Esophageal Cancer Symptoms, Causes, Survival Rate, Surgery, Treatments, Types (original) (raw)

What is the esophagus?

Difficulty swallowing and cough are symptoms of esophageal cancer.

Difficulty swallowing and cough are symptoms of esophageal cancer.

The esophagus is the first part of the gastrointestinal tract. It is a tube-like structure that connects the mouth to the stomach, allowing food and liquid to be swallowed. There are muscles that encircle the esophagus that allow it to contract and push food and liquid toward the stomach. When cancer cells develop in the tissues of this muscular tube, it is defined as esophageal cancer.

What is esophageal cancer?

Esophageal cancer describes the disease where cells that line the esophagus change or mutate and become malignant. These cells grow out of control and form a mass or tumor.

There are two main types of esophageal cancer:

There are more rare forms of cancer that affect the esophagus, including lymphoma, malignant melanoma, sarcoma, choriocarcinoma, and small cell cancer.

What are risk factors and causes of esophageal cancer?

Esophageal cancer occurs when changes happen in the DNA of cells that line the esophagus. The exact reason for these changes or mutations is uncertain, but there are known risk factors for developing these cancers.

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What are the symptoms and signs of esophageal cancer?

Esophageal cancer tends not to be associated with symptoms until it grows large enough to narrow the esophagus and make it difficult for food to pass. This also means there is time and opportunity for the cancer to grow beyond the esophagus and spread (metastasize) either to surrounding tissues or to distant parts of the body before it is discovered.

Esophageal cancer symptoms

The first symptom of esophageal cancer is almost always dysphagia (dys=abnormal + phagia=swallowing). Initially there may be difficulty swallowing solid foods, but symptoms may worsen and if the obstruction of the esophagus becomes more high-grade, there may also problems swallowing liquids.

Because adenocarcinoma of the esophagus may be related to chronic gastroesophageal reflux disease, symptoms of GERD may also be present, including heartburn and indigestion. This is often described as a burning sensation located behind or just beneath the breastbone in the upper abdomen.

Patients with esophageal cancer also can present with unexplained weight loss which occurs in more than half of patients. Esophageal cancers bleed and may cause vomiting of blood, or passing of melena (black, tarry stools). Sometimes the bleeding can be microscopic and not seen by the naked eye. The patient may experience weakness due to low red blood cell count, and because it is due to blood loss, it is most often an iron-deficiency anemia.

Pain from esophageal cancer can be felt in the lower chest behind the breastbone or in the upper abdomen. If the cancer has spread, there may be pain in other places around the chest or back.

Patients may experience voice hoarseness due to vocal cord damage caused by reflux of stomach acid into the throat. Water brash describes hypersalivation and bad taste in the back of the mouth from reflux. Acid droplets that cause this foul taste can be aspirated and can inflame the vocal cords, causing a change in voice.

As the tumor grows, it may cause nerve damage if it inflames the recurrent laryngeal nerve that helps control the vocal cords. The nerve runs close to the esophagus, so if cancer spreads to the nerve, it means the cancer has grown beyond the esophageal wall.

Esophageal cancer signs

Physical examination may not be helpful in making a diagnosis of esophageal cancer; the esophagus is hidden within the chest cavity and not easily evaluated by physical examination. In the early stage of esophageal cancer, there may be no symptoms at all. It is only when the tumor grows enough to cause problems that symptoms begin to appear. That is the reason why patient history is so important in making the diagnosis and why all complaints of difficulty swallowing should be taken seriously.

If the cancer has metastasized through the lymph system, beyond the esophagus, there may be abnormal lymph nodes palpable in the neck below the jaw or above the clavicles (collarbones). If cancer has spread to the liver, the liver may become enlarged and may be palpated on examination of the abdomen.

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How is esophageal cancer diagnosed?

The diagnosis of esophageal cancer is made by endoscopy and biopsy.

When symptoms of difficulty swallowing (dysphagia) occur, a gastroenterologist can do a procedure called an endoscopy where the patient swallows a flexible tube with an attached camera and the doctor can look at the full length of the esophagus, the stomach, and the first part of the intestine (duodenum). If a mass or tumor is seen in the esophagus, the gastroenterologist has the ability to take a sample of tissue (biopsy) through the same tube. The patient is usually sedated for endoscopy.

The tissue biopsy is examined by a pathologist using a microscope and the clinical diagnosis is then confirmed if cancer cells are found.

Plain X-rays, CT scans, and PET scans may be used to look for metastases and spread of the cancer to different sites in the body.

How is esophageal cancer staged?

Staging describes a system used to show how deep the cancer has extended into the esophageal tissue, whether it has spread to lymph nodes, and what other organs in the body might be involved.

There is a common system agreed upon by the Union for International Cancer Control and the American Joint Committee on Cancer that uses TNM staging.

With the endoscope, the gastroenterologist can use ultrasound to determine how deep into the layers of the esophagus the tumor has grown. The doctor can also tell whether lymph nodes that line the esophagus have been invaded.

Either CT scan of the chest and abdomen or PET scan is then used to determine the extent of tumor spread.

Depending on the type of cancer and the extent the tumor has spread, there are certain circumstances where more invasive procedures are warranted to help with staging: laparoscopy (an operation where a surgeon inserts a camera into the abdominal cavity), thoracoscopy (the camera is inserted into the chest cavity), and bronchoscopy (a camera is inserted into the lung airways).

What are the stages of esophageal cancer?

The stages of esophageal cancer can be complicated to understand and are related to the following:

Stages are as follows:

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What are the treatments for esophageal cancer?

The approach to cancer treatment is individualized to each patient's situation. Recommended treatments for esophageal cancer depend on the stage and health of the patient. A team of physicians will help decide with the patient and family what might be the best approach to their specific situation. These providers may include specialists in medical oncology, radiation oncology, and surgery, in addition to the patient's primary care provider.

Esophageal cancer is often found in older patients who have other underlying illnesses that complicate treatment. Esophageal cancer is usually diagnosed late in the course of the disease because symptoms often occur only after a tumor has grown and potentially spread. Most often, if the patient can tolerate it, treatment consists of a combination of chemotherapy, radiation therapy, and surgery.

The National Comprehensive Cancer Network maintains up-to-date guidelines based upon ongoing clinical trials that allow cancer specialists to offer treatment advice to patients and family.

Surgery

The decision to undergo surgery and the type of surgery that might be appropriate depends upon the type of esophageal carcinoma (squamous cell or adenocarcinoma), its staging, and the underlying health of the patient. Some patients are high-risk for surgery and anesthesia because of pre-existing health conditions such as heart or lung disease.

Treatment guidelines are continuously being evaluated and revised, based upon the development of new treatments and the results of ongoing clinical trials. Decisions about treatment effectiveness often involve statistical analysis that combines many treatment studies. This meta-analysis helps adjust treatment options and protocols as more patients are enrolled in studies, more data is obtained, and hopefully, better survival is achieved.

Surgery may involve esophagectomy or removal of the whole esophagus. Lymph nodes may also be removed.

Some patients are able to have the removed esophagus replaced with another piece of bowel to connect the mouth to the stomach. If that is not possible, percutaneous gastrostomy may be required to get food and fluid into the stomach to be digested. A tube is placed through the skin and anchored into the stomach to allow tube feedings.

Chemotherapy and radiation

Chemotherapy and radiation therapy (both external beam radiation or internal radiation, or brachytherapy) may be administered prior to surgery to help shrink the tumor. There are a variety of chemotherapy protocols that may be considered. Surgery may be delayed after the diagnosis is made to allow the chemotherapy and radiation to be administered.

Chemotherapy and radiation therapy that have been started after surgery have not been shown to increase survival. However, there may be a benefit to survival when these therapies are continued after surgery, if they were started before the operation.

Drugs and drug combinations used to treat esophageal cancer that may be administered with radiation or without include:

Other drugs used to treat esophageal cancer on their own include:

Targeted therapy

There are disease-specific genes associated with esophageal cancer. In certain circumstances, the tumor can be tested to see whether genes like HER2 are present. Targeted medications can attach or bind to different protein sites on the tumor cells and inhibit tumor growth. This is immunotherapy, specific cancer-fighting medications that try to kill only tumor cells, unlike chemotherapy, which also kills normal cells as a side effect.

Targeted therapy medications include:

Immunotherapy

Immunotherapy uses medications that help the immune system find and destroy cancer cells and can be used to treat some esophageal cancers.

Immunotherapy drugs include:

Endoscopic treatments

If there is high-grade dysplasia confined to the walls of the esophagus with no spread to the lymph nodes or distant organs (stage I), surgical removal of the tumor may be accomplished via endoscopic procedure. The gastroenterologist may be able to resect (remove) the damaged tissue using different techniques, such as:

Photodynamic therapy

Light therapy may be used to treat esophageal cancers that are small in size and have not spread or metastasized. In this treatment, a photo-sensitizing drug is injected into the body where it is absorbed by cells, where they can last for two to three days. However, cancer cells seem to keep a concentration of the drug longer. When the patient is exposed to light from a laser, the drug may kill the cancer cell.

This type of treatment is limited because light cannot penetrate deeply into the body and is effective in only small tumors. At present, photodynamic therapy is approved for esophageal cancer and non-small-cell lung cancer.

The American Cancer Society estimates there will be 22,370 new cases of esophageal cancer in the United States in 2024, with more than 16,130 deaths expected.

Esophageal cancer occurs more frequently as people age and is more commonly diagnosed in male patients 60 to 70 years of age. It is 20 times more common to be found in patients older than age 65 than in those who are younger. Esophageal cancer affects males more than females, almost four to one.

Hispanics and African-Americans are more likely than whites to have squamous cell carcinoma of the esophagus. They are also less likely to undergo esophagectomy (surgical removal of the esophagus) for their cancer. However, survival did not differ between racial groups when adjusted for types of surgery performed.

What support is available for those with esophageal cancer?

Patients, families, and friends are all affected when the diagnosis of cancer is made. Most hospitals and treatment facilities will have support systems available to help with the difficult journey ahead. In addition to the physical stress of recovering from diagnosis, treatment, and therapy, there is significant emotional stress that extends beyond the initial treatment time period.

The treating professionals will be important resources to relay understanding of the disease, the potential treatment options, and the expected outcomes. It is important for all who are involved to be advocates for the patient; much of the information can be overwhelming. It is reasonable to ask questions of the doctors, nurses, and other care providers.

There are many community resources available. The American Cancer Society is a good place to begin, contacting the organization at a local office or online. As well, most hospital cancer programs have support groups and social service programs to help provide guidance and assistance to patient and their families.

What is the prognosis with esophageal cancer?

Most often, esophageal cancer is a treatable disease but not a curable one.

Patients who have severe Barrett's esophagus (some consider this stage T0 or precancerous) and those with few cancer cells tend to have relatively successful long-term outcomes.

The overall five-year survival rate for all stages of esophageal cancer combined is estimated by the National Cancer Institute as 22%. Lymph node and other organ involvement markedly lowers survival rate.

There is a better survival rate in patients whose tumors disappeared with radiation and chemotherapy before surgery (three-year survival rate of 48%), as compared to those who had some residual tumor at time of surgery (27%).

The prognoses for squamous cell carcinoma and adenocarcinoma are about the same.

The five-year survival rate for:

Is it possible to prevent esophageal cancer?

Since squamous cell carcinoma is associated with smoking (and smokeless tobacco products), stopping smoking will significantly decrease the risk of this type of esophageal cancer.

Alcohol abuse is also related to squamous cell carcinoma, especially when combined with tobacco product use. Alcohol products should be used in moderation.

Eating a diet rich in fruits and vegetables may decrease the risk of esophageal cancer.

Obesity is a risk factor for esophageal adenocarcinoma and weight loss may be appropriate.

Esophageal adenocarcinoma is associated with GERD and the subsequent development of Barrett's esophagus. It is important to limit the risk factors for developing esophageal reflux. These include

If symptoms of GERD develop, they should be assessed and treated by your health care professional. Should symptoms persist or worsen, the recommendation may be to undergo endoscopy to determine whether Barrett's esophagus is present.

Barrett's esophagus needs to be managed and monitored to assess whether there is progression of cell damage. This may include endoscopic ablation, or killing of abnormal tissue using different techniques including radiofrequency ablation, photodynamic therapy, or cryotherapy.

References

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"Cancer Facts and Figures 2015." American Cancer Society.

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Varghese, T. K., et al. "The society of thoracic surgeons guidelines on the diagnosis and staging of patients with esophageal cancer." Annals of Thoracic Surgery. 96: 346-356.