Esophageal Cancer

Esophageal cancer occurs when cancer cells develop in the esophagus, the muscular, tube-like structure which connects the throat and the stomach. There are two main types of esophageal cancer, adenocarcinoma and squamous cell carcinoma.

Squamous cell carcinoma develops within the epithelial cells making up the lining of the esophagus and can occur anywhere along its length but is classically in the upper and middle portions. It is typically associated with the use of tobacco and alcohol.

The proportion of esophageal cancer classified as adenocarcinoma has increased in recent decades. Esophageal adenocarcinoma develops in the glandular structures within the esophagus that secrete mucus. It is associated with GERD (Gastro Esophageal Reflux Disease) and typically occurs in the lower portion of the esophagus or within a segment affected by Barrett’s Esophagus (a precancerous complication of chronic reflux).

Esophageal cancer is far more common in men than women.  Historically it is most common in whites but is now almost equally as common in African Americans.

Symptoms

Patients may not experience symptoms until the cancer is advanced. Below are listed some of the most common symptoms associated with Esophageal cancer.

  • Difficulty or pain when swallowing
  • Weight loss
  • Pain in the chest, behind the breastbone
  • Coughing
  • Hoarseness
  • Indigestion and heartburn

Diagnosis

Imaging and other studies used for diagnosis and staging can include the following:

  • Esophagogastroduodenoscopy (EGD)
  • Endoscopic ultrasonography (EUS)
  • Computed tomography (CT) of the abdomen and chest with contrast
  • Pelvic CT scan with contrast if clinically indicated
  • Positron emission tomography (PET) scanning
  • Bronchoscopy
  • Laparoscopy and thoracoscopy
  • Barium swallow
  • Laboratory / Molecular Studies
  • Bloodwork
  • Biopsy
  • Tumor sample material tested for specific genes, proteins, and antibodies (ex – HER2 testing)

Treatment

Treatment of esophageal cancer depends on many things including the stage of the cancer and the general health of the patient. Typically, a combination of modalities is used including radiation, chemotherapy, and surgery.

The esophagus is located very close to many sensitive and critical structures like the heart, lungs, and spinal cord. This position makes it very challenging for physicians to achieve the prescription dose of radiation needed to treat the cancerous cells while minimizing harmful exposure to tissue beyond the treatment site.

Proton therapy can be an especially good option for treating esophageal cancer. Protons deposit the highest dose of radiation within the target (tumor) site and stop. This means there is not an exit dose.

The precision of proton therapy allows physicians to limit and prevent exposing surrounding healthy tissue and structures to damaging radiation while administering an ideal dose to the tumor. With pencil beam scanning the radiation can conform precisely to the target area of the esophagus.

Recent studies have reported that patients with esophageal cancer have improved overall survival rates if treated with chemotherapy and radiation before surgery. (per the CROSS trial, published August 5, 2015 in Lancet Oncology) Proton therapy has also been associated with reductions in post-operative complications, and reduced hospital stays. (Simone CB et al. “Clinical outcomes and toxicities of proton radiotherapy for gastrointestinal neoplasm: a systematic review.” J Gastrointest Oncol. 2016 Aug:7(4):644-64.)

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