Esophageal cancer (esophageal carcinoma)

Esophageal cancer (esophageal carcinoma)

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International Classification (ICD) C15.-
Symptoms Difficulty swallowing, Teal Chair, regurgitation of blood, frequent belching, Heartburn, chest tightness, Painful spasms of the esophagus, Loss of appetite, Weight loss
Possible causes the decisive trigger is still largely unknown
Possible risk factors Alcohol, Smoking, very spicy food, high-fat diet, gastroesophageal reflux disease, Hot drinks and food, Radiation in the chest area, Barrett's esophagus
Possible therapies surgical procedure, Chemotherapy, Radiotherapy, Interventional procedure, Pain therapy, Targeted cancer therapy, palliative therapy

Basics

Esophageal cancer, also known as oesophageal carcinoma, can occur in any part of the oesophagus. Depending on the tissue from which the tumor forms, a distinction is made between squamous cell carcinomas and adenocarcinomas. Tumors at the junction with the stomach are also referred to as oesophageal carcinomas.

Squamous cell carcinomas are caused by various harmful influences such as smoking, hot drinks, nitrosamines and alcohol. They are mainly found in the middle third of the esophagus. Adenocarcinomas, on the other hand, usually develop on the basis of Barrett's esophagus, often as a result of inflammation caused by reflux (reflux esophagitis) in the lower third of the esophagus. They are considered to be one of the most rapidly increasing types of tumor worldwide.

The late onset of symptoms of oesophageal cancer, such as difficulty swallowing and a feeling of pressure, contributes to the fact that only around 40% of those affected are still operable at the time of diagnosis.

Speiseröhrenkrebs (iStock / Dr_Microbe)

Frequency

Malignant tumors of the oesophagus are common worldwide. In Europe, however, they are rather rare, with an annual incidence of 6 to 8 cases per 100,000 inhabitants. Men are affected by esophageal cancer about three times as often as women. Most of those affected are between 60 and 70 years old when the tumor is first diagnosed, although the cancer usually first appears after the age of 40.

Adenocarcinoma

Adenocarcinomas account for around 50 to 60 % of cases of esophageal cancer. They develop from the glandular mucosal cells in the lower section of the oesophagus and are becoming increasingly common in Western Europe. In over 90% of cases, they develop on the basis of precancerous lesions (so-called Barrett's esophagus). Barrett's oesophagus as a cylindrical cell metaplasia is the result of prolonged gastro-oesophageal reflux.

Risk factors for adenocarcinoma of the esophagus are

  • Obesity

  • Gastroesophageal reflux

  • smoking

  • Stenosis after chemical burns

  • achalasia

Adenocarcinomas in the lower oesophagus and in the area of the stomach entrance are nowadays referred to as AEG (adenocarcinomas of the oesophagogastric junction). They are classified according to Siewert (type I to III).

Squamous cell carcinoma

Squamous cell carcinomas are responsible for around 40 to 60 % of cases of esophageal cancer. The tumors usually occur in the middle third of the esophagus. They develop from the flat epithelial cells of the mucous membrane. Squamous cell carcinomas develop less frequently in the lower or upper third of the oesophagus. Physiological constrictions such as the aortic constriction are also frequent predilection sites for squamous cell carcinomas.

Risk factors for squamous cell carcinoma of the esophagus include

  • Alcohol abuse (especially high-proof alcohol)

  • smoking

  • nitrosamines

  • achalasia

  • Condition after radiotherapy in the area of the esophagus

  • Hot drinks

  • Squamous cell carcinoma in the head and neck area

  • Infection with human papillomavirus (HPV)

  • Stenosis after chemical burns

Around 75% of squamous cell carcinomas of the oesophagus are caused by exposure to nicotine and alcohol. The combination of alcohol and tobacco leads to a synergistic increase in the risk of developing the disease. For example, anyone who consumes 80 grams of alcohol a day (about 2 liters of beer or 4 glasses of wine) and also smokes 20 cigarettes has a greatly increased risk of developing squamous cell carcinoma of the esophagus.

Anatomy

The oesophagus is part of the upper digestive tract. It is an elastic, muscular tube about 25 centimetres long and transports ingested food from the mouth to the stomach. The upper part of the oesophagus lies behind the windpipe. In the lower part, it passes through the diaphragm and then opens into the stomach. The oesophagus consists of four different layers of tissue. On the inside there is a mucous membrane, then a layer of connective tissue, a layer of muscle and on the outside the oesophagus is again covered by a layer of connective tissue.

Wavelike contractions of the esophageal muscles move the chyme towards the stomach. At the end of the oesophagus there is a muscular closure device that is intended to prevent gastric acid and food residues from flowing back into the oesophagus (reflux). If this closure device does not function properly, aggressive stomach acid and bile acids can reflux and damage the oesophagus. This also causes the symptom of heartburn.

If there is an increased reflux from the stomach into the oesophagus, this can lead to inflammation of the oesophageal mucosa. The mucous membrane is then transformed from a squamous epithelium to a glandular epithelium. If heartburn occurs chronically, tumors can form in the mucous membrane due to the prolonged inflammation.

Tumor classification

Initially, every tumor, regardless of the tissue from which it originates, is limited to the uppermost layer of the oesophagus. As the tumor grows larger, it normally progressively invades deeper layers of the oesophagus, lymph nodes and then neighboring organs. Metastases from esophageal cancer occur primarily in the lymph nodes, liver and lungs. However, other organs can also be affected.

The degree of spread of the tumor is important for treatment planning and is divided into certain categories for oesophageal cancer according to the TNM scheme.

The following factors are important for this:

  • Deep infiltration of the tumor (T)

  • Involvement of the lymph nodes (N)

  • Presence of metastases (M)

The size and extent of the tumor is classified with the numbers T1 to T4. The number and location of the affected lymph nodes are described with the numbers N0 to N3. The presence or absence of metastases is designated as M0 or M1. An exact description of the TNM classification is often only possible after surgical removal of the tumor.

As with any tumor, esophageal cancer can also relapse (recurrence). This means that the cancer either recurs at the original site or affects another part of the body.

Causes

A number of risk factors are now known that can promote the occurrence of esophageal cancer:

  • Both alcohol consumption and smoking can greatly increase the risk of developing squamous cell carcinoma. In particular, the simultaneous consumption of alcohol and cigarettes carries a high risk of developing the disease.

  • The constant consumption of very spicy or too hot dishes promotes the occurrence of esophageal cancer.

  • Substances that lead to injury and scarring of the oesophageal mucosa, such as acids, alkalis and radiation, can trigger oesophageal cancer.

  • Gastroesophageal reflux disease, in which stomach acid enters the oesophagus and is often accompanied by heartburn, can lead to transformation of the mucous membrane (Barrett's oesophagus) and subsequently to adenocarcinoma.

  • Another risk factor is very fatty food, especially because this can lead to gastroesophageal reflux disease after a certain time.

Symptoms

In the early stages, esophageal cancer often progresses without symptoms. Only in the advanced stage of the disease do non-specific symptoms usually appear first:

  • Persistent pain or discomfort when swallowing

  • Painful cramps in the oesophagus

  • Heartburn or frequent belching

  • Frequent choking

  • Loss of appetite

  • Weight loss

  • Vomiting without reason

  • Vomiting of blood

  • Blood in the stool (tarry stools)

Difficulty swallowing or pain when swallowing is a typical warning symptom of esophageal cancer. However, they occur sporadically in older and younger people and therefore usually have harmless causes.

Diagnosis

The gold standard for diagnosing oesophageal cancer is an endoscopy of the oesophagus with a tissue sample taken (biopsy). If the suspicion of an esophageal tumor is confirmed, further examinations are usually arranged to clarify the tumor stage or distant metastasis. These include blood tests, various imaging procedures such as ultrasound examinations of the neck and abdomen, magnetic resonance imaging (MRI), positron emission tomography (PET) and computer tomography (CT).

(iStock / Pornpak Khunatorn)

Endoscopy of the esophagus

During an esophagoscopy, the patient swallows a finger-thick tube. This allows the doctor to examine the mucous membrane through a video camera and, if necessary, take tissue samples. The tissue samples can then be examined histologically to confirm or rule out a suspected tumor.

Endoscopy of the trachea and bronchi (bronchoscopy)

If there is a suspicion that the esophageal cancer has already grown into the trachea or bronchi, a bronchoscopy may be necessary. During this examination, a thin, flexible tube is inserted through the nose into the airways. Optics on this tube allow the bronchial mucosa to be examined. The device can also be used to take tissue samples (biopsies). Normally, patients are sedated during the examination using a medication and the mucous membranes are anaesthetized. The examination does not normally cause any pain.

Therapy

Once the diagnosis of esophageal cancer has been confirmed, treatment planning is usually carried out by experts in accordance with the guidelines in the course of a tumor board (tumor conference). The most important treatment for esophageal cancer is surgery to remove the tumor as completely as possible. In this way, the disease can ideally be completely cured. Before surgery, chemotherapy (neoadjuvant) is often carried out to reduce the size of the tumor and destroy any cancer cells that have settled.

The following therapies are possible in the course of esophageal cancer treatment:

  • Surgery with removal of the tumor

  • radiotherapy

  • chemotherapy

  • a combination of surgery, chemotherapy and radiotherapy

  • Endoscopic (interventional) treatment procedures

  • pain therapy

  • Targeted cancer therapy

  • palliative treatment

Which therapy is carried out depends in particular on the following factors:

  • State of health of the person affected

  • tumor spread

  • Age of the patient

Stent and gastric tube

The tumor can cause a narrowing of the oesophagus, making it difficult to eat. In this case, a wire prosthesis (stent) can be inserted to keep the esophagus open. If a stent can no longer be placed, for example because the narrowing is too advanced, a gastric tube can also be placed directly into the stomach through the skin of the abdominal wall.

Forecast

Tumors up to stage IIa can usually still be treated surgically or curatively (curative). In contrast, the majority of those affected in later stages of the disease can only be offered palliative treatment. As many tumors are only discovered at a late stage of the disease, the 5-year survival rate is currently less than 10 %.

The majority of patients already have stage T3 and lymph node involvement when the tumor is first diagnosed. The tumor is still operable at the time of diagnosis in only around 40 % of patients.

Prognostically favorable tumor characteristics:

  • Localization far aborally

  • Expansive growth pattern

  • Strong peritumoral infiltration by lymphocytes

  • Low tumor stage

Prognostically unfavorable features:

  • Infiltration of blood and lymph vessels

  • Infiltrative growth at the tumor edge

Complications of esophageal carcinoma include early lymphogenous metastasis, early infiltration of neighboring structures, stenosis, esophagitis and esophagotracheal fistula.

Prevent

The following measures help to reduce the risk of cancer of the esophagus:

  • Avoiding alcohol and tobacco consumption

  • Avoiding heartburn

  • Avoiding obesity

  • A balanced diet

  • Regular esophagoscopies for Barrett's esophagus

A high intake of fresh fruit and vegetables can reduce the risk of developing esophageal cancer. In particular, fatty foods should be avoided. A healthy normal weight can also help to prevent oesophageal cancer.

Tips

Oesophageal cancer can make it difficult to swallow food and cause pain when eating. Those affected should gain weight before treatment and be as well prepared as possible for the stressful treatment. It may be necessary to change the diet to high-calorie liquids or porridge even before treatment. During the hospital stay, it is then advisable to seek nutritional therapy and acquire as much knowledge as possible about nutrition with oesophageal cancer.

Der Verdauungstrakt (iStock / magicmine)

Oesophageal cancer can make it difficult to swallow food and cause pain when eating. Those affected should gain weight before treatment and be as well prepared as possible for the stressful treatment. It may be necessary to change the diet to high-calorie liquids or porridge even before treatment. During the hospital stay, it is then advisable to seek nutritional therapy and acquire as much knowledge as possible about nutrition with oesophageal cancer.

Sources

Editorial principles

All information used for the content comes from verified sources (recognised institutions, experts, studies by renowned universities). We attach great importance to the qualification of the authors and the scientific background of the information. Thus, we ensure that our research is based on scientific findings.
Dr. med. univ. Moritz Wieser

Dr. med. univ. Moritz Wieser
Author

Moritz Wieser graduated in human medicine in Vienna and is currently studying dentistry. He primarily writes articles on the most common diseases. He is particularly interested in the topics of ophthalmology, internal medicine and dentistry.

The content of this page is an automated and high-quality translation from DeepL. You can find the original content in German here.

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