esophageal cancer

esophageal cancer, disease characterized by the abnormal growth of cells in the esophagus, the muscular tube connecting the oral cavity with the stomach. There are two types of esophageal cancer: squamous cell carcinoma, which develops from epithelial cells lining the esophagus, and adenocarcinoma, which originates in glandular cells.

Squamous cell carcinoma accounts for the majority of cases of esophageal cancer globally. However, adenocarcinoma is on the rise in Western countries; in the United States and Europe it has surpassed squamous cell carcinoma. Men are more than twice as likely to develop esophageal cancer as women, and, while Blacks are more likely to develop squamous cell carcinoma than whites, whites are more likely to develop adenocarcinoma. In the 21st century esophageal cancer was the sixth most common cause of cancer-related death worldwide.

Risk factors and symptoms

Several risk factors have been identified that increase the likelihood of developing esophageal cancer. Some factors, such as older age and male sex, are impossible to control. However, tobacco and alcohol use increase risk and are modifiable behaviors. Likewise, dietary factors, such a lack of fruits and vegetables or high consumption of processed meats and hot beverages, are linked to increased risk. Children who accidentally swallow lye (sodium hydroxide) are at increased risk of developing esophageal cancer in adulthood.

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Risk of adenocarcinoma is significantly elevated by obesity. In addition, gastroesophageal reflux disease (GERD), a form of acid reflux that often is associated with obesity, may lead to a condition known as Barrett esophagus, in which the normal squamous cells that line the esophagus are replaced with glandular cells; this condition increases cancer risk. Rare disorders such as tylosis (a genetic condition), achalasia (a swallowing disorder), and Plummer-Vinson syndrome (a disorder linked to chronic iron-deficiency anemia) are also risk factors.

Esophageal cancers are usually diagnosed once symptoms have appeared, but by this time the cancer has usually developed to a relatively advanced stage. Symptoms may include difficulty or pain when swallowing, pain or tightness in the chest, unexplained weight loss, hoarseness, or frequent hiccups.

Diagnosis and prognosis

If cancer is suspected, a thorough examination is conducted to determine its type and stage. The esophagus is visually examined with an endoscope, and tissue samples are taken for biopsy. Several imaging methods are frequently used, such as chest X rays, computed tomography (CT) scans, or ultrasound. There is no definitive laboratory test for esophageal cancer.

Once esophageal cancer has been diagnosed, its stage is determined to indicate how far the cancer has progressed. Stage 0 esophageal cancer is also called carcinoma in situ and is confined to the inner layer of epithelial cells lining the esophagus. Stage I cancers have spread into the connective tissue layer below the epithelium but have not invaded the underlying muscle layer. Stage II cancers either have spread through the muscle layer to the outer boundaries of the esophagus or have spread only into the muscle layer but have reached nearby lymph nodes. Stage III esophageal cancers have spread through the esophageal wall to the lymph nodes or other local tissues. Stage IV cancers have metastasized, or spread, to distant organs such as the stomach, liver, bone, or brain.

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The survival rate for esophageal cancer is lower than for many other cancers. When the cancer is detected before it has invaded the underlying tissue layers of the esophagus, five-year survival is high, but fewer than 25 percent of esophageal cancers are diagnosed at this stage. If the cancer has moved to the tissue immediately underlying the mucosal surface, five-year survival is reduced to about 50 percent, and the rate drops significantly once the cancer has moved from the esophagus to nearby lymph nodes or other tissues. Once the cancer has spread to distant tissues in the body, five-year survival is extremely low.

Treatment

Esophageal cancers are best treated surgically when possible. If the cancer is confined to the upper region of the esophagus, an esophagectomy may be done to remove the cancerous portion, along with nearby lymph nodes, and to reconnect the remaining esophagus to the stomach. For cancers of the lower esophagus, it may be necessary to perform an esophagogastrectomy, in which a portion of the esophagus is removed along with a portion of the stomach. The stomach is then reattached directly to the remaining esophagus, or a segment of the colon is used to link the stomach and esophagus. Both of these surgeries are difficult and often result in serious complications.

Other, less-drastic surgeries may be used to relieve symptoms, especially when surgical cure is not possible. A common minimally invasive procedure for palliative care, for example, involves the placement of an esophageal stent, a hollow, often metal mesh or silicone tube that is placed in the esophagus to hold open the area blocked by a tumor. The stent allows the patient to swallow liquids and foods, helping to improve nutrition and quality of life.

Treatment with radiation alone does not cure esophageal cancer, but it may be used either before surgery to shrink the size of the tumor or following surgery to destroy remaining cancer cells. Radiation therapy is also used to relieve symptoms. The side effects of radiation treatment include vomiting, diarrhea, fatigue, and esophageal irritation. Chemotherapy is also used for some esophageal cancers. It is not curative, but it can relieve some symptoms and may be able to shrink tumors prior to surgery. Side effects resemble those of radiation therapy. Targeted therapy and immunotherapy are other options for esophageal cancer, often being administered alongside standard treatments such as chemotherapy and radiation therapy, especially for advanced stages

Prevention

Esophageal cancer cannot be completely prevented, but risk can be lowered by reducing alcohol consumption and avoiding tobacco. Individuals who are at high risk should receive regular screening in order to increase the probability of early detection. Because there is no blood test available for esophageal cancer, screening requires regular biopsies and viewing of the esophagus with an endoscope.