Esophageal cancer

Synonyms

1

Overview

Esophageal cancer is a cancer of the esophagus, the hollow tube that carries food and liquids from the throat to the stomach. As the cancer grows, symptoms may include painful or difficult swallowing, weight loss and coughing up blood. There are two subtypes: squamous cell cancer and adenocarcinoma. Squamous cell cancer arises from the cells that line the upper part of the esophagus. Adenocarcinoma arises from glandular cells that are present at the junction of the esophagus and stomach. Esophageal tumors usually lead to dysphagia (difficulty swallowing), pain and other symptoms, and are diagnosed with biopsy. Small and localized tumors are treated surgically with curative intent. Larger tumors tend not to be operable and hence cannot be cured; their growth can still be delayed with chemotherapy, radiotherapy or a combination of the two. In some cases chemo- and radiotherapy can render these larger tumors operable. Prognosis depends on the extent of the disease and other medical problems, but is fairly poor.

Symptoms

  • Difficulty swallowing (dysphagia)
  • Weight loss without trying
  • Chest pain, pressure or burning
  • Fatigue
  • Frequent choking while eating
  • Indigestion or heartburn
  • Coughing or hoarseness
  • Esophageal neoplasm
  • Feeding difficulties in infancy
  • Weight loss

Early esophageal cancer typically causes no signs or symptoms.

Causes

The exact cause is usually not known, but both environmental and genetic factors are throught to play a role in the development of this condition. In the United States, risk factors for developing esophageal cancer include smoking, heavy drinking, obesity, and damage from acid reflux.

As it is mention above, there are certain risk factors that make getting esophageal cancer more likely:

  • Age – most patients are over 60, and the median in US patients is 67.
  • Sex – the disease is more common in men.
  • Heredity – it is more likely in people who have close relatives with cancer.
  • Tobacco smoking and heavy alcohol use increase the risk, and together appear to increase the risk more than either individually. Tobacco and alcohol account for approximately 90% of all esophageal squamous cell carcinomas. Tobacco smoking is also linked to esophageal adenocarcinoma though no scientific evidence has been found between alcohol and esophageal adenocarcinoma.
  • Gastroesophageal reflux disease (GERD) and its resultant Barrett's esophagus increase esophageal cancer risk due to the chronic irritation of the mucosal lining. Adenocarcinoma is more common in this condition. A consequence of GERD is increased exposure of the esophagus to bile acids; and bile acids have been implicated as causal agents in esophageal adenocarcinoma (reviewed by Bernstein et al.)
  • Human papillomavirus (HPV)
  • Corrosive injury to the esophagus by swallowing strong alkalines (lye) or acids
  • Particular dietary substances, such as nitrosamines
  • A medical history of other head and neck cancers increases the chance of developing a second cancer in the head and neck area, including esophageal cancer.
  • Plummer–Vinson syndrome (anemia and esophageal webbing)
  • Tylosis and Howel–Evans syndrome (hereditary thickening of the skin of the palms and soles)
  • Radiation therapy for other conditions in the mediastinum
  • Coeliac disease predisposes towards squamous cell carcinoma.
  • Obesity increases the risk of adenocarcinoma fourfold.It is suspected that increased risk of reflux may be behind this association.
  • Thermal injury as a result of drinking hot beverage
  • Alcohol consumption in individuals predisposed to alcohol flush reaction
  • Achalasia

Prevention

The following may help reduce your risk of squamous cell cancer of the esophagus:

  • Avoid smoking
  • Limit or do not drink alcoholic beverages

People with symptoms of severe gastroesophageal reflux should seek medical attention.

Screening with EGD and biopsy in people with Barrett's esophagus may lead to early detection and improved survival. People who are diagnosed with Barrett's esophagus should consider getting regular checkups for esophageal cancer.

Screening:
People with Barrett esophagus (a change in the cells lining the lower esophagus) are at much higher risk, and may receive regular endoscopic screening for the early signs of cancer. Because the benefit of screening for adenocarcinoma in people without symptoms is unclear, it is not recommended in the United States. Some areas of the world with high rates of squamous-carcinoma have screening programs.

Diagnosis

Tests and procedures used to diagnose esophageal cancer include:

  • Using a scope to examine your esophagus (endoscopy). During endoscopy, your doctor passes a hollow tube equipped with a lens (endoscope) down your throat and into your esophagus. Using the endoscope, your doctor examines your esophagus looking for cancer or areas of irritation.
  • X-rays of your esophagus. Sometimes called a barium swallow, an upper gastrointestinal series or an esophagram, this series of X-rays is used to examine your esophagus. During the test, you drink a thick liquid (barium) that temporarily coats the lining of your esophagus, so the lining shows up clearly on the X-rays.
  • Collecting a sample of tissue for testing (biopsy). A special scope passed down your throat into your esophagus (endoscope) or down your windpipe and into your lungs (bronchoscope) can be used to collect a sample of suspicious tissue (biopsy). What type of biopsy procedure you undergo depends on your situation. The tissue sample is sent to a laboratory to look for cancer cells.

Esophageal cancer staging:

When you're diagnosed with esophageal cancer, your doctor works to determine the extent (stage) of the cancer. Your cancer's stage helps determine your treatment options. Tests used in staging esophageal cancer include computerized tomography (CT) and positron emission tomography (PET).

The stages of esophageal cancer are:

  • Stage I. This cancer occurs only in the top layer of cells lining your esophagus.
  • Stage II. The cancer has invaded deeper layers of your esophagus lining and may have spread to nearby lymph nodes.
  • Stage III. The cancer has spread to the deepest layers of the wall of your esophagus and to nearby tissues or lymph nodes.
  • Stage IV. The cancer has spread to other parts of your body.

Prognosis

Esophageal cancer is usually not curable. When the cancer has not spread outside the esophagus, surgery may improve the chances of survival. Radiation therapy is used instead of surgery in some cases where the cancer has not spread outside the esophagus. For patients whose cancer has spread, a cure is generally not possible. Treatment is directed toward relieving symptoms.

Treatment

What treatments you receive for esophageal cancer are based on the type of cells involved in your cancer, your cancer's stage, your overall health and your preferences for treatment.

Surgery:

Surgery to remove the cancer can be used alone or in combination with other treatments. Operations used to treat esophageal cancer include:

  • Surgery to remove very small tumors. If your cancer is very small, confined to the superficial layers of your esophagus and hasn't spread, your surgeon may recommend removing the cancer and margin of healthy tissue that surrounds it. Surgery for very early-stage cancers can be done using an endoscope passed down your throat and into your esophagus.
  • Surgery to remove a portion of the esophagus (esophagectomy). Your surgeon removes the portion of your esophagus that contains the tumor and nearby lymph nodes. The remaining esophagus is reconnected to your stomach. Usually this is done by pulling the stomach up to meet the remaining esophagus. In some situations, a portion of the colon is used to replace the missing section of esophagus.
  • Surgery to remove part of your esophagus and the upper portion of your stomach (esophagogastrectomy). Your surgeon removes part of your esophagus, nearby lymph nodes and the upper part of your stomach. The remainder of your stomach is then pulled up and reattached to your esophagus. If necessary, part of your colon is used to help join the two.

Esophageal cancer surgery carries a risk of serious complications, such as infection, bleeding and leakage from the area where the remaining esophagus is reattached. Surgery to remove your esophagus can be performed as an open procedure using large incisions or with special surgical tools inserted through several small incisions in your skin (laparoscopically). How your surgery is performed depends on your situation and your surgeon's experience and preferences.

Surgery for supportive care:

Besides treating the disease, surgery can help relieve symptoms or allow you to eat.

  • Relieving esophageal obstruction. A number of treatments are available to relieve esophageal obstruction. One option includes using an endoscope and special tools to widen the esophagus and place a metal tube (stent) to hold the esophagus open. Other options include surgery, radiation therapy, chemotherapy, laser therapy and photodynamic therapy.
  • Providing nutrition. A surgeon inserts a feeding tube (percutaneous gastronomy) so you can receive nutrition directly into your stomach or intestine. This is usually temporary until the surgical site heals or until you're finished with chemotherapy and radiation therapy.

Chemotherapy:

Chemotherapy is drug treatment that uses chemicals to kill cancer cells. Chemotherapy drugs are typically used before (neoadjuvant) or after (adjuvant) surgery in people with esophageal cancer. Chemotherapy can also be combined with radiation therapy. In people with advanced cancer that has spread beyond the esophagus, chemotherapy may be used alone to help relieve signs and symptoms caused by the cancer.

The chemotherapy side effects you experience depend on which chemotherapy drugs you receive.

Radiation therapy:

Radiation therapy uses high-powered energy beams to kill cancer cells. Radiation can come from a machine outside your body that aims the beams at your cancer (external beam radiation). Or radiation can be placed inside your body near the cancer (brachytherapy).

Radiation therapy is most often combined with chemotherapy in people with esophageal cancer. It can be used before or after surgery. Radiation therapy is also used to relieve complications of advanced esophageal cancer, such as when a tumor grows large enough to stop food from passing to your stomach.

Side effects of radiation to the esophagus include sunburn-like skin reactions, painful or difficult swallowing, and accidental damage to nearby organs, such as the lungs and heart.

Combined chemotherapy and radiation:

Combining chemotherapy and radiation therapy may enhance the effectiveness of each treatment. Combined chemotherapy and radiation may be the only treatment you receive, or combined therapy can be used before surgery. But combining chemotherapy and radiation treatments increases the likelihood and severity of side effects.

Clinical trials:

Clinical trials are research studies testing the newest cancer treatments and new ways of using existing cancer treatments. Clinical trials give you a chance to try the latest in cancer treatment, but they can't guarantee a cure. Ask your doctor if you're eligible to enroll in a clinical trial. Together you can discuss the potential benefits and risks.

Resources

  • Esophageal Cancer Awareness Association (ECAA)
  • Medline Plus
  • NIH
  • Mayo Clinic