Cancer may occur anywhere in the esophagus. The most common esophageal cancer is either squamous cell carcinoma or adenocarcinoma. The most common noncancerous tumor of the esophagus is leiomyoma, a tumor of the smooth muscle.
Esophageal cancer is more common in people whose esophagus has narrowed, those who have achalasia (failure of the lower esophageal sphincter to open properly), esophageal blockages or cancer of the head and neck. Smoking and alcohol abuse also increase the risk of esophageal cancer. Usually one of the first symptoms of esophageal cancer is difficulty in swallowing solids, then liquids and soft foods, and weight loss. Recently there has been a significant increase in cancer of the lower esophagus. This is most common in Caucasian men and is believed to be a direct result of chronic severe acid reflux from the stomach into the esophagus.
I'm curious as to why a doctor wouldn't do surgery on a cancer patient. According to the doctors, the tumor is too big and they feel they couldn't get all the cancer if they did surgery first. How can that be? I always thought with cancer that time was of the essence. What happens if the chemotherapy doesn't work? Do they then do surgery after wasting all that time? Also what determines if a tumor is too big, especially if there is no metastasis? Thanks. Lynn
Dear Lynn,
Cancer treatment depends upon the type of cancer and the type of therapy that has been proven in clinical trials to improve survival. It may include surgery, chemotherapy or radiotherapy or a combination of the above. For reasons that are not clear, gastroesophageal junction cancer incidence has been increasing in the United States.
There has been recent literature suggesting that shrinking esophageal tumors (with chemotherapy and radiotherapy) prior to performing surgery (called neoadjuvant therapy) will improve the results of the surgery.
Furthermore, the delay of surgery with this treatment does not influence survival. Many esophageal cancers are sensitive to the chemotherapy and radiation therapy combination and can actually shrink to the point where the tumor is no longer visible on standard scans.
This makes the surgery much easier to perform and therefore increases the chances that it will be more successful.
My mother is a 62-year old woman who has always been in good health. Since October she has been through angioplasty and has ongoing acid reflux. She has a feeling of being full of gas yet not being able to pass it. Yesterday, she had an endoscopy and the findings were one of two things -- either esophageal cancer or a viral ulcer. The doctor seems to think it's cancer. From what I've read, this spreads very quickly and is considered incurable. The doctor said viral ulcers are extremely rare. Can you offer information on both and how they are treated? Lynn
Dear Lynn,
It is very important to obtain the pathology from the endoscopy. If your mother has an ulcer at the lower esophagus, she may have a benign condition i.e. reflux disease or Barrett's esophagus. However, if it turns out that the ulcer is cancer, your mother will need an endoscopic ultrasound of the esophagus and possibly a CT scan of the chest to stage the degree of spread. Depending on the findings, surgery may be attempted. If resection is not feasible, then chemotherapy and radiation are offered.
If your mother has acid-induced reflux, therapy is directed towards inhibition of acid secretion.
I am looking for advice on cancer of the esophagus. We learned earlier this year that my mom has stage 3 esophageal cancer. From what I've read, this is nasty. What are we looking at here and what are the treatment options?
I'm afraid her doctor is not treating aggressively as he is only using cisplatin and 5-FU fluro (can't recall the rest of the name). He has no plans to radiate and I've suggested photodynamic therapy (PDT), surgery, cancer vaccines and thalidimide as options, but he was very unresponsive.
Do you have any suggestions? I've read about cancer vaccines. Do you have any knowledge of this? We're searching for help, so any you can give us will be greatly appreciated. Mary
Dear Mary,
We are very sorry about your mother's recent diagnosis of esophageal cancer. Each year, approximately 12,000 new cases of esophageal cancer are diagnosed in the United States. Like your mother, most patients have stage III disease at the time of diagnosis. The two most common types of esophageal cancer are called squamous cell carcinoma and adenocarcinoma.
The staging of this cancer is very important. Staging determines treatment options and predicts the prognosis of the patient. The staging system is universally applied in the United States. It stands for tumor size,for regional lymph node involvement and for distant metastasis.
A stage III cancer, implies a tumor that invades the outer lining of the esophagus or adjacent structures and with regional lymph nodes that are also affected by the cancer. Unfortunately, this is an advanced stage of the disease and for patients undergoing the most aggressive treatment options that survive the surgical procedure, the 5-year survival rate reported from major referral centers in the United States is only 15 to 20%.
There are several different treatment options, depending upon the cancer type (squamous cell carcinoma versus adenocarcinoma), the staging and the patient's general condition. Combined treatment is frequently used. It uses different combinations of:
Chemotherapy (usually fluorouracil [5-FU] and cisplatin or mitomycin).
Radiation therapy.
Surgery.
Esophageal tumor resection is a risky surgical procedure and is usually contraindicated if the patient has multiple medical problems and/or if the tumor is not resectable.
Because most cases of esophageal cancer are currently detected at an incurable stage, several palliative treatments have been described.
Palliation means that even though the treatment will not change the prognosis, it will make the patient more comfortable and improve the quality of life.
The most common symptom of advanced esophageal cancer is difficulty or inability to swallow due to the tumor obstructing the lumen of the esophagus. Some of the available palliative treatments for esophageal cancer are:
Dilatation of the narrowed esophagus with a tube that is passed through the mouth and then pulled out. The disadvantages include the risk of perforation and the short duration of symptom relief.
Metallic expandable stents(tubes) that are positioned permanently in the esophagus. This procedure has a higher risk of perforation, but the symptom relief is long lasting.
A beam of laser can be used to heat and vaporize the tumor and gradually reopen the lumen of the esophagus. This therapy is effective and relatively safe.
Photodynamic Therapy (PDT) has also been applied to patients with advanced tumors for the purpose of palliation. It uses a substance that make tissues very sensitive to a special kind of laser light. When the lining of the esophagus is exposed to this light, destruction (necrosis) of the superficial tissue is produced.
Other techniques use very low temperature to destroy tissue (cryotherapy) or injection of substances directly to the tumor.
There are no cancer vaccines or so called immunotherapy for esophageal cancer. Thalidomide has been used to promote healing of some kinds of esophageal ulcers, but does not appear to be a treatment for esophageal cancer.
My father was diagnosed with esophageal cancer in February. He is 56 years old and otherwise in fine health although he has been a smoker for years and has had problems with acid reflux for as long as I can remember. After chemo (5-FU and cisplatin and radiation treatment which were deemed successful (the tumor shrank), he has just undergone surgery to resect his entire esophagus. He is recovering well from the surgery but is very concerned about the future.
The surgeons removed his entire esophagus and 20-30% of his stomach ( his tumor was right at the junction) and then tubularized part of his remaining stomach and moved it up into his chest, leaving a small pouch of stomach to act as his "regular stomach" in the future. He has a feeding tube and is starting to try liquids but can't seem to keep anything down with this new apparatus. With no valve in place, everything comes right back up if he coughs or lies down. Will this improve? Can you give us an idea of what to expect?
Also, is this really a cure? We'd like to know what his chances are and if this is going to show up again in six months, a year or five years. Jen
Dear Jen,
You ask several important questions regarding esophageal cancer. Your father has been treated aggressively with combination therapy (chemotherapy, radiation and surgery). Hopefully, all tumor has been removed although only in retrospect will you know for certain. It is not helpful to provide statistics regarding possible tumor recurrence because these probabilities are true for populations of patients but are not necessarily valid for individual patients.
Regarding the issue of keeping food down and we suspect limited appetite, it is difficult to predict what will happen. Your father's appetite should gradually improve.
If he has substantial reflux, he could try a prokinetic agent such as Propulsid in an attempt to diminsh this symptom. In addition, your father should eat slowly and not lie down for several hours after he eats. If coughing with eating is a constant problem, ask the doctor about the possibility of a tracheo-esophageal fistula, that is a connection between the GI tract and the breathing tube so that food or saliva enters the lungs.
My father has a tumor which the surgeon was unable to remove because it was located at the junction of the esophagus and the stomach. There was also an infected lymph node between the stomach and the heart. Yesterday, the cancer doctor told him he had 6 to 12 months to live and did not recommend radiation and chemotherapy because of the side effects and said it probably would only prolong his life about three months. Also, it would take three months to see if he would be able to eat and then it still might not work. They decided not to do the treatment.
The next day my dad went to the surgeon and he advised the radiation/chemotherapy and told him he'd be able to eat anything in two weeks. My parents are in their 70s and very confused and scared. What would your best suggestion be to them? Mrs. B.
Dear Mrs. B,
We are sorry to learn of the recent course of events. Esophageal cancer is a difficult tumor for the physician because it is usually not surgically curable at the time of diagnosis.
Laser treatment can be used to maintain an esophageal lumen. This approach will require frequent endoscopic procedures and is associated with a small risk of esophageal perforation ( a serious and possibly fatal complication).
If you want to provide a means to prevent dehydration and possibly for your father to increase his caloric intake, I would suggest the placement of a feeding tube into the stomach via the anterior abdominal wall. This treatment can be done by your gastroenterologist or an interventional radiologist. The procedure takes 10-15 minutes.
After tube placement, your father will be able to take water or high caloric supplements via the tube without coughing, aspiration or food sticking in the esophagus. Side effects of tube placement are unusual but include skin infection, aspiration with pneumonia, and peritonitis. Bleeding has also been reported.
My grandfather has been diagnosed as suffering from esophageal cancer. The surgeon who was his only hope has refused to carry out surgery due to my grandfather's heart disease (50% blockage in the right ventricle). My grandfather has no apparent secondary cancer and we have been informed that chemotherapy and radiation therapy are out of the question due to the severe side effects in this type of cancer. Is that true? The only option which has been offered to him is a steel pipe inserted into his tube to make swallowing foods easier. I'd appreciate any help you could give us. Damien
Dear Damien,
We sense the anguish and frustration in your words. It is difficult to know that a loved one has a serious and possibly fatal illness.
Cancer of the esophagus is a very serious illness. Most people who have this condition do not live five years. In general terms, the only hope for cure is with surgery, although there have been rare reports of good responses to chemotherapy and radiation therapy.
Although surgery provides the best opportunity for successful treatment of this illness, the operation is quite extensive and requires that the patient not have serious concurrent illnesses of the lung and/or heart. Additionally, for technical reasons, not all patients can be offered surgery. The surgical response appears best if the cancer is in the lower third of the esophagus.Cancers in the upper third cannot be resected.
We are uncertain as to why chemotherapy and radiation therapy have been excluded as treatment options. You do not provide details regarding your grandfather's age and concurrent illnesses, but it is conceivable that these factors have influenced your physician's decisions.
Your family may consider asking the physicians about laser or photodynamic therapy. These techniques, can shrink the tumor, although the response is probably not curative.
Placement of a wall stent (a pipe in the esophagus) is an important palliative procedure that will allow your grandfather to continue oral feedings. One of the consequences of esophageal cancer is blockage of the esophagus (food pipe) so that the patient cannot maintain nutrition. The quality of life is certainly improved by this approach.
