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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{CMG}}
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| {{Editor Help}}
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| ==Overview==
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| {{Infobox Disease | | | {{Infobox Disease | |
| Name = Esophageal cancer | | | Name = Esophageal cancer | |
| Image = Esophageal adenoca.jpg | | | Image = Ec.jpg | |
| Caption = [[Esophagogastroduodenoscopy|Endoscopic]] image of patient with esophageal adenocarcinoma seen at [[gastro-esophageal junction]]. | | | Caption = [[Esophagogastroduodenoscopy|Endoscopic]] image of patient with esophageal adenocarcinoma seen at [[gastro-esophageal junction]]. Source: Melvil - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=64273320 | |
| ICD10 = C15 |
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| ICD9 = {{ICD9|150}} |
| | {{Esophageal cancer}} |
| }} | | {{CMG}}; {{AE}}{{HM}} |
| {{SI}} | |
| '''Esophageal cancer''' is [[cancer|malignancy]] of the [[esophagus]]. There are various subtypes. Esophageal tumors usually lead to [[dysphagia]] (difficulty [[swallowing]]), pain and other symptoms, and are diagnosed with [[biopsy]]. Small and localized tumors are treated with [[surgery]], and advanced tumors are treated with [[chemotherapy]], [[radiation therapy|radiotherapy]] or combinations. Prognosis depends on the extent of the disease and other medical problems, but is fairly poor.<ref name=Enzinger>Enzinger PC, Mayer RJ. Esophageal cancer. ''[[N Engl J Med]]'' 2003;349:2241-52. PMID 14657432.</ref>
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| ==Classification==
| | {{SK}} Esophageal cancer; oesophageal cancer; esophageal carcinoma; oesophageal carcinoma |
| Esophageal cancers are typically [[carcinoma]]s, which arise from the [[epithelium]], or surface lining of the esophagus. Most esophageal cancer fall into one of two classes: [[squamous cell carcinoma]]s, which are similar to [[head and neck cancer]] in their appearance and association with [[tobacco]] and [[alcohol]] consumption, and [[adenocarcinoma]]s, which are often associated with a history of [[gastroesophageal reflux disease]] and [[Barrett's esophagus]]. | |
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| ==Signs and symptoms== | | ==[[Esophageal cancer overview|Overview]]== |
| Dysphagia (difficulty swallowing) is the first symptom in most patients. [[Odynophagia]] (painful swallowing) may be present. Fluids and soft foods are usually tolerated, while hard or bulky substances (such as bread or meat) cause much more difficulty. Substantial [[weight loss]] is characteristic as a result of poor nutrition and the active cancer. [[Pain and nociception|Pain]], often of a burning nature, may be severe and worsened by swallowing, and can be spasmodic in character. An early sign may be an unusually husky or raspy voice.
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| The presence of the tumor may disrupt normal [[peristalsis]] (the organised swallowing reflex), leading to [[nausea]] and [[vomiting]], [[regurgitation]] of food, [[cough]]ing and an increased risk of [[aspiration pneumonia]]. The tumor surface may be fragile and [[hemorrhage|bleed]], causing [[hematemesis]] (vomiting up blood). Compression of local structures occurs in advanced disease, leading to such problems as [[superior vena cava syndrome]]. [[Fistula]]s may develop between the esophagus and the [[Vertebrate trachea|trachea]], increasing the pneumonia risk; this symptom is usually heralded by [[cough]], [[fever]] or aspiration.<ref name=Enzinger/>
| | ==[[Esophageal cancer classification|Classification]]== |
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| If the disease has [[metastasis|spread]] elsewhere, this may lead to symptoms related to this: [[liver]] metastasis could cause [[jaundice]] and [[ascites]], [[lung]] metastasis could cause [[dyspnea|shortness of breath]], [[pleural effusion]]s, etc.
| | ==[[Esophageal cancer pathophysiology|Pathophysiology]]== |
| | | ==[[Esophageal cancer differential diagnosis|Differentiating Esophageal cancer from other Diseases]]== |
| ==Causes and risk factors==
| | ==[[Esophageal cancer epidemiology and demographics|Epidemiology and Demographics]]== |
| ===Increased risk=== | | ==[[Esophageal cancer risk factors|Risk Factors]]== |
| [[Image:Barretts esophagus.jpg|left|thumb|150px|[[Barrett's esophagus]] is considered to be a risk factor for esophageal adenocarcinoma]] | | ==[[Esophageal cancer natural history|Natural History, Complications and Prognosis]]== |
| There are a number of risk factors for esophageal cancer.<ref name=Enzinger/> Some subtypes of cancer are linked to particular risk factors:
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| * Age. Most patients are over 60, and the median in US patients is 67.<ref name=Enzinger/>
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| * Gender. It is more common in men.
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| * [[Tobacco smoking]] and heavy [[alcoholic beverage|alcohol]] use increase the risk, and together appear to increase the risk more than these two individually.
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| * Swallowing [[lye]] or other caustic substances.
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| * Particular dietary substances, such as [[nitrosamine]].
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| * A medical history of other [[head and neck cancers]] increases the chance of developing a second cancer in the head and neck area, including esophageal cancer.
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| * [[Plummer-Vinson syndrome]] (anemia and esophageal webbing)
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| * [[Tylosis]] and [[Howel-Evans syndrome]] (hereditary thickening of the skin of the palms and soles).
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| * [[Radiation therapy]] for other conditions in the [[mediastinum]].<ref name=Enzinger/>
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| * [[Celiac disease]] predisposes towards squamous cell carcinoma.<ref>{{cite journal |author=Green PH, Fleischauer AT, Bhagat G, Goyal R, Jabri B, Neugut AI |title=Risk of malignancy in patients with celiac disease |journal=Am. J. Med. |volume=115 |issue=3 |pages=191-5 |year=2003 |pmid=12935825 |doi=}}</ref>
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| * [[Gastroesophageal reflux disease]] (GERD) and its resultant [[Barrett's esophagus]] increase esophageal cancer risk due to the chronic irritation of the mucosal lining ([[adenocarcinoma]] is more common in this condition, while all other risk factors predispose more for squamous cell carcinoma).<ref>Lagergren J, Bergstrom R, Lindgren A, Nyren O. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. ''N Engl J Med'' 1999;340:825-31. PMID 10080844.</ref> Giving that [[obesity]] predisposes to reflux, there appears to be an increased risk of adenocarinoma in obesity.<ref>{{cite journal |author=Layke JC, Lopez PP |title=Esophageal cancer: a review and update |journal=American family physician |volume=73 |issue=12 |pages=2187-94 |year=2006 |pmid=16836035 |doi=}}</ref>
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| *According to one Italian study of "diet surveys completed by 5,500 Italians" — a study which has raised debates questioning its claims among cancer researchers cited in news reports about it — eating pizza more than once a week appears "to be a favorable indicator of risk for digestive tract neoplasms in this population."<ref>Gallus S, Bosetti C, Negri E, Talamini R, Montella M, Conti E, Franceschi S, La Vecchia C. Does pizza protect against cancer? ''Int J Cancer'' 2003;107:283-4. PMID 12949808. Cited and qtd. by [http://www.webmd.com/content/article/71/81291.htm WebMD] and [http://news.bbc.co.uk/2/3086013.stm BBC News].</ref>
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| *Recent epidemiologic studies have found that obesity (measured as BMI) is another strong risk factor for esophageal adenocarcinoma.<ref>{{cite journal |author=Lagergren J, Bergström R, Lindgren A, Nyrén O |title=Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma |journal=N. Engl. J. Med. |volume=340 |issue=11 |pages=825-31 |year=1999 |pmid=10080844 |doi=}}</ref>
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| ===Decreased risk===
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| *Risk appears to be less in patients using [[aspirin]] or related drugs ([[NSAID]]s).<ref>Corley DA, Kerlikowske K, Verma R, Buffler P. Protective association of aspirin/NSAIDs and esophageal cancer: a systematic review and meta-analysis. ''Gastroenterology'' 2003;124:47-56. PMID 12512029. See also [http://www.cancer.gov/cancertopics/pdq/prevention/esophageal/healthprofessional#Section_57 NCI - "Esophageal Cancer (PDQ®): Prevention"].</ref>
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| *The role of ''[[Helicobacter pylori]]'' in progression to esophageal adenocarcinoma is still uncertain, but, on the basis of population data, it may carry a protective effect.<ref>Wong A, Fitzgerald RC. Epidemiologic risk factors for Barrett's esophagus and associated adenocarcinoma. ''Clin Gastroenterol Hepatol.'' 2005 Jan;3(1):1-10. PMID 15645398</ref><ref>Ye W, Held M, Lagergren J, Engstrand L, Blot WJ, McLaughlin JK, Nyren O. Helicobacter pylori infection and gastric atrophy: risk of adenocarcinoma and squamous-cell carcinoma of the esophagus and adenocarcinoma of the gastric cardia. ''J Natl Cancer Inst.'' 2004 Mar 3;96(5):388-96. PMID 14996860</ref> It is postulated that ''[[Helicobacter pylori|H. pylori]]'' prevents chronic [[gastritis]], which is a risk factor for [[gastroesophageal reflux disease|reflux]], which in turn is a risk factor for esophageal adenocarcinoma.<ref>Nakajima S, Hattori T. Oesophageal adenocarcinoma or gastric cancer with or without eradication of Helicobacter pylori infection in chronic atrophic gastritis patients: a hypothetical opinion from a systematic review. ''Aliment Pharmacol Ther.'' 2004 Jul;20 Suppl 1:54-61. PMID 15298606</ref>
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| *According to the [[National Cancer Institute]], "diets high in cruciferous (cabbage, broccoli, cauliflower) and green and yellow vegetables and fruits are associated with a decreased risk of esophageal cancer."<ref>NCI [http://www.cancer.gov/cancertopics/pdq/prevention/esophageal/healthprofessional#Section_57 Prevention: Dietary Factors], based on Chainani-Wu N. Diet and oral, pharyngeal, and esophageal cancer. ''Nutr Cancer'' 2002;44:104-26. PMID 12734057.</ref>
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| ==Diagnosis== | | ==Diagnosis== |
| [[Image:Mid esophageal mass.jpg|left|150px|thumb|[[Esophagogastroduodenoscopy|Endoscopy]] and radial [[endoscopic ultrasound]] images of submucosal tumour in mid-[[esophagus]].]] | | [[Esophageal cancer staging|Staging]] | [[Esophageal cancer history and symptoms|History and Symptoms]] | [[Esophageal cancer physical examination|Physical Examination]] | [[Esophageal cancer laboratory findings|Laboratory Findings]] | [[Esophageal cancer CT|CT]] | [[Esophageal cancer MRI|MRI]] | [[Esophageal cancer other imaging findings|Other Imaging Findings]] | [[Esophageal cancer other diagnostic studies|Other Diagnostic Studies]] |
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| ===Clinical evaluation===
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| Although an occlusive tumor may be suspected on a [[barium swallow]] or [[barium meal]], the diagnosis is best made with [[esophagogastroduodenoscopy]] (EGD, [[endoscopy]]); this involves the passing of a flexible tube down the esophagus and visualising the wall. [[Biopsy|Biopsies]] taken of suspicious lesions are then examined [[histology|histologically]] for signs of malignancy.
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| 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 node]]s). The sensitivity of CT scan is limited by its ability to detect masses (e.g. enlarged lymph nodes or involved organs) generally larger than 1cm. [[FDG-PET]] (positron emission tomography) scan is also being used to estimate whether enlarged masses are metabolically active, indicating faster-growing cells that might be expected in cancer. Esophageal [[endoscopic ultrasound]] (EUS) can provide staging information regarding the level of tumor invasion, and possible spread to regional lymph nodes.
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| The location of the tumor is generally measured by the distance from the teeth. The esophagus (25 cm or 10 inches 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.
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| ===Histopathology===
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| Most tumors of the esophagus are malignant. A very small proportion (under 10%) is [[leiomyoma]] (smooth muscle tumor) or [[gastrointestinal stromal tumor]] (GIST). Malignant tumors are generally [[adenocarcinoma]]s, [[squamous cell carcinoma]]s, and occasionally ''small-cell carcinomas''. The latter share many properties with small-cell [[lung cancer]], and are relatively sensitive to chemotherapy compared to the other types.
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| ==Treatment== | | ==Treatment== |
| ===General approaches===
| | [[Esophageal cancer medical therapy|Medical Therapy]] | [[Esophageal cancer surgery|Surgery]] | [[Esophageal cancer primary prevention|Primary Prevention]] | [[Esophageal cancer cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Esophageal cancer future or investigational therapies|Future or Investigational Therapies]] |
| [[Image:SEMS endo.jpg|thumb|left|150px|[[Self-expandable metallic stent]]s are used for the [[palliative care|palliation]] of esophageal cancer]] | |
| [[Image:esophagael stent.jpg|thumb|left|Shows cancer blocking esophagus. Insets show enlarged area of cancer and a stent placed in the esophagus to keep it open.]] | |
| 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.
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| If the patient cannot swallow at all, a [[stent]] may be inserted to keep the esophagus patent; 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]].
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| ===Tumor treatments=== | | ==Case Studies== |
| [[Surgery]] is possible if the disease is localised, which is the case in 20-30% of all patients. If the tumor is larger but localised, chemotherapy and/or radiotherapy may occasionally shrink the tumor to the extent that it becomes "operable"; however, this combination of treatments (referred to as neoadjuvant chemoradiation) is still somewhat controversial in most medical circles. [[Esophagectomy]] is the removal of a segment of the esophagus; as this shortens the distance between the throat and the stomach, some other segment of the digestive tract (typically the [[stomach]] or part of the [[Colon (anatomy)|colon]]) is placed in the chest cavity and interposed.<ref name=Deschamps_2005>{{cite journal |author=Deschamps C, Nichols FC, Cassivi SD, et al. |title=Long-term function and quality of life after esophageal resection for cancer and Barrett’s |journal=Surgical Clinics of North America |volume=85 |issue=3 |pages=649-656 |year=2005 |pmid=15927658}}</ref> If the tumor is metastatic, surgical resection is not considered worthwhile, but palliative surgery may offer some benefit.
| | :[[Esophageal cancer case study one|Case #1]] |
| | | ==Resources== |
| [[Laser]] therapy is the use of high-intensity light to destroy tumor cells; it affects only the treated area. This is typically done if the cancer cannot be removed by surgery. The relief of a blockage can help to reduce dysphagia and pain. [[Photodynamic therapy]] (PDT), a type of laser therapy, involves the use of drugs that are absorbed by cancer cells; when exposed to a special light, the drugs become active and destroy the cancer cells.
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| [[Chemotherapy]] depends on the tumor type, but tends to be [[cisplatin]]-based (or [[carboplatin]] or [[oxaliplatin]]) every three weeks with [[fluorouracil]] (5-FU) either continuously or every three weeks. In more recent studies, addition of [[epirubicin]] (ECF) was better than other comparable regimens in advanced nonresectable cancer.<ref>Ross P, Nicolson M, Cunningham D, Valle J, Seymour M, Harper P, Price T, Anderson H, Iveson T, Hickish T, Lofts F, Norman A. Prospective randomized trial comparing mitomycin, cisplatin, and protracted venous-infusion fluorouracil (PVI 5-FU) with epirubicin, cisplatin, and PVI 5-FU in advanced esophagogastric cancer. ''J Clin Oncol'' 2002;20:1996-2004. PMID 11956258.</ref> Chemotherapy may be given after surgery (adjuvant, i.e. to reduce risk of recurrence), before surgery (neoadjuvant) or if surgery is not possible; in this case, cisplatin and 5-FU are used. Ongoing trials compare various combinations of chemotherapy; the phase II/III REAL-2 trial - for example - compares four regimens containing [[epirubicin]] and either [[cisplatin]] or [[oxaliplatin]] and either continuously infused fluorouracil or [[capecitabine]].
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| [[Radiotherapy]] is given before, during or after chemotherapy or surgery, and sometimes on its own to control symptoms. In patients with localised disease but contraindications to surgery, "radical radiotherapy" may be used with curative intent. | |
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| ===Follow-up===
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| Patients are followed up frequently after a treatment regimen has been completed. Frequently, other treatments are necessary to improve symptoms and maximize nutrition.
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| ==Prognosis==
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| The prognosis of esophageal cancer is quite poor. Even in patients who undergo surgery with curative intent, the five year survival rate is only 25%. The prognosis is even more dismal in those who are not fit for surgery.
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| ==Epidemiology==
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| Esophageal cancer is a relatively rare form of cancer, but some world areas have a markedly higher incidence than others: China, India and Japan, as well as the United Kingdom, appear to have a higher incidence, as well as the region around the Caspian Sea.<ref name=Stewart>Stewart BW, Kleihues P (editors). ''World cancer report''. Lyon: [[International Agency for Research on Cancer|IARC]], 2003. ISBN 92-832-0411-5.</ref> | |
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| The American Cancer Society estimates that during 2007, approximately 15,560 new esophageal cancer cases will be diagnosed in the United States.<ref name=ACS>{{cite web | author = | title = What Are the Key Statistics About Cancer of the Esophagus? | work =Detailed Guide: Esophagus Cancer | url=http://www.cancer.org/docroot/cri/content/cri_2_4_1x_what_are_the_key_statistics_for_esophagus_cancer_12.asp?sitearea=cri | year = 2006 | month= Aug | publsiher=American Cancer Society | accessdate=2007-03-21}}</ref>
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| The esophageal cancer incidence and mortality rates for people of African-Americans have been higher than the rate for Caucasians. <ref name=can-gov>{{cite web | author = | title = Incidence and Mortality Rate Trends | work =A Snapshot of Esophageal Cancer | url=http://planning.cancer.gov/disease/Esophageal-Snapshot.pdf | year = 2006 | month= Sep | publsiher=National Cancer Institute | accessdate=2007-03-21}}</ref> According to the NCI, incidence of adenocarcinoma of the esophagus, which is associated with Barrett's esophagus, is rising in the United States. This type is more common in Caucasian men over the age of 60.
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| Multiple reports indicate that esophageal adenocarcinoma incidence has increased during the past 20 yr, especially in non-Hispanic white men. Esophageal adenocarcinoma age-adjusted incidence increased in New Mexico from 1973 to 1997. This increase was found in non-Hispanic whites and Hispanics and became predominant in non-Hispanic whites. <ref name=synergy>{{cite web | author = Kenneth J. Vega, M.D., M. Mazen JamaM.D.l | title =Changing pattern of esophageal cancer incidence in New Mexico | work =Changing pattern of esophageal cancer incidence in New Mexico | url=http://www.blackwell-synergy.com/doi/abs/10.1111/j.1572-0241.2000.02329.x?cookieSet=1&journalCode=ajg | year = 2000 | month= Sep | publsiher=The American Journal of Gastroenterology | accessdate=2007-03-21}}</ref>
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| ==References== | |
| <references/>
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| ==External links==
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| * [http://www.bidmc.org/YourHealth/ConditionsAZ.aspx?ChunkID=11873 Beth Israel Deaconess Medical Center: Esophageal cancer]
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| * [http://www.mayoclinic.org/esophageal-cancer/ Mayo Clinic Esophageal Cancer Information]
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| * [http://pathology2.jhu.edu/beweb/ The Johns Hopkins Esophageal Cancer Web page]
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| * [http://www.eccafe.org/ Cathy's EC Cafe] (Support group resource)
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| * [http://www.ecaware.org/ Esophageal Cancer Awareness Association]
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| * [http://massgeneral.org/cancer/crr/types/gi/eso_gi.asp "Learn More about Esophageal Cancer"]
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| * [http://www.nlm.nih.gov/medlineplus/esophagealcancer.html MedlinePlus: Esophageal Cancer] | | * [http://www.nlm.nih.gov/medlineplus/esophagealcancer.html MedlinePlus: Esophageal Cancer] |
| * [http://cancer.gov/cancerinfo/types/esophageal NCI Esophageal Cancer Home Page] | | * [http://cancer.gov/cancerinfo/types/esophageal NCI Esophageal Cancer Home Page] |
| * [http://www.cancerhelp.org.uk/help/default.asp?page=4478 Oesophageal Cancer at Cancer Research UK]
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| * [http://news.bbc.co.uk/2/hi/health/medical_notes/3244469.stm Oesophageal Cancer Facts/ Resources (BBC) (Last updated: 30 Jan. 2004)]
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| * [http://www.cancer.gov/cancertopics/factsheet/tea-and-cancer-prevention Tea and Cancer Prevention Fact Sheet (NCI Fact Sheet)]
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| * [http://www.esophagealcenter.ucla.edu/ The UCLA Center for Esophageal Disorders]
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