Source: Cancer Resource Room

What is Esophageal Cancer?
All cancers result from abnormal cells that grow and divide without control. The tumor cells can invade or grow into nearby tissues. Tumor cells can spread through the blood or lymph vessels to other parts of the body.
Esophageal cancer starts in the cells that line the inside of the esophagus. As the cells grow, they form a tumor. Tumor cells grow there, invade the layers of the esophagus and can spread to lymph nodes or other sites.

What is the esophagus? What does it do?
The esophagus is a soft tube of tissue that connects the throat with the stomach. It carries what you swallow down to the stomach by muscle contractions called peristalsis. The esophagus is next to the windpipe (trachea), starting from the throat to about the middle of the chest. Here, the windpipe branches off to the two lungs while the esophagus continues to the stomach. The top of the windpipe is open for breathing, but when you swallow, the windpipe gets covered by a flap of tissue called the epiglottis. The food passes over the epiglottis and goes into the esophagus. Muscle contractions begin to push along whatever you swallowed. A circular band of muscle between the esophagus and stomach relaxes to let the food or liquid into your stomach. That muscular band tightens again to keep the stomach fluids from going back up the esophagus.

To do its job of moving food, the esophagus is made up of several layers of tissue. The inside layer is lined by cells that make mucous to help the food slide along smoothly. There is a muscle layer to squeeze the food down the tube. And an outer layer that holds the other tissues together. A special ring of muscle where the esophagus and stomach join is called the GE- junction (Gastro-Esophageal). This muscular ring relaxes to let food into the stomach and tightens to keep food and liquid in the stomach. A common problem at the GE-junction is called "reflux" or "reflux esophagitis." It is caused by a looseness of that muscular ring. It lets the stomach fluids wash back up the esophagus. The stomach fluid is acidic which irritates the lining of the esophagus and causes inflammation. This condition can make a person more likely to develop one type of esophageal cancer.

What are the symptoms of esophageal cancer?
Symptoms of esophageal cancer are caused by the tumor taking up space inside the esophagus and disturbing its normal functions. Some symptoms are caused by cancer cells invading the layers of the esophagus and the trachea (windpipe). When symptoms occur they include:

• pain or difficulty with swallowing (especially solid foods)
• cough or hoarseness
• pain in throat or upper back
• weight loss (without dieting) or poor appetite

These symptoms may have other causes and should be checked by a doctor.

How is esophageal cancer diagnosed?
A patient's medical history and physical exam are the first steps in making a diagnosis of any disease. In the case of esophageal cancer, the patient's history may include information about chronic heartburn (reflux disease), tobacco and alcohol use, and other cancers, especially of the head and neck. The physical exam concentrates on the chest, back and lymph nodes. Blood tests and a chest x-ray check a patient's general health.

Special tests that are useful in diagnosing esophageal cancer are:

1. Barium swallow-an x-ray test in which the patient swallows a liquid containing barium. It goes down the esophagus, outlining the inside layer. X-rays show even small changes in the smooth inner surface of the esophagus.
2. Chest CT scan-x-rays made in thin cross-sections of the esophagus and surrounding tissues. This set of x-rays can show a tumor in the esophagus, as well as its spread to nearby tissues and lymph nodes.
3. Endoscopy-a flexible tube with a tiny camera in it is passed down the patient's throat. The camera transmits pictures of the inner esophagus to a TV screen. If an abnormal spot of tissue is "seen" with the camera, a small clipper inside the end of the tube takes a sample of the tissue for diagnosis. This sample is called a biopsy. The entire esophagus can be viewed by endoscopy, from the throat to the stomach. Many biopsy samples can be taken during an endoscopy. The procedure is done under sedation (a strong relaxing medication).

Are all esophageal cancers the same?
Esophageal cancer can come from different cell types. The most common are:

• Squamous cell-these cancers are often found in the upper third of the esophagus. Squamous cells are the lining cells of the esophagus.
• Adenocarcinoma-these are more often in the lower part of the esophagus near the stomach. These cells make mucous.
• Other types of cancers which occur in the esophagus include: mucoepidermoid, small-cell carcinoma, sarcoma, adenoid cystic carcinoma, and primary lymphoma. These are all rare cancers.

How is the stage of esophageal cancer determined?
The stage of a cancer describes how much cancer there is, what tissue it has invaded, and whether or not it spread to other parts of the body. The higher the stage, the more complicated the disease is.

To determine the size, invasion, and spread of esophageal cancer, several tests are done:

• CT scans-thin, cross-section x-rays of the chest, abdomen, and pelvis. These are done to show the size and local spread of tumor, the nearby lymph nodes, organs such as lungs, liver, kidneys, and distant lymph nodes. The patient is asked to drink a white liquid (called contrast) before the x-rays are taken. The liquid helps outline the esophagus.
• Bronchoscopy-a narrow tube with a camera (similar to an endoscope) is passed down the patient's windpipe (trachea). It is used to look for invasion of tumor from the esophagus to the trachea. This test is only done if the cancer is in the upper half of the esophagus.
• Endoscopic ultrasound-during endoscopy (described above), sound waves are used to show the shape of the esophagus and the tissues around it. This test is only done if the information from it will change the patient's treatment.
• Bone scan-this test shows abnormal spots in the bones if cancer has spread (or metastasized) there. The scan is done after injecting a small amount of radioactive fluid (called a "tracer") into the patient's blood. It shows the entire skeleton.

What are the stages of esophageal cancer?

• Stage 0: cancer cells are only in the lining of esophagus (in the epithelium). Cancer has not invaded the outer layers or lymph nodes. May be called, "carcinoma in situ."
• Stage I: cancer has invaded from the lining layer into outer layer of tissue, but not as far as the muscle layer. No tumor has spread to lymph nodes.
• Stage II: IIA-cancer has invaded the muscle layer and outermost covering layer or tissue, but has not spread to lymph nodes. IIB-cancer has invaded the muscle layer and spread to nearby lymph nodes. It has not invaded the covering layer of the esophagus.
• Stage III: cancer has spread as far as the outer layer of the esophagus, into nearby tissues such as the trachea, and to lymph nodes next to the esophagus. No tumor has spread to lymph nodes in the neck or abdomen, or to other organs.
• Stage IV: cancer has spread to lymph nodes away from the original tumor or to other parts of the body (liver, bones, brain).

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