Workup and Management of Esophageal Mass
The recommended workup for an esophageal mass begins with flexible endoscopy with biopsy to establish histologic diagnosis, followed by CT scan of the thorax and abdomen for initial staging, and endoscopic ultrasound for local staging if metastatic disease is not found on CT. 1
Initial Diagnostic Approach
Endoscopy and Biopsy
- Perform flexible endoscopy with multiple biopsies (minimum of six) of any mucosal abnormality 1
- Special staining techniques like Toluidine blue or Lugol can help define tumor extent 1
- Biopsy confirmation is mandatory before proceeding with treatment 1
- High-grade dysplasia findings warrant urgent repeat endoscopy and biopsy 1
Initial Imaging
- CT scan of thorax and abdomen with multiplanar reconstructions is the first staging study to detect metastatic disease 1
- For gastric/esophagogastric junction tumors, adequate gastric distension with 600-800ml of water improves visualization 1
Comprehensive Staging
Endoscopic Ultrasound (EUS)
- Perform EUS if CT does not show metastatic disease 1
- EUS provides accurate T-staging and assessment of regional lymph nodes 1
- For T1 tumors or nodularity in high-grade dysplasia, staging by endoscopic resection should be used to define depth of invasion 1
- Fine needle aspiration of suspicious regional lymph nodes should be performed during EUS 1
Additional Imaging
- PET-CT is recommended in combination with EUS and CT for assessment of esophageal and esophagogastric junction cancers 1
- PET-CT helps identify otherwise undetected distant metastases 1
- Laparoscopy should be performed in gastric cancers and selected lower esophageal/esophagogastric junction tumors to rule out peritoneal metastases 1
Other Assessments
- Bronchoscopy should be performed for mid and upper esophageal tumors to exclude tracheo-bronchial extension 1
- Head and neck examination to look for synchronous lesions in squamous cell carcinoma 1
- Assessment of respiratory function, cardiac status, and nutritional state 1
Management Based on Staging
Early Disease (Tis-T1a, N0)
- Endoscopic resection is recommended for selected patients with early cancer (Tis-T1a, N0) 1
- Surgical resection is an alternative for early-stage disease 1
Localized Disease (T1-T2, N0)
- Surgical resection is the standard treatment 1
- For esophageal adenocarcinoma: subtotal transthoracic esophagectomy with nodal clearance 1
- For distal (antral) gastric tumors: subtotal gastrectomy 1
- For proximal gastric tumors: total gastrectomy 1
Locally Advanced Disease (T3-T4 or N+)
- Preoperative (neoadjuvant) therapy is recommended:
- For inoperable cases: definitive chemoradiotherapy (RTOG schedule: four cycles of 5-FU-cisplatin with 50 Gy radiotherapy) 1
Advanced/Metastatic Disease
- Palliative chemotherapy (5-FU based regimens) 1
- Palliative interventions: stenting, endoscopic tumor ablation, or dilation for dysphagia 1
Important Considerations
Multidisciplinary Approach
- Treatment planning should involve a multidisciplinary team including gastroenterologists, surgeons, oncologists, radiologists, and pathologists 1
Pathology Reporting
- Reports on esophageal resection specimens should include: tumor type, depth of invasion, resection margins, vascular invasion, presence of Barrett's metaplasia, and lymph node status 1
- Reports on gastric resection specimens should include: tumor type, depth of invasion, resection margins, nodal disease, and metastatic spread 1
Common Pitfalls
- Antisecretory therapy should be withheld until after endoscopy to avoid misdiagnosis 1
- Gastric ulcers should be followed up to healing with repeat biopsy to exclude malignancy 1
- High-grade dysplasia diagnosis should be confirmed by an experienced pathologist with special interest in gastrointestinal disease 1
- Inadequate number of biopsies may lead to false-negative results 1
By following this systematic approach to the workup and management of esophageal masses, clinicians can ensure appropriate staging and treatment selection to optimize patient outcomes.