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esophagus-cancer

Esophagus Cancer

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What is Esophagus Cancer?

About the esophagus

The esophagus is a 10-inch long, hollow, muscular tube that connects the throat to the stomach. It is part of a person’s gastrointestinal (GI) tract. When a person swallows, the walls of the esophagus squeeze together to push food down into the stomach.

About esophageal cancer

Cancer begins when normal cells change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). Esophageal cancer, also called esophagus cancer, begins in the cells that line the esophagus.

Specifically, cancer of the esophagus begins in the inner layer of the esophageal wall and grows outward. If it spreads through the esophageal wall, it can grow into lymph nodes (the tiny, bean-shaped organs that help fight infection), blood vessels in the chest, and other nearby organs. Esophageal cancer can also spread to the lungs, liver, stomach, and other parts of the body.

There are two major types of esophageal cancer:

Squamous cell carcinoma. This type of esophageal cancer starts in squamous cells that line the esophagus. It usually develops in the upper and middle part of the esophagus.

Adenocarcinoma. This type begins in the glandular tissue in the lower part of the esophagus where the esophagus and the stomach come together.

Treatment is similar for both of these types of esophageal cancer. Other, very rare tumors of the esophagus (less than 1% of esophageal cancers) include small cell euroendocrine cancers, lymphomas, and sarcoma.

Symptoms & Signs

People with esophageal cancer may experience the following symptoms or signs. Sometimes, people with esophageal cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.    

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

Vomiting

Frequent choking on food

Unexplained weight loss

Coughing or hoarseness

Pain behind the breastbone or in the throat

Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Risk Factors

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors may raise a person’s risk of developing esophageal cancer:

Age. People between the ages of 45 and 70 have the highest risk of esophageal cancer.

Gender. Men are three to four times more likely than women to develop esophageal cancer.

Race. Black people are twice as likely as white people to develop the squamous cell type of esophageal cancer.

Tobacco. Using any form of tobacco—including cigarettes, cigars, pipes, chewing tobacco, and snuff—raises the risk of esophageal cancer, especially squamous cell carcinoma.

Alcohol. 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 esophagitis (inflammation of the esophagus), even when a person does not have symptoms of chronic heartburn. Damage to the lining of the esophagus causes abnormal changes in cells. People with Barrett's esophagus are more likely to develop adenocarcinoma of the esophagus.

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.

Obesity. Being severely overweight and having too much body fat can increase a person's risk of developing esophageal adenocarcinoma.

Lye. Children who have accidently swallowed lye have an increased risk of squamous cell carcinoma. Lye can be found in some cleansing products, such as drain cleaners.

Achalasia. Achalasia, a condition when the lower muscular ring of the esophagus does not relax during swallowing of food, increases the risk of squamous cell carcinoma.

Screening

Regular screening tests to find esophageal cancer in people without symptoms are not used in the United States. People with Barrett's esophagus (see above) may be advised to have endoscopic examinations (looking inside the esophagus through a flexible, lighted tube) and biopsies (removal of a small amount of tissue for examination under a microscope) regularly to help find cancer early or to find changes that could become cancerous over time. 

Diagnosis

Doctors use many tests to diagnose cancer and find out if it has metastasized. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Severity of symptoms

Previous test results

In addition to a physical examination, the following tests may be used to diagnose esophageal cancer:

Barium swallow (also called an esophagram). The patient swallows a liquid containing barium and then a series of x-rays (pictures of the inside of the body) are taken. Barium coats the surface of the esophagus, making a tumor or other unusual changes easier to see on the x-ray. If there is a change, your doctor may recommend an upper endoscopy and biopsy to find out if it is cancerous (see below).

Upper endoscopy (also called esophagus-gastric-duodenoscopy, or EGD). This test allows the doctor to see the lining of the esophagus. A thin, flexible tube with a light and video camera on the end, called an endoscope, is passed down the throat and into the esophagus while the patient is sedated. If an unusual change is found, a biopsy will be performed to find out if it is cancerous. An endoscopy using an inflatable balloon to stretch the esophagus can also help widen the blocked area so that food can pass through until treatment begins.

Endoscopic ultrasound. This procedure is often done at the same time as the upper endoscopy. During an ultrasound, sound waves provide a picture of structures inside the body. During an endoscopic ultrasound, a small machine that produces the sound waves is inserted into the esophagus through the mouth. The ultrasound is used to see 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. An ultrasound can also be used to help get a tissue sample from the lymph nodes.

Bronchoscopy. Similar to an upper endoscopy, the doctor passes a thin, flexible tube with a light on the end into the mouth or nose, down through the windpipe, and into the breathing passages of the lungs. A bronchoscopy may be performed if a patient’s tumor is located in the upper two-thirds of the esophagus to find out if the tumor is growing into the person’s airway, including the trachea (windpipe) and bronchial tree (area where the windpipe branches out into the lungs).

Biopsy. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. A biopsy is the removal of a small amount of tissue from the suspicious area for examination. The tissue sample removed during the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease).

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues 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.

Stages

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.

One tool that doctors use to describe the stage is the TNM system. This system judges three factors: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How large is the primary tumor and where is it located? For esophageal cancer, this refers to how deep the tumor has grown into the wall of the esophagus (Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized (spread) to other parts of the body? (Metastasis, M)

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the tumor, including whether the cancer has grown into the wall of the esophagus or nearby tissue, and if so, how deep. Some stages are also divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below.

TX: The primary tumor cannot be evaluated.

T0: There is no cancer in the esophagus.

Tis: This is called carcinoma (cancer) in situ. Carcinoma in situ is very early cancer. Cancer cells are in only one small area of the top lining of the esophagus without any spread into the lining.

T1: There is a tumor in the lamina propria and submucosa (the two inside layers of the esophagus). Cancer cells have spread into the lining of the esophagus.

T2: The tumor is in the muscularis propria (the third layer of the esophagus). Cancer cells have spread into but not through the muscle wall of the esophagus.

T3: The tumor is in the adventitia (the outer layer of the esophagus). Cancer cells have spread through the entire muscle wall of the esophagus into surrounding tissue.

T4: The tumor has spread outside the esophagus into areas around it. Cancer cells have spread to structures surrounding the esophagus, including the aorta (large blood vessel coming from the heart), windpipe, diaphragm, and pleural lining of the lung.

Node. The “N” in the TNM staging system stands for lymph nodes. In esophageal cancer, lymph nodes near the esophagus and in the chest are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The lymph nodes cannot be evaluated.

N0: The cancer was not found in any lymph nodes.

N1: The cancer has spread to one or two lymph nodes in the chest, near the tumor.

N2: The cancer has spread to three to six lymph nodes in the chest, near the tumor.

N3: The cancer has spread to seven or more lymph nodes in the chest, near the tumor.

Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body.

MX: Metastasis cannot be evaluated.

M0: The cancer has not spread to other parts of the body.

M1: The cancer has spread to another part of the body.

Grading

Tumor grade. Grade may also be used to describe the tumor, using the letter “G,” in addition to the TNM system. Grade is determined based on how similar the tumor cells are to healthy cells when viewed under a microscope. Healthy tissue usually has different types of cells grouped together (also called differentiated tissue). Tissue that is cancerous usually is made up of cells that look more like each other. In general, the more differentiated the tissue, the better the prognosis.

G1: The tissue looks more like healthy cells (well differentiated).

G2: The cells are somewhat different than healthy cells (somewhat differentiated).

G3: The tumor cells barely look like healthy cells (poorly differentiated).

G4: The cancer cells look almost alike and do not look like healthy cells (not differentiated).

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications. There are separate staging systems for the two most common types of esophageal cancer: squamous cell carcinoma and adenocarcinoma. The staging system for each is described below.

Staging of squamous cell carcinoma of the esophagus

In addition to the TNM classifications, for squamous cell carcinoma, the stages may be subdivided based on the location of the original tumor (the upper, middle, or lower section of the esophagus), as well as the grade (G) of the tumor cells.

Stage 0:  This is the same as Tis cancer, in which cancer is found in only the top lining of the esophagus (Tis, N0, M0, G1).

Stage IA: This is the same as T1 cancer, in which the cancer is located in only the two inside layers of the esophagus (T1, N0, M0, G1).

Stage IB: Either of these two conditions:

The cancer is located in only the two inside layers of the esophagus, but the tumor cells are less differentiated (T1, N0, M0, G2 or G3).

The tumor is located in the lower part of the esophagus, and the cancer has spread to either of the two outer layers of the esophagus, but not to the lymph nodes or other parts of the body (T2 or T3, N0, M0, G1).

Stage IIA: Either of these two conditions:

The tumor is located in the upper or middle part of the esophagus, and the cancer is in either of the two outer layers of the esophagus (T2 or T3, N0, M0, G1).

The tumor is located in the lower part of the esophagus, and the cancer is in either of the two outer layers of the esophagus. The tumor cells are less differentiated (T2 or T3, N0, M0, G2 or G3).

Stage IIB: Either of these two conditions:

The tumor is located in the upper or middle part of the esophagus, and cancer is in either of the two outer layers of the esophagus. The tumor cells are less differentiated (T2 or T3, N0, M0, G2 or G3).

Cancer is in the inner layers of the esophagus and has spread to one or two lymph nodes near the tumor (T1 or T2, N1, M0, any G).

Stage IIIA: Any of these three conditions:

Cancer is in the inner layers of the esophagus and has spread to three to six lymph nodes near the tumor (T1 or T2, N2, M0, any G).

Cancer is in the outside layer of the esophagus and has spread to one or two lymph nodes (T3, N1, M0, any G).

Cancer has spread beyond the esophagus to nearby tissue but not to lymph nodes or other areas of the body (T4a, N0, M0, any G).

Stage IIIB: Cancer is in the outside layer of the esophagus and in three to six lymph nodes (T3, N2, M0, any G).

Stage IIIC: Any of these three conditions:

Cancer has spread beyond the esophagus into nearby tissue. Cancer is also in six or less lymph nodes (T4a, N1 or N2, M0, any G).

Cancer has spread beyond the esophagus into nearby tissue and cannot be removed by surgery (T4b, any N, M0, any G).

Cancer has spread to seven or more lymph nodes but not to distant parts of the body (any T, N3, M0, any G).

Stage IV: Cancer has spread to another part of the body (any T, any N, M1, any G).

Staging of adenocarcinoma of the esophagus

For adenocarcinoma, doctors use the T, N, and M classifications, as well as the grade (G).

Stage 0:  This is the same as Tis cancer, in which cancer is found in only the top lining of the esophagus (Tis, N0, M0, G1).

Stage IA: This is the same as T1 cancer, in which the cancer is located in either of the two inside layers of the esophagus only (T1, N0, M0, G1 or G2).

Stage IB: Either of these two conditions:

The cancer is located in either of the two inside layers of the esophagus only, and the tumor cells are poorly differentiated (T1, N0, M0, G3).

The cancer has spread to an outer layer of the esophagus but not to the lymph nodes or other parts of the body (T2, N0, M0, G1 or G2).

Stage IIA: Cancer is in an outer layer of the esophagus, and the cells are poorly differentiated (T2, N0, M0, G3).

Stage IIB: Either of these two conditions:

Cancer is in the outside layer of the esophagus but not beyond (T3, N0, M0, any G).

Cancer is in an inner layer or the muscularis propria of the esophagus and has spread to one or two lymph nodes (T1 or T2, N1, M0, any G).

Stage IIIA: Any of these three conditions:

Cancer is in the inner layers of the esophagus and has spread to three to six lymph nodes near the tumor (T1 or T2, N2, M0, any G).

Cancer is in the outside layer of the esophagus and has spread to one or two lymph nodes (T3, N1, M0, any G).

Cancer has spread beyond the esophagus to nearby tissue but not to lymph nodes or other areas of the body (T4a, N0, M0, any G).

Stage IIIB: Cancer is in the outside layer of the esophagus and in three to six lymph nodes (T3, N2, M0, any G).

Stage IIIC: Any of these three conditions:

Cancer has spread beyond the esophagus into nearby tissue. Cancer is also in six or less lymph nodes (T4a, N1 or N2, M0, any G).

Cancer has spread beyond the esophagus into nearby tissue and cannot be removed by surgery (T4b, any N, M0, any G).

Cancer has spread to seven or more lymph nodes but not to distant parts of the body (any T, N3, M0, any G).

Stage IV: Cancer has spread to another part of the body (any T, any N, M1, any G).

Recurrent: Recurrent cancer is cancer that comes back after treatment. It may come back in the esophagus or in another part of the body. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

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