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Esophageal Cancer

Esophageal cancer, affecting mainly men, is the sixth most common cancer in non-industrialised countries, and in eighteenth place in industrialised ones. At IEO esophageal cancer is treated by Thoracic Surgery Division.

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IN SHORT

The esopaghus cancer predominantly affects men (it is three times more common in men than in women). In most cases the esophageal cancer develops after the sixth decade of life. Geographical incidence is variable of esopaghus cancer:  Eastern countries, including China and Singapore, are those where mortality of esophageal cancer is higher and there are about 20-30 cases per year per 100,000 inhabitants.

RISK FACTOR FOR ESOPHAGEAL CANCER

  • Genetic factors. Esophageal cancer, in the squamous cell form, appears in almost all patients with hand and plantar tylosis, a rare inherited disorder characterised by thickening of the skin of the palms of hands and soles of feet (hyperkeratosis), and papillomatosis of the esophagus, or the formation of small growths called papillae.
  • Alcohol and tobacco. are among the most significant risk factors in Europe and the United States for esophagus cancer. Eighty to ninety percent of esophageal cancers are caused by the consumption of alcohol and tobacco, whether smoked or chewed. Smokers are 5-10 times more likely to succumb than non-smokers, according to the number of cigarettes smoked and years of smoking (the effects of which are enhanced by alcohol). Alcohol not only acts as a direct esophageal cancer cause, but also enhances the carcinogenic action of smoking and people who consume cigarettes and alcohol together have a 100-fold increased risk of getting esophageal cancer.
  • Diet. A diet low in fruit and vegetables and a low intake of vitamin A and certain metals such as zinc and molybdenum can increase the risk of esophagus cancer. A fat rich diet and the consequent increase in body fat affect the level of many hormones that create a favourable environment for the onset of esophagus cancer (carcinogenesis). Overweight and obese people are often associated with gastro-oesophageal reflux with a consequent risk of developing the disease called Barrett's esophagus (which occurs in 8 to 20 percent of people with gastro-esophageal reflux disease).
  • Inflammatory factors. Chronic inflammation of the mucosa lining the esophagus increases the risk of esophageal cancer. The most frequent form is peptic oesophagitis, or the chronic inflammation of the lower part of the esophagus caused by reflux of acidic gastric juices due to a faulty sealing of the junction that separates the esophagus from the stomach. In the long run, chronic irritation causes the epithelium (the tissue lining the inner of the organ) of the esophagus to be replaced by one similar to that of the stomach, from which cancer may then develop. This situation is called Barrett's esophagus and it is considered a precancerous esophagus cancer which sometimes requires surgery to avoid the complete malignant transformation of the epithelium.

PREVENTION AND DIAGNOSIS

Depending on the tissue from which it originated, there are two types of esophageal cancer:

Squamous cell carcinoma

Squamous cell (squamocellular) carcinoma, which usually develops in the upper and middle part of the channel, and affects the lining cells, is the most common esophageal cancer and accounts for 60 percent of esophageal cancers.

Adenocarcinoma

Adenocarcinoma originates from the glands of the mucosa and begins most frequently in the last section, near the junction with the stomach (lower third). This type of esophageal cancer may also arise from islands of heterotopic gastric mucosa or from the lower oesophageal sphincter or submucosa. This type of cancer accounts for about 30 percent of esophageal cancers. Referring to the site of origin, 50 percent of esophageal cancers stem from the middle third, 35 percent from the lower third, and 15 percent from the upper third of the organ. The location of the esophagus cancer impacts on the potential to operate and the technique of the intervention.

Avoiding alcohol and smoking are the main precautions to prevent the formation of squamous cell esophageal cancer. Regarding adenocarcinoma, in the majority of cases it develops from a Barrett's esophagus, so the most effective way to prevent this type of esophagus cancer is reducing the risk of gastro-esophageal reflux. Esophagus cancer prevention is achieved by reducing the consumption of coffee, alcohol and cigarettes and avoiding being overweight and obesity. Although several antacid drugs are able to control the symptoms of reflux, scientific demonstrations of their efficacy in reducing the appearance of Barrett's esophagus are not available so far.

Tests for the early diagnosis of the esophageal cancer

There are no screening tests in healthy patients, but early diagnosis of esophageal cancer is extremely important once Barrett's esophagus has developed in order to catch the possible malignant transformation quickly in esophageal cancer. In patients where the esophageal mucosa has turned into gastric mucosa, endoscopy is recommended every two or three years. In patients whose transformed cells show signs of abnormality (dysplasia), it is recommended to repeat endoscopy at least two times every six months and then once a year. Finally, if the degree of dysplasia is high (that is if the cells are highly transformed), endoscopic removal or even surgery is recommended, because this is a precancerous condition at high risk of esophageal cancer transformation.

Symptoms of esophageal cancer

Almost always, initial symptoms of esophageal cancer are progressive loss of weight preceded by dysphagia, that is difficulty in swallowing, which usually appears gradually first with solid foods and after with liquids. These symptoms of esophagus cancer are reported by 90 percent of patients. In addition, growth of the esophageal cancer to the outside of the esophagus can lead to a decrease or an alteration in the tone of the voice because it involves nerves that govern the emission of sounds, or induce paralysis of the diaphragm, or even a pain in the chest just behind the breastbone, if the area between the heart, lungs, sternum and spine is involved.

In the most advanced stages of esophageal cancer, the ability to take food may be reduced. If the esophageal cancer is ulcerated, swallowing may become painful. When the mass of the esophagus cancer impedes the descent of the food down the esophagus, regurgitation episodes may occur. In more advanced forms of esophageal cancer, the lymph nodes on the sides of the neck and above the collarbone can swell, or liquid can form in the lining of the lung (pleural effusion) with the onset of dyspnea (difficulty breathing), or even bone pain may appear or an increase in size of the liver. The cause of these symptoms is usually related to the presence of esophageal cancer metastases.

Based on careful evaluation of the results from current scientific research, it has been possible to identify specific risk factors and protective nutritional factors for specific types of cancer. Experts have classified the results into four levels: "convincing evidence", "probable evidence", "limited evidence" and one last level that collects the effects for which evidence of association with the cancer is “highly unlikely." The probable and convincing evidence for the basis of the recommendations are:

Risk Factors

  • alcoholic beverages (convincing evidence)
  • being overweight and obesity (convincing evidence for adenocarcinoma).

Protective factors

  • fruit and vegetables
  • foods rich in beta-carotene, such as carrots, pumpkin, apricots, spinach, sweet and spicy peppers (probable evidence)
  • foods rich in vitamin C, such as citrus fruit juice peel, kiwi, strawberries, sweet and spicy peppers (evidence likely).

Diagnostic tests for esophageal cancer

In symptomatic patients, diagnostic strategy for esophageal cancer includes an X-ray of the esophagus with contrast medium and esophageal endoscopy (esophagogastroscopy) that allows us to see whether there is a lesion and obtain material for analysis of the cells. The combination of the two procedures increases the diagnostic sensitivity to 99 per cent. X-rays are used to exclude the presence of associated disease, the oesophagogastroscopy is the examination with the greatest diagnostic value because it allows direct visualisation of the structures and to take samples for biopsy.

Echo-endoscopy is another type of test that allows us to determine more accurately how deep the esophageal cancer infiltration of the layers in the esophageal wall is, and can point out lymph nodes that are suspicious for esophageal cancer metastatases. Once the esophagus cancer has been localised, to complete the diagnostic testing it is appropriate to perform chest CT abdomen with contrast medium and PET in order to exclude the presence of remote  esophagus cancer metastases.

CARE AND CLINICAL TRIALS

Surgical treatment of esophageal cancer

To treat esophageal cancer, surgery is the first resort. However, it is difficult to operate lesions in the upper third of the esophagus, or cases in which the esophagus cancer has already involved neighbouring organs such as the trachea and bronchi. Distant esophagus cancer metastases sometimes contraindicate the operation as well as poor general health conditions or the presence of other diseases.

Surgery for the esophageal cancer usually consists of removing the section of esophagus affected by the esophagus cancer and then reconstructing it using the stomach, that is made into a tube, and the regional lymph nodes. The procedure is called a partial or total esophagectomy associated with gastroplasty and regional lymphadenectomy.

 

Treatment of the esophageal cancer in non-operable patients

 In non-operable patients, chemotherapy accompanied by radiotherapy is the treatment of choice for the esophageal cancer. The combination of the two treatment options increases survival compared to individual options alone. In operable cases but with locally-advanced or suspected lymph node metastases, chemotherapy may be indicated, possibly associated with radiation therapy, before surgery (neoadjuvant therapy).

Patients with esophagus cancer metastases, with difficulty in swallowing and pain, for whom neither surgical treatment nor chemo-radiotherapy are feasible, may benefit from palliative care in order to enable adequate nutritional support. These may consist in the endoscopic positioning of a rigid pipe in plastic, silicone or metal through the esophagus to allow the passage of food, or in laser-therapy, namely the use of a laser beam on the tumour to restore patency.

 

MORE FOR YOU

Clinical nutrition for patients with esophagus cancer

Malnutrition is often found in patients with esophagus cancer and stomach cancer. The latter may be related to dysphagia (difficulty with or obstruction of the passage of food through the mouth, pharynx or esophagus), cachexia associated with the disease (syndrome characterised by loss of fat and muscle mass) and chemotherapy. The causes of malnutrition common to all esophagus cancer patients overlap with the nutritional abnormalities resulting from surgical treatments.

Nutritional abnormalities resulting from surgical treatment for stomach

During surgery for esophageal or gastric resection, a small probe (nutritional jejunostomy) can be positioned in order to ensure a physiological nutrition in the postoperative period (through the use of Enteral Nutrition - EN) and the required amount of nourishment when intake via the mouth is poor or inadequate compared to the need. The nutritional jejunostomy is left in place at the time of discharge, and it is used in cases when the patient is unable to take a proper diet to cover the nutritional requirements.

After gastrectomy, among the early symptoms developed are the small stomach syndrome (early satiety and gastric distension) and dumping syndrome (occurs after taking the meal and includes hypotension, tachycardia, dizziness, feeling tired, faintness, chills and profuse sweating). Diarrhoea can also be experienced and, in patients who have undergone partial gastrectomy with gastro-jejunal reconstruction, bilious vomiting may occur.

Among the later problems are anaemia and malabsorption of calcium. Blood tests should be carried out to assess any possible supplementation.

Following esophagectomy surgery, there is a reduced ability to take large volumes of food and in some patients dumping syndrome may occur.

Information for the diet of patients operated for gastric cancer

Dietary guidelines focus on the consumption of small, frequent meals throughout the day, separating liquids from solids. It is recommended to take small bites and chew well to facilitate swallowing and digestion. For the nutritional management of dumping syndrome, simple sugars have to be limited.

In the presence of diarrhoea, it is advisable to limit simple sugars and take liquids in small sips. With regard to the possible presence of bilious vomiting after intervention for subtotal gastrectomy, treatment is essentially surgical, but also in this condition the patient may benefit from a partition of the diet in small and frequent meals.

Following esophagectomy, sticky foods should be avoided, foods that are fermented and carbonated soft drinks. It is also important that the patient remains seated for 30-60 minutes after eating and at least 2 hours before going to bed.

For patients who have undergone gastric or esophageal resection, short and long term follow-up are of crucial importance, in order to immediately adapt the more appropriate dietary pattern, correct any errors present in the diet, prevent weight loss and identify any late symptoms.

 

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CREDITS

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