What is the management approach for a patient with esophageal infiltration?

Management of Esophageal Infiltration

All patients with esophageal infiltration require immediate multidisciplinary team evaluation with thorough staging via CT thorax/abdomen and endoscopic ultrasound to determine resectability and guide treatment decisions toward curative resection versus palliative management. 1

Initial Diagnostic Approach

The term "esophageal infiltration" most commonly refers to malignant invasion of the esophageal wall, though it can also describe inflammatory conditions (eosinophilic esophagitis) or rare metastatic disease from other primary cancers.

Mandatory Initial Workup

• Endoscopy with biopsy is essential to establish tissue diagnosis before any treatment decisions, as histological confirmation is required and accuracy increases with the number of biopsies obtained 1
• Withhold antisecretory therapy until after endoscopy to avoid masking malignant lesions and causing misdiagnosis 1
• Do not assume benign disease in patients with longstanding reflux or dysphagia until endoscopy with biopsy excludes malignancy 1

Critical Red Flags Requiring Urgent Evaluation

• Alarm symptoms including weight loss, vomiting, anemia, or dysphagia combined with dyspeptic symptoms warrant immediate referral and investigation 1
• Persistent pain, breathlessness, fever, or tachycardia after any esophageal procedure suggests perforation requiring emergency management 2, 3

Staging Protocol for Malignant Infiltration

Accurate staging is mandatory for all patients to plan optimal therapeutic options and avoid futile interventions. 1

Required Staging Investigations

• Spiral CT of thorax and abdomen as initial assessment to determine presence or absence of metastatic disease 1
• Endoscopic ultrasound (EUS) is the preferred method for assessing operability in the absence of metastatic disease, particularly for determining T4b status with invasion of airways, pericardium, or aorta 1
• FDG-PET/CT should be performed in surgical candidates to identify otherwise undetected distant metastases and avoid futile surgery 1

Additional Staging Modalities in Selected Cases

• Bronchoscopy with endobronchial ultrasonography when tumor growth toward central airways is suspected, especially if tumor stricture precludes EUS 1
• Laparoscopy for locally advanced (T3/T4) adenocarcinomas of the gastroesophageal junction infiltrating the cardia to rule out peritoneal metastases (found in ~15% of patients) 1
• Head and neck examination for squamous cell carcinoma patients, as 6.7% have synchronous head/neck second primary tumors that worsen prognosis 1

Treatment Algorithm Based on Stage

Resectable Disease (No Metastases, Operable by EUS)

• Surgical resection within a multidisciplinary team framework is the primary curative approach 1
• Preoperative medical risk assessment must include cardiovascular, respiratory, renal function tests, and nutritional status evaluation per ESPEN guidelines 1
• Nutritional support is integral as >50% of patients lose >5% body weight before surgery, which increases operative risk and worsens survival 1
• Supervised exercise programs should be recommended as reduced physical fitness negatively predicts long-term survival 1

Unresectable or Metastatic Disease

• Palliative management including esophageal dilation, stent insertion, or other palliative procedures for dysphagia relief 1
• Esophageal dilation can be performed safely even with concurrent radiotherapy, and mucosal biopsies do not prohibit dilation during the same procedure 1

Special Considerations for Non-Malignant Infiltration

Eosinophilic Esophagitis

• Consider this diagnosis in patients with refractory GERD symptoms unresponsive to antacid therapy, particularly when esophageal biopsies show marked eosinophilic infiltration 4
• Corticosteroids are the appropriate treatment rather than antacid drugs in confirmed eosinophilic esophagitis 4
• Endoscopic dilation or bougienage is safe and effective for esophageal stricture management in combination with medical/dietary therapy 5

Metastatic Infiltration from Other Primaries

• Suspect secondary esophageal infiltration when a patient has a history of malignancy (particularly ovarian carcinoma) combined with dysphagia and CT showing concentric esophageal wall thickening 6
• CT typically shows concentric thickening of esophageal layers, though endoscopic diagnosis may be delayed due to submucosal involvement 6

Critical Pitfalls to Avoid

• Never proceed to definitive treatment based on cytology alone—histological confirmation is mandatory 1
• Do not delay diagnosis by assuming benign stricture in patients with chronic reflux symptoms without tissue confirmation 1
• Recognize that >50% of esophageal perforations have delayed diagnosis—maintain high clinical suspicion when patients develop pain, fever, or tachycardia after procedures 2
• Contrast-enhanced CT has 92-100% sensitivity for perforation and should be obtained urgently when suspected 2