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What is the Esophagus?

The esophagus is a hollow tube that transfers food from the throat to the stomach, that is the "food tube". The tube starts just below the "epiglottis", the flap that keeps food from going into our trachea (air pipe) when we swallow. It ends at where it joins with the upper portion of the stomach, called the "cardia". The actual area of coinage is called the "gastroesophageal junction". The esophagus is muscular, to help propel food downward with swallowing. It has a complex array of nerves ("plexus") that work to coordinate the swallowing motion. The upper 2/3 of the esophagus has a inner lining ("mucosa") of a special type of cell, called "squamous" cells, which are also found in the mouth and anal region. These cells resist abrasion and heat and are able to heal quickly if damaged, say by the sharp edges on food. The lower 1/3 of the esophagus has an inner lining of a different type of mucosa called "columnar" cells.

This becomes important for considering the cancers that arise in the esophagus. If the lower portion of the esophagus becomes infiltrated with intestinal-like glands, as it is prone to do with prolonged irritation, then this is called "Barrett's" esophagus and is a risk factor to get cancer, as will be seen.

The esophagus has an outer lining, called the "adventitia", which surrounds the muscular layers and separates the esophagus from other nearby organs. The heart is directly behind the middle esophagus, while the windpipe ("trachea") is directly in front of it. The esophagus is also very close to the liver, lungs, and major blood vessels from the heart ("aorta and venal cava"). The esophagus receives most of it's blood from the aorta and drains it to the liver and venal cava. A system of "drainage channels" runs through the esophagus, between the mucosal and muscular layers. These are called "lymph channels" and act to purify the blood serum, by transporting it to nearby "lymph nodes" (glands) where the serum is filtered. Both the blood supply, and lymph channels and glands, can act as conduits to spread infection or cancer. This spread may be along the length of the esophagus, around it's diameter, to local lymph nodes or organs, or to distant body areas.

When a person has shrinkage ("cirrhosis") of the liver due to excessive alcohol or chronic infections, it places back pressure on the blood draining from the esophagus. This results in swelling of the blood vessels in the lower esophagus, called "varices". These may spontaneously bleed when there is a lot a pressure between the liver and esophagus ("portal hypertension") and is a medical emergency. Other common problems with the esophagus (besides cancer) are "rings" or "webs"-- areas of protrusion into the normally hollow interior ("lumen") of the esophagus where food can get caught. A "stricture" is an area of narrowing of the esophagus, often from scarring from ingested chemicals (i.e. lye). Achalasia is a disease where the nerves in the esophagus don't coordinate swallowing properly, so food gets caught there. An inflammation is "esophagitis", caused by bacteria, virus, or fungi, drugs or radiation.

What is Esophagus Cancer?

The esophagus, like all body tissues, is made up of individual cells. Normally, cells within the forming esophagus divide and grow very rapidly in the womb, in early childhood, and through puberty. In adulthood, new cells are only formed to replace those which have died from injury, old age or disease. The division of cells to produce new ones is under tight control by the "genes" within each cell. These genes are made up of DNA, and if it becomes damaged, the cell may start dividing out of control.Esophagus cancer starts in a single cell which has become abnormal. This cells produces millions, and eventually billions, of copies of itself. The copies are called"clones". These clones fail to function as normal esophagus tissue, but instead divert resources from healthy cells to fuel their own growth. When there are about 1 billion cells, they form a clump, or "tumor" 1/2 inch across. A "tumor" merely means a swelling, it can be caused by infection, inflammation, cancer or whatever. If a tumor only grows in it's local area (even very large) but does not have the capacity to spread to distant body areas, it is called"benign" and isnot cancer. If, however, the tumor has the ability to spread to distant body areas, it is called "malignant" andthis is cancer. The actual process of spread is called"metastasis", and can occur to any area of the body.

What are the Types of Esophagus Cancer?

The most common type had always been "squamous cell carcinoma" arising from the upper 2/3 of the esophagus. Now, however, there has been a dramatic increase in another type, called "adenocarcinoma", which tends to arise in the lower 1/3 of the esophagus. Currently, the number of each of these two types of cancer cases is about equal, and together they make up nearly 100% of today's esophagus cancers. White men tend to get the disease more commonly in the lower esophagus, while Black men get it in the middle and upper esophagus.

There are occasional rare cancers found in the esophagus, such as "sarcomas" which arise from the muscular wall, "cylindroma" which begins from glands, and "lymphoma" that starts from the body's immune system cells within the esophagus.

Staging The Disease

If the diagnosis is esophageal cancer, the doctor needs to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to what parts of the body. Knowing the stage of the disease helps the doctor plan treatment. Listed below are descriptions of the four stages of esophageal cancer.

Stage I The cancer is found only in the top layers of cells lining the esophagus.

Stage II The cancer involves deeper layers of the lining of the esophagus, or it has spread to nearby lymph nodes. The cancer has not spread to other parts of the body.

Stage III The cancer has invaded more deeply into the wall of the esophagus or has spread to tissues or lymph nodes near the esophagus. It has not spread to other parts of the body.

Stage IV The cancer has spread to other parts of the body. Esophageal cancer can spread almost anywhere in the body, including the liver, lungs, brain, and bones.

Some tests used to determine whether the cancer has spread include:

CAT (or CT) scan (computed tomography)

A computer linked to an x-ray machine creates a series of detailed pictures of areas inside the body.

Bone scan

This technique, which creates images of bones on a computer screen or on film, can show whether cancer has spread to the bones. A small amount of radioactive substance is injected into a vein; it travels through the bloodstream, and collects in the bones, especially in areas of abnormal bone growth. An instrument called a scanner measures the radioactivity levels in these areas.

Bronchoscopy

The doctor puts a bronchoscope (a thin, lighted tube) into the mouth or nose and down through the windpipe to look into the breathing passages

Treatment

Treatment for esophageal cancer depends on a number of factors, including the size, location, and extent of the tumor, and the general health of the patient. Patients are often treated by a team of specialists, which may include a gastroenterologist (a doctor who specializes in diagnosing and treating disorders of the digestive system), surgeon (a doctor who specializes in removing or repairing parts of the body), medical oncologist (a doctor who specializes in treating cancer), and radiation oncologist (a doctor who specializes in using radiation to treat cancer). Because cancer treatment may make the mouth sensitive and at risk for infection, doctors often advise patients with esophageal cancer to see a dentist for a dental exam and treatment before cancer treatment begins.

Many different treatments and combinations of treatments may be used to control the cancer and/or to improve the patient's quality of life by reducing symptoms.

Surgery is the most common treatment for esophageal cancer. Usually, the surgeon removes the tumor along with all or a portion of the esophagus, nearby lymph nodes, and other tissue in the area. (An operation to remove the esophagus is called an esophagectomy.) The surgeon connects the remaining healthy part of the esophagus to the stomach so the patient is still able to swallow. Sometimes, a plastic tube or part of the intestine is used to make the connection. The surgeon may also widen the opening between the stomach and the small intestine to allow stomach contents to pass more easily into the small intestine. Sometimes surgery is done after other treatment is finished.

Radiation therapy, a lso called radiotherapy, involves the use of high-energy rays to kill cancer cells. Radiation therapy affects cancer cells in the treated area only. The radiation may come from a machine outside the body (external radiation) or from radioactive materials placed in or near the tumor (internal radiation). A plastic tube may be inserted into the esophagus to keep it open during radiation therapy. This procedure is called intraluminal intubation and dilation. Radiation therapy may be used alone or combined with chemotherapy as primary treatment instead of surgery, especially if the size or location of the tumor would make an operation difficult. Doctors may also combine radiation therapy with chemotherapy to shrink the tumor before surgery. Even if the tumor cannot be removed by surgery or destroyed entirely by radiation therapy, radiation therapy can often help relieve pain and make swallowing easier.

Chemotherapy is the use of anticancer drugs to kill cancer cells. The anticancer drugs used to treat esophageal cancer travel throughout the body. Anticancer drugs used to treat esophageal cancer are usually given by injection into a vein (IV). Chemotherapy may be combined with radiation therapy as primary treatment (instead of surgery) or to shrink the tumor before surgery.

Laser therapy is the use of high-intensity light to destroy tumor cells. Laser therapy affects the cells only in the treated area. The doctor may use laser therapy to destroy cancerous tissue and relieve a blockage in the esophagus when the cancer cannot be removed by surgery. The relief of a blockage can help to reduce symptoms, especially swallowing problems.

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. The doctor may use PDT to relieve symptoms of esophageal cancer such as difficulty swallowing.

Complications

Esophageal dilation is usually performed effectively and without problems. However, some complications can occur. A small amount of bleeding almost always happens at the treatment site. At times, it can be excessive, requiring evaluation and treatment. An uncommon but known complication is perforation of the esophagus. The wall of the esophagus is thin and despite the best efforts of the physician, can tear. An operation may be required to correct this problem.