The esophagus is a muscular tube connecting the throat (pharynx) with the stomach, it is about 8 inches long, and is lined by moist pink tissue called mucosa. The esophagus runs behind the windpipe (trachea) and heart, and in front of the spine. They keep food and secretions from going down the windpipe.
Esophageal cancer is a condition whereby malignant cancer cells arise from the inner lining of the esophagus. Esophageal cancer is the sixth most common cause of cancer deaths worldwide. Incidence rates vary within different geographic locations. In some regions, higher rates of esophageal cancer may be attributed to tobacco and alcohol use or particular nutritional habits and obesity. The two most common forms of esophageal cancer are known as Squamous cell carcinoma and Adenocarcinoma.
A 55 year old man presented with a year history of progressively worsening epigastric pain, reflux, and fatigue.
Initially treated with acid suppression therapy by his primary care physician, which temporarily relieved the symptoms.
He noted the onset of difficulty swallowing solid food with a feeling of food getting stuck in the chest.
He was a heavy smoker with packed- history of 10 years. He denied alcohol and drug abuse, and had no family history of malignancy.
Physical examination revealed mild epigastric ( upper abdomen) tenderness on palpation of the abdomen. Routine laboratory tests were normal.
Upper gastrointestinal endoscopy (camera test) revealed the presence of a huge fungating mass in the mid-esophagus .
Biopsies ( tissue sample) from this area demonstrated poorly differentiated adenocarcinoma.
CT scan revealed no evidence of nodal or metastatic disease.
The patient was clinically staged as having T3 N0 M0 disease (Stage IIa).
He subsequently had chemoradiation followed by Ivor Lewis esophagectomy.
He then received further adjuvant chemotherapy for 6 cycles.
He is now on a three monthly surveillance by the Oncology team with CT imaging.
It’s not exactly clear what causes esophageal cancer.
Esophageal cancer occurs when cells in the esophagus develop changes (mutations) in their DNA. The changes make cells grow and divide out of control. The accumulating abnormal cells form a tumor in the esophagus that can grow to invade nearby structures and spread to other parts of the body.
Squamous cell carcinomas (SCCs) also known as epidermoid carcinomas form on the surface of the skin, on the lining of hollow organs in the body, and on the lining of the respiratory and digestive tracts. They arise in the upper and middle parts of the esophagus and is particularly associated with smoking and chronic alcohol consumption.
Squamous cell carcinoma is the most prevalent esophageal cancer worldwide.
Adenocarcinoma begins in the cells of mucus-secreting glands in the esophagus. Adenocarcinoma occurs most often in the lower portion of the esophagus. Adenocarcinoma is the most common form of esophageal cancer in the United States affecting primarily white men.
Other rare types. Some rare forms of esophageal cancer include small cell carcinoma, sarcoma, lymphoma, melanoma and choriocarcinoma.
It’s thought that chronic irritation of your esophagus may contribute to the changes that cause esophageal cancer. Factors that cause irritation in the cells of your esophagus and increase your risk of esophageal cancer include:
- People between the ages of 45 and 70 have the highest risk of esophageal cancer.
- Men are 3 to 4 times more likely than women to develop esophageal cancer.
- Black people are twice as likely as white people to develop the squamous cell type of esophageal cancer.
- Using any form of tobacco, such as cigarettes, cigars, pipes, chewing tobacco, and snuff raises the risk of esophageal cancer, especially squamous cell carcinoma.
- Heavy drinking over a long period of time increases the risk of squamous cell carcinoma of the esophagus, especially when combined with tobacco use.
- Barrett’s esophagus.This condition can develop in some people who have chronic gastroesophageal reflux disease (GERD) or inflammation of the esophagus called esophagitis, even when a person does not have symptoms of chronic heartburn. Damage to the lining of the esophagus causes the squamous cells in the lining of the esophagus to turn into glandular tissue. People with Barrett’s esophagus are more likely to develop adenocarcinoma of the esophagus, but the risk of developing esophageal cancer is still fairly low.
- Diet/nutrition.A diet that is low in fruits and vegetables and certain vitamins and minerals can increase a person’s risk of developing esophageal cancer.
- Gastro-esophageal reflux disorder (GERD)
- Bile reflux
- Having difficulty swallowing because of an esophageal sphincter that won’t relax (Achalasia)
- Having a steady habit of drinking very hot liquids
- Radiation treatment to the chest or upper abdomen
As esophageal cancer advances, it can cause complications, such as:
- Obstruction of the esophagus. Cancer may make it difficult for food and liquid to pass through your esophagus.
- Advanced esophageal cancer can cause pain.
- Bleeding in the esophagus. Esophageal cancer can cause bleeding. Though bleeding is usually gradual, it can be sudden and severe at times.
You can take steps to reduce your risk of esophageal cancer. For instance:
- Quit smoking.If you smoke, talk to your doctor about strategies for quitting. Medications and counseling are available to help you quit. If you don’t use tobacco, don’t start.
- Drink alcohol in moderation, if at all.If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and up to two drinks a day for men.
- Eat more fruits and vegetables.Add a variety of colorful fruits and vegetables to your diet.
- Maintain a healthy weight.If you are overweight or obese, talk to your doctor about strategies to help you lose weight. Aim for a slow and steady weight loss of 1 or 2 pounds a week.
Early detection and treatment of esophageal cancer are crucial to improving one’s survival and quality of life.
SIGNS AND SYMPTOMS
- Difficulty and pain with swallowing, particularly when eating meat, bread, or raw vegetables. As the tumor grows, it can block the pathway to the stomach. Even liquid may be painful to swallow.
- Pressure or burning in the chest
- Indigestion or heartburn
- Frequent choking on food
- Unexplained weight loss
- Coughing or hoarseness
- Pain behind the breastbone or in the throat
- Dysphagia which is difficulty in swallowing
- Loss of appetite
- Barium swallow study.
- Using a scope to examine your esophagus (endoscopy).
- Collecting a sample of tissue for testing (biopsy).The tissue sample is sent to a laboratory to look for cancer cells.
- Molecular testing of the tumor. Your doctor may recommend running laboratory tests on a tumor sample to identify specific genes, proteins, and other factors unique to the tumor. Results of these tests can help determine your treatment options.
Other investigations at the discretion of the managing team may include:
- Similar to an upper endoscopy, a bronchoscopy may be performed if a tumor is located in the upper two-thirds of the esophagus to find out if the tumor is growing into the airway. This part of the airway includes the trachea, or windpipe, and the area where the windpipe branches out into the lungs, called the bronchial tree.
- Endoscopic ultrasound (EUS). This procedure is often done at the same time as the upper endoscopy to find out if the tumor has grown into the wall of the esophagus, how deep the tumor has grown, and whether cancer has spread to the lymph nodes or other nearby structures.
- Computed tomography (CT or CAT) scan. Creates and takes pictures of the inside of the body and can be used to measure the tumor’s size. Usually, a special dye called a contrast medium is given before the scan to provide better detail. This dye is generally injected into a patient’s vein.
- Magnetic resonance imaging (MRI).Uses magnetic fields, not x-rays, to produce detailed images of the body. MRI can be used to measure the tumor’s size. A contrast medium is usually injected into a patient’s vein to create a clearer picture.
- Positron emission tomography (PET) scan.A PET scan is usually combined with a CT scan (see above), called a PET-CT scan. However, you may hear your doctor refer to this procedure just as a PET scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.
After diagnostic tests are done, the doctor will review all the results with the patient. If the diagnosis is cancer, these results also help the doctor describe the cancer. This is called staging.
Treatment will be based on the type of cells involved in the cancer, the cancer stage, overall health/performance status and patient’s informed preference for treatment.
Surgery to remove the cancer can be used alone or in combination with other treatments.
Treatments for esophageal obstruction and difficulty swallowing (dysphagia) can include:
- Relieving esophageal obstruction. If your esophageal cancer has narrowed your esophagus, a surgeon may use an endoscope and special tools to place a metal tube (stent) to hold the esophagus open. Other options include surgery, radiation therapy, chemotherapy, laser therapy and photodynamic therapy.
- Providing nutrition. Your doctor may recommend a feeding tube if you’re having trouble swallowing or if you’re having esophagus surgery. A feeding tube allows nutrition to be delivered directly to your stomach or small intestine, giving your esophagus time to heal after cancer treatment.
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 (Palliative Chemotherapy).
The chemotherapy side effects that you experience depend on which chemotherapy drugs you receive.
Radiation therapy uses high-energy beams, such as X-rays and protons, to kill cancer cells. Radiation typically will come from a machine outside your body that aims the beams at your cancer (external beam radiation). Or, less commonly, 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’s typically used before surgery, or occasionally 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.
Targeted drug therapy
Targeted drug treatments focus on specific weaknesses present within cancer cells. By blocking these weaknesses, targeted drug treatments can cause cancer cells to die. For esophageal cancer, targeted drugs are usually combined with chemotherapy for advanced cancers or cancers that don’t respond to other treatments.
Immunotherapy is a drug treatment that helps your immune system to fight cancer. Your body’s disease-fighting immune system might not attack cancer because the cancer cells produce proteins that make it hard for the immune system cells to recognize the cancer cells as dangerous. Immunotherapy works by interfering with that process. For esophageal cancer, immunotherapy might be used when the cancer is advanced, cancer has come back or the cancer has spread to other parts of the body.
CANCER ISN’T A DEATH SENTENCE. HOWEVER, EARLY DETECTION SAVES LIFE.