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Esophageal cancer

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From MayoClinic.com


Although your esophagus is essentially a hollow tube, its walls are composed of a number of highly-specialized layers, including an inner lining made up of thin, flat cells (squamous cells), a layer below the inner lining (submucosa) that contains mucus-secreting glands, and a thick band of muscle tissue.

When you eat or drink, a muscle in the upper part of your esophagus (upper esophageal sphincter) relaxes, allowing food and liquid to enter. Smooth muscles in the esophagus wall then move the food along in a series of rhythmic contractions — a process called peristalsis. It usually takes four to 10 seconds for food to flow through your esophagus.

Another ring of muscle, the lower esophageal sphincter, sits at the junction where your esophagus and stomach connect. It opens to allow food into your stomach and then clamps shut so that corrosive stomach acids and digestive enzymes don't back up into the esophagus.

Cancer can occur almost anywhere along the length of the esophagus and is classified according to the types of cells in which it originates:

  • Squamous cell or epidermoid carcinoma. The most common esophageal cancer in black Americans, squamous cell carcinoma develops in the flat squamous cells that line the esophagus.

  • Adenocarcinoma. This arises in the glandular tissue in the lower part of the esophagus nearest the stomach.

  • Others. Although squamous cell and adenocarcinoma are the primary types of esophageal cancer, other, rare forms of the disease sometimes occur. These include sarcoma, lymphoma, small cell carcinoma and spindle cell carcinoma. In addition, cancer that starts in the breast or lung can spread (metastasize) through the bloodstream or lymph system to the esophagus.

Contributing factors

Healthy cells grow and divide in an orderly way. This process is controlled by DNA — the genetic material that contains the instructions for every chemical process in your body. When DNA is damaged, changes occur in these instructions. One result is that cells may begin to grow out of control and eventually form a tumor — a mass of malignant cells.

Although researchers don't know all the causes of esophageal cancer, they have identified several factors that can damage DNA in your esophagus. These factors include:

  • Heavy alcohol consumption. Esophageal squamous cell carcinomas is a result from chronic alcohol abuse. Long-term heavy drinking irritates the lining of the esophagus, leading to inflammation that eventually may cause malignant changes in the cells.

  • Tobacco use. Using tobacco in any form, including cigarettes, cigars, pipes and chewing tobacco, increases the likelihood of developing esophageal squamous cell carcinoma. The risk increases with long-term use and rises dramatically for people who both smoke and drink.

  • Chronic acid reflux. Sometimes the lower esophageal sphincter relaxes abnormally or weakens, allowing caustic stomach acids to back up into your esophagus (esophageal reflux). The result is heartburn — a burning chest discomfort that in severe cases may mimic the symptoms of a heart attack. Occasional heartburn usually isn't serious, but chronic acid reflux can lead to Barrett's esophagus, a condition in which cells similar to the stomach's glandular cells develop in the lower esophagus. These new cells are resistant to stomach acid, but they also have a high potential for malignancy.

  • Chemical irritation. Each year, nearly 1 million children under age 5 accidentally drink toxic household substances. Some of these chemicals, especially drain cleaners that contain lye, burn the lining of the esophagus and may contribute to esophageal cancer later in life.

  • Diet. Eating a diet low in fruits and vegetables appears to contribute to esophageal cancer. Especially implicated are diets lacking in vitamins A, C, B1 (riboflavin), the mineral selenium, and beta-carotene — a substance found especially in orange and yellow fruits and vegetables that is converted into vitamin A in your body.

  • Obesity. Weighing 20 to 30 pounds more than your ideal weight has been linked to an increased risk of adenocarcinoma.

Sometimes esophageal cancer is associated with certain rare medical conditions, including:

  • Achalasia. In this disorder, food collects at the bottom of the esophagus, both because the esophagus lacks normal peristalsis to move food along and because the lower esophageal sphincter doesn't relax normally. For reasons that aren't clear, having achalasia seems to increase your risk of esophageal cancer.

  • Esophageal webs. These thin protrusions of tissue can appear anywhere in the esophagus. Some webs cause no symptoms, but others can make swallowing difficult. When other problems — including anemia and abnormalities of the tongue, fingernails and spleen — occur in conjunction with esophageal webs, the condition is called Plummer-Vinson or Paterson-Kelly syndrome. People with this syndrome are at risk of developing esophageal cancer.

  • Tylosis. This rare, inherited disorder causes excess skin to form on the soles and palms. Close to half the people with tylosis eventually develop esophageal cancer. A genetic defect appears to be responsible for both tylosis and the associated cancer.

Risk factors

Heavy drinking and smoking are the two greatest risk factors for esophageal squamous cell carcinoma. The risk increases substantially if you drink as well as smoke. If you drink heavily every day for several years, your risk of esophageal cancer is 18 times greater than it is for someone who drinks in moderation or not at all. When you also smoke, your risk nearly doubles.

Other risk factors for esophageal cancer include:

  • Age. Your risk of developing esophageal cancer increases as you grow older. Most people with the disease are between 45 and 70. The risk is much less if you're under 40.

  • Sex. Men are three times as likely to develop esophageal cancer as women are.

  • Race. Squamous esophageal cancer affects three times as many black Americans as whites, whereas whites have much higher rates of esophageal adenocarcinoma than do blacks. Although the reason for this disparity isn't known, genetic factors may play a role.

  • Diet. If your diet is low in fruits and vegetables, or you're very overweight, you're at increased risk of esophageal cancer.

  • Chronic heartburn or Barrett's esophagus. Both conditions, which occur when stomach acid backs up into your esophagus, increase your risk of esophageal cancer.

When to seek medical advice

See your doctor if you have difficulty swallowing, a chronic cough or unintended weight loss. Having these signs and symptoms doesn't mean you have esophageal cancer. A number of other conditions can cause similar problems, and your doctor can perform tests to help determine the cause.

Also seek treatment if you experience chronic heartburn, which can cause inflammation in your esophagus and increase your risk of esophageal cancer. In many cases, you can control mild or moderate heartburn by changing your diet and using over-the-counter antacids. When these measures aren't enough, your doctor may recommend stronger medications.

Signs and symptoms of gastroesophageal reflux include:

  • A sour taste and the sense of food re-entering your mouth (regurgitation)

  • Burning chest pain, especially after meals or at night when lying down

  • Difficulty swallowing, often due to a spasm or stricture in your esophagus

  • Coughing, wheezing, asthma, hoarseness or sore throat, often resulting from acid reflux in your throat or windpipe

Screening and diagnosis

To help find the cause of your symptoms, your doctor will take a complete medical history and perform a physical exam. You're also likely to have a chest X-ray and other diagnostic tests, such as:

  • A barium swallow (esophagram). A diagnostic test often given to people who have difficulty swallowing, a barium swallow uses a series of X-rays to examine the esophagus. Before the test, you'll drink a thick liquid (barium) that temporarily coats the lining of your esophagus so that the lining shows up clearly on the X-rays. You may also have air blown into your esophagus, to help push the barium against the esophagus walls. Although a barium swallow can help diagnose cancer, it may not show whether a tumor has spread beyond the esophagus. After the test you can eat normally and resume your daily activities, although you'll need to drink extra water to help flush the barium from your system and prevent constipation. A barium swallow briefly exposes you to ionizing radiation. The danger from this exposure is small and doesn't appear to increase even if you have a number of X-rays. Even so, care is taken to produce the best images with the lowest amount of radiation and the fewest possible X-rays.

  • Esophagoscopy (upper endoscopy). During this procedure, your doctor examines the inside of your esophagus using an endoscope — a thin, lighted tube with a tiny camera on the end that sends images to a TV monitor. Your throat will likely be sprayed with a topical anesthetic before you're asked to swallow the tube, and you may also receive medication through your veins (intravenously) to keep you relaxed and comfortable. The endoscope allows your doctor to clearly see any masses in the wall of your esophagus as well as to take a tissue sample (biopsy) if abnormal cells are found. The samples are then sent to a laboratory for analysis. Risks of the procedure include a reaction to the medication and bleeding at a biopsy site. If your doctor needs to make a wider opening (dilate) your esophagus because of a stricture or narrowing, there's also a small risk of creating a hole in your esophagus (esophageal perforation).

Screening tests

Screening tests check for a disease in its early stages, before you develop symptoms. If you're at high risk of esophageal cancer, especially if you have Barrett's esophagus or tylosis, you're likely to have regular endoscopic examinations and biopsies. Many doctors recommend having these tests every two to three years if you don't have cell abnormalities (dysplasia). When cell abnormalities are present, you'll usually need tests more often.

Staging tests

If cancer is diagnosed, you're likely to have more tests to determine whether and where the cancer has spread (metastasized), a process known as staging. This step is especially important because it helps your doctor determine the best possible treatment. Esophageal cancers are staged using the numbers 0 through IV. In general, the higher the number the more advanced the cancer.

  • Stage 0 (carcinoma in situ). These cancers, also called noninvasive or in situ (in one place) cancers or high-grade dysplasia, don't have the ability to spread to other parts of your body. Still, it's important to have them followed closely or removed because they eventually may become invasive.

  • Stage I. This cancer occurs only in the top layer of cells lining your esophagus.

  • Stage II. At this stage, the cancer has invaded deeper layers of your esophagus lining and may have also spread to nearby lymph nodes.

  • Stage III. The cancer has spread even more deeply into the wall of your esophagus and to nearby tissues or lymph nodes.

  • Stage IV. At this stage, the cancer has spread to other parts of your body.

To help stage esophageal cancer, you may have one or more of these tests:

  • Bronchoscopy. In this procedure, which is similar to esophagoscopy, your doctor uses an endoscope to examine your windpipe (trachea) and the air passages leading to your lungs (bronchi) to determine whether cancer has spread to these areas.

  • Computerized tomography (CT) scan. This X-ray technique produces more detailed images of your internal organs than do conventional X-ray studies. That's because a computer translates information from X-rays into images of thin sections (slices) of your body at different levels. CT scans can confirm the location of a tumor within the esophagus and whether cancer has spread to nearby lymph nodes or other organs. A CT scan exposes you to more ionizing radiation than plain X-rays do and usually isn't recommended if you're pregnant.

  • Endoscopic ultrasound. This procedure may prove to be more accurate than either CT scans or upper endoscopy in determining how far an esophageal cancer has spread into nearby tissues. During the test, a tiny ultrasound probe is passed through an endoscope into your esophagus. The probe produces very sensitive sound waves that penetrate deep into tissues. A computer then translates the sound waves into close-up images of your esophagus and nearby tissues. Your doctor can also take biopsies of lymph nodes and other tissues during the procedure. Endoscopic ultrasound uses sound waves rather than X-rays to create images, and the risks of the procedure, such as bleeding or perforation of the esophagus, are slight.

  • Positron emission tomography (PET) scan. During this test, your doctor injects a small amount of a radioactive tracer — typically a form of glucose — into your body. All tissues in your body absorb some of this tracer, but tumors absorb greater amounts and appear brighter on the scan than healthy tissue does. A PET scan exposes you to a small amount of radiation, but because the radioactivity is short-lived, your overall exposure is low.

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