Esophageal Cancer

Esophageal cancer refers to the abnormal cell growth in the esophagus- the long muscular tube connecting the throat and stomach. These abnormal cells form a mass, usually in the inner layers first and then spreading to the outer layers.

Associated Anatomy

Esophagus (food pipe)

Alternate Name of Esophageal Cancer

Esophagus cancer

Signs or Symptoms of Esophageal Cancer

Esophageal cancer might go unnoticed in the early stages. The first sign is usually difficulty in swallowing, and it could present with the following symptoms:

• Unexplained weight loss
• Hoarseness of voice
• Chronic cough
• Heartburn
• Indigestion
• Pain in the food pipe or during swallowing
• Chest pain
• Feeling of pressure in the chest
• Blood in stools
• Coughing blood

Causes of Esophageal Cancer

Esophageal cancer is caused by the genetic mutations in the genes, and the following could contribute:

• Family history leads to the inherited genetic mutations leading to esophageal cancer
• Exposure to radiation or harmful chemicals such as solvents or petrochemicals is associated with esophageal cancer.
• The Human Papillomavirus (HPV) is also known to cause esophageal cancer.

Stages of Esophageal Cancer

The staging of esophageal cancer depends on the location, spread, and tissues involved. Below are the staging criteria:

• Stage 0: Presence of abnormal cells in the inner lining of the esophagus, which are not yet cancerous
• Stage I: Presence of the cancerous cells in the inner lining of the esophagus
• Stage II: Spread of cancer to outer layers of esophagus or muscles and has affected 1-2 lymph nodes
• Stage III: Spread of cancer to deeper tissues and nearby organs
• Stage IV: Spread of cancer to distant organs as this is the most advanced stage

Esophageal Cancer Diagnosis

Differential Diagnosis of Esophageal Cancer

A differential diagnosis is required to rule out other medical conditions that could mimic the symptoms of esophageal cancer such as gastric cancer, esophageal spasm, esophageal stricture due to gastroesophageal reflux disease, reflux esophagitis, esophageal candidiasis, esophageal leiomyoma, achalasia, pseudoachalasia, esophageal motility disorder, diffuse inflammation, systemic sclerosis, and Chagas disease.

Typical Test

Esophageal cancer is diagnosed by various imaging techniques such as Chest X-ray and bronchoscopy. A CT scan can also be used to create high-resolution images of the esophagus to identify the affected area. Additionally, endoscopic ultrasound could be used to confirm the diagnosis and measure the size of the tumor. In a few cases, thoracoscopy and laparoscopy can be used to examine the organs and extract samples for biopsy.

Possible Treatments For Esophageal Cancer

The treatment approach depends on the stage, location, and health condition of the patient. Various treatment options include:

• Surgery: Surgical procedure is used to remove the cancerous mass or part from the esophagus.
• Chemotherapy: Strong medicines are administered(often intravenously) to kill the cancerous cells. It is usually given along with radiotherapy or post-surgery.
• Radiotherapy: High-intensity radiations are used to destroy the cancerous cells
• Immunotherapy: Therapy to activate the immune cells that kill the specific tumor cells.
• Targeted therapy: Medications specifically target the cancerous cells/tissues, sparing the healthy cells.
• Laser therapy: Specialized laser beam is used to kill cancer cells.
• Cryotherapy: Freezing the cancerous cells and killing them

Risk Factors of Esophageal Cancer

• Age: People above 60 years are more at risk of developing esophageal cancer.
• Gender: Males are 3-times more at risk of developing esophageal cancer.
• Ethnicity: Africans and Asians are at more risk to develop squamous cell carcinoma, while caucasian people are more prone to develop adenocarcinoma.
• Smoking and alcohol use: People who use tobacco or alcohol are at higher risk.
• HPV infection: An important risk factor
• People with chronic acid reflux disease and Barrett’s esophagus are at increased risk.
• History of other cancer or radiotherapy
• Exposure to chemicals such as solvents and petrochemicals
• Family history

Possible Complications of Esophageal Cancer

Advancements in carcinoma lead to various complications that could be related to the progression of the disease or recurrences. Esophageal obstruction is the most common complication leading to difficulty in swallowing food and liquids. Other complications could include pain in the food pipe and esophageal bleeding. Bleeding can be severe and lead to life-threatening conditions and urgent medical attention.

Prevention of Esophageal Cancer

Primary Prevention

The primary prevention includes working on the potential risk factors of esophageal cancer. The following preventive should be taken:

• Quit smoking: Tobacco use has been associated with esophageal cancer. Quit smoking and any other tobacco usage.
• Limit alcohol use: Cut down on alcohol intake. Alcohol significantly increases the chances of esophageal cancer.
• Dietary changes: Have more fruits and vegetables rich in antioxidants and phytochemicals. Avoid the use of canned or frozen foods.
• Maintain a healthy weight: Healthy weight helps manage obesity, which can significantly reduce the chances of esophageal cancer and associated complications.

Secondary Prevention

• Regular follow-ups: Follow-ups should be made as per the schedule to assess the recovery, risk of recurrence, and overall quality of life.
• Symptom watch-out: Always look for symptoms of recurrence or complications and seek immediate medical attention.
• Lifestyle: Exercise regularly and eat a well-balanced diet.
• Manage weight and diabetes: Managing diabetes, obesity, and weight will help to reduce the chances of complications or recurrences.
• Awareness: Being aware of the disease and having realistic expectations helps in better planning and management.

Epidemiology

• Worldwide, esophageal cancer is the 6th most common of the cancers leading to death.
• Esophageal cancer is three times more common in males than in females.
• Approximately 4.2 out of every 1,00,000 persons develop new-onset esophageal cancer every year.
• The high prevalence of esophageal cancer in certain areas has been reported to be associated with obesity, tobacco use, and alcohol use.

Expected Prognosis

Prognosis is dependent on the age, stage of cancer, and response to treatment. In the initial stages, the treatment of esophageal cancer is more effective, and the survival rate is higher. The chances of 5-year survival in metastatic stage-IV cancer are approximately 5%.

Natural Progression

Untreated esophageal cancer will progress from the inner layers of the esophagus to the outer layers. Further, metastatic cancer will spread to tissues and organs beyond the esophagus, such as lymph nodes, stomach, intestine, etc.

Pathophysiology

Mutations in the genes lead to uncontrolled growth of the cells that continue to divide and form a mass/ tumor in the inner layer of the esophagus. Adenocarcinomas originate in the mucus-secreting glands, while squamous cell carcinoma originates in the squamous cells in the lining of the esophagus. This tumor then invades the outer layers and other tissues.