Esophageal Cancer

esophagusEsophageal cancer is a disease in which malignant (cancer) cells form in the tissues of the esophagus.

The esophagus is the hollow, muscular tube that moves food and liquid from the throat to the stomach. The wall of the esophagus is made up of several layers of tissue, including mucous membrane, muscle, and connective tissue. Esophageal cancer starts at the inside lining of the esophagus and spreads outward through the other layers as it grows.

The two most common forms of esophageal cancer are named for the type of cells that become malignant (cancerous):

  • Squamous cell carcinoma: Cancer that forms in squamous cells, the thin, flat cells lining the esophagus. This cancer is most often found in the upper and middle part of the esophagus, but can occur anywhere along the esophagus. This is also called epidermoid carcinoma.
  • Adenocarcinoma: Cancer that begins in glandular (secretory) cells. Glandular cells in the lining of the esophagus produce and release fluids such as mucus. Adenocarcinomas usually form in the lower part of the esophagus, near the stomach.

Risk Factors
Symptoms
Screening and Diagnosis
Staging
Treatment
Support

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Risk Factors

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors include the following:

  • Tobacco use.
  • Heavy alcohol use.
  • Barrett esophagus: A condition in which the cells lining the lower part of the esophagus have changed or been replaced with abnormal cells that could lead to cancer of the esophagus. Gastric reflux (the backing up of stomach contents into the lower section of the esophagus) may irritate the esophagus and, over time, cause Barrett esophagus.
  • Older age.
  • Being male.
  • Being African-American.

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Symptoms

These and other signs and symptoms may be caused by esophageal cancer or by other conditions. Check with your doctor if you have any of the following:

  • Painful or difficult swallowing.
  • Weight loss.
  • Pain behind the breastbone.
  • Hoarseness and cough.
  • Indigestion and heartburn.

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Screening and Diagnosis

Tests that examine the esophagus are used to detect (find) and diagnose esophageal cancer.

The following tests and procedures may be used:

  • Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • Barium swallow: A series of x-rays of the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and stomach, and x-rays are taken. This procedure is also called an upper GI series.
  • Esophagoscopy: A procedure to look inside the esophagus to check for abnormal areas. An esophagoscope is inserted through the mouth or nose and down the throat into the esophagus. An esophagoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope
    for signs of cancer. When the esophagus and stomach are looked at, it is called an upper endoscopy.
  • Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. The biopsy is usually done during an esophagoscopy. Sometimes a biopsy shows changes in the esophagus that are not cancer but may lead to cancer.

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Staging

After esophageal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the esophagus or to other parts of the body.

The process used to find out if cancer cells have spread within the esophagus or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

  • Bronchoscopy: A procedure to look inside the trachea and large airways in the lung for abnormal areas. A bronchoscope is inserted through the nose or mouth into the trachea and lungs. A bronchoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the chest, abdomen, and pelvis, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. A PET scan and CT scan may be done at the same time. This is called a PET-CT.
  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the body, usually through the mouth or rectum. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.
  • Thoracoscopy: A surgical procedure to look at the organs inside the chest to check for abnormal areas. An incision (cut) is made between two ribs and a thoracoscope is inserted into the chest. A thoracoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node samples, which are checked under a microscope for signs of cancer. In some cases, this procedure may be used to remove part of the esophagus or lung.
  • Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples to be checked under a microscope for signs of disease.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

  • Tissue. The cancer spreads from where it began by growing into nearby areas.
  • Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
  • Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

  • Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
  • Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if esophageal cancer spreads to the lung, the cancer cells in the lung are actually esophageal cancer cells. The disease is metastatic esophageal cancer, not lung cancer.

The following stages are used for squamous cell carcinoma of the esophagus:

Stage 0 (High-grade Dysplasia)

In stage 0, abnormal cells are found in the inner (mucosal) layer of the esophageal wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called high-grade dysplasia.

Stage I squamous cell carcinoma of the esophagus

Stage I is divided into Stage IA and Stage IB, depending on where the cancer is found.

  • Stage IA: Cancer has formed in the inner (mucosal) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope.
  • Stage IB: Cancer has formed:
    • in the inner (mucosal) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope; or
    • in the inner (mucosal) layer and spread into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope. The tumor is in the lower esophagus or it is not known where the tumor is.

Stage II squamous cell carcinoma of the esophagus

Stage II is divided into Stage IIA and Stage IIB, depending on where the cancer has spread.

  • Stage IIA: Cancer has spread:
    • into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope. The tumor is in either the upper or middle esophagus; or
    • into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope. The tumor is in the lower esophagus or it is not known where the tumor is.
  • Stage IIB: Cancer:
    • has spread into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope. The tumor is in either the upper or middle esophagus; or
    • is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in 1 or 2 lymph nodes near the tumor.

Stage III squamous cell carcinoma of the esophagus

Stage III is divided into Stage IIIA, Stage IIIB, and Stage IIIC, depending on where the cancer has spread.

  • Stage IIIA: Cancer:
    • is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in 3 to 6 lymph nodes near the tumor; or
    • has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in 1 or 2 lymph nodes near the tumor; or
    • has spread into the diaphragm, sac around the heart, or tissue that covers the lungs and lines the inner wall of the chest cavity. The cancer can be removed b surgery.
  • Stage IIIB: Cancer has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in 3 to 6 lymph nodes near the tumor.
  • Stage IIIC: Cancer has spread:
    • into the diaphragm, sac around the heart, or tissue that covers the lungs and lines the inner wall of the chest cavity; the cancer can be removed by surgery. Cancer is found in 1 to 6 lymph nodes near the tumor; or
    • into other nearby organs such as the aorta, trachea, or spine, and the cancer cannot be removed by surgery; or
    • to 7 or more lymph nodes near the tumor.

Stage IV squamous cell carcinoma of the esophagus

In Stage IV, cancer has spread to other parts of the body.

The following stages are used for adenocarcinoma of the esophagus:

Stage 0 (High-grade Dysplasia)

In stage 0, abnormal cells are found in the inner (mucosal) layer of the esophageal wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called high-grade dysplasia.

Stage I adenocarcinoma of the esophagus

Stage I is divided into Stage IA and Stage IB, depending on where the cancer is found.

  • Stage IA: Cancer has formed in the inner (mucosal) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope.
  • Stage IB: Cancer has formed:
    • in the inner (mucosal) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope and they grow quickly; or
    • in the inner (mucosal) layer and spread into the middle (muscle) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope.

Stage II adenocarcinoma of the esophagus

Stage II is divided into Stage IIA and Stage IIB, depending on where the cancer has spread.

  • Stage IIA: Cancer has spread into the middle (muscle) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope and they grow quickly.
  • Stage IIB: Cancer:
    • has spread into the outer (connective tissue) layer of the esophageal wall; or
    • is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in 1 or 2 lymph nodes near the tumor.

Stage III adenocarcinoma of the esophagus

Stage III is divided into Stage IIIA, Stage IIIB, and Stage IIIC, depending on where the cancer has spread.

  • Stage IIIA: Cancer:
    • is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in 3 to 6 lymph nodes near the tumor; or
    • has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in 1 or 2 lymph nodes near the tumor; or
    • has spread into the diaphragm, sac around the heart, or tissue that covers the lungs, and lines the inner wall of the chest cavity. The cancer can be removed by surgery.
  • Stage IIIB: Cancer has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in 3 to 6 lymph nodes near the tumor.
  • Stage IIIC: Cancer has spread:
    • into the diaphragm, sac around the heart, or tissue that covers the lungs and lines the inner wall of the chest cavity; the cancer can be removed by surgery. Cancer is found in 1 to 6 lymph nodes near the tumor; or
    • into other nearby organs such as the aorta, trachea, or spine, and the cancer cannot be removed by surgery; or
    • to 7 or more lymph nodes near the tumor.

Stage IV adenocarcinoma of the esophagus

In Stage IV, cancer has spread to other parts of the body.

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Treatment

At Huntsman Cancer Institute (HCI), esophageal cancer is treated by a team of specialists, including gastroenterologists (doctors who specialize in treating problems of the digestive organs), surgeons, medical oncologists (doctors who treat cancer with medicine), radiation oncologists (doctors who treat cancer with radiation), nurses, dietitians, respiratory therapists, speech pathologists, and social workers.

Different types of treatment are available for patients with esophageal cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Patients have special nutritional needs during treatment for esophageal cancer. Many people with esophageal cancer find it hard to eat because they have trouble swallowing. The esophagus may be narrowed by the tumor or as a side effect of treatment. Some patients may receive nutrients directly into a vein. Others may need a feeding tube (a flexible plastic tube that is passed through the nose or mouth into the stomach) until they are able to eat on their own. View HCI's Nutrition Care Services to learn more about our dietitians and ways to cope with nutrition-related changes.

Six types of standard treatment are used:

New treatments are being tested in clinical trials.

Surgery

Surgery is the most common treatment for cancer of the esophagus. Part of the esophagus may be removed in an operation called an esophagectomy.

The doctor will connect the remaining healthy part of the esophagus to the stomach so the patient can still swallow. A plastic tube or part of the intestine may be used to make the connection. Lymph nodes near the esophagus may also be removed and viewed under a microscope to see if they contain cancer. If the esophagus is partly blocked by the tumor, an expandable metal stent (tube) may be placed inside the esophagus to help keep it open.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

A plastic tube may be inserted into the esophagus to keep it open during radiation therapy. This is called intraluminal intubation and dilation.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated. Learn more about this treatment in our introduction to chemotherapy video.

 

Chemoradiation therapy

Chemoradiation therapy combines chemotherapy and radiation therapy to increase the effects of both.

Laser therapy

Laser therapy is a cancer treatment that uses a laser beam (a narrow beam of intense light) to kill cancer cells.

Electrocoagulation

Electrocoagulation is the use of an electric current to kill cancer cells.

Clinical trials

These studies discover and evaluate new and improved cancer treatments. Patients are encouraged to talk with their doctors about participating in a clinical trial or any questions regarding research studies. For more information, visit HCI's clinical trials website.

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Support

When you or someone you love is diagnosed with cancer, concerns about treatments and side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, work, or normal daily life.

There are several places you can go for support:

  • Your health care team can answer your questions and talk to you about your concerns. They can help you with any side effects and keep you informed of all your treatments, test results, and future doctor visits.
  • The G. Mitchell Morris Cancer Learning Center has hundreds of free brochures and more than 3,000 books, DVDs, and CDs available for checkout. You can browse the library, perform Internet research, or talk with a cancer information specialist.
  • Our Patient and Family Support Services offer emotional support and resources for coping with cancer and its impact on daily life to Huntsman Cancer Institute (HCI) patients and their families.
  • The Linda B. and Robert B. Wiggins Wellness-Survivorship Center offers many programs to increase the quality of life and well-being of HCI patients and their families

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Adapted from the National Cancer Institute's Physician Data Query (PDQ®) Cancer Information Summaries
This information last updated on HCI website December 2013

*If you are interested in a trial that is currently marked *Not Open, please contact the Patient Education team at 1-888-424-2100 or patient.education@hci.utah.edu for other trial options. Enrollment is updated daily.

Forte Research Systems in partnership with Huntsman Cancer Institute

Douglas G. Adler, M.D.

Locations
Huntsman Cancer Institute (801) 213-9797
Redwood Health Center (801) 213-9797
University Hospital (801) 213-9797
University Hospital (801) 213-9797

Specialties: Biliary Cancer, Endoscopic Retrograde Cholangiopancreatography (ERCP), Endoscopic Ultrasound, Endoscopy, Esophageal Diseases, Gastroenterology, Pancreatic Cancer, Therapeutic Endoscopy

Shamus R. Carr, M.D., FACS

Locations
Huntsman Cancer Hospital (801) 587-4470
University Hospital (801) 581-5311

Specialties: Barrett's Esophagus, Bronchoscopy surgery, Cardiothoracic Surgery, Esophageal Diseases, Gastroesophageal Reflux Disease (GERD), Lung Cancer, Minimally Invasive Gastrointestinal Surgery, Therapeutic Endoscopy

John C. Fang, M.D.

Locations
Redwood Health Center (801) 213-9797
University Hospital (801) 213-9797
University Hospital (801) 213-9797

Specialties: Barrett's Esophagus, Endoscopy, Enteral Nutrition, Esophageal Diseases, GI Motility, Gastroenterology, Gastroesophageal Reflux Disease (GERD), Therapeutic Endoscopy

Robert E. Glasgow, M.D.

Locations
Huntsman Cancer Hospital (801) 585-6035
University Hospital (801) 585-6035

Specialties: Acute Care Surgery, Barrett's Esophagus, Colorectal Surgery, Endocrine Surgery (Adrenal, Thyroid, Parathyroid), Esophageal Diseases, Esophageal Surgery, GI Motility, Gastric/Esophageal Surgery, Gastroesophageal Reflux Disease (GERD), Hepatopancreatobiliary (Liver/Pancreas/Biliary) Surgery, Hernia Surgery (open and laparoscopic), Minimally Invasive Gastrointestinal Surgery, Minimally Invasive Lung & Esophageal Surgery, Soft Tissue Sarcoma Surgery, Surgery, General, Therapeutic Endoscopy, Upper Gastrointestinal Tract Surgery

Kathryn A. Peterson, M.D.

Locations
South Jordan Health Center (801) 213-9797
University Hospital (801) 213-9797
University Hospital (801) 213-9797

Specialties: Barrett's Esophagus, Endoscopy, Esophageal Diseases, GI Motility, Gastroenterology, Inflammatory Bowel Disease/Crohn's/Ulcerative Colitis, Women's GI Health

Eric T. Volckmann, M.D.

Locations
University Hospital (801) 587-3856

Specialties: Bariatric Surgery, Barrett's Esophagus, Endocrine Surgery (Adrenal, Thyroid, Parathyroid), Esophageal Diseases, GI Motility, Gastric/Esophageal Surgery, Gastroesophageal Reflux Disease (GERD), Hernia Surgery (open and laparoscopic), Minimally Invasive Gastrointestinal Surgery, Surgery, General, Therapeutic Endoscopy, Upper Gastrointestinal Tract Surgery

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Care coordinator: Christy Steele
Phone: 801-587-4422
E-mail: christy.steele@hci.utah.edu

Did You Know?

  • In the United States, men are more than three times as likely as women to develop esophageal cancer.
  • Early esophageal cancer may not cause symptoms.
  • Dietitians and speech pathologists at Huntsman Cancer Institute work closely with esophageal cancer patients who may have trouble eating or swallowing.
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