Esophageal cancer (esophageal carcinoma)

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.

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.

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.

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).

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.

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.

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.

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.