Esophageal Cancer

Picture of Esophageal Cancer (Cancer of the Esophagus)

The esophagus is a muscular tube measuring 20-25 cm (8-10 in) long and 2-3 cm (0.75-1.25 in) wide that serves as a conduit for moving food and drink from the mouth to the stomach. Two major types of esophageal cancers exist, as follows:

• Squamous cell carcinoma arises from the surface (epithelial) cells that line the esophagus.
• Adenocarcinoma arises from the esophageal glands or within a segment of Barrett's esophagus
• Although tumors can arise anywhere in the esophagus, adenocarcinoma arises more frequently in the lower portion while squamous cell carcinoma arises more frequently in the upper part of the esophagus.
• Other tumor types are rarely seen (lymphoma, melanoma, or sarcoma).
• Symptoms of esophageal cancer usually do not show up until the disease has reached an advanced stage.
• Five-year survival for esophageal cancer can exceed 50% for stage 1 and then drop to 0% for stage 4.

Esophageal cancer is a disease where the tissues of the tube-like structure that connects the throat to the stomach (esophagus) become malignant (cancer).

Esophageal cancers may be generally termed "esophagus cancer" or more specifically termed in relation to their location and type such as "gastroesophageal junction adenocarcinoma" (meaning an adenoma located where the stomach and esophagus are connected).

• Symptoms of esophageal cancer usually do not show up until the disease has reached an advanced stage.
• The most common symptom is difficulty swallowing (dysphagia).
  • Initially, swallowing solids is difficult.
  • Over time, even swallowing liquids becomes difficult.
• The following symptoms may accompany cancer of the esophagus. Any of these symptoms are indications of advanced disease and should be considered as a sign to get medical attention.
  • Weight loss
  • Central chest pain and/or pain behind the breastbone
  • Pain upon swallowing
  • Vomiting
  • Chronic cough and/or hoarseness
  • Symptoms of gastrointestinal bleeding
    • Black stools
    • Vomiting blood or material that looks like coffee grounds

According to the American Cancer Society and others who treat esophageal cancers, the exact cause or causes of this disease are not known. However, researchers suspect that certain risk factors (see below) may cause DNA damage in cells that may result in the disease.

Both types of esophageal cancer more commonly affect men older than 60 years, but the risk factors for adenocarcinoma are different from those of squamous cell carcinoma.

• Adenocarcinoma of the esophagus is most commonly seen within a segment of Barrett's esophagus, where they arise from chronic peptic sores in the lower esophagus. This is an acquired condition characterized by precancerous cells that replace the standard cellular lining of the lowest portion of the esophagus. The condition occurs as a complication of chronic reflux of gastric contents (GERD) into the lower esophagus.
• Squamous cell carcinoma occurs more commonly in people who heavily use tobacco and alcohol or who have previously swallowed some caustic substance, for example, lye condition. The disease is also more common in people who have been diagnosed with squamous cell cancer of the head and neck.
• Men are up to five times more likely than women to be diagnosed with esophageal cancer.
  • Among men, African Americans have the highest rate, more than 2.7 times greater than the rate for non-Hispanic white men.
  • Incidence rates generally increase with age in all racial and ethnic groups.
• Cancer of the esophagus is common cancer in developing countries of the world, where most tumors are squamous cell cancers.
• Important risk factors in developing countries include the following:
  • Nutritional deficiencies related to a lack of fresh fruit and vegetables
  • Drinking hot beverages
  • A range of chewing and smoking habits
  • HPV infection (squamous cell cancer of the esophagus)
• Adenocarcinoma is becoming more common in the developed world than squamous cell cancer.

Your team of doctors may include

• gastroenterologists,
• oncologists,
• surgeons,
• radiation oncologists,
• pathologists, and
• support personnel such as dietitians.

Together, they can develop diagnostic tests and treatments best suited for your individual disease.

The best diagnosis is based on findings from an endoscopic examination of the esophagus.

• This study may be carried out either in a hospital or in a doctor's office.
• The doctor administers a topical anesthetic to the throat to suppress the gag reflex. Doctors frequently give intravenous (IV) sedation just before the procedure.
• The doctor then inserts an endoscope into the esophagus. An endoscope is a thin, flexible plastic tube that contains fiberoptic bundles.
  • Using a tiny camera in the endoscope, the doctor searches the surface of the esophagus for areas of concern and may biopsy tissue.
  • Doctors define esophageal tumors in terms of their size and location.
    • Stage I - Tumor limited to the top layers of the cell lining
    • Stage II - Tumor extending deeper into muscle layers of the esophagus or into adjacent lymph nodes
    • Stage III - Tumor extensively involving the wall of the esophagus, adjacent tissues, or lymph nodes
    • Stage IV - Tumor involving distant parts of the body (metastases) and may involve the liver, lungs, brain, or bones
  • These factors are important in determining the stage of cancer and treatment options.
  • The doctor can take biopsies to confirm whether the abnormality is cancer and to determine its type.
• Upper gastrointestinal (GI) barium contrast studies help the doctor to detect cancers but may fail to detect small tumors more easily seen through endoscopy or esophagoscopy.
• Endoscopic ultrasound: Pictures created with sound waves passed through the endoscope can help to determine the depth of invasion of cancer and the status of the surrounding tissues, including lymph nodes.
• Once the presence of cancer has been confirmed, the doctor tries to determine the spread of the malignancy beyond the esophagus. Doctors may use the following imagery:
  • CT scan of the chest and abdomen
  • Chest X-ray
  • PET scan in combination with CT scan
  • Nuclear bone scans
  • Thoracoscopy

Treatment for esophageal cancer depends on the results of tests and your underlying health.

• People with advanced heart or lung disease may not be candidates for aggressive therapy.
• In many cases, esophageal cancer has advanced too far for any available treatment to work.
  • In these cases, the doctor considers the following palliative procedures:
    • Placing a metal or plastic tube (stent) in the esophagus to allow passage of food and liquids
    • Radiation therapy
    • Photodynamic therapy (tissues are sensitized chemically and then treated with a focused light source internally)
    • Widening (cautious dilation) of the esophagus or laser destruction of the esophageal tumor
    • Other palliative procedures (electrocoagulation, laser ablation, for example)
    • Pain management
    • Managing complications such as bleeding

In otherwise healthy people with localized disease, surgery may offer the best chance at long-term survival.

• Surgery involves removing the diseased portion of the esophagus and connecting the remaining portion to the stomach (resection).
• Preoperative chemotherapy and radiation often accompany surgery.
• Studies now underway will determine whether a combination of chemotherapy and radiation therapy without surgery is as effective as surgery in lengthening long-term survival. Present results give conflicting opinions. Research continues.

When esophageal cancer spreads to organs beyond the esophagus, long-term survival is uncommon. The chance of recovery improves when doctors detect cancer at an early stage.

Five-year survival for esophageal cancer can exceed 50% for stage 1, and then drop to

• 20% in stage 2,
• 10%-15% in stage 3, and
• essentially zero for stage 4.

Once cancer invades the muscle layer of the esophagus, most people already have developed widespread cancer.

• For these people, cancers invariably come back following surgical removal. Few people survive long-term.
• Following completion of therapy, whether with surgery, radiation, chemotherapy, or a combination of these, the patient needs regular follow-up endoscopic examinations as well as repeat CT scans of the chest and abdomen.
• Often, people who undergo surgery on their esophagus develop significant side effects, such as narrowing at the site of the surgery. They require frequent esophageal dilatations or insertion of stents.

The esophagus lies between the mouth and the stomach and serves as a conduit for food and liquids to the gastrointestinal tract.

• Reducing the use of tobacco and alcohol can reduce the frequency of squamous cell carcinoma of the esophagus. Today it is recognized that HPV infection increases the risk of squamous cell carcinoma of the esophagus three-fold. HPV vaccination programs for young men and women can be expected to reduce the risk of this disease over time.
• Adenocarcinoma of the esophagus is a frequent complication in Barrett's esophagus, which may be found in some people with symptoms of gastroesophageal reflux disease (GERD).
  • People with frequent symptoms of acid reflux (heartburn or regurgitation) should undergo screening with endoscopy.
  • People with Barrett's esophagus should have regular endoscopic tests to detect precancerous changes in the esophageal lining.
  • They also require tight control of the symptoms of gastroesophageal reflux, which may include dietary and lifestyle changes as well as medications and possible surgery, to prevent the progression of Barrett's esophagus.