Esophageal cancer

 

What is esophageal cancer?

Cancer that occurs anywhere in the esophagus or food pipe is called esophageal cancer.

Cancer of the esophagus typically occurs in one of two forms, squamous cell carcinoma arising from the stratified squamous epithelial lining of the organ, and adenocarcinoma affecting columnar glandular cells that replace the squamous epithelium. Other types of esophageal cancer are uncommon.

Cancers that start in the area where the esophagus joins the stomach (the GE junction) including about the first 2 inches of the stomach tend to behave like esophageal cancers; they are grouped with esophageal cancers.

What is Esophagus?

The esophagus, also known as the food pipe is a muscular tube measuring 20-25 cm long and 2-3 cm wide that serves as a conduit for moving food and drink from the mouth to the stomach.

 

Burden of the disease

  • Esophageal cancer is the 6th most common cancer in India
  • 6th most common cause of cancer-related deaths in India
  • New cases: 52,396
  • Deaths: 46,504
  • Regional variation exists in the rates of esophageal cancer in India
  • Number of cases in men is more than double than that in women (male: female ratio 2.4:1)

Are you at risk?

  • Gender: The incidence is generally higher in men than women.
  • Tobacco consumption: Smokers have a 5-times higher risk of developing this disease compared to non-smokers. Chewing of betel nut/ supari, often mixed with tobacco, increases risk of esophageal cancer.
  • Alcohol
  • Gastroesophageal reflux disease and Barrett’s esophagus: In people with chronic reflux, the lining of esophagus changes to glandular (Barrett’s esophagus). In Barrett’s esophagus, the risk of adenocarcinoma is higher than in people not having it.
  • Obesity
  • Diet: Having a diet rich in processed meat or drinking very hot liquids increase the risk of esophageal cancer. A diet containing lots of fruits and vegetables lowers the risk of this disease.

The risk of having esophageal cancer can be reduced by:

  • Avoiding tobacco (in any form) and alcohol intake
  • Eating a healthy diet rich in fruits and vegetables
  • Maintaining a healthy weight
  • Treating reflux disease (heartburn)

When should you consult a doctor?

If you have any of the following symptoms, it is advisable to consult your doctor:

  • Difficulty in swallowing food (dysphagia)
  • Unexplained weight loss
  • Worsening indigestion or heartburn
  • Tightness or pain in the chest
  • Cough or hoarseness of voice

Screening for esophageal cancer is recommended if you are at a high risk, for example if you have Barrett’s esophagus.

If you are at high risk of esophageal cancer, upper GI endoscopy at regular intervals with biopsy from suspicious areas is recommended.

  • Endoscopy: A flexible tube equipped with a camera is pushed down the throat into the esophagus. Using the endoscope, the doctor examines the esophagus, looking for suspicious areas and takes a piece of tissue for pathologic examination.

Endoscopic ultrasound (using an ultrasound probe at the end of an endoscope) helps the doctor to see the extent of growth of tumor into nearby areas as well as to check for enlarged lymph nodes.

  • Imaging tests can help to look for suspicious areas, check for spread of cancer and during treatment to look if the disease is responding or not.
  • Barium swallow: In this test, you will have to drink thick chalky liquid called barium that coats the walls of the esophagus. X-rays are taken which show the suspicious areas in the lining of esophagus, from which a tissue piece can be taken and examined for abnormal cells.
  • CT scan: To look for the spread of cancer to nearby organs and lymph nodes
  • MRI scan: Helps in detecting spread of tumor, especially to brain and spinal cord
  • PET scan: Helps to see the spread of cancer to other parts of the body.
  • Biopsy is done in cases of suspected malignancy on endoscopy or imaging studies. The tissue piece removed during endoscopy is sent to the laboratory for pathological examination to look for cancerous cells.
  • Bronchoscopy may be done if you have cancer in the upper part of your esophagus to check for spread to the windpipe (trachea) or the tubes leading from the windpipe into the lungs (bronchi).

The stages of esophageal cancer range from 0 to IV.

Stage 0. Cancer is limited to the epithelium or the cells lining the esophagus.

Stage I. The size of the tumor is small (7 cm or less) and is limited to the esophagus.

Stage II. Cancer has either involved all the layers of esophagus but without spread to lymph nodes OR is limited to the inner three layers of esophagus with involvement of 1-2 nearby lymph nodes.

Stage III. Cancer involves all the layers of esophagus and has spread to nearby lymph nodes (not more than 6 in number).

Stage IV. Cancer has spread to 7 or more lymph nodes OR involved the coverings of lungs (pleura) or heart (pericardium) OR spread to trachea, aorta, spine OR to distant organs like liver and lungs.

Treatment

The National Comprehensive Cancer Network (NCCN) provides guidelines for the treatment of esophageal cancer [27]. The treatment options depend on the stage of the cancer as well as your overall health.

  • Surgery:
    • Endoscopic resection (for very small tumors)
    • Removing a part of esophagus (esophagectomy)
    • Removing a part of esophagus and upper portion of stomach (esophagogastrectomy)
  • Chemotherapy: Use of drugs to kill cancer cells. This can be used before or after surgery or in combination with radiation therapy.
  • Radiation therapy or radiotherapy: Often combined with chemotherapy and used before surgery and sometimes after surgery. Radiotherapy may also be used for relieving symptoms of advanced esophageal cancer.
  • Targeted therapy: Trastuzumab (herceptin) may be used if your esophageal cancer is positive for HER2. Anti-angiogenic therapy (drugs that stop the making of new blood vessels to starve the cancer) may be used if chemotherapy has not worked.
  • Immunotherapy: may be used to boost your body’s defense mechanism to fight cancer cells.

References

  1. GLOBOCAN 2012 (IARC) , Section of Cancer Surveillance (1/3/2018)
  2. Bray F, Jemal A, Grey N, Ferlay J, Forman D. Global cancer transitions according to the Human Development Index (2008-2030): A population-based study. Lancet Oncol 2012;13:790-801.
  3. Brown LM, Devesa SS, Chow WH. Incidence of adenocarcinoma of the esophagus among white Americans by sex, stage, and age. J Natl Cancer Inst 2008;100:1184-7.
  4. Cherian JV, Sivaraman R, Muthusamy AK, Jayanthi V. Carcinoma of the esophagus in Tamil Nadu (South India): 16-year trends from a tertiary center. J Gastrointestin Liver Dis 2007;16:245-9
  5. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://www.globocan.iarc.fr
  6. Blot WJ, Devesa SS, Fraumeni JF. Continuing climb in rates of esophageal adenocarcinoma: an update. JAMA 1993; 270: 1320
  7. Young JL, Percy CL, Asire AJ, Berg JW, Cusano MM, Gloeckler LA, Horm JW, Lourie WI, Pollack ES, Shambaugh EM. Zhang Y. Risk factors of esophageal cancer WJG|www.wjgnet.com 5604 September 14, 2013|Volume 19|Issue 34| Cancer incidence and mortality in the United States, 1973-77. Natl Cancer Inst Monogr 1981; (57): 1-187
  8. Kwatra KS, Prabhakar BR, Jain S, Grewal JS. Sarcomatoid carcinoma (carcinosarcoma) of the esophagus with extensive areas of osseous differentiation: a case report. Indian J Pathol Microbiol 2003; 46: 49-51
  9. Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 2003; 349: 2241-2252 [PMID: 14657432 DOI: 10.1056/NEJMra035010]
  10. Cook MB. Non-acid reflux: the missing link between gastric atrophy and esophageal squamous cell carcinoma? Am J Gastroenterol 2011; 106: 1930-1932 [PMID: 22056574 DOI: 10.1038/ ajg.2011.288]
  11. Dawsey SM, Lewin KJ, Wang GQ, Liu FS, Nieberg RK, Yu Y, Li JY, Blot WJ, Li B, Taylor PR. Squamous esophageal histology and subsequent risk of squamous cell carcinoma of the esophagus. A prospective follow-up study from Linxian, China. Cancer 1994; 74: 1686-1692
  12. Dawsey SM, Lewin KJ, Liu FS, Wang GQ, Shen Q. Esophageal morphology from Linxian, China. Squamous histologic findings in 754 patients. Cancer 1994; 73: 2027-2037
  13. Huang Q, Fang DC, Yu CG, Zhang J, Chen MH. Barrett’ s esophagus-related diseases remain uncommon in China. J Dig Dis 2011; 12: 420-427 [PMID: 22118690 DOI: 10.1111/ j.1751-2980.2011.00535.x]
  14. Kountourakis P, Papademetriou K, Ardavanis A, Papamichael D. Barrett’s esophagus: treatment or observation of a major precursor factor of esophageal cancer? J BUON 2011; 16: 425-430
  15. Conteduca V, Sansonno D, Ingravallo G, Marangi S, Russi S, Lauletta G, Dammacco F. Barrett’s esophagus and esophageal cancer: an overview. Int J Oncol 2012; 41: 414-424 [PMID: 22615011 DOI: 10.3892/ijo.2012.1481]
  16. Hongo M, Nagasaki Y, Shoji T. Epidemiology of esophageal cancer: Orient to Occident. Effects of chronology, geography and ethnicity. J Gastroenterol Hepatol 2009; 24: 729-735 [PMID: 19646015 DOI: 10.1111/j.1440-1746.2009.05824.x]
  17. Shaheen N, Ransohoff DF. Gastroesophageal reflux, barrett esophagus, and esophageal cancer: scientific review. JAMA 2002; 287: 1972-1981
  18. Pedrazzani C, Bernini M, Giacopuzzi S, Pugliese R, Catalano F, Festini M, Rodella L, de Manzoni G. Evaluation of Siewert classification in gastro-esophageal junction adenocarcinoma: What is the role of endoscopic ultrasonography? J Surg Oncol 2005; 91: 226-231 [PMID: 16121346 DOI: 10.1002/jso.20302]
  19. Suh YS, Han DS, Kong SH, Lee HJ, Kim YT, Kim WH, Lee KU, Yang HK. Should adenocarcinoma of the esophagogastric junction be classified as esophageal cancer? A comparative analysis according to the seventh AJCC TNM classification. Ann Surg 2012; 255: 908-915 [PMID: 22504190 DOI: 10.1097/SLA.0b013e31824beb95]
  20. Schumacher G, Schmidt SC, Schlechtweg N, Roesch T, Sacchi M, von Dossow V, Chopra SS, Pratschke J, Zhukova J, Stieler J, Thuss-Patience P, Neuhaus P. Surgical results of patients after esophageal resection or extended gastrectomy for cancer of the esophagogastric junction. Dis Esophagus 2009; 22: 422-426 [PMID: 19191862 DOI: 10.1111/j.1442-2050.2008.00923.x]
  21. Hasegawa S, Yoshikawa T, Aoyama T, Hayashi T, Yamada T, Tsuchida K, Cho H, Oshima T, Yukawa N, Rino Y, Masuda M, Tsuburaya A. Esophagus or stomach? The seventh TNM classification for Siewert type II/III junctional adenocarcinoma. Ann Surg Oncol 2013; 20: 773-779
  22. Hosokawa Y, Kinoshita T, Konishi M, Takahashi S, Gotohda N, Kato Y, Daiko H, Nishimura M, Katsumata K, Sugiyama Y, Kinoshita T. Clinicopathological features and prognostic factors of adenocarcinoma of the esophagogastric junction according to Siewert classification: experiences at a single institution in Japan. Ann Surg Oncol 2012; 19: 677-683
  23. Fang WL, Wu CW, Chen JH, Lo SS, Hsieh MC, Shen KH, Hsu WH, Li AF, Lui WY. Esophagogastric junction adenocarci noma according to Siewert classification in Taiwan. Ann Surg Oncol 2009; 16: 3237-3244 [PMID: 19636628 DOI: 10.1245/ s10434-009-0636-9]
  24. Yoon HY, Kim HI, Kim CB. [Clinicopathologic characteristics of adenocarcinoma in cardia according to Siewert classification]. Korean J Gastroenterol 2008; 52: 293-297 [PMID: 19077475] 27 Szántó I, Vörös A, Gonda G, Nagy P, Altorjay A, Banai J, Gamal EM, Cserepes E. [Siewert-Stein classification of adenocarcinoma of the esophagogastric junction]. Magy Seb 2001; 54: 144-149
  25. María José Domper Arnal, Ángel Ferrández Arenas, and Ángel Lanas Arbeloa. Esophageal cancer: Risk factors, screening and endoscopic treatment in Western and Eastern countries. World J Gastroenterol. 2015 Jul 14; 21(26): 7933–7943.
  26. Lao-Sirieix P, Fitzgerald RC. Screening for oesophageal cancer. Nat Rev Clin Oncol. 2012;9:278–287.
  27. Ajani JA, Barthel JS, Bentrem DJ, et al. Esophageal and esophagogastric junction cancers. J Natl Compr Canc Netw 2011;9:830-87