Esophageal cancer is cancer arising from the esophagus—the food pipe that runs between the throat and the stomach.

Symptoms often include trouble swallowing and weight loss. Other symptoms may include pain with swallowing, a hoarse voice, enlarged lymph nodes (glands) around the clavicle (collarbone), a dry cough, and possibly coughing up or vomiting blood.

The two main sub-types of esophageal cancer are squamous cell carcinoma, which is more common in the developing world, and adenocarcinoma, which is more common in the developed world.

A number of less common types also occur. Squamous-cell carcinoma arises from the skin cells that line the esophagus.

Adenocarcinoma arises from glandular cells present in the lower third of the esophagus, often where they have already transformed into intestinal cell type (a condition known as Barrett’s esophagus).

The most common causes of the squamous-cell type are tobacco, alcohol, very hot drinks, and a poor diet. The most common causes of the adenocarcinoma type are smoking tobacco, obesity, and acid reflux.

The disease is diagnosed by biopsy done by an endoscope (a fiber-optic camera). Prevention includes stopping smoking and a healthy diet.

Treatment is based on the cancer’s stage and location, together with the person’s general condition and individual preferences.

Small localized squamous-cell cancers may be treated with surgery alone with the hope of a cure. In most other cases, chemotherapy with or without radiation therapy is used along with surgery.

Larger tumors may have their growth slowed with chemotherapy and radiation therapy. In the presence of extensive disease or if the affected person is not fit enough to undergo surgery, palliative care is often recommended.

Outcomes are related to the extent of the disease and other medical conditions but generally tend to be fairly poor, as diagnosis is often late. Five-year survival rates are around 13% to 18%.

Prominent symptoms usually do not appear until the cancer has infiltrated over 60% of the tube’s circumference, by which time the tumor is already in an advanced stage. Onset of symptoms is usually caused by stenosis (i.e. narrowing of the tube due to the physical presence of the tumor).

The first and the most common symptom is usually difficulty in swallowing (dysphagia), often initially experienced with solid foods and later with softer foods and liquids. Pain when swallowing is less usual initially.

Weight loss is often an initial symptom in cases of squamous-cell carcinoma, though not usually in cases of adenocarcinoma. Eventual weight loss due to reduced appetite and malnutrition is common.

Pain behind the sternum (breastbone) or in the epigastric region around the stomach often feels like heartburn.

The pain can frequently be severe, worsening when food of any sort is swallowed. Another sign may be an unusually husky, raspy, or hoarse-sounding cough, a result of the tumor affecting the recurrent laryngeal nerve.

The presence of the tumor may disrupt the normal contractions of the esophagus on swallowing.

This can lead to nausea and vomiting, regurgitation of food, coughing, and an increased risk of aspiration pneumonia. Abnormal connections (fistulas) occasionally develop between the esophagus and the trachea (windpipe).

Early signs of this serious complication may be coughing on drinking or eating. Fistulas often lead to pneumonia, which is usually heralded by cough, fever, or aspiration. The tumor surface may be fragile and bleed, causing vomiting of blood.

Compression of local structures occurs in advanced disease, leading to such problems as upper airway obstruction and superior vena cava syndrome. Symptoms of hypercalcemia (excess calcium in the blood) may occur.

If the cancer has spread elsewhere, symptoms related to metastatic disease may appear. Common sites of spread include nearby lymph nodes, the liver, lungs, and bone. Liver metastasis can cause jaundice and abdominal swelling (ascites). Lung metastasis can cause shortness of breath, pleural effusions, etc.

Causes

The two main types (i.e. squamous-cell carcinoma and adenocarcinoma) have distinct risk factors, but both types are generally more common in men and are most common in the over-60s.

Esophageal squamous-cell carcinoma is strongly associated with lifestyle factors such as smoking and alcohol, whereas the adenocarcinoma type is linked to long-term acid reflux. Tobacco is a risk factor for both types.

Squamous-cell carcinoma

The two major risk factors for esophageal squamous-cell carcinoma are tobacco (smoking or chewing) and alcohol. The combination of these two exposures seems to exert a strong additive effect.

Some data suggest that about half of all cases are due to tobacco and about one-third to alcohol, while over three-quarters of the cases in men are due to the combination of smoking and heavy drinking.

High levels of dietary exposure to nitrosamines (chemical compounds found both in tobacco smoke and certain foodstuffs) appear to be a relevant risk factor.

Unfavorable dietary patterns seem to involve exposure to nitrosamines through processed and barbecued meats, pickled vegetables, etc., and a low intake of fresh foods. Other associated factors include nutritional deficiencies, low socioeconomic status, and poor oral hygiene.

Adenocarcinoma

Risk of esophageal adenocarcinoma has been linked to the long-term effects of acid reflux, an extremely common condition also known as gastroesophageal reflux disease (GERD).

Longstanding GERD can induce a change of cell type in the lower portion of the esophagus in response to the erosion of its squamous lining.

Having symptomatic GERD or bile reflux makes Barrett’s esophagus more likely, which in turn raises the risk of further changes that in certain cases may ultimately lead to adenocarcinoma.

The risk of developing adenocarcinoma in the presence of Barrett’s esophagus is unclear, and may in the past have been overestimated.

Obesity is also associated with an increased risk of adenocarcinoma. Abdominal obesity encourages GERD and may also exert other relevant biological effects.

Corrosive injury to the esophagus by accidentally or intentionally swallowing caustic substances is also a risk factor, as is radiation therapy for other conditions in the chest.



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