Esophagus cancer

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Esophageal cancer occurs when cancer cells develop in the esophagus. The two most common types are squamous cell carcinoma and adenocarcinoma. Esophageal cancer may have no symptoms in its early stages and is most often found in men over 50 years of age.

Your doctor may perform a physical exam, chest x-ray, chest CT scan, upper gastrointestinal (GI) tract x-ray, esophagoscopy, or PET/CT to help determine if you have cancer and if it has spread. A biopsy is needed to confirm the diagnosis of cancer. Treatment options depend on the extent of the disease and include surgery, radiation therapy, and chemotherapy, or a combination of both.

What is esophageal cancer?
Esophageal cancer occurs when cancer cells develop in the esophagus, a long, tube-like structure that connects the throat and stomach. The esophagus carries ingested food to the stomach and is part of the upper digestive system.

There are two main types of esophageal cancer:

Squamous cell carcinoma, in which cancer develops from the thin, flat cells (called squamous cells) that make up the inner lining of the esophagus.
Adenocarcinoma, in which cancer develops from glandular cells in the lining of the esophagus.

In the early stages of esophageal cancer there may be no symptoms. In more advanced cancers, symptoms may include:

difficulty swallowing (feeling like choking or food getting stuck)
weightloss
chest pain
cough and regurgitation
hoarseness
vomiting blood
tarry stools or blood in the stool
indigestion and heartburn
Doctors usually don’t find esophageal cancer until it’s advanced. It is most common in adults over 50 years of age and is twice as likely to occur in men. In addition to gender and age, risk factors for esophageal cancer include:

to smoke
excessive alcohol consumption
gastroesophageal reflux disease (GERD), a condition in which the contents of the stomach back up into the lower section of the esophagus. This can irritate the esophagus and eventually lead to Barrett’s esophagus. This is a condition in which the squamous cells in the inner lining of the lower esophagus have changed or been replaced by other glandular cells. Most people with Barrett’s esophagus do not develop cancer of the esophagus.
The glandular cells affected by Barrett’s esophagus can become abnormal over time, leading to a precancerous condition called dysplasia. If dysplasia is present, or if there is a family history of Barrett’s esophagus, the risk of cancer is increased.

How is esophageal cancer diagnosed and evaluated?
Your doctor will ask about your medical history, your risk factors, and your symptoms. They will also do a physical exam.

Your doctor may order one or more of the following imaging tests to help find out if you have cancer and if it has spread.

Chest or chest x-ray: This common test uses a very small dose of radiation to produce images of the inside of the chest, including the lungs, heart, and chest wall.

Computed tomography (CAT) of the chest thorax: This exam uses X-ray technologies to produce multiple images of the interior of the body. Sectional images generated during a CT scan can be reformatted using multiple planes, and can even generate three-dimensional images. These images can be viewed on a computer monitor, printed on an X-ray plate, or transferred to a CD or DVD.

X-Ray (Radiography) of the Upper Gastrointestinal (GI) Tract: An x-ray of the upper gastrointestinal tract is also known as the upper GI. It uses a form of real-time x-ray called fluoroscopy and barium contrast material to produce images of the esophagus, stomach, and small intestine. Oral contrast material is coated into the esophagus and stomach, and the doctor takes a series of X-rays. Examination of the upper GI tract that focuses on the esophagus is called a barium swallow test or an esophagram.

Esophagoscopy: This procedure uses an esophagoscope, a thin, tube-like instrument with a light and lens. It allows doctors to see the esophagus directly. The doctor inserts the esophagoscope through the mouth or nose and into the esophagus, through the throat. Some esophagoscopes have tools to remove tissue samples for evaluation under a microscope to check for cancer.

Endoscopic Ultrasound (EUS): During an EUS, an endoscope, a thin, tube-like instrument that has a light and a lens for viewing, is inserted through the mouth. A probe at the end of the endoscope bounces high-energy waves (ultrasound) off internal structures to create an echo. The echo forms a picture of body tissues called an ultrasound. EUS is also called endosonography.

Positron emission tomography – computed tomography (PET/CT) scan: PET uses small amounts of radioactive material called radiotracers, a special camera, and a computer to help evaluate the functions of your organs and tissues. By identifying changes in the body at the cellular level, PET may be able to detect early-onset disease before it becomes apparent with other imaging tests. PET/CT can detect esophageal cancer and determine if it has spread. It can also determine the effectiveness of a treatment plan and whether the cancer has come back after treatment.

If these tests do not clearly show that an abnormality is benign, a biopsy is needed. The biopsy removes a tissue sample for evaluation in the laboratory. Biopsies use different ways of obtaining tissue samples. Some biopsies remove a small amount of tissue with a needle. Others might surgically remove the entire lump, or nodule, that is considered suspicious. Your doctor may perform a biopsy during an upper endoscopy that reveals Barrett’s esophagus. This would help them eliminate the possibility of dysplasia and/or adenocarcinoma.

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Your doctor will use the results of this test to help determine the presence and extent or stage of esophageal cancer.

If these tests do not suggest cancer, no further tests are needed. However, your doctor may want to monitor the area during future visits. Barrett’s esophagus frequently requires six months of follow-up and/or control. Your doctor will use an upper endoscopy to determine if your condition is progressing to dysplasia.

How is esophageal cancer treated?
Treatment of esophageal cancer may include surgery, radiation therapy, chemotherapy, and targeted therapy or immunotherapy. The optimal combination of treatments will depend on the type, location, and stage of the disease. Some therapies may only be accessible through participation in clinical trials. See the page on clinical studies for more information. The earlier esophageal cancer is found, the better the chance of recovery. Advanced-stage esophageal cancer can be treated, but it is very rare that it can be cured.

Surgery: Surgery is the most common treatment for esophageal cancer. Your doctor may use it alone or in combination with other treatments for advanced disease. If the cancer is a small tumor confined to the first layer of the lining of the esophagus, the surgeon may remove the tumor and a small amount of surrounding healthy tissue (called a margin). Your doctor may use a procedure called a thoracoscopy to remove part of your esophagus or lung. This is also known as minimally invasive resection surgery. The doctor makes an incision between two ribs and inserts a thoracoscope, a thin, tube-like instrument with a light and lens for viewing.

In more advanced cancers, a surgeon might remove part of the esophagus in an operation called an esophagectomy. The surgeon removes the cancerous portion of the esophagus along with nearby lymph nodes. They reconnect the rest of the esophagus to the patient’s stomach or to a part of the patient’s gastrointestinal (GI) tract. In an esophagogastrectomy, the surgeon removes the diseased part of the esophagus, the nearby lymph nodes, and part of the stomach.

Radiation therapy: This treatment uses high-energy x-rays or other types of radiation to kill cancer cells. Doctors usually use radiation therapy in combination with chemotherapy and surgery. They often use it on patients who are not candidates for surgery. Doctors might use radiation therapy before surgery to help shrink the cancer (called neoadjuvant treatment), or after surgery to kill any remaining cancer cells (called adjuvant therapy). They might also use it to help control symptoms and complications of advanced disease, including pain and tumor growth that prevents food from passing into the stomach. See the Introduction to Cancer Therapy (Radiation Oncology) page for more information.

How is esophageal cancer treated?
Treatment of esophageal cancer may include surgery, radiation therapy, chemotherapy, and targeted therapy or immunotherapy. The optimal combination of treatments will depend on the type, location, and stage of the disease. Some therapies may only be accessible through participation in clinical trials. See the page on clinical studies for more information. The earlier esophageal cancer is found, the better the chance of recovery. Advanced-stage esophageal cancer can be treated, but it is very rare that it can be cured.

Surgery: Surgery is the most common treatment for esophageal cancer. Your doctor may use it alone or in combination with other treatments for advanced disease. If the cancer is a small tumor confined to the first layer of the lining of the esophagus, the surgeon may remove the tumor and a small amount of surrounding healthy tissue (called a margin). Your doctor may use a procedure called a thoracoscopy to remove part of your esophagus or lung. This is also known as minimally invasive resection surgery. The doctor makes an incision between two ribs and inserts a thoracoscope, a thin, tube-like instrument with a light and lens for viewing.

In more advanced cancers, a surgeon might remove part of the esophagus in an operation called an esophagectomy. The surgeon removes the cancerous portion of the esophagus along with nearby lymph nodes. They reconnect the rest of the esophagus to the patient’s stomach or to a part of the patient’s gastrointestinal (GI) tract. In an esophagogastrectomy, the surgeon removes the diseased part of the esophagus, the nearby lymph nodes, and part of the stomach.

Radiation therapy: This treatment uses high-energy x-rays or other types of radiation to kill cancer cells. Doctors usually use radiation therapy in combination with chemotherapy and surgery. They often use it on patients who are not candidates for surgery. Doctors might use radiation therapy before surgery to help shrink the cancer (called neoadjuvant treatment), or after surgery to kill any remaining cancer cells (called adjuvant therapy). They might also use it to help control symptoms and complications of advanced disease, including pain and tumor growth that prevents food from passing into the stomach. See the Introduction to Cancer Therapy (Radiation Oncology) page for more information.

Chemotherapy: This treatment uses substances or drugs to kill cancer cells or to stop cancer cells from dividing. Doctors might use chemotherapy before or after surgery for esophageal cancer and in combination with radiation therapy. Chemotherapy also helps relieve symptoms when esophageal cancer has spread (metastasized) beyond the esophagus.

Other treatments for esophageal cancer include:

Endoscopic treatments: These procedures treat early-stage cancers and pre-cancers of the esophagus and provide pain relief (palliative treatment). The doctor inserts an endoscope down the throat into the esophagus. They use tools at the end of the instrument to remove cancerous tissue.

Monoclonal antibody therapy (also called targeted therapy): A small group of esophageal cancers have a very high amount of a protein called HER2 on the surface of their cells. The drug known as trastuzumab (Herceptin) is a monoclonal antibody that binds to the HER2 protein on cancer cells and interferes with the cancer cells’ ability to grow. Your doctor might combine targeted therapy with chemotherapy.

Immunotherapy: This approach uses drugs to strengthen the patient’s immune system to help control the cancer. Some, but not all, studies have shown better survival rates when patients are given these drugs after surgery.

Chemoprevention: Drugs, vitamins, and other agents are being studied to try to reduce the risk of cancer and/or slow its development or recurrence. For example, nonsteroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors, and berries are being studied as chemopreventive agents to help prevent transformation of Barrett’s esophagus into cancer.

Radiofrequency ablation: Doctors may use radiofrequency ablation to assess the progression of Barrett’s esophagus to dysplasia and/or adenocarcinoma.

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Esophageal cancer can affect a person’s ability to eat food. Therefore, additional treatments may be needed to ensure adequate nutrition during and after treatment. Some patients may receive nutrients directly into the vein. Others may require a feeding tube. The feeding tube is a flexible plastic tube that is passed through the nose or mouth into the stomach. The doctor will leave the tube in place until patients can eat on their own.

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