Definition:
Esophageal carcinoma is a rare, potentially fatal cancer that is usually advanced at the time of clinical presentation. The esophagus has three layers: the inner layer (mucosa), the middle layer (submucosa) and the outer muscular layer. The cancer usually starts in the mucosa of the esophagus, and it tends to invade the submucosa and the muscular layers subsequently. Structures next to the esophagus, such as the trachea, aorta, or recurrent laryngeal nerve are at risk for invasion, as well as the lymph nodes, liver, and lungs. The etiology is thought to be changes in the cells of the esophagus secondary to noxious/toxic stimuli. There are two cancer types: Squamous Cell Carcinoma and Adenocarcinoma. Risk factors for SCCA include: chronic ingestion of hot foods, vitamin deficiencies, exposure to nitrosamines, SMOKING, CHRONIC ALCOHOL, caustic injury, and Plummer-Vinson syndrome. Risk factors for Adeno include: GERD (reflux disease) leading to Barrett's esophagus and cancer.
Symptoms:
- Dysphagia (difficulty swallowing) - most common symptom
- Usually starts with solids, and eventually goes to solids and liquids
- Weight loss
- Pain felt in the retrosternal area (in the upper central chest area) or epigastric area (above the stomach)
- Hoarseness (usually indicates that the recurrent laryngeal nerve has been invaded)
- Breathing problems
Diagnosis:
- Blood work - shows anemia (low blood count) with abnormal liver function levels
- Barium swallow - detects strictures and masses within the esophagus
- EGD - visualize the esophagus directly and biopsy tumor
- CT Chest/Abdomen - determine spread of tumor to other structures
- Bronchoscopy - visualize the trachea to determine if esophageal tumor has spread there
- Bone scan - if patient has bone pain, concern for spread of cancer to bones
- Laparoscopy - operative procedure to look at lymph nodes and determine staging of cancer
- PET Scan - helps determine if tumor is growing by seeing how metabolically active it is
Treatment:
- Medical care - for nonsurgical patients, goal is to treat symptoms
- Surgical care
- Esophagectomy (resection of the esophagus) with 2 types:
- THE - TransHiatal Esophagectomy (incision in the abdomen and cervical area)
- TTE - Transthoracic Esophagectomy (incision in the abdomen and right chest area)
- Also, minimal invasive surgery with shorter hospitalization
- Indications for surgery
- Diagnosis of esophageal cancer needed
- High-grade dysplasia in Barrett's esophagus
- Contraindications for surgery
- Invasion of certain nodes and solid organs (liver, lungs, etc)
- Invasion of adjacent structures (trachea, aorta, etc)
- Comorbid conditions (heart disease, lung disease)
