Esophageal Cancer

Esophageal cancer is a condition in which malignant cells form in the tissues of the esophagus.

Smoking, heavy alcohol use and conditions like Barrett’s esophagus can increase the risk of esophageal cancer.

Symptoms of this cancer type include weight loss and painful swallowing or difficulty swallowing. Diagnostic tests to examine the esophagus can detect the presence of esophageal cancer. Different factors affect prognosis and treatment.

WashU Medicine and Siteman Cancer Center provide patients with screening, diagnoses and treatment options.

Esophageal cancer definition, symptoms and complications

What is esophageal cancer?

The esophagus is the hollow, muscular tube in the throat that moves food and liquid to the stomach. The esophagus is made of several layers of tissue, including a mucous membrane, muscle, and connective tissue.

Cancer beginning in the esophagus occurs when abnormal cells begin to grow out of control in the lining of the esophagus, often then spreading outwards through the layers as it progresses. The tumors beginning in the esophagus can spread to lymph nodes, tissues and other organs.

Are there different types of esophageal cancer?

The two most common forms of esophageal cancer are named for the type of body tissue cells that become malignant (cancerous):

• Squamous cell carcinoma: Sometimes called epidermoid carcinoma, this cancer forms in the thin, flat cells lining the inside of the esophagus. Squamous cell carcinoma can occur anywhere along the esophagus but is most often found in the upper and middle portions.
• Adenocarcinoma: This cancer begins in glandular cells in the lining of the esophagus. Glandular cells produce and release fluids such as mucus. Adenocarcinomas usually form in the lower part of the esophagus, closer to the stomach.

What are the symptoms of esophageal cancer?

Esophageal cancer is often asymptomatic, especially in early stages. The below signs and symptoms may be caused by esophageal cancer, but they may also be the result of other conditions:

• Weight loss
• Painful or difficult swallowing
• Pain behind the breastbone
• Hoarseness and cough
• Indigestion and heartburn
• Anemia
• Upper GI bleeding or vomiting blood
• A lump under the skin of the throat

What are the stages of esophageal cancer?

Like other cancers, esophageal cancer progresses in stages, during which symptoms may change or become more severe. The following stages are used to track the progress of both squamous cell carcinoma or adenocarcinoma of the esophagus:

• Stage 0 (High-grade Dysplasia): The cancer is only in the top layer of cells lining the esophagus.
• Stage I: The cancer is growing into the tissue or muscle under the epithelium of the esophagus but has not spread elsewhere.
• Stage II: The cancer has grown into the thick muscle layer or outer layer of the esophagus but has not spread to any other organs or lymph nodes.
• Stage III: The cancer has progressed from the esophagus to no more than six nearby lymph nodes OR the pleura (membrane around lungs), pericardium (membrane around heart), or diaphragm (muscle below heart and lungs). It has also spread to no more than two lymph nodes but no organs.
• Stage IV: The cancer has advanced to more lymph nodes, crucial body structures (like the trachea or spine), other organs (like the lungs or liver), and/or more than seven lymph nodes.

Are there complications to esophageal cancer?

Common complications resulting from esophageal cancer include fistulas (holes) in the trachea or esophagus, anemia due to esophageal bleeding, weight loss if the tumor prevents proper food consumption, pneumonia if food enters the lung as a result of esophagus blockage, or metastases as the cancer moves to other areas of the body.

Esophageal cancer causes, risk factors and prevention

What causes or contributes to the development of esophageal cancer?

There are no absolute causes for esophageal cancer, but Barrett’s esophagus is a contributing condition. Barrett’s esophagus is generally caused by gastric reflux (GERD), which causes stomach contents to reenter the lower section of the esophagus.

If this GERD is untreated, it irritates the esophagus, producing abnormal cells that can become cancerous, known as dysplasia.

In those with advanced high-grade dysplasia, the risk that the condition will advance to become cancer can be as high as 6 percent. Early Barrett’s esophagus, which involves low-grade dysplasia, has a low risk of cancer and is handled by periodic surveillance, screening and biopsies.

Are there risk factors for developing esophageal cancer?

Anything that increases the risk of getting a disease is called a risk factor. Having a risk factor does not mean that someone will get a particular type of cancer; not having risk factors doesn’t mean that someone will not get a particular type of cancer.

Risk factors for developing esophageal cancer include:

• Older age
• Tobacco use
• Heavy alcohol use
• Obesity
• Chronic acid reflux disease (GERD)
• Barrett’s esophagus

Can esophageal cancer be prevented? How?

Preventative measures to reduce the chance of developing esophageal cancer include avoiding risk factors.

To prevent squamous cell carcinoma of the esophagus, it is best to reduce tobacco and alcohol use.

To prevent adenocarcinoma of the esophagus, it is recommended to seek treatment for gastric reflux, GERD and Barret’s esophagus.

Maintaining a healthy weight and getting proper exercise may also prevent the development of esophageal cancer.

Esophageal cancer diagnosis and treatment

How is esophageal cancer diagnosed?

The following screenings, tests and procedures may be used to detect or diagnose esophageal cancer and determine the stage of its progress:

• Physical exam and health history: A full body exam to check general signs of health, including signs of disease or abnormalities. A history of the patient’s health habits, illnesses and treatments will also be taken.
• Chest x-ray: An x-ray of the organs and bones inside the chest, where the middle and lower esophagus is located.
• Esophagoscopy: A procedure to check for abnormal areas in the esophagus. A specialized scope is inserted through the mouth or nose and into the esophagus, a procedure known as an esophagoscopy. The scope, or esophagoscope, is a thin, tube-like instrument with a light and lens for viewing. It may also have a tool to remove tissue samples, or biopsies (below).
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. The biopsy is usually done during an esophagoscopy (above). Sometimes a biopsy shows changes in the esophagus that are not cancer but may lead to cancer (dysplasia).
• Brush cytology: A procedure in which cells are “brushed” from the lining of the esophagus with a special tool and viewed under a microscope to see if they are abnormal. This may be done during an esophagoscopy (above).
• Balloon cytology: A procedure in which a deflated balloon is swallowed by the patient, inflated and then pulled out of the esophagus. Esophageal cells are collected from the lining of the esophagus and viewed under a microscope to see if they are abnormal.
• Chromoendoscopy: This visual test involves a specialized medical dye that is sprayed on the lining of the esophagus during an esophagoscopy (above). Increased staining of the lining may indicate early Barrett esophagus.
• Fluorescence spectroscopy: A detection test that uses a special light to view tissue in the lining of the esophagus. The light probe is passed through an endoscope, and the light reflected by the cells lining the esophagus is measured. Lower levels of light indicates abnormal, potentially malignant tissues.

What options are available for esophageal cancer treatment? Are any more common or successful?

There are multiple factors of esophageal cancer that require medical attention, and several methods of treatment may be necessary to address all patient symptoms. Treatment also depends on cancer stage. Treatment methods include:

• Surgery: Surgical resection involves removing the diseased part during an operation called an esophagectomy. After that is done, the stomach is pulled up and joined to the remaining esophagus. Occasionally, a part of the intestine may be used to make the connection. During the operation, the surgeon will remove nearby lymph nodes to test for cancer and improve the outcomes of therapy. Siteman Cancer Center performs robotic-assisted esophagectomies, which are minimally invasive and easier on the body than traditional, open esophagectomies.
• Nutritional therapy: Because the esophagus is the primary way we get nutrients, patients with esophageal cancer have special nutritional needs during treatment. Patients may receive nutrients directly from a feeding tube into the stomach or small intestine until they are able to eat on their own.
• Chemotherapy: For advanced esophageal cancer, chemotherapy is the main treatment. Chemotherapy involves the administration of drugs, either orally or intravenously, to kill cancer cells. Recently, several new drugs have increased the options for physicians treating patients with esophageal cancer.
• Radiation therapy: Radiation oncology is an important component for treatment and can be delivered in a variety of ways. Siteman is a leader in using shorter radiation durations than the national average with equal or improved outcomes. Radiation therapy is commonly used as part of the treatment program for tumors in the esophagus and nearby lymph nodes. Options include:
  • External beam radiation: Siteman fine-tunes the radiation planning with intensity modulated therapy, using a CT scan simulator for 3D planning to precisely target therapy. Our team was the first in the world to have the ability to do external radiation with MRI guidance, and the first to treat patients with that technology. Ninety-five percent of radiation treatment at Siteman is external beam from outside the body.
  • Brachytherapy: Internal radiation may be used in some cases to implant in seeds or catheters adjacent to the cancer.
  • Chemoradiation: Often given together to treat different stages of esophageal cancer, the two together can work more effectively than either alone, depending on the stage. This treatment combines chemotherapy and radiation to increase the effects of both.
• Laser therapy: using a laser beam instead of surgery to kill cancer cells.
• Electrocoagulation: using an electrical current to kill cancer cells.
• Cryotherapy: freezing cancer cells.

New combinations of therapies are always being tested in clinical trials and are available at Siteman Cancer Center before most other places may have access to them.

What is the prognosis for esophageal cancer? Is there a cure?

The prognosis and treatment options depend on the following:

• The stage of the cancer (whether it affects part of the esophagus, involves the whole esophagus, or has spread to other places in the body).
• Whether the tumor can be completely removed by surgery.
• The patient’s general health.

When esophageal cancer is found very early, there is a better chance of recovery. Esophageal cancer is often in an advanced stage when it is diagnosed. At later stages, esophageal cancer can be treated but rarely can be cured.