Esophageal Cancer

There are two main types of esophageal cancer: squamous cell carcinoma and adenocarcinoma. While overall the rate of esophageal cancer has remained the same, adenocarcinoma has increased in incidence while squamous cell carcinoma has seen a decrease.

Squamous cell carcinoma grows in the cells that form the top layer of the inner lining of the esophagus, known as squamous cells. This type of cancer can grow anywhere along the esophagus. The cause of squamous cell cancer is unclear but seems to be associated with a history of smoking and alcohol intake. The incidence of squamous cell carcinoma has slightly decreased over the past two decades in the U.S. but continues to be common in many other countries.

Adenocarcinoma develops in the glandular tissue in the lower part of the esophagus, near the opening of the stomach. While the incidence of squamous cell carcinoma has been decreasing in the United States, the incidence of adenocarcinoma has been rising rapidly. This switch in incidence may be related to gastroesophageal reflux disease and certain lifestyle changes, including diet, that are associated with western cultures.

• All forms of tobacco use, including cigarettes, cigars, and chewing tobacco
• High intake of alcohol over prolonged periods
• A history of combined alcohol and tobacco use
• A diet deficient in fruits and vegetables
• Older than 55
• Male
• Drinking very hot liquids frequently
• Swallowing or breathing caustic irritants such as lye and other chemicals
• History of head and neck cancers
• History of achalasia, a disease of the muscle of the esophagus

• Heartburn or reflux disease
• Barrett’s esophagus, a condition caused by prolonged acid reflux
• Smoking
• Obesity
• Older than 55
• Male

• Difficult swallowing (dysphagia)
• Painful swallowing
• Weight loss
• Heartburn
• Regurgitation of undigested food
• Hoarseness or persistent chronic cough
• Hiccups that persist
• Vomiting
• Blood in stools or black-looking stools
• Coughing up blood
• Anemia
• Pneumonia
• Pain in mid-chest, throat, back, behind breastbone, between shoulder blades

There is no routine screening examination for esophageal cancer; however, people with Barrett's esophagus should be examined often (with endoscopy) because they are at greater risk for developing the disease. When esophageal cancer is found very early, there is a better chance of recovery. Esophageal cancer is often in an advanced stage when diagnosed. However, there are treatments to manage and successfully treat all stages of esophageal cancer. Diagnostic tests and procedures include:

• Physical exam and medical history
• Complete blood count
• Blood chemistry studies
• Chest X-ray
• Upper GI (gastrointestinal) series (also called barium swallow) For this series of stomach X-rays of the stomach, patients drink a liquid that contains barium (a silver-white metallic compound). It coats the stomach, and we take X-rays of it. This procedure is also called an upper GI series.
• Esophagoscopy (or endoscopy), an esophagoscope, a thin tube with a lighted lens, is inserted, using some sedation, through the mouth or nose and down the throat into the esophagus to look at and if needed remove tissue samples, which are checked under a microscope for cancer. When the esophagus and stomach are looked at in this way, the procedure is called an upper endoscopy.
• Endoscopic Ultrasound (EUS) can show how deeply the cancer has invaded the wall of the esophagus and whether cancer has spread to nearby lymph nodes. It helps determine staging (determining how advanced the cancer is) and the next best step for treatment. An endoscope is inserted into the body, usually through the mouth. 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.
• CT-scan and PET Scan

Less common tests:

• Fecal occult blood test checks your stool for blood that can be seen only with a microscope.
• Bronchoscopy looks inside the trachea and large airways in the lung for abnormal areas. A bronchoscope, a thin, tube-like instrument with a light, is inserted through the nose or mouth into the trachea and lungs. It may also have a tool to remove tissue samples.
• Thoracoscopy and laparoscopy allows the surgeon to examine lymph nodes and other structures inside the chest or abdomen with a hollow, lighted tube inserted through a small cut in the skin, and to remove suspicious areas for testing.
• Laryngoscopy checks the larynx (voice box) with a mirror or with a laryngoscope. A laryngoscope is a thin, tube-like instrument with a light and a lens for viewing.

The process used to find out if cancer has spread within the esophagus or to other parts of the body is called staging. The stage is determined from the results of physical exams, imaging tests and biopsies that have been done. Learn more about the stages of esophageal cancer.

Treatment for esophageal cancer depends on many factors including the stage of the cancer and where it is located. Your thoracic surgeon will discuss the best treatment for your particular situation. Often a combination of therapies will be recommended.

• Surgery is the most common treatment for esophageal cancer. The goal of surgery is to completely remove the cancer and all surrounding lymph nodes. Surgery is most effective with early disease, but can be used in conjunction with chemotherapy and radiation for advanced cancer. Surgery also provides relief of symptoms such as obstruction and dysphagia (difficulty swallowing).
  • Minimally invasive esophagectomy is the approach of choice that our surgeons used to remove esophageal cancer. This operation has largely replaced at our hospital the open esophagectomy approach that is still used by most other surgeons in this and other countries to treat esophageal cancer. Instead of large incisions and cutting ribs, our surgeons are able to do this operation through small incision using video scopes to guide them. These video thoracoscopic and laparoscopic, and occasionally robotic, techniques allow for fewer complications, less pain and faster recovery.
  • Photodynamic Therapy (PDT), an endoscope with a laser on the end is used to destroy cancer cells on or near the inner lining of the esophagus. This approach is used to relieve blockage of the esophagus caused by cancer.
  • Esophageal staging and jejunostomy, Not infrequently patients may present with intermediate stage esophageal cancer which is best treated by first shrinking the cancer with chemotherapy and radiation therapy and then taking the remaining cancer out by surgery as described above. Patients who have difficulty eating, may benefit from a minimally invasive video laparoscopy with placement of a feeding tube prior to initiation of therapy so that they can continue to receive nutrition while receiving chemotherapy, and be strong enough to later tolerate the esophagectomy operation.
  • Esophageal stent: To overcome obstruction from tumor, our surgeons will occasionally place a cylindrical stent that crosses the obstruction in the esophagus using an endoscope. This is usually done under anesthesia as an outpatient procedure.

Other surgical procedures:

There are a number of ways to remove the esophagus, all of which have been previously developed by an open surgical technique and have been practiced by our surgeons using minimally invasive techniques. They generally refer to how much esophagus is removed and where the incisions are. These are usually related to the location of the tumor.

• Transhiatal esophagectomy
• Three hole esophagectomy
• Ivor-Lewis esophagectomy
• Thoracoabdominal esophagectomy
• Subtotal gastrectomy
• Total gastrectomy

In all of these operations, the esophagus is removed and reconstructed by elongating the stomach. In some cases, however, the colon or small bowel may be used as an esophageal replacement. A feeding tube is placed during surgery to provide nutrition until you can eat adequately.

Non-surgical cancer treatments

• Radiation Therapy uses high-energy rays to kill or shrink cancer cells. Radiation is often used in conjunction with chemotherapy before surgery to shrink the tumor. The Radiation Oncology service at Dana-Farber Brigham Cancer Center uses the most advanced equipment and techniques to deliver radiation to cancerous areas, while minimizing exposure to normal tissues
• Chemotherapy. Chemotherapy uses anticancer drugs to kill cancer cells throughout the entire body. Chemotherapy is often used before or after surgery or alone in the most advanced cases of esophageal cancer. The purpose is to shrink the tumor with the goal of making the tumor small enough that it can be surgically removed. It is often used in conjunction with radiation.
• Clinical trials and targeted therapy

You will receive a thorough diagnostic and staging (determining how advanced the cancer is) evaluation and receive clinically proven treatment by a board-certified thoracic surgeon who specializes in esophageal cancer. Your experience post-treatment will vary depending upon the stage of your cancer. Early detection and the involvement of an experienced thoracic surgeon are important to the successful outcome for esophageal cancer treatment. After treatment, routine life-long surveillance is necessary.

Brigham and Women's Hospital provides a multidisciplinary approach to patient care, collaborating with colleagues in other medical specialties. Our treatment team includes thoracic surgeons, medical oncologists, radiation oncologists, nutritionists, pathologists, anesthesiologists and gastroenterologists. If your thoracic surgeon discovers an underlying illness or concern, you will be referred to a BWH physician for an expert evaluation.

Visit the Dana-Farber Brigham Cancer Center for more information about esophageal cancer.

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