is
Malignancy of the
Esophagus . There are various subtypes. Esophageal tumors usually lead to
Dysphagia (difficulty
Swallowing ), pain and other symptoms, and is diagnosed with
Biopsy . Small and localized tumors are treated with
Surgery , and advanced tumors are treated with
Chemotherapy ,
Radiotherapy or combinations. Prognosis depends on the extent of the disease and other medical problems, but is fairly poor.
Dysphagia (difficulty swallowing) is the first symptom in most patients.
Odynophagia (painful swallowing) may be present. Fluids and soft foods are usually tolerated, while hard or bulky substances (such as
Bread or
Meat ) cause much more difficulty. Substantial
Weight Loss is characteristic as a result of poor nutrition and the active cancer.
Pain , often of a burning nature, may be severe and worsened by swallowing, and can be spasmodic in character.
The presence of the tumor may disrupt normal
Peristalsis (the organised swallowing reflex), leading to
Nausea and
Vomiting ,
Regurgitation of food,
Cough ing and an increased risk of
Aspiration Pneumonia . The tumor surface may be fragile and
Bleed , causing
Hematemesis (vomiting up blood). Compression of local structures occurs in advanced disease, leading to such problems as
Superior Vena Cava Syndrome .
Fistula s may develop between the esophagus and the
Trachea , increasing the pneumonia risk; this symptom is usually heralded by
Cough ,
Fever or aspiration (Enzinger & Mayer 2003).
If the disease has metastasis could cause
Jaundice and
Ascites ,
Lung metastasis could cause
Shortness Of Breath ,
Pleural Effusion s, etc.
There are a number of risk factors for esophageal cancer. Some subtypes of cancer are linked to particular risk factors:
Risk appears to be less in patients using
Aspirin or related drugs (
NSAID s). Statistically, it appears that ''
Helicobacter Pylori '', known for increasing risk for
Gastric Cancer , actually decreases the risk of esophageal cancer (O'Connor 1999); the exact mechanism for this phenomenon is unclear.
Although an occlusive tumor may be suspected on a
Barium Swallow or
Barium Meal , the diagnosis is best made with
Esophagogastroduodenoscopy (EGD,
Endoscopy ); this involves the passing of a flexible tube down the esophagus and visualising the wall.
Biopsies taken of suspicious lesions are then examined
Histologically for signs of malignancy.
Most tumors of the esophagus are malignant. A very small proportion (under 10%) is
Leiomyoma (smooth muscle tumor) or
Gastrointestinal Stromal Tumor (GIST). Malignant tumors are generally
Adenocarcinoma s,
Squamous Cell Carcinoma s, and occasionally ''small-cell carcinomas''. The latter share many properties with small-cell
Lung Cancer , and are relatively sensitive to chemotherapy compared to the other types.
The location of the tumor is generally measured by the distance from the teeth. The esophagus (25 cm or 10 inches long) is commonly divided into three parts for purposes of determining the location. Adenocarcinomas tend to occur distally and squamous cell carcinomas proximally, but the converse may also be the case.
The treatment is determined by the cellular type of cancer (adenocarcinoma or squamous cell carcinoma vs. other types), the stage of the disease, the general condition of the patient and other diseases present. On the whole, adequate
Nutrition needs to be assured, and adequate dental care is vital.
If the patient cannot swallow at all, a
Stent may be inserted to keep the esophagus patent; stents may also assist in occluding fistulas. A
Nasogastric Tube may be necessary to continue feeding while treatment for the tumor is given, and some patients require a
Gastrostomy (feeding hole in the skin that gives direct access to the stomach). The latter two are especially important if the patient tends to aspirate food or saliva into the airways, predisposing for
Aspiration Pneumonia .
Surgery is possible if the disease is localised, which is the case in 20-30% of all patients. If the tumor is larger but localised, chemotherapy and/or radiotherapy may occasionally shrink the tumor to the extent that it becomes "operable"; however, this combination of treatments (referred to as neoadjuvant chemoradiation) is still somewhat controversial in most medical circles.
Esophagectomy is the removal of a segment of the esophagus; as this shortens the distance between the throat and the stomach, some other segment of the digestive tract (typically the
Stomach or part of the
Colon ) is placed in the chest cavity and interposed. If the tumor is metastatic, surgical resection is not considered worthwile, but palliative surgery may offer some benefit.
Laser therapy is the use of high-intensity light to destroy tumor cells; it affects only the treated area. This is typically done if the cancer cannot be removed by surgery. The relief of a blockage can help to reduce dysphagia and pain.
Photodynamic Therapy (PDT), a type of laser therapy, involves the use of drugs that are absorbed by cancer cells; when exposed to a special light, the drugs become active and destroy the cancer cells.
Chemotherapy depends on the tumor type, but tends to be
Cisplatin -based (or
Carboplatin or
Oxaliplatin ) every three weeks with
Fluorouracil (5-FU) either continuously or every three weeks. In more recent studies, addition of
Epirubicin (ECF) was better than other comparable regimens in advanced nonresectable cancer (Ross ''et al'' 2002). Chemotherapy may be given after surgery (adjuvant, i.e. to reduce risk of recurrence), before surgery (neoadjuvant) or if surgery is not possible; in this case, cisplatin and 5-FU are used. Ongoing trials compare various combinations of chemotherapy; the phase II/III REAL-2 trial - for example - compares four regimens containing
Epirubicin and either
Cisplatin or
Oxaliplatin and either continuously infused fluorouracil or
Capecitabine .
Radiotherapy is given before, during or after chemotherapy or surgery, and sometimes on its own to control symptoms. In patients with localised disease but contraindications to surgery, "radical radiotherapy" may be used with curative intent.
Patients are followed up frequently after a treatment regimen has been completed. Frequently, other treatments are necessary to improve symptoms and maximize nutrition.
Prognosis of esophageal cancer is fairly poor. Even in patients who undergo surgery with curative intent, the five year survival rate is only 25%, and prognosis is poorer in those who are not fit for surgery. Early emphasis on symptom control and
Palliative Care may improve the
Quality Of Life .
Esophageal cancer is a relatively rare form of cancer, but some world areas have a markedly higher incidence than others:
China ,
India and
Japan , as well as the
United Kingdom , appear to have a higher incidence, as well as the region around the
Caspian Sea (Stewart & Kleihues 2003).
Annual incidence is between 3-11 per 100,000 for males and 0.6-6 per 100,000 for females (Stewart & Kleihues 2003).
- Enzinger PC, Mayer RJ. Esophageal cancer. '' N Engl J Med '' 2003;349:2241-52. PMID 14657432.
- O'Connor HJ. ''Helicobacter pylori'' and gastro-oesophageal reflux disease-clinical implications and management. ''Aliment Pharmacol Ther'' 1999;13:117-27. PMID 10102940.
- Ross P, Nicolson M, Cunningham D, Valle J, Seymour M, Harper P, Price T, Anderson H, Iveson T, Hickish T, Lofts F, Norman A. Prospective randomized trial comparing mitomycin, cisplatin, and protracted venous-infusion fluorouracil (PVI 5-FU) with epirubicin, cisplatin, and PVI 5-FU in advanced esophagogastric cancer. ''J Clin Oncol'' 2002;20:1996-2004. PMID 11956258.
- Stewart BW, Kleihues P (editors). ''World cancer report''. Lyon: IARC , 2003. ISBN 9283204115.
