Esophageal Cancer

Preventative steps can help you avoid esophageal cancer. These include eating a healthy diet, maintaining a healthy weight and limiting smoking and alcohol use. It is important to be aware of risk factors that can increase your chances of getting esophageal cancer, which include:

• Gastroesophageal reflux disease (acid reflux)
• Barrett's esophagus
• Obesity
• Achalasia (condition where the muscle at the lower end of the esophagus does not relax properly)
• Alcohol use
• Tobacco use
• Plummer-Vinson syndrome
• Workplace exposures
• Burns to the esophagus
• History of other cancers
• HPV (human papilloma virus)

Be on the lookout for any of the following, especially if you are in a high risk group:

• Food sticking when you swallow
• Chest pain
• Weight loss
• Chronic cough and hoarseness
• Vomiting
• Hiccups
• Pneumonia
• Bone pain
• Bleeding into the esophagus

Endoscopy (a flexible esophagogastroduoenoscopy or EGD) is essential for the evaluation of esophageal cancer. During an endoscopy, you doctor passes a flexible, narrow tube equipped with a small video lense down your throat and into your esophagus while you are sedated. This procedure is essential for allowing your physicians to understand how much of your esophagus (and possibly stomach) are involved with cancer and to biopsy areas of concern. Especially for smaller, early-stage cancers, your doctors may also recommend an endoscopic ultrasound (EUS) to examine how deep the cancer spreads into the wall of the esophagus and whether there are abnormal appearing lymph nodes.

Currently in the United States, esophageal cancer screening (finding cancer before symptoms develop) for the general public is not recommended. However, people who a have high risk of esophageal cancer may be considered for an endoscopic screening exam.

If cancer is seen on a biopsy, additional imaging studies (a CT scan or PET scan) or minor procedures (EUS and/or staging laparoscopy) are needed. These studies called clinical staging help your doctors understand the extent of cancer spread, establish the cancer stage (I, II, III or IV), and allow them to establish a personalized treatment plan.

In order to provide you with the best treatment possible, staging must be as accurate as possible. Staging may include a combination of imaging studies and minor procedures, depending on your potential treatment plan.

• Computed tomography (CT) or positron emission tomography (PET)/CT
• Endoscopic ultrasound (EUS)
• Diagnostic laparoscopy

These methods complement each other. Together, they provide the most current accurate assessment of the stage of your cancer and help us individualize your treatment.

A staging procedure includes multiple small procedures. To provide you with efficient care, all the procedures are performed on the same day during one anesthesia setting while you are asleep.
These procedures include:

• Bronchoscopy
• Esophagogastroduodenoscopy (EGD)
• Staging laparoscopy with or without jejunostomy feeding tube placement
• Long-term access port placement

A staging laparoscopy procedure allows us to examine the tumor closely. We will make four or five small incisions in your abdomen and fill it with carbon dioxide to push the abdominal wall away from the organs so that the surgeon can see them clearly and examine the tumor.

First, we will determine whether the tumor has spread beyond the tissues that we can remove during an esophagectomy, such as those from the liver, the inner lining of the abdomen (the peritoneum), or the fatty apron of tissue that drapes off the lower edge of your stomach (the omentum). We will also look for cancerous fluid inside the abdomen (malignant ascites). Patients with cancer that has spread to these areas are usually not candidates for an esophagectomy. These cancers are better treated with chemotherapy. During this inspection, we will occasionally find evidence of cancer spreading that was missed with a PET/CT.

Second, we will look for involvement of the tumor with surrounding structures and for large, bulky lymph nodes. Finally, we will look at the surface of the stomach to determine whether or not the stomach can be used to make a new esophagus. This will be necessary if you undergo an esophagectomy. Depending on what we see, we may or may not perform biopsies.

Treatment options depend on the following:

• The patient’s general health
• The stage of the cancer (whether it affects part of the esophagus, involves the whole esophagus, or has spread to other places in the body)
• Whether the tumor can be completely removed by surgery

Procedures for the evaluation of esophageal cancer include:

• Esophagogastroduodenoscopy (EGD)
• Endoscopic ultrasound
• Staging laparoscopy

Supportive procedures may include

• Jejunostomy feeding tube
• Long-term access port placement
• Palliation of malignant strictures

Treatment procedures may include:

• Endoscopic management of Barrett’s esophagus and early-stage esophageal cancer
• Esophagectomy
• Minimally invasive esophagectomy