Esophageal cancer is cancer arising from the esophagus.

Clinical evaluation

Although an occlusive tumor may be suspected on a barium swallow or barium meal, the diagnosis is best made with esophagogastroduodenoscopy (endoscopy). This involves the passing of a flexible tube down the esophagus and examining the wall. Biopsies taken of suspicious lesions are then examined histologically for signs of malignancy.

Additional testing is usually performed to estimate the tumor stage. Computed tomography (CT) of the chest, abdomen, and pelvis can evaluate whether the cancer has spread to adjacent tissues or distant organs (especially liver and lymph nodes).

The sensitivity of a CT scan is limited by its ability to detect masses (e.g. enlarged lymph nodes or involved organs) generally larger than 1 cm.

Positron emission tomography is also used to estimate the extent of the disease and is regarded as more precise than CT alone.

Esophageal endoscopic ultrasound can provide staging information regarding the level of tumor invasion, and possible spread to regional lymph nodes.

The location of the tumor is generally measured by the distance from the teeth. The esophagus (25 cm or 10 in long) is commonly divided into three parts for purposes of determining the location.

Adenocarcinomas tend to occur distally and squamous cell carcinomas proximally, but the converse may also be the case.

Classification

Esophageal cancers are typically carcinomas that arise from the epithelium, or surface lining, of the esophagus.

Most esophageal cancers fall into one of two classes: squamous-cell carcinomas, which are similar to head and neck cancer in their appearance and association with tobacco and alcohol consumption, and adenocarcinomas, which are often associated with a history of GERD and Barrett’s esophagus.

A general rule of thumb is that a cancer in the upper two-thirds of the esophagus is a squamous-cell carcinoma and one in the lower one-third is an adenocarcinoma.

Prevention

Prevention includes stopping smoking or chewing tobacco.

According to the National Cancer Institute, “diets high in cruciferous (cabbage, broccoli/broccolini, cauliflower, Brussels sprouts) and green and yellow vegetables and fruits are associated with a decreased risk of esophageal cancer.”

Dietary fiber is thought to be protective, especially against esophageal adenocarcinoma.

Screening

People with Barrett esophagus (a change in the cells lining the lower esophagus) are at much higher risk and may receive regular endoscopic screening for the early signs of cancer. Because the benefit of screening for adenocarcinoma in people without symptoms is unclear, it is not recommended in the United States.

Management

The treatment is determined by the cellular type of cancer (adenocarcinoma or squamous cell carcinoma vs other types), the stage of the disease, the general condition of the patient, and other diseases present. On the whole, adequate nutrition needs to be assured, and adequate dental care is vital.

If the person cannot swallow at all, an esophageal stent may be inserted to keep the esophagus open; stents may also assist in occluding fistulas.

A nasogastric tube may be necessary to continue feeding while treatment for the tumor is given, and some patients require a gastrostomy (feeding hole in the skin that gives direct access to the stomach).

The latter two are especially important if the patient tends to aspirate food or saliva into the airways, predisposing for aspiration pneumonia.

Esophagectomy is the removal of a segment of the esophagus; as this shortens the length of the remaining esophagus, some other segment of the digestive tract (typically the stomach or part of the colon or jejunum) is pulled up to the chest cavity and interposed.

If the tumor is not resectable or the patient is not fit for surgery, palliative esophageal stenting can allow the patient to tolerate a soft diet.



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