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ESOPHAGUS CANCER TREATMENT INFORMATION

What is the Esophagus?

The esophagus is a hollow tube that transfers food from the throat to the stomach, that is the
"food tube". The tube starts just below the "epiglottis", the flap that keeps food from going into
our trachea (air pipe) when we swallow. It ends at where it joins with the upper portion of the
stomach, called the "cardia". The actual area of coinage is called the "gastroesophageal junction".
The esophagus is muscular, to help propel food downward with swallowing. It has a complex
array of nerves ("plexus") that work to coordinate the swallowing motion.

The upper 2/3 of the esophagus has a inner lining ("mucosa") of a special type of cell, called
"squamous" cells, which are also found in the mouth and anal region. These cells resist abrasion
and heat and are able to heal quickly if damaged, say by the sharp edges on food. The lower 1/3
of the esophagus has an inner lining of a different type of mucosa called "columnar" cells.

This becomes important for considering the cancers that arise in the esophagus. If the lower
portion of the esophagus becomes infiltrated with intestinal-like glands, as it is prone to do with
prolonged irritation, then this is called "Barrett's" esophagus and is a risk factor to get cancer, as
will be seen.

The esophagus has an outer lining, called the "adventitia", which surrounds the muscular layers
and separates the esophagus from other nearby organs. The heart is directly behind the middle
esophagus, while the windpipe ("trachea") is directly in front of it. The esophagus is also very
close to the liver, lungs, and major blood vessels from the heart ("aorta and venal cava").

The esophagus receives most of it's blood from the aorta and drains it to the liver and venal cava.
A system of "drainage channels" runs through the esophagus, between the mucosal and muscular
layers. These are called "lymph channels" and act to purify the blood serum, by transporting it to
nearby "lymph nodes" (glands) where the serum is filtered. Both the blood supply, and lymph
channels and glands, can act as conduits to spread infection or cancer. This spread may be along
the length of the esophagus, around it's diameter, to local lymph nodes or organs, or to distant
body areas.

When a person has shrinkage ("cirrhosis") of the liver due to excessive alcohol or chronic
infections, it places back pressure on the blood draining from the esophagus. This results in
swelling of the blood vessels in the lower esophagus, called "varices". These may spontaneously
bleed when there is a lot a pressure between the liver and esophagus ("portal hypertension") and
is a medical emergency. Other common problems with the esophagus (besides cancer) are "rings"
or "webs"-- areas of protrusion into the normally hollow interior ("lumen") of the esophagus
where food can get caught.

A "stricture" is an area of narrowing of the esophagus, often from scarring from ingested
chemicals (i.e. lye). Achalasia is a disease where the nerves in the esophagus don't coordinate
swallowing properly, so food gets caught there. An inflammation is "esophagitis", caused by
bacteria, virus, or fungi, drugs or radiation.
What is Esophagus Cancer?

The esophagus, like all body tissues, is made up of individual cells. Normally, cells within the
forming esophagus divide and grow very rapidly in the womb, in early childhood, and through
puberty. In adulthood, new cells are only formed to replace those which have died from injury,
old age or disease. The division of cells to produce new ones is under tight control by the "genes"
within each cell. These genes are made up of DNA, and if it becomes damaged, the cell may start
dividing out of control.Esophagus cancer starts in a single cell which has become abnormal. This
cells produces millions, and eventually billions, of copies of itself. The copies are called"clones".

These clones fail to function as normal esophagus tissue, but instead divert resources from
healthy cells to fuel their own growth. When there are about 1 billion cells, they form a clump, or
"tumor" 1/2 inch across. A "tumor" merely means a swelling, it can be caused by infection,
inflammation, cancer or whatever. If a tumor only grows in it's local area (even very large) but
does not have the capacity to spread to distant body areas, it is called"benign" and isnot cancer.
If, however, the tumor has the ability to spread to distant body areas, it is called "malignant"
andthis is cancer. The actual process of spread is called"metastasis", and can occur to any area of
the body.

The most common type of benign esophageal tumor arises from the muscular layer, and is called
a "leiomyoma". Unfortunately, a quickly growing tumor within the esophagus is most likely to
be cancerous.

How Common is Esophagus Cancer?

There were 14,500 new cases of esophagus cancer last year. It Accounts for 5% of
Gastrointestinal cancers and about 1% of all new cancers in the U.S.A. The overall number of
cases each year is steadily increasing. In some places, like Northern China, it is 10 times more
common than in North America. It is the 7th most common cancer worldwide. In the U.S.A. men
are affected more than twice as commonly as women, and Black men 3 times as often as White
men. The average patient is 60 years old.

What are the Types of Esophagus Cancer?

The most common type had always been "squamous cell carcinoma" arising from the upper 2/3
of the esophagus. Now, however, there has been a dramatic increase in another type, called
"adenocarcinoma", which tends to arise in the lower 1/3 of the esophagus. Currently, the number
of each of these two types of cancer cases is about equal, and together they make up nearly 100%
of today's esophagus cancers. White men tend to get the disease more commonly in the lower
esophagus, while Black men get it in the middle and upper esophagus.

There are occasional rare cancers found in the esophagus, such as "sarcomas" which arise from
the muscular wall, "cylindroma" which begins from glands, and "lymphoma" that starts from the
body's immune system cells within the esophagus.
Staging System

The staging system used in esophageal cancer is designed to describe the extent of disease within
the esophagus, in the surrounding lymph nodes, and distantly. The staging system used to
describe esophageal tumors is the "TNM system", as described by the American Joint Committee
on Cancer. The TNM systems are used to describe many types of cancers. They have three
components: T-describing the extent of the "primary" tumor (the tumor in the esophagus itself);
N-describing the spread to the lymph nodes; M-describing the spread to other organs (i.e.-
metastases). The staging system for esophageal cancer his complex, particularly regarding lymph
node spread, where the location of the esophageal cancer with in the esophagus affects the
staging.

The "T" stage is as follows:

• Tis-carcinoma in situ
• T1-tumor confined to the inner layer of the esophageal wall (submucosa or lamina
propria)
• T2-tumor invades into the muscular layer of the wall
• T3-tumor invades into the outer layer of the wall (adventitia)
• T4-tumor invades into other structures or organs
The "N" stage is as follows for any subsite:
• N0-no spread to lymph nodes
• N1-tumor spread to regional lymph nodes
○ lymph nodes outside the chest are considered "M1"
The "M" stage is as follows:
• M0-no tumor spread to other organs
• M1-tumor spread to other organs
This is also broken down by site of the primary tumor within the esophagus:

Tumors of the lower esophagus:


• M1a-cancer spread to the lymph nodes in the abdomen (called celiac nodes).
• M1b-cancer has spread to other parts of the body.

Tumors of the upper esophagus:


• M1a-cancer spread to the lymph nodes in the neck (called cervical or supraclavicular
nodes).
• M1b-cancer has spread to other parts of the body.
The overall stage is based on a combination of these T, N, and M parameters:
Stage 0: Cancer in situ.
Stage I: Cancer in the two inside layers of the esophagus (T1N0M0)
Stage IIA: Cancer in any of the four layers of the esophagus (T2-3N0M0)
Stage IIB: Cancer in any layer of the esophagus, with spread to lymph nodes near the tumor
(T1-2N1M0)
Stage III: Cancer is in the outside layer of the esophagus, or through the wall. Cancer is also in
the lymph nodes (T3-4N1M0)
Stage IVA: Cancer spread to the lymph nodes of the abdomen or neck (T1-4N0-1M1a)
Stage IVB: Cancer has spread to other parts of the body (T1-4N0-1M1b)

What Causes, or Increases the Risk for Esophagus Cancer?

Like any cancer, the exact reason why one person gets esophagus cancer and another does not
remainsunknown. However, various "risk factors" have been noted to increase the risk for
developing esophagus cancer.

People don't think much about their esophagus (food tube) unless it gets diseased. Esophagus
cancer used to be uniformly fatal, but newer treatments offer more hope of survival and comfort
than ever before.

It is critical to get the right treatment for esophagus cancer- this can literally make the difference
between life and death. Understanding your choices gives you the peace-of-mind of knowing that
you have done everything possible to fight esophagus cancer successfully.