What is the esophagus ?
The esophagus muscular tube travels down through the chest, between the lungs. It then passes through a hole in the diaphragm to connect with the stomach.
Risk for esophageal cancer
Risk factors for this type of cancer include smoking and alcohol use. Other potential carcinogens include nitrosamines, asbestos fibers, and petroleum products.
Lower esophageal cancer in most cases arise in the setting of Barrett’s esophagus (chronic irritation due to stomach acid called as Gastro esophageal reflux disease), which is a condition in which the normal lining of the esophagus is replaced by lining normally found in the stomach. Barrett’s esophagus is diagnosed by endoscopy. Other pre-existing esophageal conditions may also increase the risk like achalasia, which is a condition where there is ineffective peristalsis (movement) in the esophagus, as well as caustic esophageal injury, from acid ingestion, can increase the risk of esophageal cancer
How to prevent esophgeal cancer ?
Smoking cessation and decreasing alcohol intake are by far the best methods of decreasing the risk of developing squamous cell carcinoma of the esophagus. The best prevention of adenocarcinoma would be decreasing the risk of chronic GERD, the cause of Barrett’s esophagus.
What screening tests are available ?
The “gold standard” for diagnosis is endoscopy and biopsy.
The primary goal of endoscopy is to detect dysplasia early perticularly in Barrett’s esophagus.
What are signs of esophageal cancer ?
Over 90% of people with esophageal cancer present with problems swallowing, often leading to a significant amount of weight loss prior to the actual diagnosis. Patients also report a sensation that food “gets stuck” somewhere in the chest, where the growing of the cancer precludes the passage of food. Problems usually start with food, though eventually even liquids could “get stuck” if the cancer progresses and continues to grow into the hollow tube that the esophagus is. A larger tumor can erode the wall to the point where it causes bleeding. This can cause patients to cough up blood, or vomit blood. Additionally, if the blood is swallowed, one may notice blood in the stool or black tarry stools also known as melena. The trachea (windpipe) is located directly in front of the esophagus, and it is possible for an esophageal cancer to erode the entire way through the esophageal wall and into the trachea, creating what is called a tracheoesophageal (respiratory) fistula. This causes cough, an irritating sensation with breathing (especially with deep breaths), and hoarseness.
How is esophageal cancer diagnosed ?
An endoscopy is commonly done when people first present with symptoms. Using endoscopy, the area of concern in the esophagus can be viewed directly with the fiber-optic camera, and the location of the abnormality, the presence or absence of bleeding, and the amount of obstruction can all be seen. Endoscopy also allows a biopsy to be performed. The standard of care today would also include performing an ultrasound during the endoscopy, called an endoscopic ultrasound examination (EUS). This allows for the prediction of how much of the esophageal wall is involved by tumor.
The CT scan should include imaging of chest and upper abdomen to assess the stage.
What are the treatments for esophageal cancer?
Certain very early tumors, limited to the submucosa (the superficial layer of the esophagus), may be treated with endoscopic resection. More commonly, people present with advanced stage disease because symptoms often develop only after the tumor has grown to a large size or has spread. There are a number of different modalities that can be used to treat esophageal cancer including surgery, radiation, and chemotherapy. However, in people who can tolerate it, combined modality is preferred. When the esophagus is removed, the stomach is pulled up into the chest to keep the passageway for food intact. Not only is there a risk of infection and bleeding from the surgery itself, but the recovery period after surgery can be difficult. Additionally, there is the risk of a leak forming at the new connection that is formed between the stomach and the remaining portion of the esophagus (known as an anastamosis), which can then require further surgery and potentially lead to very serious complications. Though the results of these studies are somewhat mixed, it is thought that both radiation and chemotherapy add a benefit. Therefore, radiation therapy (for local tumor control) and chemotherapy (for distant control as well as to improve the effectiveness of radiation therapy) is almost always recommended either before or after the surgery.