A 57-year-old man comes to the office due to chest pain. The pain is burning in nature and is not related to meals. The patient has lost 18 kg (40 lb) over the last 6 months; he attributes this to eating a selective diet and carefully chewing his food before swallowing. In addition, the patient has had fatigue and malaise as well as decreased interest in his usual activities. His medical history is notable for long-standing gastroesophageal reflux for which he takes famotidine. He has a 20-pack-year smoking history but quit 4 years ago. The patient occasionally drinks alcohol. He works as a missionary and makes frequent trips abroad. His father died at age 67 from lung cancer. The patient's vital signs are normal. Physical examination, including lymph node, cardiopulmonary, and abdominal examinations, is unremarkable. Chest x-ray reveals no abnormalities. Which of the following is the best next step in management of this patient?
Esophageal cancer | |
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GI = gastrointestinal; PET = positron emission tomography. | |
Esophageal cancer should be strongly suspected in this patient given his age, persistent burning chest pain, significant weight loss, and possible dysphagia (although carefully chewing food before swallowing is sometimes used as a weight loss technique, it can be a subtle sign of progressive dysphagia). Because manifestations can be subtle and nonspecific, esophageal cancer often presents at an advanced stage. Most esophageal malignancies are either adenocarcinoma or squamous cell carcinoma. Adenocarcinoma usually arises within an area of Barrett esophagus near the gastroesophageal junction; risk is increased with smoking and gastroesophageal reflux disease (GERD). Squamous cell carcinoma can occur anywhere in the esophagus; risk is increased with smoking and heavy alcohol consumption.
Definitive diagnosis of esophageal cancer requires esophageal endoscopy with biopsy. Young, low-risk patients with undetermined esophageal symptoms may start with barium esophagram, but those who are age >50 as well as those with alarm symptoms (eg, weight loss, gross or occult bleeding, early satiety) will usually proceed directly to endoscopy. Subsequent staging procedures may include CT scan and positron emission tomography (Choice B). For patients with limited-stage disease, surgery for definitive cure.
(Choices A and B) Bronchoscopy is indicated for evaluation of accessible pulmonary masses or for patients with additional symptoms (eg, hemoptysis) of an endobronchial lesion. This patient has a normal chest x-ray and possible dysphagia, making esophageal cancer more likely than lung malignancy. Low-dose chest CT scan for lung cancer screening in eligible patients is a noncontrast study; a chest CT with and without contrast is not indicated.
(Choices C and D) Nutritional review is advised for patients with weight loss due to behavioral disorders, swallowing dysfunction, or food intolerance. Proton pump inhibitors (eg, omeprazole, lansoprazole) are useful for patients with typical symptoms of GERD who fail other medications. However, patients with alarm symptoms or other features of malignancy should have a more definitive evaluation first.
(Choice E) Helicobacter pylori infection is usually not associated with esophageal disorders. Testing would be considered in some patients with unexplained dyspepsia and no alarm symptoms for stomach malignancy; this patient has several alarm symptoms for malignancy.
Educational objective:
Diagnosis of esophageal cancer requires esophageal endoscopy with biopsy. Young, low-risk patients with undetermined esophageal symptoms may start with barium esophagram, but those who are age >50 or with alarm symptoms (eg, weight loss, gross or occult bleeding, early satiety) should proceed directly to endoscopy.