Long-standing GERD; gradual progressive solid dysphagia; smooth, tapered distal narrowing on EGD; biopsy benign
— Treated with endoscopic dilation + lifelong PPI
— Must biopsy — adenocarcinoma can mimic stricture
— Intermittent solid-food dysphagia (steakhouse syndrome), classically with meat/bread
— Smooth thin ring at GEJ; treated with dilation; biopsy if atypical
— Not progressive — distinguishes from cancer
— Cervical/upper esophagus; iron-deficiency anemia in middle-aged women
— Increased SCC risk — surveillance after diagnosis
— Progressive dysphagia for both solids and liquids, years duration, regurgitation of undigested food, weight loss, bird-beak on barium
— High-resolution manometry confirms (absent peristalsis, impaired LES relaxation)
— Pseudoachalasia from distal esophageal/GEJ adenocarcinoma must be excluded — EGD required, low threshold for EUS in older patients with short symptom duration
— Intermittent chest pain and dysphagia; corkscrew/rosary bead on barium; manometry confirms
— Not typically with weight loss or anemia
— Young adults, atopy, food impactions, intermittent solid dysphagia
— EGD: rings, furrows, white plaques, narrow-caliber esophagus
— Biopsy ≥15 eos/HPF from proximal and distal esophagus
— Treat with PPI, topical steroids (swallowed budesonide/fluticasone), elimination diet
— Key distinction: young patient with food impaction + dysphagia → EoE, not cancer
— Odynophagia in immunocompromised (HIV, chemotherapy, steroids, transplant)
— Candida: linear white plaques; HSV: punched-out ulcers; CMV: large linear ulcers
— Treat with fluconazole, acyclovir, ganciclovir respectively
— Bisphosphonates, doxycycline, KCl, NSAIDs, iron
— Acute retrosternal pain, odynophagia after pill ingestion with insufficient water
— Endoscopy shows discrete ulcers; resolves with offending drug discontinuation
— Zenker: cervical bulging, halitosis, regurgitation of old food, gurgling neck — barium swallow is diagnostic of choice
— Submucosal masses; EUS characterizes; usually asymptomatic, found incidentally
— Difficulty initiating swallow, coughing/choking with swallow, nasal regurgitation, aspiration
— Causes: stroke (most common in older adults), Parkinson disease, ALS, myasthenia gravis, polymyositis/dermatomyositis, Zenker diverticulum, pharyngeal cancer
— Workup: videofluoroscopic swallow study (modified barium swallow) with speech pathology — not EGD as first test
— Key distinction: transfer dysphagia symptoms (coughing/nasal regurg) point to oropharyngeal pathology; sticking sensation seconds after swallow points to esophageal
— Myasthenia gravis: fatigable bulbar weakness, ptosis, diplopia; anti-AChR antibodies
— ALS: dysarthria + dysphagia + limb weakness + fasciculations
— Parkinson disease: later in disease course; aspiration is leading cause of death
— Stroke (brainstem, lateral medullary): acute onset
— Pharyngeal, laryngeal, tongue base SCC — share risk factors with esophageal SCC (tobacco, alcohol, HPV)
— Examine oral cavity, neck nodes; refer to ENT for laryngoscopy
— Synchronous primaries with esophageal SCC in 3–5%
— Lung cancer (especially upper lobe, mediastinal nodes), lymphoma, thyroid goiter, aortic aneurysm or dysphagia lusoria (aberrant right subclavian artery) — extrinsic compression on barium swallow
— GERD chest pain, esophageal spasm, MI can confuse the picture
— Always consider ACS in older patient with chest pain — even if dysphagia is the primary complaint
— Functional sensation of lump in throat, not actually with swallowing, no weight loss, no progression — diagnosis of exclusion after EGD and ENT exam
— Distal hypomotility + severe GERD + Raynaud + skin changes
— Manometry: absent distal peristalsis, low LES pressure
— High risk for Barrett and adenocarcinoma — surveillance
— Late consideration; exclude organic disease first
— History and physical with weight, nutritional assessment: every 3–6 months × 2 years, every 6 months years 3–5, annually thereafter
— CT chest/abdomen/pelvis: every 6–12 months × 2 years, then annually × 3 years
— EGD: every 6–12 months for the first 2 years if endoscopic resection was the primary therapy or if Barrett surveillance is needed; not routinely required after esophagectomy unless symptomatic
— CBC, CMP, nutritional labs (B12, iron, vitamin D, prealbumin) at follow-up visits
— PET/CT: for symptoms or rising tumor markers, not routine
— Recurrence peaks at 1–2 years; ~90% of recurrences within 3 years
— PPI lifelong (omeprazole 20 mg or equivalent) — manage bile/acid reflux into gastric conduit
— Iron, B12, vitamin D, calcium supplementation — gastric reservoir loss impairs absorption
— Pancreatic enzyme replacement in select patients with fat malabsorption
— Antidiarrheals/loperamide for dumping syndrome as needed
— PPI BID plus surveillance EGD with biopsies per Seattle protocol
— Surveillance interval depends on residual dysplasia status
— Counsel on reflux lifestyle measures: weight loss, head-of-bed elevation, avoid late meals
— Tobacco cessation: mandatory — improves treatment tolerance, reduces second primaries (head/neck, lung); offer varenicline or combination NRT + behavioral counseling
— Alcohol cessation: especially in SCC; reduces second primary risk
— Weight management: central obesity drives reflux/EAC recurrence risk
— Mediterranean-style diet, regular physical activity as tolerated
— GERD control
— Annual influenza
— Pneumococcal (PCV20 or PCV15 + PPSV23) in adults ≥65 or with comorbidities
— COVID-19 boosters
— Shingles (Shingrix) ≥50
— HPV if eligible age — relevant in SCC
— Depression and anxiety screening (PHQ-9, GAD-7)
— Support groups, survivorship clinic
— Sexual health, return to work, financial toxicity discussions
— Document goals of care, POLST/MOLST, healthcare proxy at diagnosis of advanced disease and revisit at transitions
— Hospice referral when curative options exhausted and prognosis <6 months
— Post-esophagectomy patients lose 10–20% of preoperative body weight in the first 6 months
— Small, frequent meals (6–8/day), high-protein, calorie-dense
— Separate solids and liquids to reduce dumping
— Avoid lying flat for 1–2 hours after meals; head of bed elevated 30–45° at night
— Slow eating, thorough chewing
— Registered dietitian follow-up at 2 weeks post-discharge, then monthly × 3, then quarterly
— Goal: stabilize weight by 6–12 months; intervene with supplemental J-tube feeds if losing >10% post-discharge
— Post-RLN injury or radiation: SLP-led swallow therapy, diet texture modification (mechanical soft, thickened liquids), Mendelsohn maneuver, supraglottic swallow
— Repeat VFSS as needed
— Consider vocal cord medialization for persistent unilateral RLN palsy with aspiration
— Important after thoracotomy: incentive spirometry, breathing exercises, gradual aerobic reconditioning
— Pulmonary rehab program if persistent dyspnea or post-radiation pneumonitis
— Post-thoracotomy pain syndrome is common; multimodal: gabapentinoids, acetaminophen, NSAIDs (caution with stomach conduit), topical lidocaine, intercostal nerve blocks, low-dose tricyclics; minimize chronic opioids
— CBC, CMP before each cycle; growth factor support if needed
— TSH every 6 weeks on checkpoint inhibitors (thyroid dysfunction common)
— LFTs, amylase, glucose for irAEs (hepatitis, pancreatitis, diabetes)
— LVEF for trastuzumab — baseline and every 3 months
— Symptom-directed evaluation of new cough/dyspnea (pneumonitis), diarrhea (colitis), rash, fatigue
— Affects 20–40% of post-esophagectomy patients in first year
— Present with recurrent dysphagia, food impaction
— EGD with endoscopic balloon dilation; serial sessions every 2–4 weeks until durable patency; intralesional steroids for refractory cases
— Screen depression/anxiety at each visit
— Refer to oncology social work, financial counseling
— Survivorship care plan document provided to patient and PCP
— Discharge summary to PCP within 7 days of hospitalization
— Oncology + PCP shared care model; PCP manages comorbidities, vaccinations, age-appropriate screening
— Reconcile medications carefully — PPI lifelong, supplements, opioid taper plan
— High-stakes, high-morbidity procedure — 2–10% perioperative mortality, 50%+ major complication rate
— Consent must include: anastomotic leak, RLN injury (hoarseness, aspiration), chylothorax, conduit necrosis, pneumonia, AF, prolonged ICU/hospital stay, need for J-tube, lifelong dietary changes, dumping syndrome, recurrence risk
— Discuss alternatives: definitive chemoradiation, palliative care, no treatment
— Consent must occur with the operating surgeon, in a language and health literacy level the patient understands, with adequate time — not the morning of surgery for elective cases
— Decision aids and shared decision-making especially important when oncologic outcomes are similar (e.g., definitive chemoradiation vs surgery in cervical SCC or borderline operative candidates)
— Severe cachexia, electrolyte derangement, opioid use, or depression can impair decisional capacity — reassess and treat reversible contributors before obtaining consent for major intervention
— Capacity is decision-specific — a patient may have capacity to refuse a feeding tube but not to manage finances
— Early palliative care at diagnosis of advanced or metastatic disease — concurrent with oncology, not "end of the line"
— Establish healthcare proxy, advance directive, POLST/MOLST
— Address artificial nutrition explicitly — many advanced patients and families assume tube feeding will help; data show no survival benefit in end-stage cancer cachexia, and risks aspiration, infection, decubitus from prolonged bedrest
— Verify treatment plan with time-out before each RT fraction; daily image guidance
— Chemotherapy double-check with two independent verifications; barcoded administration
— Monitor for DPYD deficiency before 5-FU/capecitabine — pretest in high-risk patients can prevent fatal toxicity
— Neutropenic precautions education at discharge
— Post-esophagectomy discharge: medication reconciliation (PPI, anticoagulation, opioids), J-tube care training, follow-up appointments with surgery, oncology, nutrition, PCP within 1–2 weeks
— Handoff from inpatient to outpatient oncology — pending pathology, biomarker results, planned adjuvant therapy
— Pending biopsy results at discharge must have a closed-loop tracking system to prevent missed cancer diagnoses
— Cancer registry reporting is mandated by state law for all new diagnoses
— Workplace exposures (rare for esophageal but consider): document occupational history
— Driving and aspiration risk: counsel patients with severe dysphagia or post-RLN injury about choking risk
— Black patients have higher SCC incidence and worse outcomes; address barriers to high-volume center access, clinical trial enrollment, and language-concordant care
— Insurance/financial toxicity counseling
— Upper/middle third: SCC predominates
— Lower third / GEJ: adenocarcinoma predominates
— SCC: "SMASH" — Smoking, Mucosal injury (lye, hot drinks, achalasia), Alcohol, Squamous risk syndromes (tylosis, Plummer-Vinson), HPV
— EAC: "ABCDEF" — Acid reflux/Age, Barrett, Caucasian, Diet (low fruit/veg), Esophageal hiatal hernia, Fat (obesity)
— Salmon-colored mucosa extending ≥1 cm above GEJ with intestinal metaplasia (goblet cells) on biopsy
— Annual EAC risk: 0.1–0.3% for non-dysplastic; ~0.5% for LGD; ~5–7% for HGD
— Seattle protocol biopsies: 4-quadrant every 2 cm (every 1 cm for known dysplasia)
— Surveillance intervals: NDBE 3–5 yr, LGD 6–12 mo (or ablation), HGD → endoscopic eradication
— CEA, CA 19-9 — used in metastatic adenocarcinoma follow-up; not screening
— "Apple-core" lesion, asymmetric stricture, shouldering on barium = malignancy
— "Bird's beak" = achalasia
— "Corkscrew" = diffuse esophageal spasm
— Virchow node (left supraclavicular), Sister Mary Joseph nodule (periumbilical), Krukenberg tumor (ovarian — more gastric, can occur with GEJ)
— Most common metastatic sites: liver, lung, bone, distant nodes
— CROSS: neoadjuvant carboplatin/paclitaxel + 41.4 Gy → surgery (standard for resectable locally advanced)
— FLOT4: perioperative FLOT > ECF for GEJ/gastric adenocarcinoma
— CheckMate 577: adjuvant nivolumab × 1 yr after R0 resection with residual disease
— KEYNOTE-590, CheckMate 648: chemoimmunotherapy first-line metastatic
— HER2 → trastuzumab (adenocarcinoma)
— PD-L1 CPS → pembrolizumab/nivolumab
— MSI-H / dMMR → checkpoint inhibitors (rare in esophageal)
— Claudin 18.2 → zolbetuximab (GEJ/gastric)
— Gastric conduit is the workhorse reconstruction
— Recurrent laryngeal nerves at risk in cervical and thoracic dissection
— Thoracic duct runs right of midline lower, crosses to left at T5 — chylothorax risk
— Localized (I): 45–50%
— Regional (II–III): 25–30%
— Distant (IV): <5%
— Overall: ~20%
— "A 64-year-old man with a 30-year history of heartburn presents with 3 months of progressive dysphagia to solids and a 6 kg weight loss. He is a former smoker..."
— Best next step: Upper endoscopy with biopsy
— Wrong answers: empiric PPI trial, barium swallow first, esophageal manometry, CT chest
— "Biopsy confirms moderately differentiated adenocarcinoma of the distal esophagus. CT chest/abdomen/pelvis shows no distant disease. Best next step?"
— Answer: PET/CT and EUS (often paired); diagnostic laparoscopy for GEJ Siewert II/III
— Wrong answers: proceed directly to esophagectomy, start chemotherapy without staging
— "T3N1M0 distal esophageal adenocarcinoma, ECOG 1, age 62, fit. Optimal management?"
— Answer: Neoadjuvant chemoradiation (CROSS) followed by esophagectomy (or perioperative FLOT)
— Wrong answers: surgery alone, chemoradiation without surgery (unless cervical SCC), palliative care
— "70-year-old with 6 months of dysphagia for solids and liquids, 8 kg weight loss; barium swallow shows bird-beak narrowing. Next step?"
— Answer: EGD with biopsy — exclude malignancy at GEJ before treating as achalasia
— The short duration + older age + significant weight loss are the tells
— "POD 6 after Ivor Lewis esophagectomy: fever 38.6°C, HR 118, new left pleural effusion, leukocytosis. Most likely diagnosis? Best next step?"
— Diagnosis: Anastomotic leak
— Next step: CT chest with oral water-soluble contrast, NPO, broad-spectrum antibiotics, surgical consult
— "Metastatic disease, unable to swallow solids, weight loss. Best initial palliative measure?"
— Answer: Self-expanding metal stent for rapid relief (in non-curative setting); palliative radiation if longer life expectancy
— "Non-dysplastic Barrett 4 cm with adequate biopsies. Next surveillance EGD?"
— Answer: 3–5 years
— "32-year-old with palmoplantar hyperkeratosis and a family history of esophageal cancer. Screening recommendation?"
— Answer: Annual EGD starting at age 30 for SCC surveillance
— "Patient on neoadjuvant 5-FU develops chest pain and ECG with ST changes. Next step?"
— Answer: Hold 5-FU, evaluate for coronary vasospasm, troponin, cardiology consult; switch regimen for future cycles
— "Post-esophagectomy with ypT2N1 after neoadjuvant CROSS. Best next step?"
— Answer: Adjuvant nivolumab × 1 year
Esophageal cancer is a malignancy of progressive solid-food dysphagia and weight loss in an older patient with risk factors (chronic GERD/Barrett for adenocarcinoma; tobacco/alcohol for SCC) that requires upfront EGD with biopsy followed by CT chest/abdomen/pelvis, PET/CT, and EUS for staging, then stage-directed therapy ranging from endoscopic resection (T1a) to esophagectomy or trimodality CROSS chemoradiation + surgery (locally advanced) to palliative systemic therapy with biomarker-driven immunotherapy and stenting (metastatic).