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Esophageal cancer

Last reviewed: 5 Sep 2023
Last updated: 25 Apr 2023



History and exam

Key diagnostic factors

  • dysphagia
  • odynophagia
  • weight loss
More key diagnostic factors

Other diagnostic factors

  • hoarseness
  • hiccups
  • postprandial/paroxysmal cough
Other diagnostic factors

Risk factors

  • male sex
  • older age
  • tobacco use
  • excessive alcohol use (squamous cell carcinoma)
  • Barrett esophagus (adenocarcinoma)
  • GERD (adenocarcinoma)
  • hiatal hernia (adenocarcinoma)
  • family history of esophageal or other cancer (squamous cell carcinoma)
  • low socioeconomic status
  • nonwhite race (squamous cell carcinoma)
  • high-temperature beverages and foods (squamous cell carcinoma)
  • drinking maté (squamous cell carcinoma)
  • low intake of fresh fruit and vegetables
  • hereditary cancer syndromes
  • obesity (adenocarcinoma)
  • human papillomavirus (squamous cell carcinoma)
  • achalasia
  • vitamin and mineral deficiencies (squamous cell carcinoma)
  • poor oral hygiene (squamous cell carcinoma)
More risk factors

Diagnostic investigations

1st investigations to order

  • esophagogastroduodenoscopy (EGD) with biopsy
  • CT thorax and abdomen
  • (18F)-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) scan
More 1st investigations to order

Investigations to consider

  • comprehensive metabolic panel
  • MRI thorax and abdomen
  • endoscopic ultrasound (EUS) ± fine needle aspiration (FNA)
  • bronchoscopy ± FNA
  • thoracoscopy and laparoscopy
  • molecular and pathologic tests
  • liquid biopsy
  • pulmonary function tests
  • cardiac stress test
  • echocardiogram
More investigations to consider

Treatment algorithm


limited disease (cT1, cN0, M0)

localized disease (cT2, cN0, M0): suitable for surgery

localized disease (cT2, cN0, M0): unsuitable for surgery

locally advanced disease (cT3-4, cN1-3, M0): suitable for surgery

locally advanced disease (cT3-4, cN1-3, M0): unsuitable for surgery

metastatic (M1) disease


recurrent disease



Naureen Starling, BSc(Hons), MBBS, MD(Res), FRCP

Consultant Medical Oncologist in GI Cancers

Associate Director of Clinical Research, GI and Lymphoma

The Royal Marsden Hospital NHS Trust




NS has received research funding from AstraZeneca, BMS, and Pfizer; travel and accommodation funding from AstraZeneca, BMS, Eli Lilly, Merck, Roche, and MSD Oncology; honoraria from Eli Lilly, Merck Serono, MSD Oncology, Pierre Fabre, Servier, GSK, and Amgen. She has been on the advisory board for Pfizer, AstraZeneca, Servier, and MSD (Merck). NS is an Honorary Clinical Senior Lecturer within the Division of Clinical Studies at the Institute of Cancer Research and serves on the UK National Cancer Research Institute (NCRI) esophagogastric sub-group. NS has acted as a clinical expert in esophagogastric cancer for NICE (guideline committee and technology appraisal) and is an upper GI expert for International Cancer Benchmarking Partnership. She is a Trustee for Pancreatic Cancer UK and a member of the EORTC General Assembly representing The Royal Marsden, as well as a member of the European Society for Medical Oncology (ESMO) Gastrointestinal Faculty. Educational roles include the NIHR Training Lead for NIHR Biomedical Research Centre, member of the Cancer Research Centre of Excellence training committee, Deputy Training Program Director (one of three) for South London Medical Oncology Training, member of the pan-London specialist Medical oncology training committee, and member of the Medical Oncology National Recruitment steering committee.

Caroline Fong, MBChB, MRes, MRCP

Clinical Research Fellow

GI and Lymphoma Unit

The Royal Marsden Hospital NHS Trust




CF declares that she has received honoraria from Bristol Myers Squibb.


Dr Naureen Starling and Dr Caroline Fong would like to gratefully acknowledge Dr Mark J. Krasna and Dr Ghulam Abbas, previous contributors to this topic.


MJK is an author of several references cited in this topic. GA declares that he has no competing interests.

Peer reviewers

Peter McCulloch, MBChB, MA, MD, FRCS (Ed), FRCS (Glas)

Clinical Reader in Surgery

Nuffield Department of Surgery

University of Oxford




PM declares that he has no competing interests.

Nikhil I. Khushalani, MD

Assistant Professor of Oncology

Roswell Park Cancer Institute




NIK has received funding for the conduction of clinical trials and associated translational studies from Merck, Pfizer, and Astra-Zeneca. NIK has a grant from the National Comprehensive Cancer Network (from research support by Roche).

  • Esophageal cancer images
  • Differentials

    • Benign stricture
    • Achalasia
    • Barrett esophagus
    More Differentials
  • Guidelines

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    • NCCN clinical practice guidelines in oncology: management of immunotherapy-related toxicities
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  • Patient leaflets

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