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Management of superficial esophageal cancer

Cameron D Wright, MD
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Section Editor
Kenneth K Tanabe, MD
Deputy Editor
Diane MF Savarese, MD


The epidemiology of esophageal cancer has evolved over the last two decades. Although the most marked change is a reversal in the ratio of squamous cell cancers to adenocarcinomas [1], there has also been a shift in stage distribution. The incidence of superficial esophageal cancer (invading no deeper than the submucosa) is increasing, particularly in Asian countries where screening for upper digestive tract cancers is common [2-4]. A similar trend has been seen in the United States and attributed, at least in part, to routine endoscopic surveillance for malignancy and high-grade dysplasia (HGD) in patients with Barrett's esophagus, a complication of longstanding gastroesophageal reflux disease [5-7]. (See "Barrett's esophagus: Pathogenesis and malignant transformation" and "Barrett's esophagus: Surveillance and management" and "Epidemiology, pathobiology, and clinical manifestations of esophageal cancer".)

For many years, the standard treatment for both HGD and superficial esophageal cancer has been esophagectomy. High cure rates were achieved but at the cost of treatment-related morbidity and mortality. Endoscopic approaches to definitive therapy (eg, endoscopic resection [ER], photodynamic therapy [PDT], laser therapy, and argon plasma coagulation [APC]) have increasingly been used in this country following encouraging early reports from Japan and Europe. However, these techniques are only appropriate for patients who have a very low risk of lymph node metastases or who are poor candidates for esophageal surgery.

This topic review will focus on treatment strategies for superficial esophageal cancer. The epidemiology, clinical presentation, diagnosis, and staging of esophageal cancer; surgical techniques for esophagectomy; and combined modality approaches for the treatment of muscle-invasive disease are discussed in detail elsewhere. (See "Epidemiology, pathobiology, and clinical manifestations of esophageal cancer" and "Diagnosis and staging of esophageal cancer" and "Endoscopic ultrasound in esophageal carcinoma" and "Surgical management of resectable esophageal and esophagogastric junction cancers" and "Radiation therapy, chemoradiotherapy, neoadjuvant approaches, and postoperative adjuvant therapy for localized cancers of the esophagus".)


A critical component of choosing the appropriate management strategy for a superficial esophageal cancer is an accurate assessment of disease extent. Submucosal involvement is the most important prognostic determinant for early esophageal cancers because the presence of lymphatic vessels within the submucosa facilitates dissemination of cancer cells. Thus an accurate assessment of tumor extent, often with the utilization of high frequency endoscopic ultrasound, is needed to direct therapy.

Pathologic subclassification and the risk of nodal metastases — Early esophageal cancers are those that are classified as Tis (high-grade dysplasia, which includes all noninvasive neoplastic epithelial that was formerly called carcinoma in situ) or T1 tumors, which are split into T1a and T1b subcategories depending on the depth of invasion (table 1) [8]. The risk of nodal metastases is higher for T1b than for T1a tumors [9,10]. In one series, of 3963 patients derived from the National Cancer Data Base (NCDB) who were treated surgically for localized esophageal cancer, the risk of nodal metastases for T1a and T1b tumors was 5 versus 16.6 percent [9].

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Literature review current through: Nov 2017. | This topic last updated: Dec 15, 2016.
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