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Esophageal Cancer

Esophageal cancer is cancer that develops in the esophagus, the muscular tube that connects the throat to the stomach. The esophagus, located just behind the trachea (wind-pipe), is about 10 to 13 inches in length and carries food from the mouth to the stomach for digestion. The wall of the esophagus is made up of several layers and cancers generally start from the inner layer and grow out. There are two main types of esophageal cancer: squamous cell carcinoma and adenocarcinoma and a few rare ones, including melanoma, small cell carcinoma, and leiomyosarcoma.

Types of Esophageal Cancer

There are two main types of esophageal cancer:

  • Squamous cell carcinoma 
  • Adenocarcinoma

While overall the rate of esophageal cancer has remained the same, adenocarcinoma has increased in incidence while squamous cell carcinoma has seen a decrease.

Squamous Cell Carcinoma

Squamous cell carcinoma grows in the cells that form the top layer of the inner lining of the esophagus, known as squamous cells. This type of cancer can grow anywhere along the esophagus. The cause of squamous cell cancer is unclear but seems to be associated with a history of smoking and alcohol intake. The incidence of squamous cell carcinoma has slightly decreased over the past two decades.

Risk Factors of Squamous Cell Carcinoma
  • All forms of tobacco use, including cigarettes, cigars, and chewing tobacco,
  • High intake of alcohol over prolonged periods,
  • A history of combined alcohol and tobacco use,
  • A diet deficient in fruits and vegetables,
  • Older than 55,
  • Male,
  • Drinking very hot liquids frequently,
  • Swallowing or breathing caustic irritants such as lye and other chemicals,
  • History of head and neck cancers,
  • History of achalasia, a disease of the muscle of the esophagus,

Adenocarcinoma

Adenocarcinoma develops in the glandular tissue in the lower part of the esophagus, near the opening of the stomach. While the incidence of squamous cell carcinoma has been decreasing in the United States, the incidence of adenocarcinoma has been rising rapidly. This switch in incidence may be related to gastroesophageal reflux disease and certain lifestyle changes, including diet.

Risk Factors of Adenocarcinoma

  • Heartburn or reflux disease,
  • Barrett’s esophagus, a condition caused by prolonged acid reflux,
  • Smoking,
  • Obesity,
  • Older than 55,
  • Male.
Symptoms of Esophageal Cancer

People with early-stage esophageal cancer usually have minimal symptoms. Symptoms typically do not appear until the disease is more advanced. The most common symptoms are:

  • Difficulty swallowing (dysphagia)
  • Painful swallowing
  • Weight loss
  • Heartburn
  • Regurgitation of undigested food
  • Hoarseness or persistent chronic cough
  • Hiccups that persist
  • Vomiting
  • Blood in stools or black-looking stools
  • Coughing up blood
  • Anemia
  • Pneumonia
  • Pain in mid-chest, throat, back, behind the breastbone, between shoulder blades

 

Diagnosis of Esophageal Cancer

There is no routine screening examination for esophageal cancer; however, people with Barrett’s esophagus should be examined often (with endoscopy) because they are at greater risk for developing the disease. When esophageal cancer is found very early, there is a better chance of recovery. Esophageal cancer is often in an advanced stage when diagnosed. However, there are treatments to manage and successfully treat all stages of esophageal cancer. Diagnostic tests and procedures include:

  • Physical exam and medical history
  • Complete blood count
  • Blood chemistry studies
  • Chest X-ray
  • Upper GI (gastrointestinal) series (also called barium swallow) For this series of stomach X-rays of the stomach, patients drink a liquid that contains barium (a silver-white metallic compound). It coats the stomach, and we take X-rays of it. This procedure is also called an upper GI series.
  • Esophagoscopy (or endoscopy), an esophagoscope, a thin tube with a lighted lens, is inserted, using some sedation, through the mouth or nose and down the throat into the esophagus to look at and if needed remove tissue samples, which are checked under a microscope for cancer. When the esophagus and stomach are looked at in this way, the procedure is called an upper endoscopy.
  • Endoscopic Ultrasound (EUS) can show how deeply cancer has invaded the wall of the esophagus and whether cancer has spread to nearby lymph nodes. It helps determine staging (determining how advanced the cancer is) and the next best step for treatment. An endoscope is inserted into the body, usually through the mouth. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
  • CT-scan and PET Scan

 

Stages of Esophageal Cancer

The process used to find out if cancer has spread within the esophagus or to other parts of the body is called staging. The stage is determined by the results of physical exams, imaging tests, and biopsies that have been done. Learn more about the stages of esophageal cancer.

Treatment for Esophageal Cancer

Treatment for esophageal cancer depends on many factors including the stage of cancer and where it is located. Your thoracic surgeon will discuss the best treatment for your particular situation. Often a combination of therapies will be recommended.

Surgery is the most common treatment for esophageal cancer. The goal of surgery is to completely remove cancer and all surrounding lymph nodes. Surgery is most effective with an early disease but can be used in conjunction with chemotherapy and radiation for advanced cancer. Surgery also provides relief of symptoms such as obstruction and dysphagia (difficulty swallowing).

Minimally invasive esophagectomy

Minimally invasive esophagectomy is the approach of choice that our surgeons used to remove esophageal cancer. This operation has largely replaced at our hospital the open esophagectomy approach that is still used by most other surgeons in this and other countries to treat esophageal cancer. Instead of large incisions and cutting ribs, our surgeons can do this operation through a small incision using video scopes to guide them. These videos thoracoscopic and laparoscopic, and occasionally robotic, techniques allow for fewer complications, less pain, and faster recovery.

Photodynamic Therapy (PDT)

Photodynamic Therapy (PDT), an endoscope with a laser on the end is used to destroy cancer cells on or near the inner lining of the esophagus. This approach is used to relieve the blockage of the esophagus caused by cancer.

Esophageal staging and jejunostomy

Not infrequently patients may present with intermediate stage esophageal cancer which is best treated by first shrinking cancer with chemotherapy and radiation therapy and then taking remaining cancer out by surgery as described above. Patients who have difficulty eating may benefit from a minimally invasive video laparoscopy with the placement of a feeding tube before initiation of therapy so that they can continue to receive nutrition while receiving chemotherapy, and be strong enough to later tolerate the esophagectomy operation.

Esophageal stent

To overcome obstruction from the tumor, our surgeons will occasionally place a cylindrical stent that crosses the obstruction in the esophagus using an endoscope. This is usually done under anesthesia as an outpatient procedure.

Other surgical procedures

There are some ways to remove the esophagus, all of which have been previously developed by an open surgical technique and have been practiced by our surgeons using minimally invasive techniques. They generally refer to how much esophagus is removed and where the incisions are. These are usually related to the location of the tumor.

  • Transhiatal esophagectomy
  • Three-hole esophagectomy
  • Ivor-Lewis esophagectomy
  • Thoracoabdominal esophagectomy
  • Subtotal gastrectomy
  • Total gastrectomy

 

In all of these operations, the esophagus is removed and reconstructed by elongating the stomach. In some cases, however, the colon or small bowel may be used as an esophageal replacement. A feeding tube is placed during surgery to provide nutrition until you can eat adequately.

Non-surgical cancer treatments

Radiation Therapy uses high-energy rays to kill or shrink cancer cells. Radiation is often used in conjunction with chemotherapy before surgery to shrink the tumor. The Radiation Oncology service at Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC) uses the most advanced equipment and techniques to deliver radiation to cancerous areas while minimizing exposure to normal tissues

Chemotherapy. Chemotherapy uses anticancer drugs to kill cancer cells throughout the entire body. Chemotherapy is often used before or after surgery or alone in the most advanced cases of esophageal cancer. The purpose is to shrink the tumor to make the tumor small enough that it can be surgically removed. It is often used in conjunction with radiation.