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Esophageal cancer, originates from the cells lining the inside of the esophagus.
Since almost all of the esophagus is lined with squamous cells, malignant tumors arising from these cells are called squamous cell cancer (squamous cell cancer).
The lowest part of the esophagus, where it joins the stomach, is lined with columnar cells (prismatic cells), and malignant tumors arising from these cells are also called adenocarcinoma.
Sometimes, cell aggregates similar to small intestine tissue may occur in the esophagus. This change, called Barrett’s esophagus, is an important risk factor for the development of adenocarcinoma.
Anaplastic tumors, adenoid-cystic carcinomas, malignant melanoma, carcinosarcomas, Kaposi’s sarcoma and lymphomas are other rare malignant tumors of the esophagus and life expectancy is worse than squamous cell cancer and adenocancer.
Esophageal cancer is not as common as breast, lung, prostate and colon cancers. It ranks 9th among all cancers in terms of incidence.
It constitutes 1.5-2% of cancers in the human body and 5-7% of all digestive system cancers.
It is responsible for 4% of cancer-related deaths. Although its incidence varies according to geographical location, it is seen in 5 out of 100,000 people (1-6/100,000).
While the incidence of esophageal cancer in the USA is 2.5-5 out of 100,000 people (this means 8,000 new cases each year), the frequency is increasing in Asia and the Near East, especially in Azerbaijan, Iran, China and other regions of Southeast Asia, reaching 80/100,000.
The incidence and mortality rates are even higher in societies with a low socioeconomic structure. In general, esophageal cancer is seen 5 times more in men than in women, and 95% of the patients are Caucasian.
It is seen with equal frequency in both sexes in Asia and Africa. It is more common in men aged 60 years and older, and can occur at younger ages in women.
In recent years, while the frequency of squamous cell cancer has decreased slightly, there has been a significant increase in the incidence of esophageal adenocarcinoma.
Today, approximately half of newly diagnosed patients and 80% of cancers originating from the lowest part of the esophagus are adenocarcinomas.
The cause of esophageal cancer varies depending on the type of cancer. Risk factors for squamous cell cancer are smoking and excessive alcohol consumption.
The risk of developing squamous cell esophageal cancer is approximately 150 times higher in those who consume 120 g or more of alcohol and 2 packs or more of cigarettes per day than those who do not use these substances.
Very hot eating and drinking habits, human papilloma virus (HPV) infection, achalasia (a benign esophageal disease with difficulty in swallowing), radiotherapy, Plummer-Vinson syndrome (narrowing of the upper end of the esophagus in iron deficiency anemia and causing difficulty in swallowing) Other factors suggested to be facilitating the development of esophageal cancer can be listed as; damage to the esophagus due to drinking caustic substances such as cedar or bleach, gluten allergy, vitamin A, riboflavin and zinc deficiency, excess nitrosamine in the diet.
Esophageal cancer risk factors are less well understood. Barrett’s esophagus, a complication of gastroesophageal reflux disease, is the best known risk factor for esophageal adenocarcinoma.
The condition known as Barrett’s esophagus or Barrett’s metaplasia is a serious and silent complication of gastroesophageal reflux disease. In this disease, the tissue lining the inner surface of the esophagus is replaced by the tissue lining the inner surface of the stomach or intestines.
In general, the incidence of Barrett’s metaplasia in people who underwent gastroscopy for complaints other than reflux is 0.5-1%, while this rate rises to 5-15% in those who undergo endoscopy due to reflux. In patients who develop stenosis in the esophagus, this rate may increase up to 50%.
Although Barrett’s esophagus can be seen at any age, its incidence increases after the age of 40. It is more common in western society and white race. The importance of Barrett’s esophagus is that it is a disease that can transform into cancer.
The incidence of cancer in the esophagus in patients with Barrett’s esophagus is around 0.5% per year, which means that the risk of developing esophageal cancer in patients with Barrett’s esophagus is 30 to 50 times higher than in the general population.
For this reason, patients with Barrett’s esophagus should be followed up by performing gastroscopy at regular intervals and taking tissue samples, and patients with early signs of cancer transformation should be treated with surgical treatment.
Does gastroesophageal reflux disease lead to esophageal cancer? Although studies show that the incidence of esophageal cancer increases slightly in the presence of gastroesophageal reflux disease, this increase is not so evident in moderate and mild reflux cases.
(0.002% in those without reflux complaints, 0.003%-0.018% in those with mild and moderate reflux, 0.035% in those with severe reflux).
Our current knowledge shows that there is a slight but insignificant increase in the incidence of esophageal cancer in reflux disease. This risk is significantly lower than the probability of developing serious complications (0.5-1.5%) that can be seen in surgical treatment.
The most common complaints are difficulty in swallowing (the feeling of food getting stuck in the esophagus before reaching the stomach) and/or pain during swallowing. Swallowing difficulties are usually progressive.
Initially, it is formed by swallowing large pieces of solid and not well-chewed foods, but over time, difficulty occurs in swallowing liquid foods.
In particular, meat, bread and apples are defined as foods that cause difficulty in swallowing by patients.
Apart from these, symptoms such as weight loss, increased salivation, returning of undigested food to the mouth, discharge of a liquid that contaminates the pillow and sometimes bloody from the mouth during sleep, feeling of discomfort in the chest, chest pain that can spread to the back, blood coming from the mouth during vomiting, black stools are also present. may be.
Patients may have anemia, hoarseness and cough.
Difficulty in swallowing and/or pain during swallowing and weight loss, which are symptoms of esophageal cancer, may be sufficient reasons to consult a physician. There is no simple method yet to find out if you have esophageal cancer. In general, tests are applied to determine whether there is a mass in the esophagus that will cause difficulty in swallowing.
What methods are used to diagnose esophageal cancer? A variety of tests may be performed on someone with suspected esophageal cancer.
Since patients usually apply to the physician with swallowing difficulties, the first diagnostic method to be applied is barium esophagus graphy.
In this method, a liquid (barium solution) is given to the patient and a film (barium graphy) is taken during this time. Tumors can be detected in 75% of patients with this examination in the early period. When the double contrast technique is used, this rate rises to 90%.
Endoscopy is another method that should be applied because it provides the opportunity to see the lesion directly and to take a biopsy (tissue sample). It can be used as the first diagnostic method in esophageal cancer in patients with painful swallowing.
(See Endoscopy and Gastroscopy). This method is based on the principle of viewing the esophagus by entering through the mouth with an instrument (endoscope) with a camera at the end.
In addition, it may be necessary to have a chest and abdominal computed tomography that gives an idea about the lungs, liver and other organs, which are the formations near the esophagus.
The treatment method to be chosen in esophageal cancer is determined by the stage and type of the tumor, the age and general condition of the patient. Since the difficulty in swallowing occurs months after the cancer begins to grow, cancer of the esophagus is usually diagnosed late.
Today, the treatment of esophageal cancer is generally not for therapeutic purposes, but is aimed at eliminating symptoms and increasing the patient’s quality of life. The reason for this is that only 1/3 of the patients are at the stage where surgical treatment can be applied at the time of first admission.
Early-stage tumors involving the superficial layers of the esophagus can be treated endoscopically. However, for this, the tumor must be limited to the mucosa or spread up to the upper 1/3 of the submucosa layer.
Since the probability of lymph node involvement is high in tumors that have reached deeper layers, surgical treatment should be applied. Removal of a large part of the esophagus is the main treatment principle in patients where the cancer has not spread to other organs and is treatable.
Chemotherapy and radiotherapy treatments can also be done in addition, although there is not very conclusive evidence that it works in many patients. Many cancer centers are investigating the benefit of chemotherapy and radiotherapy given before surgery in treatable patients.
Combining chemotherapy and radiotherapy is the main treatment principle in patients whose cancer has spread to neighboring organs or who cannot be operated for any other reason.
Since problems with swallowing cannot be corrected immediately with this treatment method, other methods are tried to correct swallowing. These include placing a flexible tube (stent) in the area where the tumor is in order to keep the esophagus open and opening this area by burning it with laser or argon current.
The likelihood of being cured depends on the stage of the disease at the time of diagnosis. Life expectancy and 5-year disease-free survival after treatment are 80-90% in patients caught at an early stage.
However, since most esophageal cancers (30-40% of patients) are diagnosed at an advanced stage, treatment success is low. The extent of spread of the tumor to the esophagus, involvement of lymph nodes and whether the tumor has spread to distant organs (metastasis) are the most important data determining the survival time.
