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NCI/PDQ^® Patients: Esophageal Cancer Treatment (PDQ®)

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National Cancer Institute
Last Modified: December 13, 2012

TABLE OF CONTENTS

• General Information About Esophageal Cancer

• Stages of Esophageal Cancer

• Recurrent Esophageal Cancer

• Treatment Option Overview

• Treatment Options By Stage
  • Stage 0 (High-grade Dysplasia)
  • Stage I Esophageal Cancer
  • Stage II Esophageal Cancer
  • Stage III Esophageal Cancer
  • Stage IV Esophageal Cancer

• Treatment Options for Recurrent Esophageal Cancer

• To Learn More About Esophageal Cancer

• Changes to This Summary (12/13/2012)

• Get More Information From NCI

• About PDQ®

General Information About Esophageal Cancer

Esophageal cancer is a disease in which malignant (cancer) cells form in the tissues of the esophagus.

The esophagus is the hollow, muscular tube that moves food and liquid from the throat to the stomach. The wall of the esophagus is made up of several layers of tissue, including mucous membrane, muscle, and connective tissue. Esophageal cancer starts at the inside lining of the esophagus and spreads outward through the other layers as it grows.The stomach and esophagus are part of the upper digestive system.

The two most common forms of esophageal cancer are named for the type of cells that become malignant (cancerous):

• Squamous cell carcinoma: Cancer that forms in squamous cells, the thin, flat cells lining the esophagus. This cancer is most often found in the upper and middle part of the esophagus, but can occur anywhere along the esophagus. This is also called epidermoid carcinoma.
• Adenocarcinoma: Cancer that begins in glandular (secretory) cells. Glandular cells in the lining of the esophagus produce and release fluids such as mucus. Adenocarcinomas usually form in the lower part of the esophagus, near the stomach.

Smoking, heavy alcohol use, and Barrett esophagus can increase the risk of developing esophageal cancer.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors include the following:

• Tobacco use.
• Heavy alcohol use.
• Barrett esophagus: A condition in which the cells lining the lower part of the esophagus have changed or been replaced with abnormal cells that could lead to cancer of the esophagus. Gastric reflux (the backing up of stomach contents into the lower section of the esophagus) may irritate the esophagus and, over time, cause Barrett esophagus.
• Older age.
• Being male.
• Being African-American.

The most common signs of esophageal cancer are painful or difficult swallowing and weight loss.

These and other symptoms may be caused by esophageal cancer or by other conditions. Check with your doctor if you have any of the following problems:

• Painful or difficult swallowing.
• Weight loss.
• Pain behind the breastbone.
• Hoarseness and cough.
• Indigestion and heartburn.

Tests that examine the esophagus are used to detect (find) and diagnose esophageal cancer.

The following tests and procedures may be used:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken.
• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• Barium swallow: A series of x-rays of the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and stomach, and x-rays are taken. This procedure is also called an upper GI series.Barium swallow. The patient swallows barium liquid and it flows through the esophagus and into the stomach. X-rays are taken to look for abnormal areas.
• Esophagoscopy: A procedure to look inside the esophagus to check for abnormal areas. An esophagoscope is inserted through the mouth or nose and down the throat into the esophagus. An esophagoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer. When the esophagus and stomach are looked at, it is called an upper endoscopy. Esophagoscopy. A thin, lighted tube is inserted through the mouth and into the esophagus to look for abnormal areas.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. The biopsy is usually done during an esophagoscopy. Sometimes a biopsy shows changes in the esophagus that are not cancer but may lead to cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

• 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).
• The size of the tumor.
• The patient's general health.

When esophageal cancer is found very early, there is a better chance of recovery. Esophageal cancer is often in an advanced stage when it is diagnosed. At later stages, esophageal cancer can be treated but rarely can be cured. Taking part in one of the clinical trials being done to improve treatment should be considered. Information about ongoing clinical trials is available from the NCI Web site.

Stages of Esophageal Cancer

After esophageal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the esophagus or to other parts of the body.

The process used to find out if cancer cells have spread within the esophagus or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

• Bronchoscopy: A procedure to look inside the trachea and large airways in the lung for abnormal areas. A bronchoscope is inserted through the nose or mouth into the trachea and lungs. A bronchoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the chest, abdomen, and pelvis, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. A PET scan and CT scan may be done at the same time. This is called a PET-CT.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the body, usually through the mouth or rectum. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.
• Thoracoscopy: A surgical procedure to look at the organs inside the chest to check for abnormal areas. An incision (cut) is made between two ribs and a thoracoscope is inserted into the chest. A thoracoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node samples, which are checked under a microscope for signs of cancer. In some cases, this procedure may be used to remove part of the esophagus or lung.
• Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples to be checked under a microscope for signs of disease.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

• Through tissue. Cancer invades the surrounding normal tissue.
• Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
• Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The following stages are used for squamous cell carcinoma of the esophagus:

Stage 0 (High-grade Dysplasia)

In stage 0, abnormal cells are found in the inner (mucosal) layer of the esophageal wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called high-grade dysplasia.

Stage I squamous cell carcinoma of the esophagus

Stage I is divided into Stage IA and Stage IB, depending on where the cancer is found.

• Stage IA: Cancer has formed in the inner (mucosal) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope.
• Stage IB: Cancer has formed:
  • in the inner (mucosal) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope; or
  • in the inner (mucosal) layer and spread into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope. The tumor is in the lower esophagus or it is not known where the tumor is.

Stage II squamous cell carcinoma of the esophagus

Stage II is divided into Stage IIA and Stage IIB, depending on where the cancer has spread.

• Stage IIA: Cancer has spread:
  • into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope. The tumor is in either the upper or middle esophagus; or
  • into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope. The tumor is in the lower esophagus or it is not known where the tumor is.

• Stage IIB: Cancer:
  • has spread into the middle (muscle) layer or the outer (connective tissue) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope. The tumor is in either the upper or middle esophagus; or
  • is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in 1 or 2 lymph nodes near the tumor.

Stage III squamous cell carcinoma of the esophagus

Stage III is divided into Stage IIIA, Stage IIIB, and Stage IIIC, depending on where the cancer has spread.

• Stage IIIA: Cancer:
  • is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in 3 to 6 lymph nodes near the tumor; or
  • has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in 1 or 2 lymph nodes near the tumor; or
  • has spread into the diaphragm, sac around the heart, or tissue that covers the lungs and lines the inner wall of the chest cavity. The cancer can be removed by surgery.

• Stage IIIB: Cancer has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in 3 to 6 lymph nodes near the tumor.

• Stage IIIC: Cancer has spread:
  • into the diaphragm, sac around the heart, or tissue that covers the lungs and lines the inner wall of the chest cavity; the cancer can be removed by surgery. Cancer is found in 1 to 6 lymph nodes near the tumor; or
  • into other nearby organs such as the aorta, trachea, or spine, and the cancer cannot be removed by surgery; or
  • to 7 or more lymph nodes near the tumor.

Stage IV squamous cell carcinoma of the esophagus

In Stage IV, cancer has spread to other parts of the body.

The following stages are used for adenocarcinoma of the esophagus:

Stage 0 (High-grade Dysplasia)

In stage 0, abnormal cells are found in the inner (mucosal) layer of the esophageal wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called high-grade dysplasia.

Stage I adenocarcinoma of the esophagus

Stage I is divided into Stage IA and Stage IB, depending on where the cancer is found.

• Stage IA: Cancer has formed in the inner (mucosal) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope.
• Stage IB: Cancer has formed:
  • in the inner (mucosal) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope and they grow quickly; or
  • in the inner (mucosal) layer and spread into the middle (muscle) layer of the esophageal wall. The tumor cells look a lot like normal cells under a microscope.

Stage II adenocarcinoma of the esophagus

Stage II is divided into Stage IIA and Stage IIB, depending on where the cancer has spread.

• Stage IIA: Cancer has spread into the middle (muscle) layer of the esophageal wall. The tumor cells do not look at all like normal cells under a microscope and they grow quickly.
• Stage IIB: Cancer:
  • has spread into the outer (connective tissue) layer of the esophageal wall; or
  • is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in 1 or 2 lymph nodes near the tumor.

Stage III adenocarcinoma of the esophagus

Stage III is divided into Stage IIIA, Stage IIIB, and Stage IIIC, depending on where the cancer has spread.

• Stage IIIA: Cancer:
  • is in the inner (mucosal) layer and may have spread into the middle (muscle) layer of the esophageal wall. Cancer is found in 3 to 6 lymph nodes near the tumor; or
  • has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in 1 or 2 lymph nodes near the tumor; or
  • has spread into the diaphragm, sac around the heart, or tissue that covers the lungs, and lines the inner wall of the chest cavity. The cancer can be removed by surgery.

• Stage IIIB: Cancer has spread into the outer (connective tissue) layer of the esophageal wall. Cancer is found in 3 to 6 lymph nodes near the tumor.
• Stage IIIC: Cancer has spread:
  • into the diaphragm, sac around the heart, or tissue that covers the lungs and lines the inner wall of the chest cavity; the cancer can be removed by surgery. Cancer is found in 1 to 6 lymph nodes near the tumor; or
  • into other nearby organs such as the aorta, trachea, or spine, and the cancer cannot be removed by surgery; or
  • to 7 or more lymph nodes near the tumor.

Stage IV adenocarcinoma of the esophagus

In Stage IV, cancer has spread to other parts of the body.

Recurrent Esophageal Cancer

Recurrent esophageal cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the esophagus or in other parts of the body.

Treatment Option Overview

There are different types of treatment for patients with esophageal cancer.

Different types of treatment are available for patients with esophageal cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Patients have special nutritional needs during treatment for esophageal cancer.

Many people with esophageal cancer find it hard to eat because they have trouble swallowing. The esophagus may be narrowed by the tumor or as a side effect of treatment. Some patients may receive nutrients directly into a vein. Others may need a feeding tube (a flexible plastic tube that is passed through the nose or mouth into the stomach) until they are able to eat on their own.

Six types of standard treatment are used:

Surgery

Surgery is the most common treatment for cancer of the esophagus. Part of the esophagus may be removed in an operation called an esophagectomy. Esophagectomy. A portion of the esophagus is removed and the stomach is pulled up and joined to the remaining esophagus.The doctor will connect the remaining healthy part of the esophagus to the stomach so the patient can still swallow. A plastic tube or part of the intestine may be used to make the connection. Lymph nodes near the esophagus may also be removed and viewed under a microscope to see if they contain cancer. If the esophagus is partly blocked by the tumor, an expandable metal stent (tube) may be placed inside the esophagus to help keep it open.Esophageal stent. A device (stent) is placed in the esophagus to keep it open to allow food and liquids to pass through into the stomach.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

A plastic tube may be inserted into the esophagus to keep it open during radiation therapy. This is called intraluminal intubation and dilation.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Chemoradiation therapy

Chemoradiation therapy combines chemotherapy and radiation therapy to increase the effects of both.

Laser therapy

Laser therapy is a cancer treatment that uses a laser beam (a narrow beam of intense light) to kill cancer cells.

Electrocoagulation

Electrocoagulation is the use of an electric current to kill cancer cells.

New types of treatment are being tested in clinical trials.

Information about clinical trials is available from the NCI Web site.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Treatment Options By Stage

A link to a list of current clinical trials is included for each treatment section. For some types or stages of cancer, there may not be any trials listed. Check with your doctor for clinical trials that are not listed here but may be right for you.

Stage 0 (High-grade Dysplasia)

Treatment of stage 0 is usually surgery.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage 0 esophageal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage I Esophageal Cancer

Treatment of stage I esophageal squamous cell carcinoma or adenocarcinoma may include the following:

• Surgery.
• Chemoradiation therapy followed by surgery.
• Clinical trials.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I esophageal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage II Esophageal Cancer

Treatment of stage II esophageal squamous cell carcinoma or adenocarcinoma may include the following:

• Chemoradiation therapy followed by surgery.
• Chemoradiation therapy alone.
• Surgery alone.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage II esophageal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage III Esophageal Cancer

Treatment of stage III esophageal squamous cell carcinoma or adenocarcinoma may include the following:

• Chemoradiation therapy followed by surgery.
• Chemoradiation therapy alone.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage III esophageal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Stage IV Esophageal Cancer

Treatment of stage IV esophageal squamous cell carcinoma or adenocarcinoma may include the following:

• An esophageal stent as palliative therapy to relieve symptoms and improve quality of life.
• External or internal radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
• Laser surgery or electrocoagulation as palliative therapy to relieve symptoms and improve quality of life.
• Chemotherapy.
• Clinical trials of chemotherapy.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IV esophageal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Treatment Options for Recurrent Esophageal Cancer

Treatment of recurrent esophageal cancer may include the following:

• Use of any standard treatments as palliative therapy to relieve symptoms and improve quality of life.
• Clinical trials.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent esophageal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

To Learn More About Esophageal Cancer

For more information from the National Cancer Institute about esophageal cancer, see the following:

• Esophageal Cancer Home Page
• What You Need to Know About Cancer of the Esophagus
• Esophageal Cancer Prevention
• Esophageal Cancer Screening
• Smoking Home Page (Includes help with quitting)
• Lasers in Cancer Treatment

For general cancer information and other resources from the National Cancer Institute, see the following:

• What You Need to Know About Cancer
• Understanding Cancer Series: Cancer
• Cancer Staging
• Chemotherapy and You: Support for People With Cancer
• Radiation Therapy and You: Support for People With Cancer
• Coping with Cancer: Supportive and Palliative Care
• Questions to Ask Your Doctor About Cancer
• Cancer Library
• Information For Survivors/Caregivers/Advocates

Changes to This Summary (12/13/2012)

The PDQ® cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Editorial changes were made to this summary.

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