esophageal cancer

▪ pathology

Introduction

      disease characterized by the abnormal growth of cells in the esophagus, the muscular tube connecting the oral cavity with the stomach. Most esophageal cancers develop from epithelial (epithelium) cells lining the esophagus. Approximately half are derived from flat surface cells (squamous cell carcinomas (carcinoma)), whereas the others begin in glandular cells (adenocarcinomas). Worldwide, men are more than twice as likely to develop esophageal cancer as women. In the United States, blacks are three times more likely than whites to develop the disease.

Causes and symptoms

      Several risk factors have been identified that increase the likelihood of developing esophageal cancer. Some factors, such as age, sex, and race, are impossible to control. However, tobacco and alcohol use increase risk, and these behaviours can be controlled. People who accidently swallowed lye as children also have a higher risk of esophageal cancer as adults. Long-term problems with acid reflux may lead to a condition called Barrett's esophagus, in which the normal squamous cells that line the esophagus are replaced with glandular cells; this condition increases cancer risk. Rare disorders such as tylosis, achalasia, and Plummer-Vinson syndrome are also risk factors.

      Esophageal cancers are usually diagnosed once symptoms have appeared, but by this time the cancer has usually developed to a relatively advanced stage. Symptoms may include difficulty or pain when swallowing, pain or tightness in the chest, unexplained weight loss, hoarseness, or frequent hiccups.

Diagnosis and prognosis

      If cancer is suspected, a thorough examination is conducted to determine its type and stage. The esophagus is visually examined with an endoscope, and tissue samples are taken for biopsy. Several imaging methods are frequently used, such as chest X rays, computed tomography (computerized axial tomography) (CT) scans, or ultrasound (diagnosis). There is no definitive laboratory test for esophageal cancer.

      Once esophageal cancer has been diagnosed, its stage is determined to indicate how far the cancer has progressed. Stage 0 esophageal cancer is also called carcinoma in situ and is confined to the inner layer of epithelial cells lining the esophagus. Stage I cancers have spread into the connective tissue layer below the epithelium but have not invaded the underlying muscle layer. Stage II cancers either have spread through the muscle layer to the outer boundaries of the esophagus or have spread only into the muscle layer but have reached nearby lymph nodes. Stage III esophageal cancers have spread through the esophageal wall to the lymph nodes or other local tissues. Stage IV cancers have metastasized, or spread, to distant organs such as the stomach, liver, bone, or brain.

      The survival rate for esophageal cancer is lower than for many other cancers. When the cancer is detected before it has invaded the underlying tissue layers of the esophagus, five-year survival is high, but fewer than 25 percent of esophageal cancers are diagnosed at this stage. If the cancer has moved to the tissue immediately underlying the mucosal surface, five-year survival is reduced to about 50 percent, and the rate drops significantly once the cancer has moved from the esophagus to nearby lymph nodes or other tissues. Once the cancer has spread to distant tissues in the body, five-year survival is extremely low.

Treatment

      Esophageal cancers are best treated surgically (surgery) when possible. If the cancer is confined to the upper region of the esophagus, an esophagectomy may be done to remove the cancerous portion, along with nearby lymph nodes, and to reconnect the remaining esophagus to the stomach. For cancers of the lower esophagus, it may be necessary to perform an esophagogastrectomy, in which a portion of the esophagus is removed along with a portion of the stomach. The stomach is then reattached directly to the remaining esophagus, or a segment of the colon is used to link the stomach and esophagus. Both of these surgeries are difficult and often result in serious complications. Other, less-drastic surgeries may be used to relieve symptoms, especially when surgical cure is not possible.

      Treatment with radiation alone does not cure esophageal cancer, but it may be used either before surgery to shrink the size of the tumour or following surgery to destroy remaining cancer cells. radiation therapy is also used to relieve symptoms. The side effects of radiation treatment include vomiting, diarrhea, fatigue, and esophageal irritation. chemotherapy is also used for some esophageal cancers. It is not curative, but it can relieve some symptoms and may be able to shrink tumours prior to surgery. Side effects resemble those of radiotherapy.

Prevention

      Esophageal cancer cannot be completely prevented, but risk can be lowered by reducing alcohol consumption and avoiding tobacco. Individuals who are at high risk should receive regular screening in order to increase the probability of early detection. Because there is no blood test available for esophageal cancer, screening requires regular biopsies and viewing of the esophagus with an endoscope.

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