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Esophageal Cancer

Carcinoma Esophagus

The esophagus is a muscular tube also known as food pipe in general public transmits food material from mouth (base of pharynx) to the stomach. Cancers of esophagus is one of the deadliest malignancies of human body. The incidence of this malignancy is increasing in general population due to poor life style as well as changes in environment.

Carcinoma of esophagus is divided into two types -

  1. Squamous cell carcinoma - Cancer that forms in tissues lining the esophagus. Mostly found in upper and middle 1/3rd of esophagus. Incidence increases with age with most common age group between 55-60 years with male preponderance.
  2. Adenocarcinoma - cancer that begins in esophageal lining cell that secret mucus. Most commonly found in lower esophagus and at the meeting point of esophagus and stomach. Commonly presented in patients with age group 50 years or younger.

Risk factors for Esophageal malignancy -

  1. Smoking and alcohol - smoking for a long duration and chronic alcohol consumption
  2. Esophageal inner mucosal lining damage from physical agents -

    • Long term ingestion of hot liquids.
    • Caustic ingestion (corrosive poisoning).
    • Radiation induced damage.

  3. Carcinogens in food and water - nitrates, nitrite, nitrosamine,

    • Smoked opiates, fungal toxins in pickles.

  4. Obesity - increased risk for adenocarcinoma of esophagus. Incidence of gastroesophageal reflux increased in obesity due to lax lower esophageal junction to stomach which leads to Barrett's esophagus. If condition does not revert with time, Barrett's esophagus can turn into cancer.
  5. Chronic iron deficiency anemia in females leading to plummer Vinson Syndrome.
  6. Congenital hyperkeratosis of palms and sole called Tylosis.
  7. Helicobacter pylori infection.
  8. Long standing Achalasia Cardia.
  9. Dietary deficiencies of molybdenum, Zinc, Vitamin A etc.

Symptoms of Esophageal Malignancy:

  1. Liquid food in the late stage of disease. Dysphagia is the most common presentation. Patient may have difficulty in swallowing of solid food in early stage of disease and solid as well as --
    1. Liquid food in the late stage of disease.
    2. Weight loss - recent significant unintentional loss.
    3. Coughing and choking during meal.
    4. Change in voice - hoarseness.
    5. Weakness and easy fatigability.
    6. Pain behind sternum - occasional
    7. Heart burn and reflux
    8. Malena and sometimes haematemesis.

Diagnosis of esophageal malignancy

The patient is evaluated on the basis of history, symptoms and clinical signs. Along with routine blood test and X-ray some endoscopic and radiological investigations are done which include -

  1. Barium sallow x- ray - thin barium is allowed to shallow and x-ray of esophagus taken. This shows the site and outline of tumor. This test is seldom used these days.
  2. Endoscopy - the endoscope is passed through mouth to esophagus to see the inner lining of esophagus and tumor. If it shows any abnormal growth then a small piece of tissue from the suspected area is taken for confirmation of the diagnosis. These tissues are examined under a microscope for the presence of cancer.
  3. Bronchoscopy - in cases of advanced tumor arising from upper ½ of esophageal an endoscope is passed into trachea (wind pipe) to rule out local spread of the tumor to lungs and wind pipe (trachea).
  4. Endoscopic Ultrasound - for early tumor endoscopic ultrasound is passed in esophagus to find out local spread of tumor. This test can be done in early cancers only when there is no complete blocking of food pipe.
  5. For tumor staging radiological investigation like computed tomography (CT) scans of chest and abdomen and positron emission tomography (PET) scan are performed to determine outer spread of esophageal tumor to surrounding vital organs and distant spread to other organs like Lungs, liver, bones etc.
  6. Thoracoscopy and Laparoscopy - By these methods detection rate of lymphnodal and distal spread of esophageal malignancy is high, which are missed on CECT/PET scan (due to small size).

Treatment of Esophageal cancer

Patients with esophageal cancer are managed based on its stage. Overall general condition of the patients affects management.

Stage I -

Tis and T1aN0 stage -

Endoscopic therapy like mucosal resection or submucosal dissection with the help of endoscopic ultrasound (EUS)

Photodynamic therapy

Radiofrequency ablation

T1b N0 & T2 N0 stage - Surgery (esophagectomy) to remove the part/whole of esophagus that contains the cancer.

Stages II-III - Chemoradiation followed by surgery (trimodal therapy)

Patient with squamous cell carcinoma with well preserved general condition chemotherapy and radiotherapy started to downstage the tumor before definitive surgery.

Patients with adenocarcinoma of lower end esophagus where stomach meet (gastroesophageal junction) are given chemotherapy or chemoradiation before surgery.

Patients with serious co-morbidities who are not candidate for surgery are managed with radical chemoradiation with curative intension.

Stage IV - Chemotherapy/Radiotherapy or symptomatic and supportive care Treatment is given only for palliation to relieve the symptoms like pain, difficulties in swallowing etc.

Esophageal stenting (plastic/metallic) is done in situations where the patient cannot swallow at all and having Tracheo/broncheo esophageal fistula (communication between food pipe and wind pipe.

Patient who are unable to tolerate oral feeds a nasogastric tube may be required to continue feeding.

Some times gastrostomy/jejunostomy tube is required where patients become intolerant to nasogastric tube or tend to aspirate food.

Laser therapy is done in cases in which esophagus is totally occluded by cancer and the cancer cannot be removed by surgery. The relief of a blockage by laser can help to reduce dysphagia and pain. The therapy is less often used.

Chemotherapy:Chemotherapy may be given after surgery (adjuvant) to reduce risk of recurrence or before surgery (neoadjuvant) to down stage the disease.


Radiotherapy is given before, during or after chemotherapy or surgery. It is also used in palliation to control pain.

Surgery is contraindications in following situation:

  1. Locally advanced cancer engulfing adjacent vital structures like trachea, lung, aorta, recurrent laryngeal nerve.
  2. Esophageal Cancer with wide dissemination (metastasis) to distant lymph nodes and vital organs.
  3. Severe co-morbidity involving cardiovascular and respiratory system.

Surgical options: - Surgery is performed by either open or minimal invasive method depending upon patient's general condition and availability of experts. Now a days minimal invasive approach of esophagectomy has become very popular among surgeons because of low surgical morbidity, short hospital stay and similar oncological outcomes.

Types of esophagectomy:

(1) Minimal Invasive Esophagectomy (MIE) – Minimal invasive Esophagectomy is done by Thoracoscopic and laproscopic methods (key hole surgery). The esophgus is removed with slander instrument from key hole under guidance of camera and monitor. The oncological results are similar to open methods but early recovery and less ICU stay and lest chest complications are seen with MIE. The minimal Invasive esophagectomy can also be performed with Robotic assistance which also has the same advantages of thoracoscopy . The current evidence does not support the superiority of robotic surgery, prticularly in view of high cost involed.

  1. Transhiatal Esophagectomy (THE)
  2. Transthoracic Esophagectomy (TTE) - Thoraco abdominal Mc Keown's & Ivor Lewis esophagectomy.

In Thoracoabdominal Approach –both the abdominal and thoracic cavities opened together.

Ivor Lewis Esophagectomy –two-stage approach involves an initial laparotomy and construction of a gastric tube, followed by a right thoracotomy to excise the tumor and create an esophagogastric anatomises in chest.

McKeown Esophagectomy –Three-stage approach which include incision in the neck to complete the cervical anastomosis in neck.

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