Esophageal Cancer
by I. Mountzios, M.D., Medical Oncologist

Introduction

Esophageal Cancer is the cancer of the esophagus. The esophagus is a 10-inch long, hollow, muscular tube that connects the throat to the stomach. It is part of a person’s gastrointestinal tract. When a person swallows, the walls of the esophagus squeeze together to push food down into the stomach.

Specifically, cancer of the esophagus begins in the inner layer of the esophageal wall and grows outward. If it spreads through the esophageal wall, it can grow into lymph nodes (the tiny, bean-shaped organs that help fight infection), blood vessels in the chest, and other nearby organs. Esophageal cancer can also spread to the lungs, liver, stomach, and other parts of the body.

 

Etiology-epidemiology

Esophageal cancer is relatively rare in the western world. Its frequency in the United States is approximately 4-5 new cases in every 100,000 persons and the death rate is approximately 4.4 deaths among 100,000 persons. The relative risk is 0.8 for men and 0.3 for women, and increases with age.

In the industrial countries, there has been an impressive increase in the incidence of esophageal adenocarcinoma, a particular type of esophageal cancer, which is usually located in the lower third of the esophagus or the esophagogastric junction. With an annual increase of 5-10% adenocarcinoma has now become the most frequent histological type, followed by squamous-cell carcinoma of the esophagus.

Potential etiological factors that have been etiologically correlated with esophageal cancer include chronic gastroesophageal reflux, obesity, smoking and alcohol consumption. Especially for gastroesophageal relapse, it has been shown that persons with a long history of gastroesophageal reflux disease have an up to 43,5-fold increase in the risk , compared to the general population.

 

Clinical Symptoms

Patients with esophageal cancer may experience the following symptoms or signs

  • Difficult and painful swallowing, particularly with meat, bread, or raw vegetables. In more advanced stage, the pathway to the stomach can be blocked, and even liquid may be painful to swallow.
  • Pressure or burning in the chest
  • Indigestion
  • Vomiting
  • Frequent choking on food
  • Weight loss
  • Coughing or hoarseness
  • Pain behind the breastbone or in the throat

Sometimes, people with esophageal cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. In order to address concerns about a symptom or sign on this list, a patient should consult their doctor.

The doctor will ask questions about the symptoms, to help find out the cause of the problem, called a diagnosis. This may include how long the patient has been experiencing the symptom(s) and how often.

 

Diagnosis and Staging

Diagnosis of esophageal cancer is usually made by endoscopic examination of the esophagus (esophagoscopy), which is an examination very similar to gastroscopy. During this procedure, one or more biopsy specimens are obtained from the tumor or the suspicious lesion and the material is sent for pathologic examination (examination under microscope). The pathologic examination is the most accurate examination that establishes the diagnosis of esophageal cancer.

After the diagnosis of esophageal cancer has been established, the next step is staging. Staging is a special procedure comprising a constellation of tests that allows the doctors to define accurately to what extent has the disease spread into the patient’s body, and bears very important information about the patient’s prognosis and the expected outcome of treatment. Usually, the therapeutic regimen also depends on the stage of the disease at the time of diagnosis.

Other useful tests for the staging of esophageal cancer are the following:

  • CT scans of the thorax and the abdomen
  • MRI scans of the thorax and the abdomen when indicated
  • Bronchoscopy (in cases of possible invasion of the trachea by cancer_
  • Endoscopic Ultrasound (very sensitive for the determination of the degree of invasion of the tumor to the esophageal wall and the detection of lymph nodes around the esophagus that are enlarged because of cancer infiltration.
  • Thoracoscopy-laparoscopy (surgical exploration of the thoracic or peritoneal cavity) is indicated in rare difficult cases)
  • PET/CT scan (a very sensitive scan resembling CT scan, but allows for better imaging of the tumor by exploiting its increased metabolic activity).

Based on these tests the tumor is usually classified into one of the following four categories:

  1. Stage 1: Tumor restricted to the inner layer (mucosa) of the esophagus
  2. Stage 2: Tumor extending in the muscular wall of the esophagus
  3. Stage 3: Tumor extending outside the esophageal wall and/or invading regional lymph nodes but without distant metastases
  4. Stage 4: Presence of distant metastases (Lung, liver etc).

 

Pathology

There are two major types of esophageal cancer:

  1. Squamous cell carcinoma: This type of esophageal cancer starts in squamous cells that line the esophagus. It usually develops in the upper and middle part of the esophagus.
  2. AdenocarcinomaThis type begins in the glandular tissue in the lower part of the esophagus where the esophagus and the stomach come together.

These two histological subtypes have quite distinct epimiological and biological characteristics and sometimes even different  biological and clinical behavior of the tumor, Morover, today modern therapeutic protocols take into account the histology of the tumor and treatment strategies very according to the histological subtype. This is why it is important for the doctors to obtain a biopsy and be aware of the precise histological type of the tumor.

 

Treatment Strategies

Basic principles

For patients with a tumor that has not spread beyond the esophagus and lymph nodes (i.e up to stage 3), oncologists often recommend combining three types of treatment: radiation therapy, chemotherapy, and surgery.

The order of treatments varies, and several factors are considered, including the type of esophageal cancer.

Particularly for squamous cell cancer, chemotherapy and radiation therapy (a combination called chemo-radiotherapy) are commonly recommended as the first treatment, with surgery afterwards depending on how well chemo-radiotherapy has worked and especially how much has it shrunk the initial tumor. Recent studies show using either chemotherapy or chemoradiotherapy before surgery is better than surgery alone.  

For adenocarcinoma, the most common treatment on Europe is:

  • surgery in stage 1
  • surgery with or without adjuvant (complementary) chemotherapy in stage 2
  • chemotherapy or chemo-radiotherapy, followed by surgery if possible in stage 3.

Surgery is almost always recommended after chemoradiotherapy, unless there are risk factors, such as a patient’s age or overall health conditions.

 

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation, and has traditionally been the most common treatment for esophageal cancer.

However, currently, surgery is used as the primary (first) treatment only for patients with early-stage esophageal cancer (Stages 1 and 2).

For patients with stage 3 (the so-called locally-advanced esophageal cancer), a combination of chemotherapy and radiation therapy (see below), or chemotherapy alone in some situations, may be used before surgery to shrink the tumor.

For people who cannot have surgery, the best treatment option is often a combination of chemotherapy and radiation therapy.

The most common type of operation to treat esophageal cancer is called an esophagectomy, where the doctor removes the esophagus and then connects the remaining healthy part of the esophagus to the stomach so that the patient can swallow normally. The stomach or part of the intestine may sometimes be used to make the connection. The surgeon also removes lymph nodes around the esophagus.

 

Surgery for supportive or palliative care

In addition to surgery to treat the disease, surgery may be used to help patients eat and relieve symptoms caused by the cancer. This is called supportive or palliative surgery. Potential interventions of this type include:

  • A percutaneous gastrostomy or jejunostomy (feeding tube) is placed, so that the patient can receive nutrition directly into the stomach or intestine.
  • Dilatation (expansion) of the esophagus. This procedure can be repeated if the tumor grows and causes obstruction.
  • An esophageal stent is placed into the esophagus. An esophageal stent is a metal device that is expanded to keep the esophagus open.

 

Radiation therapy

Radiation therapy (the use of high-energy X-rays or other particles to kill cancer cells) is another treatment option.

The most common type of radiation therapy is external beam radiation. A radiation therapy schedule usually consists of a specific number of treatments given over a period of time.

Side effects from radiation therapy may include fatigue, mild skin reactions, soreness in the throat and esophagus, difficulty or pain with swallowing, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished and are usually adequately managed by medication including anti-biotics, anti-fungal pharmaceutical agents, steroids and analgesics, intravenous fluids and eating soft food.

 

Chemotherapy

Chemotherapy is often administered in parallel with radiation therapy in order to treat esophageal cancer at the locally advanced stage.
Chemotherapy alone is usually used to treat generalized disease. The side effects of chemotherapy can include weakness, risk of infection, hair loss, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually subside once treatment is completed.

 

Metastatic esophageal cancer

If cancer has spread to another location in the body, it is called metastatic cancer. In this case, the goal of treatment is usually not to cure but to prolong a person’s life, while easing symptoms such as pain and problems with eating. The survival expectation in these cases may be less than a year or even some months, but this may vary according to the kind of metastases and the biological behavior of the tumor.

The only useful treatment strategy in these cases is chemotherapy, that has been shown to prolong the time interval until progression of the cancer to the body, and palliative radiotherapy, which may be used to alleviate symptoms of esophagus obstruction or compression.

For many patients, a diagnosis of metastatic cancer can be very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. 

 

Content on this site is not a substitute for professional medical advice. You should always consult your doctor.