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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
Key points
- Progressive dysphagia to solids then liquids with weight loss is esophageal cancer until proven otherwise
- Adenocarcinoma: distal esophagus, Barrett, GERD, obesity, White male risk pattern
- Squamous cell carcinoma: upper/mid esophagus, tobacco, alcohol, caustic injury, achalasia
- Diagnosis: upper endoscopy with biopsy
- Staging: CT/PET for metastasis and EUS for local T/N staging when no distant metastasis
Overview
Esophageal cancer occurs as adenocarcinoma or squamous cell carcinoma. Adenocarcinoma arises from Barrett esophagus and predominates distally in the United States. Squamous cell carcinoma is linked to tobacco, alcohol, caustic injury, achalasia, and some dietary exposures.
Epidemiology
Esophageal adenocarcinoma has increased with obesity and GERD. SCC remains common worldwide and in patients with heavy tobacco/alcohol exposure. Prognosis is often poor because symptoms develop after significant narrowing or invasion.
Clinical Features
Symptoms
Progressive dysphagia initially to solids then liquids
Unintentional weight loss, anorexia, fatigue
Odynophagia or chest/back pain
Hoarseness from recurrent laryngeal nerve involvement
Hematemesis, melena, or iron deficiency anemia
Aspiration/cough with tracheoesophageal fistula
Signs
Weight loss/cachexia
Supraclavicular lymphadenopathy
Signs of aspiration pneumonia
Hepatomegaly or bone tenderness in metastasis
Investigations
First-line
Upper endoscopy with biopsyDiagnostic test of choice
CBC/CMPAnemia, nutrition status, hepatic involvement
Barium esophagramAnatomic assessment but not definitive
Second-line
CT chest/abdomen/pelvisInitial staging
PET/CTOccult distant metastases
EUST and N staging if no distant metastasis
Specialist
BronchoscopyUpper/mid tumors near airway
Diagnostic laparoscopySelected GE junction tumors
1
Localized disease
- Endoscopic resection/ablation for very early mucosal disease or high-grade Barrett dysplasia
- Neoadjuvant chemoradiation followed by esophagectomy for many locally advanced tumors
- Perioperative chemotherapy for selected distal/GE junction adenocarcinomas
2
Advanced disease
- Systemic therapy guided by HER2, PD-L1, MSI/MMR, performance status
- Radiation or stenting for dysphagia palliation
- Nutrition support with enteral feeding when needed
3
Prevention/surveillance
- Treat chronic GERD
- Screen selected high-risk patients for Barrett
- Endoscopic eradication therapy for Barrett dysplasia
Complications
- Obstruction/malnutrition: Progressive dysphagia.
- Aspiration: Regurgitation or fistula.
- Tracheoesophageal fistula: Coughing with swallowing.
- Metastasis: Liver, lung, bone, lymph nodes.
USMLE Step 2 CK Exam Tips
- 1Solids-only dysphagia progressing to liquids = mechanical obstruction/cancer
- 2Achalasia has solids and liquids from the start
- 3Distal adenocarcinoma = Barrett/GERD/obesity; mid-upper SCC = tobacco/alcohol
- 4EGD with biopsy is diagnostic
- 5EUS is staging, not initial diagnosis
- 6Hoarseness means recurrent laryngeal nerve involvement
- 7Barrett is precursor to adenocarcinoma, not squamous cancer
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