Esophageal Cancer Treatment (PDQ®)


Information for: Patients | Healthcare Professionals

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.

Gastrointestinal (digestive) system anatomy; shows esophagus, liver, stomach, large intestine, and small intestine. 
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.

Signs and symptoms of esophageal cancer are weight loss and painful or difficult swallowing.

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

  • 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 metalliccompound). The liquid coats the esophagus and stomach, and x-rays are taken. This procedure is also called an upper GI series.
    Barium swallow; shows barium liquid flowing through the esophagus and into the stomach.  
    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; shows endoscope inserted through the mouth and into the esophagus. Inset shows patient on table having an esophagoscopy. 
    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 cancercells 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 malignanttumor cells in the body. A small amount of radionuclideglucose (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.

Cancer can spread through tissue, the lymph system, and the blood:

  • Tissue. The cancer spreads from where it began by growing into nearby areas.
  • Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
  • Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

  • Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
  • Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if esophageal cancer spreads to the lung, the cancer cells in the lung are actually esophageal cancer cells. The disease is metastatic esophageal cancer, not lung cancer.

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

Stage 0 (High-grade Dysplasia)

In stage 0, abnormalcells 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-gradedysplasia.

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 tumorcells look a lot like normal cells under a microscope.
  • Stage IB: Cancer has formed:
    • in the inner (mucosal) layer of the esophageal wall. The tumorcells 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 tumorcells 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 tumorcells 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, tissue that covers the lungs and lines the inner wall of the chest cavity, or sac around the heart. 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, tissue that covers the lungs and lines the inner wall of the chest cavity, or sac around the heart. 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, abnormalcells 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-gradedysplasia.

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 tumorcells look a lot like normal cells under a microscope.
  • Stage IB: Cancer has formed:
    • in the inner (mucosal) layer of the esophageal wall. The tumorcells 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 tumorcells 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, tissue that covers the lungs and lines the inner wall of the chest cavity, or sac around the heart. 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, tissue that covers the lungs and lines the inner wall of the chest cavity, or sac around the heart. 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

Recurrentesophageal 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.

Three-panel drawing showing esophageal cancer surgery; first panel shows area of esophagus with cancer, middle panel shows cancer and nearby tissue removed, last panel shows the stomach pulled up and joined to the remaining esophagus. 
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. Shows cancer blocking esophagus. Insets show  enlarged area of cancer and a stent placed in the esophagus to 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

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. Talk with your doctor about clinical trials that may be right for you. 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. Talk with your doctor about clinical trials that may be right for you. 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. Talk with your doctor about clinical trials that may be right for you. 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. Talk with your doctor about clinical trials that may be right for you. 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. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.

Treatment Options for Recurrent Esophageal Cancer

Treatment of recurrentesophageal 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. Talk with your doctor about clinical trials that may be right for you. 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:

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


This information is provided by the National Cancer Institute.

This information was last updated on June 16, 2014.


General Information About Esophageal Cancer

Incidence and Mortality

Estimated new cases and deaths from esophageal cancer in the United States in 2014:[1]

  • New cases: 18,170.
  • Deaths: 15,450.

The incidence of esophageal cancer has risen in recent decades, coinciding with a shift in histologic type and primary tumor location.[2][3] Adenocarcinoma of the esophagus is now more prevalent than squamous cell carcinoma in the United States and western Europe, with most tumors located in the distal esophagus. The cause for the rising incidence and demographic alterations is unknown.

Risk Factors and Survival

While risk factors for squamous cell carcinoma of the esophagus have been identified (e.g., tobacco, alcohol, diet), the risk factors associated with esophageal adenocarcinoma are less clear.[3] The presence of Barrett esophagus is associated with an increased risk of developing adenocarcinoma of the esophagus, and chronic reflux is considered the predominant cause of Barrett metaplasia. The results of a population-based, case-controlled study from Sweden strongly suggest that symptomatic gastroesophageal reflux is a risk factor for esophageal adenocarcinoma. The frequency, severity, and duration of reflux symptoms were positively correlated with increased risk of esophageal adenocarcinoma.[4]

Esophageal cancer is a treatable disease, but it is rarely curable. The overall 5-year survival rate in patients amenable to definitive treatment ranges from 5% to 30%. The occasional patient with very early disease has a better chance of survival. Patients with severe dysplasia in distal esophageal Barrett mucosa often have in situ or even invasive cancer within the dysplastic area. Following resection, these patients usually have excellent prognoses.

Treatment Modalities

Primary treatment modalities include surgery alone or chemotherapy with radiation therapy. Combined modality therapy (i.e., chemotherapy plus surgery, or chemotherapy and radiation therapy plus surgery) is under clinical evaluation. Effective palliation may be obtained in individual cases with various combinations of surgery, chemotherapy, radiation therapy, stents,[5] photodynamic therapy,[6][7][8] and endoscopic therapy with Nd:YAG laser.[9]

Diagnostics for Staging

One of the major difficulties in allocating and comparing treatment modalities for patients with esophageal cancer is the lack of precise preoperative staging. Standard noninvasive staging modalities include computed tomography (CT) of the chest and abdomen and endoscopic ultrasound (EUS). The overall tumor depth staging accuracy of EUS is 85% to 90%, as compared with 50% to 80% for CT; the accuracy of regional nodal staging is 70% to 80% for EUS and 50% to 70% for CT.[10][11] EUS-guided fine-needle aspiration (FNA) for lymph node staging is under prospective evaluation; one retrospective series reported a 93% sensitivity and 100% specificity of regional nodal staging with EUS-FNA.[12] Thoracoscopy and laparoscopy have been used in esophageal cancer staging at some surgical centers.[13][14][15] An intergroup trial reported an increase in positive lymph node detection to 56% of 107 evaluable patients using thoracoscopy/laparoscopy, from 41% (using noninvasive staging tests, e.g., CT, magnetic resonance imaging, EUS) with no major complications or deaths.[16] Noninvasive positron emission tomography using the radiolabeled glucose analog 18-F-fluorodeoxy-D-glucose for preoperative staging of esophageal cancer is under clinical evaluation and may be useful in detecting stage IV disease.[17][18][19][20]

Other tumors of the esophagus

Gastrointestinal stromal tumors can occur in the esophagus and are usually benign. (Refer to the PDQ summary on Gastrointestinal Stromal Tumors Treatment for more information.)

Related Summaries

Other PDQ summaries containing information related to esophageal cancer include the following:

  • Esophageal Cancer Prevention
  • Esophageal Cancer Screening

References:

  1. American Cancer Society: Cancer Facts and Figures 2014. Atlanta, Ga: American Cancer Society, 2014. Available online. Last accessed May 21, 2014.

  2. Devesa SS, Blot WJ, Fraumeni JF Jr: Changing patterns in the incidence of esophageal and gastric carcinoma in the United States. Cancer 83 (10): 2049-53, 1998.

  3. Blot WJ, McLaughlin JK: The changing epidemiology of esophageal cancer. Semin Oncol 26 (5 Suppl 15): 2-8, 1999.

  4. Lagergren J, Bergström R, Lindgren A, et al.: Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med 340 (11): 825-31, 1999.

  5. Tietjen TG, Pasricha PJ, Kalloo AN: Management of malignant esophageal stricture with esophageal dilation and esophageal stents. Gastrointest Endosc Clin N Am 4 (4): 851-62, 1994.

  6. Lightdale CJ, Heier SK, Marcon NE, et al.: Photodynamic therapy with porfimer sodium versus thermal ablation therapy with Nd:YAG laser for palliation of esophageal cancer: a multicenter randomized trial. Gastrointest Endosc 42 (6): 507-12, 1995.

  7. Kubba AK: Role of photodynamic therapy in the management of gastrointestinal cancer. Digestion 60 (1): 1-10, 1999 Jan-Feb.

  8. Heier SK, Heier LM: Tissue sensitizers. Gastrointest Endosc Clin N Am 4 (2): 327-52, 1994.

  9. Bourke MJ, Hope RL, Chu G, et al.: Laser palliation of inoperable malignant dysphagia: initial and at death. Gastrointest Endosc 43 (1): 29-32, 1996.

  10. Ziegler K, Sanft C, Zeitz M, et al.: Evaluation of endosonography in TN staging of oesophageal cancer. Gut 32 (1): 16-20, 1991.

  11. Tio TL, Coene PP, den Hartog Jager FC, et al.: Preoperative TNM classification of esophageal carcinoma by endosonography. Hepatogastroenterology 37 (4): 376-81, 1990.

  12. Vazquez-Sequeiros E, Norton ID, Clain JE, et al.: Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma. Gastrointest Endosc 53 (7): 751-7, 2001.

  13. Bonavina L, Incarbone R, Lattuada E, et al.: Preoperative laparoscopy in management of patients with carcinoma of the esophagus and of the esophagogastric junction. J Surg Oncol 65 (3): 171-4, 1997.

  14. Sugarbaker DJ, Jaklitsch MT, Liptay MJ: Thoracoscopic staging and surgical therapy for esophageal cancer. Chest 107 (6 Suppl): 218S-223S, 1995.

  15. Luketich JD, Schauer P, Landreneau R, et al.: Minimally invasive surgical staging is superior to endoscopic ultrasound in detecting lymph node metastases in esophageal cancer. J Thorac Cardiovasc Surg 114 (5): 817-21; discussion 821-3, 1997.

  16. Krasna MJ, Reed CE, Nedzwiecki D, et al.: CALGB 9380: a prospective trial of the feasibility of thoracoscopy/laparoscopy in staging esophageal cancer. Ann Thorac Surg 71 (4): 1073-9, 2001.

  17. Flamen P, Lerut A, Van Cutsem E, et al.: Utility of positron emission tomography for the staging of patients with potentially operable esophageal carcinoma. J Clin Oncol 18 (18): 3202-10, 2000.

  18. Flamen P, Van Cutsem E, Lerut A, et al.: Positron emission tomography for assessment of the response to induction radiochemotherapy in locally advanced oesophageal cancer. Ann Oncol 13 (3): 361-8, 2002.

  19. Weber WA, Ott K, Becker K, et al.: Prediction of response to preoperative chemotherapy in adenocarcinomas of the esophagogastric junction by metabolic imaging. J Clin Oncol 19 (12): 3058-65, 2001.

  20. van Westreenen HL, Westerterp M, Bossuyt PM, et al.: Systematic review of the staging performance of 18F-fluorodeoxyglucose positron emission tomography in esophageal cancer. J Clin Oncol 22 (18): 3805-12, 2004.

Cellular Classification of Esophageal Cancer

Fewer than 50% of esophageal cancers are squamous cell carcinomas. Adenocarcinomas, typically arising in Barrett esophagus, account for at least 50% of malignant lesions, and the incidence of this histology appears to be rising. Barrett esophagus contains glandular epithelium cephalad to the esophagogastric junction.

Three different types of glandular epithelium can be seen:

  • Metaplastic columnar epithelium.
  • Metaplastic parietal cell glandular epithelium within the esophageal wall.
  • Metaplastic intestinal epithelium with typical goblet cells.

Dysplasia is particularly likely to develop in the intestinal type mucosa.

Gastrointestinal stromal tumors can occur in the esophagus and are usually benign. (Refer to the PDQ summary on Gastrointestinal Stromal Tumors Treatment for more information.)

Stage Information for Esophageal Cancer

The stage determines whether the intent of the therapeutic approach will be curative or palliative.

Definitions of TNM

The AJCC has designated staging by TNM classification to define cancer of the esophagus and esophagogastric junction.[1]

Table 1. Primary Tumor (T)a,b

TX

Primary tumor cannot be assessed.

T0

No evidence of primary tumor.

Tis

High-grade dysplasia.c

T1

Tumor invades lamina propria, muscularis mucosae, or submucosa.

T1a

Tumor invades lamina propria or muscularis mucosae.

T1b

Tumor invades submucosa.

T2

Tumor invades muscularis propria.

T3

Tumor invades adventitia.

T4

Tumor invades adjacent structures.

T4a

Resectable tumor invading pleura, pericardium, or diaphragm.

T4b

Unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc.

aReprinted with permission from AJCC: Esophageal and esophagogastric junction. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 103-15.

b(1) At least maximal dimension of the tumor must be recorded, and (2) multiple tumors require the T(m) suffix.

cHigh-grade dysplasia includes all noninvasive neoplastic epithelia that was formerly called carcinoma in situ, a diagnosis that is no longer used for columnar mucosae anywhere in the gastrointestinal tract.

Table 2. Regional Lymph Nodes (N)a,b

NX

Regional lymph nodes cannot be assessed.

N0

No regional lymph node metastasis.

N1

Metastases in 1–2 regional lymph nodes.

N2

Metastases in 3–6 regional lymph nodes.

N3

Metastases in ≥7 regional lymph nodes.

aReprinted with permission from AJCC: Esophageal and esophagogastric junction. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 103-15.

bNumber must be recorded for total number of regional nodes sampled and total number of reported nodes with metastasis.

Table 3. Distant Metastasis (M)a

M0

No distant metastasis.

M1

Distant metastasis.

aReprinted with permission from AJCC: Esophageal and esophagogastric junction. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 103-15.

Table 4. Anatomic Stage/Prognostic Groupsa

Squamous Cell Carcinomab

Stage

T

N

M

Grade

Tumor Locationc

0

Tis (HGD)

N0

M0

1, X

Any

IA

T1

N0

M0

1, X

Any

IB

T1

N0

M0

2–3

Any

T2–3

N0

M0

1, X

Lower, X

IIA

T2–3

N0

M0

1, X

Upper, middle

T2–3

N0

M0

2–3

Lower, X

IIB

T2–3

N0

M0

2–3

Upper, middle

T1–2

N1

M0

Any

Any

IIIA

T1–2

N2

M0

Any

Any

T3

N1

M0

Any

Any

T4a

N0

M0

Any

Any

IIIB

T3

N2

M0

Any

Any

IIIC

T4a

N1–2

M0

Any

Any

T4b

Any

M0

Any

Any

Any

N3

M0

Any

Any

IV

Any

Any

M1

Any

Any

Adenocarcinoma

Stage

T

N

M

Grade

0

Tis (HGD)

N0

M0

1, X

IA

T1

N0

M0

1–2, X

IB

T1

N0

M0

3

T2

N0

M0

1–2, X

IIA

T2

N0

M0

3

IIB

T3

N0

M0

Any

T1–2

N1

M0

Any

IIIA

T1–2

N2

M0

Any

T3

N1

M0

Any

T4a

N0

M0

Any

IIIB

T3

N2

M0

Any

IIIC

T4a

N1–2

M0

Any

T4b

Any

M0

Any

Any

N3

M0

Any

IV

Any

Any

M1

Any

HGD = high-grade dysplasia.

aReprinted with permission from AJCC: Esophageal and esophagogastric junction. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 103-15.

bOr mixed histology, including a squamous component or not otherwise specified.

cLocation of the primary cancer site is defined by the position of the upper (proximal) edge of the tumor in the esophagus.

The current staging system for esophageal cancer is based largely on retrospective data from the Japanese Committee for Registration of Esophageal Carcinoma. It is most applicable to patients with squamous cell carcinomas of the upper third and middle third of the esophagus, as opposed to the increasingly common distal esophageal and gastroesophageal junction adenocarcinomas.[2] In particular, the classification of involved abdominal lymph nodes as M1 disease has been criticized. The presence of positive abdominal lymph nodes does not appear to carry as grave a prognosis as metastases to distant organs.[3] Patients with regional and/or celiac axis lymphadenopathy should not necessarily be considered to have unresectable disease caused by metastases. Complete resection of the primary tumor and appropriate lymphadenectomy should be attempted when possible.

References:

  1. Esophagus and esophagogastric junction. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 103-11.

  2. Iizuka T, Isono K, Kakegawa T, et al.: Parameters linked to ten-year survival in Japan of resected esophageal carcinoma. Japanese Committee for Registration of Esophageal Carcinoma Cases. Chest 96 (5): 1005-11, 1989.

  3. Korst RJ, Rusch VW, Venkatraman E, et al.: Proposed revision of the staging classification for esophageal cancer. J Thorac Cardiovasc Surg 115 (3): 660-69; discussion 669-70, 1998.

Treatment Option Overview

The prevalence of Barrett metaplasia in adenocarcinoma of the esophagus suggests that Barrett esophagus is a premalignant condition. Strong consideration should be given to resection in patients with high-grade dysplasia in the setting of Barrett metaplasia. Endoscopic surveillance of patients with Barrett metaplasia may detect adenocarcinoma at an earlier stage more amenable to curative resection.[1] The survival rate of patients with esophageal cancer is poor. Asymptomatic small tumors confined to the esophageal mucosa or submucosa are detected only by chance. Surgery is the treatment of choice for these small tumors. Once symptoms are present (e.g., dysphagia, in most cases), esophageal cancers have usually invaded the muscularis propria or beyond and may have metastasized to lymph nodes or other organs.

In the presence of complete esophageal obstruction without clinical evidence of systemic metastasis, surgical excision of the tumor with mobilization of the stomach to replace the esophagus has been the traditional means of relieving the dysphagia. In the United States, the median age of patients who present with esophageal cancer is 67 years.[2] The results of a retrospective review of 505 consecutive patients who were operated on by a single surgical team over 17 years found no difference in the perioperative mortality, median survival, or palliative benefit of esophagectomy on dysphagia when the group of patients older than 70 years were compared to their younger peers.[3][Levels of evidence: 3iiA and 3iiB] All of the patients in this series were selected for surgery on the basis of potential operative risk. Age alone should not determine therapy for patients with potentially resectable disease.

The optimal surgical procedure is controversial. One approach advocates transhiatal esophagectomy with anastomosis of the stomach to the cervical esophagus. A second approach advocates abdominal mobilization of the stomach and transthoracic excision of the esophagus with anastomosis of the stomach to the upper thoracic esophagus or the cervical esophagus. One study concluded that transhiatal esophagectomy was associated with lower morbidity than transthoracic esophagectomy with extended en bloc lymphadenectomy; however, median overall disease-free and quality-adjusted survival did not differ significantly.[4] Similarly, no differences in long-term quality of life (QOL) using validated QOL instruments have been reported.[5] In patients with partial esophageal obstruction, dysphagia may, at times, be relieved by placement of an expandable metallic stent [6] or by radiation therapy if the patient has disseminated disease or is not a candidate for surgery. Alternative methods of relieving dysphagia have been reported, including laser therapy and electrocoagulation to destroy intraluminal tumor.[7][8][9][10]

Surgical treatment of resectable esophageal cancers results in 5-year survival rates of 5% to 30%, with higher survival rates in patients with early-stage cancers. This is associated with a less than 10% operative mortality rate.[11] In an attempt to avoid this perioperative mortality and to relieve dysphagia, definitive radiation therapy in combination with chemotherapy has been studied. A Radiation Therapy Oncology Group randomized trial (RTOG-8501) of chemotherapy and radiation therapy versus radiation therapy alone resulted in an improvement in 5-year survival for the combined modality group (27% vs. 0%).[12][Level of evidence: 1iiA] An eight-year follow-up of this trial demonstrated an overall survival (OS) rate of 22% for patients receiving chemoradiation therapy.[12] An Eastern Cooperative Oncology Group trial (EST-1282) of 135 patients showed that chemotherapy plus radiation provided a better 2-year survival rate than radiation therapy alone,[13] which was similar to that shown in the Intergroup trial.[12][Level of evidence: 1iiA] In an attempt to improve upon the results of RTOG-8501, Intergroup-0123 (RTOG-9405) randomly assigned 236 patients with localized esophageal tumors to chemoradiation with high-dose radiation therapy (64.8 Gy) and four monthly cycles of fluorouracil (5-FU) and cisplatin versus conventional-dose radiation therapy (50.4 Gy) and the same chemotherapy schedule.[14] Although originally designed to accrue 298 patients, this trial was closed in 1999 after a planned interim analysis showed that it was statistically unlikely that there would be any advantage to using high-dose radiation. At 2 years' median follow-up, no statistical differences were observed between the high-dose and conventional-dose radiation therapy arms in median survival (13 months vs. 18 months), 2-year survival (31% vs. 40%), or local/regional failures (56% vs. 52%).[14][Level of evidence: 1iiA]

Preoperative Chemoradiation Therapy

Chemoradiation followed by surgery is a standard treatment option for patients with stages IB, II, III, and IVA esophageal cancer, based on the results of several randomized trials.

The ongoing CROSS (NCT01498289) study randomly assigned 366 patients with resectable esophageal or junctional cancers to receive either surgery alone or weekly administration of carboplatin (dose titrated to achieve an AUC [area under the curve] of 2 mg/mL/minute) and paclitaxel (50 mg/m2 of BSA [body surface area]) and concurrent radiation therapy (41.4 Gy in 23 fractions) administered over 5 weeks.[15][Level of evidence: 1iiA] The majority of the patients enrolled in the study have adenocarcinoma (75%).

With a median follow-up of 45 months, preoperative chemoradiation was found to improve median OS from 24 months in the surgery-alone group to 49.4 months (hazard ratio [HR], 0.657; 95% confidence interval [CI], 0.495–0.871, P = .003). Additionally, preoperative chemoradiation improved the rate of R0 resections (R0 is defined as complete resection with no tumor within 1 mm of resection margins, 92% vs. 69%, P < .001). A complete pathologic response was achieved in 29% of patients who underwent resection after chemoradiation therapy. Postoperative complications and in-hospital mortality were equivalent in both groups. The most common hematologic side effects in the chemoradiation group were leukopenia (6%) and neutropenia (2%). The most common nonhematologic side effects were anorexia (5%) and fatigue (3%).[15]

Other phase III trials have compared preoperative concurrent chemoradiation therapy to surgery alone for patients with esophageal cancer.[15][16][17][18][19][Level of evidence: 1iiA] A multicenter prospective randomized trial in which preoperative combined chemotherapy (i.e., cisplatin) and radiation therapy (37 Gy in 3.7 Gy fractions) followed by surgery was compared to surgery alone in patients with squamous cell carcinoma showed no improvement in OS and a significantly higher postoperative mortality (12% vs. 4%) in the combined modality arm.[16] In patients with adenocarcinoma of the esophagus, a single-institution phase III trial demonstrated a modest survival benefit (16 months vs. 11 months) for patients treated with induction chemoradiation therapy consisting of 5-FU, cisplatin, and 40 Gy (2.67 Gy fractions) plus surgery over resection alone.[17] A subsequent single-institution trial randomly assigned patients (75% with adenocarcinoma) to 5-FU, cisplatin, vinblastine, and radiation therapy (1.5 Gy twice daily to a total of 45 Gy) plus resection versus esophagectomy alone.[18] At a median follow-up of more than 8 years, there was no significant difference between the surgery alone and combined modality therapy with respect to median survival (17.6 months vs. 16.9 months), OS (16% vs. 30% at 3 years), or disease-free survival (16% vs. 28% at 3 years). An Intergroup trial (CALGB-9781) planned to randomly assign 475 patients with resectable squamous cell or adenocarcinoma of the thoracic esophagus to treatment with preoperative chemoradiation therapy (5-FU, cisplatin, and 50.4 Gy) followed by esophagectomy and nodal dissection or surgery alone.[19][Level of evidence: 1iiA] The trial was closed as a result of poor patient accrual; however, the results of the 56 enrolled patients, with a median follow-up of 6 years, were reported. The median survival was 4.48 years (95% CI, 2.4 years to not estimable) for trimodality therapy versus 1.79 years (95% CI, 1.41–2.59 years) for surgery alone (P = .002), with 5-year OS of 39% (95% CI, 21%–57%) versus 16% (95% CI, 5%–33%) for trimodality therapy versus surgery alone.

A phase III German trial also compared induction chemotherapy (three courses of bolus 5-FU, leucovorin, etoposide, and cisplatin) followed by chemoradiation therapy (cisplatin, etoposide, and 40 Gy) followed by surgery (arm A), or the same induction chemotherapy followed by chemoradiation therapy (at least 65 Gy) without surgery (arm B) for patients with T3 or T4 squamous cell carcinoma of the esophagus.[20][Level of evidence: 1iiA] OS was the primary outcome. The analysis of 172 eligible, randomly assigned patients showed that OS at 2 years was not statistically significantly different between the two treatment groups (arm A: 39.9%; 95% CI, 29.4%–50.4%; arm B: 35.4%; 95% CI, 25.2%–45.6%; log-rank test for equivalence with 0.15, P < .007). Local progression-free survival (PFS) was higher in the surgery group (2-year PFS, 64.3%; 95% CI, 52.1%–76.5%) than in the chemoradiation therapy group (2-year PFS, 40.7%; 95% CI, 28.9%–52.5%; HR for arm B vs. arm A, 2.1; 95% CI, 1.3–3.5; P < .003). Treatment-related mortality was higher in the surgery group compared with the chemoradiation therapy group (12.8% vs. 3.5%, respectively; P < .03).

Preoperative Chemotherapy Alone

The effects of preoperative chemotherapy are being evaluated in randomized trials, as was done in the NCT00525785 trial.[21][22][Level of evidence: 1iiA]. An Intergroup trial randomly assigned 440 patients with local and operable esophageal cancer of any cell type to three cycles of preoperative 5-fluorouracil (5-FU) and cisplatin followed by surgery and two additional cycles of chemotherapy versus surgery alone. After a median follow-up of 55 months, there were no significant differences between the chemotherapy/surgery and surgery-alone groups in median survival (14.9 months and 16.1 months, respectively) or 2-year survival (35% and 37%, respectively). The addition of chemotherapy did not increase the morbidity associated with surgery. The Medical Research Council Oesophageal Cancer Working Party randomly assigned 802 patients with resectable esophageal cancer also of any cell type to two cycles of preoperative 5-FU and cisplatin followed by surgery versus surgery alone. At a median follow-up of 37 months, median survival was significantly improved in the preoperative chemotherapy arm (16.8 months vs. 13.3 months with surgery alone; difference 3.5 months; 95% CI, 1–6.5 months), as was 2-year OS (43% and 34% respectively; difference 9%; 95% CI, 3–14 months). The interpretation of the results from both of these trials is challenging because T or N staging was not reported and prerandomization and radiation could be offered at the discretion of the treating oncologist.

The Japanese Clinical Oncology Group randomly assigned 330 patients with clinical stage II or III, excluding T4, squamous cell carcinomas to receive either two cycles of preoperative cisplatin and 5-FU (fluorouracil) followed by surgery versus surgery followed by postoperative chemotherapy of the same regimen.[23][Level of evidence: 1iiC] A planned interim analysis was conducted after patient accrual, and although the primary endpoint of PFS was not met, there was a significant benefit in OS among patients treated with preoperative chemotherapy (P = .01). As a result of these findings, the Data and Safety Monitoring Committee recommended early publication.

With a median follow-up of 61 months, the 5-year OS was 55% among patients treated with preoperative chemotherapy compared with 43% among patients treated with postoperative chemotherapy (P = .04). However, there was no significant difference between groups with respect to PFS (5-year PFS, 39% vs. 44%; P = .22). Additionally, there were no significant differences between the two groups with respect to postoperative complications or treatment-related toxicities.[23] Based on these results, preoperative chemotherapy without radiation therapy should still be considered under clinical evaluation.

Two randomized trials have shown no significant OS benefit for postoperative radiation therapy over surgery alone.[24][25][Level of evidence: 1iiA] All newly diagnosed patients should be considered candidates for therapies and clinical trials comparing various treatment modalities.

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

Special attention to nutritional support is indicated in any patient undergoing treatment of esophageal cancer. (Refer to the PDQ summary on Nutrition in Cancer Care for more information.)

References:

  1. Lerut T, Coosemans W, Van Raemdonck D, et al.: Surgical treatment of Barrett's carcinoma. Correlations between morphologic findings and prognosis. J Thorac Cardiovasc Surg 107 (4): 1059-65; discussion 1065-6, 1994.

  2. Ginsberg RJ: Cancer treatment in the elderly. J Am Coll Surg 187 (4): 427-8, 1998.

  3. Ellis FH Jr, Williamson WA, Heatley GJ: Cancer of the esophagus and cardia: does age influence treatment selection and surgical outcomes? J Am Coll Surg 187 (4): 345-51, 1998.

  4. Hulscher JB, van Sandick JW, de Boer AG, et al.: Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 347 (21): 1662-9, 2002.

  5. de Boer AG, van Lanschot JJ, van Sandick JW, et al.: Quality of life after transhiatal compared with extended transthoracic resection for adenocarcinoma of the esophagus. J Clin Oncol 22 (20): 4202-8, 2004.

  6. Saxon RR, Morrison KE, Lakin PC, et al.: Malignant esophageal obstruction and esophagorespiratory fistula: palliation with a polyethylene-covered Z-stent. Radiology 202 (2): 349-54, 1997.

  7. Campbell WR Jr, Taylor SA, Pierce GE, et al.: Therapeutic alternatives in patients with esophageal cancer. Am J Surg 150 (6): 665-8, 1985.

  8. Mellow MH, Pinkas H: Endoscopic therapy for esophageal carcinoma with Nd:YAG laser: prospective evaluation of efficacy, complications, and survival. Gastrointest Endosc 30 (6): 334-9, 1984.

  9. Fleischer D, Sivak MV Jr: Endoscopic Nd:YAG laser therapy as palliation for esophagogastric cancer. Parameters affecting initial outcome. Gastroenterology 89 (4): 827-31, 1985.

  10. Karlin DA, Fisher RS, Krevsky B: Prolonged survival and effective palliation in patients with squamous cell carcinoma of the esophagus following endoscopic laser therapy. Cancer 59 (11): 1969-72, 1987.

  11. Kelsen DP, Bains M, Burt M: Neoadjuvant chemotherapy and surgery of cancer of the esophagus. Semin Surg Oncol 6 (5): 268-73, 1990.

  12. Cooper JS, Guo MD, Herskovic A, et al.: Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85-01). Radiation Therapy Oncology Group. JAMA 281 (17): 1623-7, 1999.

  13. Smith TJ, Ryan LM, Douglass HO Jr, et al.: Combined chemoradiotherapy vs. radiotherapy alone for early stage squamous cell carcinoma of the esophagus: a study of the Eastern Cooperative Oncology Group. Int J Radiat Oncol Biol Phys 42 (2): 269-76, 1998.

  14. Minsky BD, Pajak TF, Ginsberg RJ, et al.: INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combined-modality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy. J Clin Oncol 20 (5): 1167-74, 2002.

  15. van Hagen P, Hulshof MC, van Lanschot JJ, et al.: Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 366 (22): 2074-84, 2012.

  16. Bosset JF, Gignoux M, Triboulet JP, et al.: Chemoradiotherapy followed by surgery compared with surgery alone in squamous-cell cancer of the esophagus. N Engl J Med 337 (3): 161-7, 1997.

  17. Walsh TN, Noonan N, Hollywood D, et al.: A comparison of multimodal therapy and surgery for esophageal adenocarcinoma. N Engl J Med 335 (7): 462-7, 1996.

  18. Urba SG, Orringer MB, Turrisi A, et al.: Randomized trial of preoperative chemoradiation versus surgery alone in patients with locoregional esophageal carcinoma. J Clin Oncol 19 (2): 305-13, 2001.

  19. Tepper J, Krasna MJ, Niedzwiecki D, et al.: Phase III trial of trimodality therapy with cisplatin, fluorouracil, radiotherapy, and surgery compared with surgery alone for esophageal cancer: CALGB 9781. J Clin Oncol 26 (7): 1086-92, 2008.

  20. Stahl M, Stuschke M, Lehmann N, et al.: Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus. J Clin Oncol 23 (10): 2310-7, 2005.

  21. Kelsen DP, Ginsberg R, Pajak TF, et al.: Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. N Engl J Med 339 (27): 1979-84, 1998.

  22. Medical Research Council Oesophageal Cancer Working Group: Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial. Lancet 359 (9319): 1727-33, 2002.

  23. Ando N, Kato H, Igaki H, et al.: A randomized trial comparing postoperative adjuvant chemotherapy with cisplatin and 5-fluorouracil versus preoperative chemotherapy for localized advanced squamous cell carcinoma of the thoracic esophagus (JCOG9907). Ann Surg Oncol 19 (1): 68-74, 2012.

  24. Ténière P, Hay JM, Fingerhut A, et al.: Postoperative radiation therapy does not increase survival after curative resection for squamous cell carcinoma of the middle and lower esophagus as shown by a multicenter controlled trial. French University Association for Surgical Research. Surg Gynecol Obstet 173 (2): 123-30, 1991.

  25. Fok M, Sham JS, Choy D, et al.: Postoperative radiotherapy for carcinoma of the esophagus: a prospective, randomized controlled study. Surgery 113 (2): 138-47, 1993.

Stage 0 Esophageal Cancer

Stage 0 squamous esophageal cancer is rarely seen in the United States, but surgery has been used for this stage of cancer.[1][2]

Current Clinical Trials

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage 0 esophageal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References:

  1. Rusch VW, Levine DS, Haggitt R, et al.: The management of high grade dysplasia and early cancer in Barrett's esophagus. A multidisciplinary problem. Cancer 74 (4): 1225-9, 1994.

  2. Heitmiller RF, Redmond M, Hamilton SR: Barrett's esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy. Ann Surg 224 (1): 66-71, 1996.

Stage I Esophageal Cancer

Standard treatment options:

  • Chemoradiation with subsequent surgery.
  • Surgery.

Treatment options under clinical evaluation:

  • Clinical trials.

Current 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. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Stage II Esophageal Cancer

Standard treatment options:

  1. Chemoradiation with subsequent surgery.
  2. Chemoradiation alone.
  3. Surgery alone.

Current Clinical Trials

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage II esophageal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Stage III Esophageal Cancer

Standard treatment options:

  1. Chemoradiation with subsequent surgery.
  2. Chemoradiation alone.

Current Clinical Trials

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage III esophageal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Stage IV Esophageal Cancer

At diagnosis, approximately 50% of patients with esophageal cancer will have metastatic disease and will be candidates for palliative therapy.[1]

Standard treatment options:

  1. Chemoradiation with subsequent surgery (for patients with stage IVA disease).
  2. Endoscopic-placed stents to provide palliation of dysphagia.[2]
  3. Radiation therapy with or without intraluminal intubation and dilation.
  4. Intraluminal brachytherapy to provide palliation of dysphagia.[3][4]
  5. Nd:YAG endoluminal tumor destruction or electrocoagulation.[5]
  6. Chemotherapy has provided partial responses for patients with metastatic distal esophageal adenocarcinomas.[6][7][8]

Treatment options under clinical evaluation:

Many agents are active in esophageal cancer. Objective response rates of 30% to 60% and median survivals of less than 1 year are commonly reported with platinum-based combination regimens with fluorouracil, taxanes, topoisomerase inhibitors, hydroxyurea, or vinorelbine.[1][8][9]

  • Clinical trials evaluating single-agent or combination chemotherapy.

Current Clinical Trials

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IV esophageal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References:

  1. Enzinger PC, Ilson DH, Kelsen DP: Chemotherapy in esophageal cancer. Semin Oncol 26 (5 Suppl 15): 12-20, 1999.

  2. Baron TH: Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med 344 (22): 1681-7, 2001.

  3. Sur RK, Levin CV, Donde B, et al.: Prospective randomized trial of HDR brachytherapy as a sole modality in palliation of advanced esophageal carcinoma--an International Atomic Energy Agency study. Int J Radiat Oncol Biol Phys 53 (1): 127-33, 2002.

  4. Gaspar LE, Nag S, Herskovic A, et al.: American Brachytherapy Society (ABS) consensus guidelines for brachytherapy of esophageal cancer. Clinical Research Committee, American Brachytherapy Society, Philadelphia, PA. Int J Radiat Oncol Biol Phys 38 (1): 127-32, 1997.

  5. Bourke MJ, Hope RL, Chu G, et al.: Laser palliation of inoperable malignant dysphagia: initial and at death. Gastrointest Endosc 43 (1): 29-32, 1996.

  6. Waters JS, Norman A, Cunningham D, et al.: Long-term survival after epirubicin, cisplatin and fluorouracil for gastric cancer: results of a randomized trial. Br J Cancer 80 (1-2): 269-72, 1999.

  7. Ross P, Nicolson M, Cunningham D, et al.: Prospective randomized trial comparing mitomycin, cisplatin, and protracted venous-infusion fluorouracil (PVI 5-FU) With epirubicin, cisplatin, and PVI 5-FU in advanced esophagogastric cancer. J Clin Oncol 20 (8): 1996-2004, 2002.

  8. Taïeb J, Artru P, Baujat B, et al.: Optimisation of 5-fluorouracil (5-FU)/cisplatin combination chemotherapy with a new schedule of hydroxyurea, leucovorin, 5-FU and cisplatin (HLFP regimen) for metastatic oesophageal cancer. Eur J Cancer 38 (5): 661-6, 2002.

  9. Conroy T, Etienne PL, Adenis A, et al.: Vinorelbine and cisplatin in metastatic squamous cell carcinoma of the oesophagus: response, toxicity, quality of life and survival. Ann Oncol 13 (5): 721-9, 2002.

Recurrent Esophageal Cancer

All recurrent esophageal cancer patients present difficult problems in palliation. All patients, whenever possible, should be considered candidates for clinical trials as outlined in treatment overview.

Standard treatment options:

  • Palliative use of any of the standard therapies, including supportive care.

Treatment options under clinical evaluation:

  • Clinical trials.

Current 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. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.


This information is provided by the National Cancer Institute.

This information was last updated on July 31, 2014.


 
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