The Farber Center: For Radiation Oncology

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.

TYPES OF ESOPHAGEAL CANCER

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.

There are several signs and symptoms in patients found to have gastrointestinal cancer, which vary from person to person and depend on the anatomic location. Not all patients exhibit any or all symptoms, which may include:

• Dysphagia: difficulty swallowing
• Odynophagia: painful swallowing
• Weight loss: from poor nutrition
• Regurgitation or vomiting
• Heartburn
• Hiccups
• Chest or throat pain

Risk Factors

• Age: risk increases with age. It is rarely found in people under age 55.
• Gender: men are 3 times more likely to get esophageal cancer.
• Barrett's esophagus:  Repeated exposure to stomach acid may lead to a change in the composition of the cells lining the lower esophagus. There are often no other symptoms, but this condition is often found in people with GERD.
• Tobacco: Using any form of tobacco raises the risk of this cancer. The longer a person uses tobacco, the greater the risk. More than half of all squamous cell esophageal cancer is linked to smoking.
• Alcohol: Drinking alcohol also increases the risk of esophageal cancer. The chance of getting esophageal cancer increases the more a person drinks. Combining smoking and drinking alcohol raises the risk of esophageal cancer much more than using either alone.
• Gastroesophageal reflux disease (GERD):  Commonly called acid reflux, GERD is a digestive disease. Heartburn, a symptom of GERD, occurs when stomach acids flow back up the esophagus. The stomach acid can irritate the lining of the esophagus and long-term acid reflux can damage the epithelium.
• Injury or scarring: Damage to the esophagus or injuries that cause chronic scarring are also considered risk factors.
• Chemical exposure: Some industrial chemicals and fumes, may increase the risk of esophageal cancer. For example, chemical used in dry cleaning solvents may lead to a greater risk of this cancer. Lye is found in strong cleaners like drain cleaners. It can burn and destroy cells. If a child drinks one of these cleaning liquids, the lining of the esophagus will scar. A child who has swallowed lye has a higher risk of squamous cell cancer as an adult.

Diagnosing Esophageal Cancers

Barium swallow or upper GI x-rays: a series of x-rays taken after the patient swallows barium, a dense liquid that shows up on x-rays. Barium coats the surface of the esophagus and helps make a good picture. Any lumps on the lining of the esophagus show up on the x-ray. A barium swallow is often the first test to be done in people who have trouble swallowing.

CT scan (computed tomography): an x-ray test that produces detailed cross-sectional images of your body. A CT scanner takes many pictures as it rotates around. A computer combines these pictures into images of slices of the part of your body being studied. Unlike a regular x-ray, a CT scan creates detailed images of the soft tissues in the body. CT scans can be helpful in finding out the where and how big the cancer is. CT scans can also be used to guide a biopsy needle (see below) into an area that might be cancer. The needle is used to remove a sample of tissue for study in the lab.

MRI (magnetic resonance imaging): Provide detailed images of soft tissues in the body. They use radio waves and strong magnets instead of x-rays, which are absorbed and then released in a pattern formed as they penetrate through different types of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body.

PET scan (positron emission tomography): a special type of scanner that uses a form of sugar that contains a radioactive atom. Because cancer cells in the body are growing rapidly, they absorb large amounts of the radioactive sugar. This allows for cancer cells to show up brighter in the images because they absorb more sugar than normal cells. PET scans are also useful to check if the cancer may have spread elsewhere in the body. PET can reveal spread of cancer to the liver, bones, adrenal glands, or some other organs. Some machines are able to perform both a PET and CT scan at the same time (PET/CT scan).

Chest x-rays: may be done to see whether the cancer has spread to the lungs.

Endoscopy (upper): is an important test for diagnosing esophageal cancer. An endoscope is a thin, flexible tube with a light and video camera on the end. The doctor uses it to look at the inside of the esophagus and the stomach. If there are any areas of concern, a small piece of tissue can be removed through the tube to see if the area is cancer (biopsy).

Endoscopic ultrasound: Ultrasound tests use sound waves to take pictures of parts of the body. For an endoscopic ultrasound, the probe that gives off the sound waves is at the end of an endoscope. This allows the probe to get very close to the cancer. The ultrasound can show how far the cancer has grown into the esophagus.

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.

Bronchoscopy: A thin flexible tube with a tiny camera, a bronchoscope, is inserted through the nose or mouth to examine the airways leading down into the lungs. A bronchoscope can also take a small tissue sample for biopsy for review under a microscope.

Thoracoscopy and laparoscopy: These are methods that allow the doctor to see lymph nodes inside the chest or belly (abdomen) with a hollow lighted tube. The doctor can also remove lymph nodes through the same tube to test them for cancer. For these tests the patient is in the hospital and is put into a deep sleep (general anesthesia).

Biopsy: removal of a small piece of tissue which can be done during a bronchoscopy, thoracoscopy, or laparascopy, or with a needle inserted through the skin directly into the abnormal area using CT guidance. This tissue is looked at under the microscope to determine if cancer is present and if so, the type and stage of the cancer.

Staging of Gastrointestinal Cancers
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 esophageal cancer:
Stage 0 (Carcinoma in Situ)
In stage 0, abnormal cells are found in the innermost layer of tissue lining the esophagus. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I
In stage I, cancer has formed and spread beyond the innermost layer of tissue to the next layer of tissue in the wall of the esophagus.

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

• Stage IIA: Cancer has spread to the layer of esophageal muscle or to the outer wall of the esophagus.
• Stage IIB: Cancer may have spread to any of the first three layers of the esophagus and to nearby lymph nodes.

Stage III
In stage III, cancer has spread to the outer wall of the esophagus and may have spread to tissues or lymph nodes near the esophagus.

Stage IV
Stage IV esophageal cancer is divided into stage IVA and stage IVB, depending on where the cancer has spread.

• Stage IVA: Cancer has spread to nearby or distant lymph nodes.
• Stage IVB: Cancer has spread to distant lymph nodes and/or organs in other parts of the body.

The management of gastrointestinal cancer depends on the site of the tumor several factors. Depending on the stage of the disease and these other factors, such as type, size, location of tumor, and general health, the main treatment options for people with gastrointestinal cancers include:

SURGERY
Part of the esophagus may be removed in an operation called an esophagectomy. 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.

RADIATION THERAPY as External beam radiation treatment is most often used in conjunction with surgery, but it can also be combined with chemotherapy as an alternative to surgery.

• Neoadjuvant therapy: radiotherapy (sometimes along with chemotherapy) delivered prior to surgery to shrink a tumor and make it more manageable
• Adjuvant therapy: radiotherapy (sometimes along with chemotherapy) given after surgery to kill any cancer cells that may have been left behind
• Primary therapy: radiotherapy given as the main treatment (sometimes along with chemotherapy) for more advanced cancers or for some people who are not deemed to be surgical candidates
• Concurrent (chemoradiation) therapy: radiotherapy given along with chemotherapy

External beam radiation therapy involves focusing a beam of ionizing radiation to the tumor while sparing the surrounding tissue. It is delivered by a series of painless outpatient treatments over several weeks. Treatments are given Monday through Friday and last less than 30 minutes.

3-Dimensional Conformal Radiotherapy (3D-CRT) is a method of treatment delivery that combines multiple radiation treatment fields using 3-dimensional computer planning to produce a high-dose area of radiation that conforms to the shape of the area to be treated. This technique allows the tailoring of delivery of precise doses of radiation to the targeted area while sparing surrounding normal healthy tissue.

Intensity modulated radiation therapy (IMRT) is an advanced form of 3D-CRT that modifies the intensity or strength of each radiation beam. It utilizes a sophisticated system of treatment delivery that allows a precise adjustment of the radiation beam intensity to the tissue within the target area while minimizing effects on surrounding tissue. This may allow for a higher dose of radiation to be delivered to the tumor from multiple angles.

IGRT or Image Guided Radiation Therapy is another technology that can also be used to ensure better targeting of daily radiation treatments. 

Stereotactic body radiation therapy (SBRT) is a specialized form of 3D-CRT that delivers high doses of radiation over a period of five to ten days. Instead of giving small doses of radiation each day for several weeks, SBRT involves delivery of very focused beams of high-dose radiation. Several beams are aimed at the tumor from different angles. In order to precisely target the radiation, a specially designed body frame is used for each treatment. This helps to minimize the movement of the lung tumor during breathing. . If it is delivered in a single fraction it is known as stereotactic body radiosurgery. Like other forms of external radiation, these treatments are painless. It can be used for some very early stage (small) lung cancers when surgery isn't an option usually for other medical reasons. There is emerging data that have demonstrated that this technique may provide an alternative first-line approach to surgery.

Brachytherapy (internal radiation therapy) is used most often to shrink tumors to relieve symptoms caused by the cancer. In some cases it may be part of a larger treatment regimen trying to cure the cancer.

High-dose-rate brachytherapy (HDR): a small source of radioactive material is placed directly into the cancer or into the airway next to the cancer. It involves placing thin plastic tubes (catheters) into the area to treat. These tubes are connected to a special HDR delivery machine. A small amount of radioactive material is computer-driven through these catheters allowing a high dose of radiation to be delivered to a small, precise area while sparing surrounding normal healthy tissue. The radiation and catheters are removed at the end of each treatment. A plastic tube may be inserted into the esophagus to keep it open during radiation therapy. This is called intraluminal intubation and dilation.

CHEMOTHERAPY
Is the use of anticancer drugs injected into a vein or taken by mouth to destroy certain types of tumors and is utilized in different stages of lung cancer. These drugs enter the bloodstream and go throughout the body, making this treatment useful for cancer that has spread (metastasized) to distant organs. Depending on the type and stage of lung cancer, chemotherapy may be used in different situations (see Radiation Therapy Section):

• Neoadjuvant therapy: chemotherapy (sometimes along with radiation therapy) delivered prior to surgery to shrink a tumor and make it more manageable
• Adjuvant therapy: chemotherapy (sometimes along with radiation therapy) given after surgery to kill any cancer cells that may have been left behind
• Primary therapy: chemotherapy given as the main treatment (sometimes along with radiation therapy) for more advanced cancers or for some people who are not deemed to be surgical candidates.

LASER THERAPY
a cancer treatment that uses a laser beam (a narrow beam of intense light) to kill cancer cells.

ELECTROCOAGULATION
use of an electric current to kill cancer cells.

Possible Treatment Side Effects
Dr. Farber, Dr. Spierer, and their staff at The Farber Center for Radiation Oncology will discuss potential side effects with you before, during, and after treatment, and ensure that your experience is personalized.