Diagnosis and Management of Esophageal Cancer
March 16, 2025
Dr. Preeti Vijayakumaran, a surgical oncologist at Artemis Hospital, Gurugram, trained at Tata Memorial Hospital, Mumbai, walks doctors across Africa through the diagnosis, staging and multimodality treatment of esophageal cancer, a cancer with a particularly high burden across South East Asia and the African continent. The session covers how early and advanced disease present differently, when endoscopic treatment can substitute for surgery, and what the major international trials say about combining chemotherapy, radiation and surgery for locally advanced disease.
Questions Doctors Asked Dr. Preeti Vijayakumaran
Real questions from the live masterclass, answered by Dr. Preeti Vijayakumaran, Consultant, Surgical Oncology.
How do you differentiate gastroesophageal junction cancer and lower esophageal cancer, and the difference in their care?
Asked by Dr. Christian Ngwu
The protocol is endoscopic mapping. The endoscopist localises exactly where the tumour sits relative to the GE junction, using a standard landmark of around 40 cm from the incisors, which varies slightly with the patient's own oesophageal length. Once that is determined, the malignancy is mapped against the gastroesophageal junction, and this is cross-checked against the axial imaging. If there is any disagreement between the endoscopic and imaging findings, the axial imaging representation is preferred to finalise the diagnosis.
Answered by Dr. Preeti Vijayakumaran
What is the role of immunotherapy in esophageal cancer?
Asked by Dr. Mukia
Immunotherapy's role is currently established in the adjuvant setting, more so for esophageal squamous cell carcinoma. A patient who completes neoadjuvant therapy, undergoes surgery, and is found to have residual disease is followed with adjuvant nivolumab. If there is no residual disease, adjuvant nivolumab is not advocated. In the neoadjuvant setting, the role of immunotherapy is still experimental and yet to be answered.
Answered by Dr. Preeti Vijayakumaran
Cryotherapy is one of the treatment options for the cancer. Would you repeat the disadvantages of applying cryotherapy for esophageal cancer?
Asked by Dr. Alicia
Cryotherapy, along with other ablative therapies, is applicable only in very early and especially screen-detected cases of esophageal malignancy. Staging accuracy is critical here: if endoscopy and endoscopic ultrasound confirm a flat, high-grade dysplastic lesion or an early intramucosal carcinoma, ablation can be applied, though it does leave structural changes at the site that make future surveillance harder. If there is any suspicion of nodular disease, or of invasion into the submucosa or muscularis propria, endoscopic resection is recommended over an ablative procedure like cryotherapy alone.
Answered by Dr. Preeti Vijayakumaran
Given that the prevalence is much higher in men than in women, is there a predisposing genetic factor?
Asked by Dr. Wassim
This is a question on my mind as well. There is no established genetic risk factor explaining why esophageal cancer is more common in men than women. A lot of it is attributed to other risk factors instead, like smoking habits and diet habits, but on the genetic side there really isn't an answer yet.
Answered by Dr. Preeti Vijayakumaran
In cases of widespread metastasis, can chemotherapy improve the prognosis?
Asked by Dr. Wassim
Yes. In widespread metastasis there is a possible benefit from chemotherapy combined with immunotherapy or targeted therapy. How much survival advantage this brings is, statistically, maybe a couple of months, but it will definitely improve the patient's quality of life during that period.
Answered by Dr. Preeti Vijayakumaran
What is the role of imaging in the workup of esophageal cancer?
Asked by Dr. Shipamba
Essentially, whole-body axial imaging: a PET-CT if it is available, and if not, a contrast-enhanced scan covering the neck, thorax, abdomen and pelvis for staging. In addition, endoscopic ultrasound is used in early-stage disease for more accurate T and N staging, and bronchoscopy and laparoscopy may be used in locally advanced disease, laparoscopy specifically to rule out peritoneal metastasis in cases of adenocarcinoma.
Answered by Dr. Preeti Vijayakumaran
What are the methods of preventing esophageal cancer?
Asked by Dr. Morris
Prevention starts with understanding the risk factors, which depend on the histological subtype. For adenocarcinoma, the drivers can be obesity, reflux disease, and smoking and alcohol, so limiting smoking and alcohol matters, and an existing reflux disease needs to be managed medically. Patients with an already existing condition should also be started early on more stringent endoscopic surveillance. For squamous cell carcinoma, the pathology is more related to smoking and diet habits, and regulating those can make a difference.
Answered by Dr. Preeti Vijayakumaran
Based on your experience, what do you recommend to junior doctors about such an annoying disease of our patients?
Asked by Dr. Dinaol Dinegde
There is a lot of ignorance in our community, especially in our country, about a complex disease like esophageal cancer. Patients have early, subtle symptoms of difficulty swallowing, but they are often ignored and mistaken for some other common ailment. The need for awareness is foremost. As doctors, we should involve ourselves in educating more and more of the public about the disease, its diagnosis and the treatments available, so that if it is detected early, we can offer patients the maximum curative options.
Answered by Dr. Preeti Vijayakumaran
In routine practice we frequently encounter cases of PPD poisoning due to suicide attempts, which lead to caustic esophageal injury resulting in chronic esophagitis. In such cases, can chronic esophagitis be considered a precancerous lesion?
Asked by Dr. Wassim
That is a very valid question. Even in our community we see a lot of cases of caustic esophageal injury, and this chronic esophagitis can eventually lead to stricturous disease and become a predisposing cause for esophageal cancer. Patients who survive such an injury and go on to develop stricturous disease should be kept on a very stringent surveillance protocol.
Answered by Dr. Preeti Vijayakumaran
Is there any specific age at which to start screening by endoscopy or another modality?
Asked by Dr. Gutu
In our practice, screening is recommended after the age of 35 to 40 years, particularly for patients with reflux symptoms or a risk of Barrett's esophagus, though this is a variable number depending on institutional protocol. In practice, we take these patients up for endoscopic mapping: any area showing dysplastic change is biopsied. If there is no evidence of dysplasia after multiple biopsies, the patient is kept on surveillance. Low-grade dysplasia is followed up. High-grade dysplasia in a flat lesion under 2 cm is ablated, and high-grade dysplasia over 2 cm, or with a nodular appearance, is taken for endoscopic resection with histopathology follow-up on the specimen.
Answered by Dr. Preeti Vijayakumaran
In this case of caustic injury from PPD poisoning, what preventive measures should be taken?
Asked by Dr. Wassim
Most of these patients go on to develop stricturous disease, leading to significant dysphagia and a chronic inability to take oral nutrition. In such patients, an esophagectomy with a neo-esophagus is offered. In patients who do not develop stricturous disease, six-monthly endoscopic evaluation with biopsy of any suspicious area is done instead, and further imaging is not required unless a biopsy proves malignancy.
Answered by Dr. Preeti Vijayakumaran
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