Esophageal cancer differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2]Hadeel Maksoud M.D.[3]

Overview

Esophageal cancer must be differentiated from gastroesophageal reflux disease (GERD), Barrett's esophagus, esophageal achalasia, gastritis, gastric ulcer, and stomach cancer.

Differentiating Esophageal cancer from other Diseases

Approach to dysphasia

Dysphagia

Oropharyngeal dysphagia

Esophageal dysphagia

Solids only

Solids and Liquids

Solids only

Solids and Liquids

❑Zenker's diverticulum ❑Neoplasm ❑Webs

Neurogenic

Myogenic

Pain

❑Achalasia ❑Scleroderma ❑DES

❑Myasthenia gravis ❑Connective tissue disorder ❑Myotonic dystrophy

No

Yes

❑Heart burn

Barium swallow

Mental status

❑Pill esophagitis ❑Caustic injury ❑Chemotherapy

Yes

No

Impaired

Normal

Non progressive

Progressive

Sac

Webs

Mass

❑Scleroderma

❑Achalasia ❑DES

❑Stroke

❑ALS ❑Parkinsonism

❑Rings ❑Webs

❑Strictures ❑Cancer

❑Zenker's diverticulum

❑Plummer-Vinson syndrome

❑Carcinoma

Chest pain and manometry

Barium swallow

Weight loss

Increase LES pressure

❑Rings

❑Webs

Yes

No

Rapid

Slow

❑Achalasia

❑DES

❑Esophageal cancer

❑Strictures/GERD

Differentiating Esophageal cancer from other Diseases

• Esophageal adenocarcinoma must be differentiated from other causes of dysphagia, odynophagia and food regurgitation such as GERD, esophageal stricture, reflux esophagitis, systemic sclerosis, esophageal spasm, pseudoachalasia, stroke, esophageal candidiasis and Chagas disease.

Disease	Signs and Symptoms				Barium esophagogram	Endoscopy	Other imaging and laboratory findings	Gold Standard
	Dysphagia	Weight loss	Heartburn	Other findings
Esophageal carcinoma	Gradual progressive dysphasia to solid and liquid	+	±	Lymphadenopathy Cachexia	Irregular stricture Pre-stricture dilatation Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 4232f	Esophageal obstruction Staging of disease {{#ev:youtube|5ucSlgqGAno}}	CT and PET scan for staging of the disease	Biopsy
Plummer-Vinson syndrome	Gradual non-progressive dysphagia to solids	±	-	Glossitis Koilonychia Weakness Pale color of the skin Cold intolerance Reduced resistance to infection Altered behavior Craving for for unusual items (such as ice or cold vegetables)	Thin projections on the anterior esophageal wall Multiple upper esophageal constrictions Barium esophagogram (Source: Case courtesy of Dr Hani Salam, Radiopaedia.org, rID: 14029)	Direct visualization of esophageal webs Superior to esophagogram {{#ev:youtube|HFfsTgsB6Pg}}	Videofluoroscopy shows mucosal and submucosal foldings Iron deficiency anemia	Triad of Iron deficiency anemia Esophageal webs Glossitis
Esophageal stricture	Sudden onset and gradual progressive dysphasia to solids	+/-	+/-	Odynophagia Cough Chest pain	Sacculations Fixed transverse folds Esophageal intramural pseudodiverticula    Case courtesy of Dr Ahmed Abd Rabou, Radiopaedia.org, rID: 23008	Mucosal edema Circumferential thickening in GERD Pale mucosa with white exudate in lymphocytic esophagitis Swelling and hemorrhagic congestion in caustic ingestion {{#ev:youtube|vax5E-jMnQ}}	Manometry may show dysmotility CT scan for staging malignant strictures	Barium esophagogram
Diffuse esophageal spasm	Sudden non-progressive dysphagia to solid and liquid	+	+	Chest pain	Nonperistaltic and nonpropulsive contractions Corkscrew or rosary bead esophagus Barium swallow appearance of DES Source:By Nevit Dilmen [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)	Inconclusive {{#ev:youtube|2ipA34iMA3c}}	Manometry shows high-amplitude esophageal contractions CT scan may show hypertrophy of esophageal muscles	Manometry
Achalasia	Gradual non-progressive dysphagia to solid and liquid	+/-	-	Regurgitation of undigested food Chest pain	"Bird's beak" or "rat tail" appearance Dilated esophageal body Air fluid level (absent peristalsis) Absence of an intragastric air bubble Case courtesy of Dr Mario Umana, Radiopaedia.org, rID: 38071	Dilated esophagus Residual food fragments Normal mucosa {{#ev:youtube|ydLcskQzEjM}}	Residual pressure of LES > 10 mmHg Incomplete relaxation of the LES Increased resting tone of LES Aperistalsis	History of dysphagia with positive endoscopy and manometry
Systemic sclerosis	Gradual progressive dysphasia to solid and liquid	+/-	+	Muscle and joint pain Raynaud's phenomenon Skin changes	Dysmotility Patulous esophagus	Mucosal damage Peptic stricture (advanced cases)	Positive serology for Antinuclear antibodies Rheumatoid factor Creatine kinase ESR	Skin biopsy
Zenker's diverticulum	Gradual dysphasia to solid	+/-	-	Food regurgitation Halitosis Cough Hoarseness	Thin projections on esophageal wall over Killian's triangle	Outpouching of posterior pharyngeal wall Exclude the presence of SCC {{#ev:youtube|FdEruFsNdVA}}	CT & MRI shows out-pouching over the posterior esophagus in the Killian's triangle	Barium esophagography
Stroke (Cerebral hemorrhage)	Sudden progressive dysphasia to solid and liquid	+	+/-	Dysarthria Limb weakness Fatigue	Pooling of contrast in the pharynx Aspiration of barium contrast into the airway	Reduced opening of upper esophageal sphincter Reduced larynx elevation	CT without contrast shows acute hemorrhage as a hyperattenuating clot	CT without contrast
Motor disorders (Myasthenia gravis)	Gradual progressive dysphasia to solid and liquid	+/-		Ptosis Diplopia Fatigue	Stasis in pharynx and pooling in pharyngeal recesses	Velopharyngeal insufficiency Delayed swallowing function	CT may show anterior mediastinal mass (thymoma) Positive tensilon test	Anti–acetylcholine receptor antibody test
GERD	Sudden onset gradual progressive dysphasia to solid	+/-	+	Cough Hoarseness	Free acid reflux Esophagitis with scarring Strictures Barrett's oesophagus	Erythema, erosions and ulceration Barrett's esophagus	Esophageal manometry may show decreased tone of LES	24 hour esophageal pH monitoring
Esophageal web	Gradual progressive dysphasia to solid and/or liquid	-	+/-	Findings of the underlying cause such as iron deficiency anemia or bullous pemphigoid	Symmetrical narrowing of the esophagus	Smooth membrane not encircling the whole lumen	Videofluoroscopy shows mucosal and submucosal foldings	Barium esophagogram

	Manifestations	Diagnostic tools
Achalasia	Dyspnea Dysphagia for solids and liquids is the most common feature, being seen in 91 % and 85% of patients respectively Regurgitation of undigested food occurs in 76-91% of patients Cough mainly when lying down in 30%	Esophagogastroduodenoscopy findings include a dilated esophagus with residual food fragments, normal mucosa and occasionally candidiasis (due to the prolonged stasis). Barium swallow shows the characteristic bird's beak appearance. Barium swallow showing bird's beak appearance - By Farnoosh Farrokhi, Michael F. Vaezi. - Idiopathic (primary) achalasia. Orphanet Journal of Rare Diseases 2007, 2:38(http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2040141), CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=2950922
GERD	Retrosternal burning chest pain. Cough and hoarseness of voice. May present with complications such as strictures and dysphagia.	Upper GI endoscopy shows the complications such as esophagitis and barret esophagus. Esophageal manometry may show decreased tone of the lower esophageal sphincter. 24-hour esophageal pH monitoring may be done to confirm the diagnosis. Barret's esophagus - By Samir धर्म - taken from patient with permission to place in public domain, Copyrighted free use, https://commons.wikimedia.org/w/index.php?curid=1595945
Corckscrew esophagus	Retrosternal chest pain that presents with or without food intake. The condition is not progressive and not causing complications.	Barium swallow shows the characteristic corckscrew appearance of the esophagus. Corckscrew esophagus - Case courtesy of Radswiki, Radiopaedia.org, rID: 11680
Esophageal stricture	Patient may present with the symptoms of the underlying GERD. Dysphagia and odynophagia.	Barium esophagography provides information about the site and the diameter of the stricture before the endoscopic intervention. Peptic stricture - By Samir धर्म - From en.wikipedia.org, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1931423
Plummer-Vinson syndrome	Common symptoms of Plummer-Vinson syndrome include: Difficulty swallowing (more for solids) Weakness Pain Burning sensation in mouth Dry tongue Painful cracks in the angles of a dry mouth Pale color of the skin Less common symptoms Cold intolerance Reduced resistance to infection Altered behavior Craving for for unusual items (such as ice or cold vegetables)	Lab tests are consistent with the diagnosis of iron deficiency anemia. Findings on an x-ray (barium esophagogram) suggestive of esophageal web/strictures associated with Plummer-Vinson syndrome appear as either: Thin projections on the anterior esophageal wall. Multiple upper (cervical) esophageal constrictions consistent with esophageal webs. Plummer-Vinson syndrome (Source: Case courtesy of Dr Hani Salam, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/14029">rID: 14029</a>)

References

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