esophageal cancer

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Esophageal Cancer



Esophageal cancer is a malignancy that develops in tissues of the hollow, muscular canal (esophagus) along which food and liquid travel from the throat to the stomach.


Esophageal cancer usually originates in the inner layers of the lining of the esophagus and grows outward. In time, the tumor can obstruct the passage of food and liquid, making swallowing painful and difficult. Since most patients are not diagnosed until the late stages of the disease, esophageal cancer is associated with poor quality of life and low survival rates.
Squamous cell carcinoma is the most common type of esophageal cancer, accounting for 95% of all esophageal cancers worldwide. The esophagus is normally lined with thin, flat squamous cells that resemble tiny roof shingles. Squamous cell carcinoma can develop at any point along the esophagus but is most common in the middle portion.
Adenocarcinoma has surpassed squamous cell carcinoma as the most common type of esophageal cancer in the United States. Adenocarcinoma originates in glandular tissue not normally present in the lining of the esophagus. Before adenocarcinoma can develop, glandular cells must replace a section of squamous cells. This occurs in Barrett's esophagus, a pre-cancerous condition in which chronic acid reflux from the stomach stimulates a transformation in cell type in the lower portion of the esophagus.
A very small fraction of esophageal cancers are melanomas, sarcomas, or lymphomas.
There is great variability in the incidence of esophageal cancer with regard to geography, ethnicity, and gender. The overall incidence is increasing. About 13,000 new cases of esophageal cancer are diagnosed in the United States each year. During the same 12-month period, 12,000 people die of this disease. It strikes between five and ten North Americans per 100,000. In some areas of China the cancer is endemic.
Squamous cell carcinoma usually occurs in the sixth or seventh decade of life, with a greater incidence in African-Americans than in others. Adenocarcinoma develops earlier and is much more common in white patients. In general, esophageal cancer occurs more frequently in men than in women.

Causes and symptoms

The exact cause of esophageal cancer is unknown, although many investigators believe that chronic irritation of the esophagus is a major culprit. Most of the identified risk factors represent a form of chronic irritation. However, the wide variance in the distribution of esophageal cancer among different demographic groups raises the possibility that genetic factors also play a role.
Several risk factors are associated with esophageal cancer.
  • Tobacco and alcohol consumption are the major risk factors, especially for squamous cell carcinoma. Smoking and alcohol abuse each increase the risk of squamous cell carcinoma by five-fold. The effects of the two are synergistic, in that the combination of smoking and alchohol increases the risk by 25- to 100- fold. It is estimated that drinking about 13 ounces of alcohol every day for an extended period of time raises the risk of developing esophageal cancer by 18%. That likelihood increases to 44% in individuals who also smoke one or two packs of cigarettes a day. Smokeless tobacco also increases the risk for esophageal cancer.
  • Gastroesophageal reflux is a condition in which acid from the stomach refluxes backwards into the lower portion of the esophagus, sometimes causing symptoms of heartburn. In some cases of gastroesophageal reflux, the chronic exposure to acid causes the inner lining of the lower esophagus to change from squamous cells to glandular cells. This is called Barrett's esophagus. Patients with Barrett's esophagus are roughly 30 to 40 times more likely than the general population to develop adenocarcinoma of the esophagus.
  • A diet low in fruits, vegetables, zinc, riboflavin, and other vitamins can increase risk of developing to esophageal cancer.
  • Caustic injury to the esophagus inflicted by swallowing lye or other substances that damage esophageal cells can lead to the development of squamous cell esophageal cancer in later life.
  • Achalasia is a condition in which the lower esophageal sphincter (muscle) cannot relax enough to let food pass into the stomach. Squamous cell esophageal cancer develops in about 6% of patients with achalasia.
  • Tylosis is a rare inherited disease characterized by excess skin on the palms and soles. Affected patients have a much higher probability of developing esophageal cancer than the general population. They should have regular screenings to detect the disease in its early, most curable stages.
  • Esophageal webs, which are protrusions of tissue into the esophagus, and diverticula, which are out-pouchings of the wall of the esophagus, are associated with a higher incidence of esophageal cancer.


Unfortunately, symptoms generally don't appear until the tumor has grown so large that the patient cannot be cured. Dysphagia (trouble swallowing or a sensation of having food stuck in the throat or chest) is the most common symptom. Swallowing problems may occur occasionally at first, and patients often react by eating more slowly and chewing their food more carefully and, as the tumor grows, switching to soft foods or a liquid diet. Without treatment, the tumor will eventually prevent even liquid from passing into the stomach. A sensation of burning or slight mid-chest pressure is a rare, often-disregarded symptom of esophageal cancer. Painful swallowing is usually a symptom of a large tumor obstructing the opening of the esophagus. It can lead to regurgitation of food, weight loss, physical wasting, and malnutrition. Anyone who has trouble swallowing, loses a significant amount of weight without dieting, or cannot eat solid food because it is too painful to swallow should see a doctor.


A barium swallow is usually the first test performed on a patient whose symptoms suggest esophageal cancer. After the patient swallows a small amount of barium, a series of x rays can highlight any bumps or flat raised areas on the normally smooth surface of the esophageal wall. It can also detect large, irregular areas that narrow the esophagus in patients with advanced cancer, but it cannot provide information about disease that has spread beyond the esophagus. A double contrast study is a barium swallow with air blown into the esophagus to improve the way the barium coats the esophageal lining. Endoscopy is a diagnostic procedure in which a thin lighted tube (endoscope) is passed through the mouth, down the throat, and into the esophagus. Cells that appear abnormal are removed for biopsy. Once a diagnosis of esophageal cancer has been confirmed through biopsy, staging tests are performed to determine whether the disease has spread (metastasized) to tissues or organs near the original tumor or in other parts of the body. These tests may include computed tomography, endoscopic ultrasound, thoracoscopy, laparoscopy, and positron emission tomography.


Treatment for esophageal cancer is determined by the stage of the disease and the patient's general health. The most important distinction to make is whether the cancer is curable. If the cancer is in the early stages, cure may be possible. If the cancer is advanced or if the patient will not tolerate major surgery, treatment is usually directed at palliation (relief of symptoms only) instead of cure.


Stage 0 is the earliest stage of the disease. Cancer cells are confined to the innermost lining of the esophagus. Stage I esophageal cancer has spread slightly deeper, but still has not extended to nearby tissues, lymph nodes, or other organs. In Stage IIA, cancer has invaded the thick, muscular layer of the esophagus that propels food into the stomach and may involve connective tissue covering the outside of the esophagus. In Stage IIB, cancer has spread to lymph nodes near the esophagus and may have invaded deeper layers of esophageal tissue. Stage III esophageal cancer has spread to tissues or lymph nodes near the esophagus or to the trachea (windpipe) or other organs near the esophagus. Stage IV cancer has spread to distant organs like the liver, bones, and brain. Recurrent esophageal cancer is disease that develops in the esophagus or another part of the body after initial treatment.


The most common operations for the treatment of esophageal cancer are esophagectomy and esophagogastrectomy. Esophagectomy is the removal of the cancerous part of the esophagus and nearby lymph nodes. This procedure is performed only on patients with very early cancer that has not spread to the stomach. Esophagogastrectomy is the removal of the cancerous part of the esophagus, nearby lymph nodes, and the upper part of the stomach. The resected esophagus is replaced with the stomach or parts of intestine so the patient can swallow. These procedures can significantly relieve symptoms and improve the nutritional status of more than 80% of patients with dysphagia. Although surgery can cure some patients whose disease has not spread beyond the esophagus, but more than 75% of esophageal cancers have spread to other organs before being diagnosed. Less extensive surgical procedures can be used for palliation.


Oral or intravenous chemotherapy alone will not cure esophageal cancer, but pre-operative treatments can shrink tumors and increase the probability that cancer can be surgically eradicated. Palliative chemotherapy can relieve symptoms of advanced cancer but will not alter the outcome of the disease.


External beam or internal radiation, delivered by machine or implanted near cancer cells inside the body, is only rarely used as the primary form of treatment. Post-operative radiation is sometimes used to kill cancer cells that couldn't be surgically removed. Palliative radiation is effective in relieving dysphagia in patients who cannot be cured. However, radiation is most useful when combined with chemotherapy as either the definitive treatment or preoperative treatment.


In addition to surgery, chemotherapy, and radiation, other palliative measures can provide symptomatic relief. Dilatation of the narrowed portion of the esophagus with soft tubes can provide short-term relief of dysphagia. Placement of a flexible, self-expanding stent within the narrowed portion is also useful in allowing more food intake.

Follow-up treatments

Regular barium swallows and other imaging studies are necessary to detect recurrence or spread of disease or new tumor development.

Alternative treatment

Photodynamic therapy (PDT) involves intravenously injecting a drug that is absorbed by cancer cells and kills them after they are exposed to specific laser beams. PDT can be used for palliation, but it also cured some early esophageal cancers during preliminary studies. Researchers are comparing its benefits with those of more established therapies.
Endoscopic laser therapy involves delivering short, powerful laser treatments to the tumor through an endoscope. It can improve dysphagia, but multiple treatments are required, and the benefit is seldom long-lasting.


Since most patients are diagnosed when the cancer has spread to lymph nodes or other structures, the prognosis for esophageal cancer is poor. Generally, no more than half of all patients are candidates for curative treatment. Even if cure is attempted, the cancer can recur.


There is no known way to prevent esophageal cancer.



Heitmiller, Richard F., Arlene A. Forastiere, and Lawrence R. Kleinberg. "Esophagus." In Clinical Oncology, edited by Martin D. Abeloff, 2nd ed. New York: Churchill Livingstone, 2000.
Zwischenberger, Joseph B., Scott K. Alpard, and Mark B.Orringer. "Esophageal Cancer." In Sabiston Textbook of Surgery, edited by Courtney Townsend, Jr., 16th ed. Philadelphia: W. B. Saunders Company, 2001.


American Cancer Society. 1599 Clifton Road NE, Atlanta, GA 30329. (800)ACS-2345.
National Coalition for Cancer Survivorship. 1010 Wayne Avenue, 5th Floor, Suite 300, Silver Spring, MD 20910. Telephone: 1-888-650-9127.

Key terms

Computed tomography — A radiology test by which images of cross-sectional planes of the body are obtained.
Endoscopic ultrasound — A radiology test utilizing high frequency sound waves, conducted via an endoscope.
Laparoscopy — Examination of the contents of the abdomen through a thin, lighted tube passed through a small incision.
Positron emission tomography — A radiology test by which images of cross-sectional planes of the body are obtained, utilizing the properties of the positron. The positron is a subatomic particle of equal mass to the electron, but of opposite charge.
Synergistic — The combined action of two or more processes is greater than the sum of each acting separately.
Thoracoscopy — Examination of the contents of the chest through a thin, lighted tube passed through a small incision.
Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved.

esophageal cancer

GI disease A malignancy of the esophagus, most commonly, SCC and adenoCA Epidemiology ♂:♀, 3:1; age 55-70; ↑ in China, Japan, Scotland, Russia, Scandinavia; ±12,000 new cases/yr US; blacks have a 4-fold greater risk than whites–rate 1/105 ♀, 4/105 ♂ Risk factors Alcohol, tobacco use, poor nutrition, Hx of achalasia, corrosive esophagitis, Barrett's esophagus, tylosis palmaris et plantaris Clinical Dysphagia, retrosternal discomfort and pain, pressure, burning, and a sensation of food being stuck, eventually, narrowing of esophagus becomes severe, with choking, vomiting, weight loss Types SCC, ≥ 70%; adenoCA in Barrett's esophagus–10-20% Diagnosis Barium swallow to ID lesions arising in the esophageal mucosa, upper GI endoscopy/esophagoscopy with Bx and cytology brushings Staging CT, MRI, ultrasound Treatment Cisplatin, 5-FU, RT–5000 cGy is better than RT alone–6400 cGy for local control of CA, metastasis, ↑ survival, but ↑ side effects Prognosis Median survival, 10 months; 5-yr survival, 20–36%
Esophageal cancer–stages
I  CA in esophageal mucosa; no spread to nearby tissues, lymph nodes, or organs
II  CA in all layers of esophagus and/or regional lymph nodes; no spread to other tissues
III  CA has spread to tissues or lymph nodes near the esophagus; no metastasis
IV  CA has metastasized
McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.

Esophageal Cancer

DRG Category:326
Mean LOS:15.4 days
Description:SURGICAL: Stomach, Esophageal, and Duodenal Procedure With Major CC
DRG Category:375
Mean LOS:5.5 days
Description:MEDICAL: Digestive Malignancy With CC

Carcinoma is the most common cause of obstruction of the esophagus. Approximately half of all esophageal cancers are squamous cell carcinomas, which usually occur in the middle and lower two-thirds of the esophagus and are often associated with alcohol and tobacco use. The remaining 50% are adenocarcinomas, which generally begin in glandular tissue of the esophagus. Adenocarcinomas are associated with Barrett’s esophagus, a condition that occurs because of continued reflux of fluid from the stomach into the lower esophagus. Over time, reflux changes the cells at the end of the esophagus. Adenocarcinomas may invade the upper portion of the stomach.

Esophageal tumors begin as benign growths and grow rapidly because there is no serosal layer to inhibit growth. Because of the vast lymphatic network of the esophagus, esophageal cancers spread rapidly, both locally to regional lymph nodes and distantly to the lungs and liver. Complications include pulmonary problems that result from fistulae and aspiration; invasion of the tumor into major vessels, causing a massive hemorrhage; and obstruction and compression of the other structures in the head and neck. Although survival rates are improving, esophageal cancer is usually diagnosed at a late stage, and most patients die within 6 months of diagnosis. It is estimated that 17,990 new cases of esophageal cancer were diagnosed in 2013, and approximately 15,000 people die from the disease each year. The 5-year survival rate for localized disease is 38%. While the survival rates have been improving over the last 50 years, only 15% of whites and 8% of African Americans will survive 5 years after diagnosis.


Although its etiology is unknown, for many years in the United States, the primary risk factors were alcohol and tobacco use. In recent decades, there has been a progressive increase related to gastroesophageal reflux disease. Recently, oral exposure of the human papillomavirus infection has also been identified as a risk factor. In parts of the world where it is most common (Southeast Asia, the Middle East, and South Africa), the disease has been linked to nitrosamines and other contaminants in the soil. It has also been found to have a higher incidence in individuals whose diets are chronically deficient in fresh fruits, vegetables, vitamins, and proteins. Other risk factors include obesity, caustic injuries from lye ingestion, and occupational exposure with perchloroethylene, which is used in the automotive and dry cleaning industries.

Genetic considerations

Although the exact cause of esophageal cancer is not clear, environmental risk factors appear to be predominant. Epidemiologic studies have found likely autosomal recessive patterns; in Chinese populations, however, the combination of genes and environment may be most likely.

Gender, ethnic/racial, and life span considerations

Cancer of the esophagus usually occurs in men between the ages of 50 and 70. The disorder affects men in a 3:1 ratio to women. African Americans are affected three times as often as European Americans. It is also more common in Asian American males than in the general population. Squamous cell carcinoma is more common in European Americans, whereas adenocarcinomas are more common in African Americans.

Global health considerations

The global incidence of esophageal cancer is 10 per 100,000 males and 5 per 100,000 females, but in some countries with high soil contamination, rates are as high as 800 per 100,000 individuals. In developing nations, females have a higher incidence of the condition than in developed nations, whereas the male incidence of esophageal cancer is approximately the same across nations.



Obtain an accurate history of risk factors, including race, cultural background, use of cigarettes and alcohol, and any esophageal problems. Dysphagia is usually experienced when at least 60% of the esophagus is occluded. Initially, it is mild and intermittent, and it occurs only with solid foods. Patients may report a sensation that “food is sticking in their throat.” Symptoms of the disease soon progress to the inability to swallow semisoft or liquid food, and the patient experiences a severe weight loss, as much as 40 to 50 pounds over 2 to 3 months. Eventually, the patient is unable to swallow her or his own saliva. Also inquire about regurgitation, vomiting, chronic hiccups, odynophagia (painful swallowing), and dietary patterns. Patients may report pain radiating to the neck, jaw, ears, and shoulders.

Physical examination

Dysphagia is the most common symptom. Observe the patient’s ability to swallow food. Note any chronic coughing and increased oral secretions. Listen to the patient’s voice: Tumors in the upper esophagus can involve the larynx and cause hoarseness. Place the patient in the recumbent position; pain, hoarseness, coughing, and potential aspiration often occur in this position. Weigh the patient and determine the patient’s strength and motion of the extremities. Severe weight loss and weakness are common symptoms.


The patient needs to make a psychological adjustment to the diagnosis of a chronic illness that is usually terminal. Evaluate the patient for evidence of altered mood (e.g., depression or anxiety) and assess the coping mechanisms and support systems.

Diagnostic highlights

TestNormal ResultAbnormality With ConditionExplanation
Barium swallowNormal esophagusIrregular areas in or narrowing of the esophagusLocates and describes irregularities in the esophageal wall or fistulae
EsophagogastroduodenoscopyVisualization of a normal esophagus and stomachDirect visualization of tumor or fistulaLocates the tumor for a biopsy

Other Tests: Computed tomography scan, endoscopic ultrasound, thoracoscopy, laparoscopy, liver scan, bronchoscopy, magnetic resonance imaging, positive emission tomography

Primary nursing diagnosis


Altered nutrition: Less than body requirements related to dysphagia


Nutritional status: Food and fluid intake; Nutrient intake; Biochemical measures; Body mass; Energy; Endurance


Nutrition management; Nutrition therapy; Nutritional counseling and monitoring; Fluid/electrolyte management; Medication management

Planning and implementation


Surgery, radiotherapy, chemotherapy, laser therapy, and endoscopic therapy are all options for treating cancer of the esophagus, and they may be used alone or in combination. Early-stage patients may be treated with endoscopic therapies, such as endoscopic mucosal resection or endoscopic submucosal dissection. Trimodal therapy, which includes chemotherapy and radiotherapy (chemoradiation), followed by surgery is recommended for those who can tolerate this rigorous treatment regime. Preoperative chemotherapy followed by surgery has poorer patient outcomes than trimodal therapy. Two surgical procedures are commonly performed: esophagectomy (removal of all or part of the esophagus with a Dacron graft replacing the part that was removed) and esophagogastrectomy (resection of the lower part of the esophagus together with a proximal portion of the stomach, followed by anastomosis of the remaining portion of the esophagus and stomach). Postoperatively, monitor the nasogastric (NG) tube for patency. Expect some bloody drainage initially; within 24 to 48 hours, the drainage should change to a yellowish-green. Do not irrigate or reposition the NG tube without a physician’s order. Fluid and electrolyte balance as well as intake and output should be monitored carefully. Monitor the patient who has had an anastomosis for signs and symptoms of leakage, which is most likely to occur 5 to 7 days postoperatively. These include low-grade fever, inflammation, accumulation of fluid, and early symptoms of shock (tachycardia, tachypnea).

For patients who are not candidates for surgery but rather for palliation, chemotherapy, radiotherapy, and laser therapy reduce the size of the tumor and provide some relief to the patient. Usually, external beam radiation therapy is used. Normal esophageal tissue is also affected by the radiation, which is given over a 6- to 8-week period to minimize the side effects. Side effects include edema, epithelial desquamation, esophagitis, odynophagia, anorexia, nausea, and vomiting. Although radiation by itself does not cure esophageal cancer, it eases symptoms such as pain, bleeding, and dysphagia.

Pharmacologic highlights

Medication or Drug ClassDosageDescriptionRationale
ChemotherapyVaries by drugTypes of chemotherapy: 5-fluorouracil, capecitabine, cisplatin, carboplatin, docetaxel, bleomycin, mitomycin, doxorubicin, methotrexate, paclitaxel, vinorelbine, topotecan, irinotecan, mitoguazone, epirubicin, porfimerKills cancer cells; primary chemotherapy will not cure esophageal cancer unless surgery and/or radiation is also used; preoperatively, chemotherapy may be given to reduce tumor size; approximately 10%–40% of patients will have a significant shrinking of the tumor from these drugs


Carefully monitor the patient’s nutritional intake and involve the patient in planning their diet. Maintain a daily record of caloric intake and weight. Monitor the skin turgor and mucous membranes to detect dehydration. Keep the head of the bed elevated at least 30 degrees to prevent reflux and pulmonary aspiration. If the patient is having problems swallowing saliva, keep a suction catheter with an oral suction at the bedside at all times. Teach the patient how to clear his or her mouth with the oral suction.

When appropriate, discuss expected preoperative and postoperative procedures, including information about x-rays, intravenous hydration, wound drains, NG tube and suctioning, and chest tubes. Immediately after surgery, implement strategies to prevent respiratory complications.

Provide emotional support. Focus on the patient’s quality of life and discuss realistic planning with the family. Involve the patient as much as possible in decisions concerning care. If the patient is terminally ill, encourage the significant others to involve the patient in discussions about funeral arrangements and terminal care, such as hospice care. Provide a referral to the patient to the American Cancer Society, support groups, and hospice care as appropriate.

Evidence-Based Practice and Health Policy

Wright, C.D., Kucharczuk, J.C., O'Brien, S.M., Grab, J.D., & Allen, M.S. (2009). Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: A Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model. Journal of Thoracic and Cardiovascular Surgery, 137(3), 587–595.

  • In a study of 2,315 patients who underwent esophagectomies for esophageal cancer, hospital discharge mortality was 2.7%.
  • Major morbidities, including bleeding, anastomotic leak, pneumonia, and re-intubation, occurred in 24% of patients.
  • In this sample, morbidity risk increased significantly among patients with insulin-dependent diabetes, hypertension, and steroid use (p = 0.009, p = 0.029, and p = 0.026, respectively).

Documentation guidelines

  • Physical assessment data: Ability to eat and swallow, patency of airway, regularity of breathing, temperature, daily weights, breath sounds, intake and output, calorie counts
  • Chronologic record of symptoms and response to interventions
  • The nature, location, duration, and intensity of pain; response to pain medication or other interventions
  • Patient’s emotional response to a poor prognosis and treatment modalities

Discharge and home healthcare guidelines

The patient should be able to state the name, purpose, dosage, schedule, common side effects, and importance of taking her or his medications.

Teach the patient to report any dysphagia or odynophagia, which may indicate a regrowth of the tumor. Teach the patient to inspect the wound daily for redness, swelling, discharge, or odor, which indicates the presence of infection.

home care.
Teach family members to assist the patient with ambulation, splinting the incision, and chest physiotherapy. Educate caregivers on nutritional guidelines, food preparation, tube feedings, and parenteral nutrition, as appropriate. Inform the patient and family about the availability of high-caloric, high-protein, liquid supplements to maintain the patient's weight.

Provide patients with a list of resources for support after discharge: visiting nurses, American Cancer Society, hospice, support groups.

Diseases and Disorders, © 2011 Farlex and Partners
References in periodicals archive ?
Worldwide, oesophageal malignancy is eighth most common type of cancer and the sixth most common cause of death.1 Oesophageal squamous cell carcinoma (OSCC) occurs throughout the world, its frequency differs among countries, even area of a similar nation.
[USA], Feb 28 (ANI): A new research has found that blocking two molecular pathways that send signals inside cancer cells could stave off oesophageal adenocarcinoma (EAC), the most common oesophageal malignancy in the United States.
The recognition of oesophageal malignancy in mucosal biopsy specimen is usually straight forward; 176 cases of squamous cell carcinoma and 18 cases of adenocarcinoma initially diagnosed with endoscopic biopsy evaluation and the ratio between squamous cell carcinoma and adenocarcinoma is 8.2:1.
Spontaneous rupture (Boerhaave's Syndrome)--mainly classical postemetic, but also rarely spontaneously in association with oesophageal malignancy or infection.
The findings like hypopharynx and oesophagus growth (Postcricoid webs, postcricoid growth and oesophageal malignancy) is more in the study group because of the high incidence of dysphagia as the alarming symptoms.
Oesophageal malignancy in the young (age <50 years) was 13/36 (36%) cases with highest incidence between 41-50 years of age.
Out of 36 cases of oesophageal malignancy, 20 resection specimens were received in the laboratory.