Esophageal adenocarcinoma: Form of esophageal cancer

An adenocarcinoma of the esophagus is a type of esophageal cancer (carcinoma) that arises in the gland cells (adeno). These cells produce mucus in the lining of the esophagus. The lower part of the esophagus is particularly affected by this type of cancer. The patient has difficulty swallowing food and later also liquid. Weight loss, sore throat and hoarseness are some other features of the disease. Various treatment methods are possible, depending on the stage of the disease and the age and general condition of the patient. The prognosis is good in a very early stage of the disease, but an adenocarcinoma has a very poor outlook when the tumor is aggressive and when it has spread to other parts of the body.

  • Epidemiology and risk factors
  • Symptoms of tumor: Swallowing problems
  • Diagnosis of disease and examination of the degree of cancer
  • Treatment of adenocarcinoma of the esophagus
  • Prognosis form of esophageal cancer

Obesity is a risk factor for esophageal adenocarcinoma / Source: Tobyotter, Flickr (CC BY-2.0)

Epidemiology and risk factors

An adenocarcinoma of the esophagus is the most common form of esophageal cancer (swallowing problems and problems with eating). The incidence of this tumor varies between 3.7 to 8.7/100,000 persons. Cancer of the esophagus mainly occurs in the age group of sixty to seventy year olds.

Other risk factors of an adenocarcinoma include:

  • certain foods (such as betel nut)
  • certain molds or yeasts
  • caustic injuries
  • breast cancer treated with radiotherapy (treatment via radiation)
  • celiac disease (stomach and intestinal problems after eating gluten)
  • Barrett’s esophagus (damage to the wall of the esophagus due to reflux)
  • drinking boiling hot liquids
  • smoking tobacco
  • long-term, severe gastroesophageal reflux (heartburn due to stomach contents flowing back into the esophagus) (risk is up to eight times higher)
  • environmental factors such as nitrosamines in the soil
  • tylosis: a rare autosomal dominant disorder with hyperkeratosis (strong keratinization of the epidermis) of the palms and soles
  • diet with a vitamin deficiency; a high intake of carotenoids and vitamin C reduces the risk
  • obesity

Symptoms of tumor: Swallowing problems

With an adenocarcinoma of the esophagus, the patient has progressive swallowing problems. Initially he only has difficulty swallowing (dysphagia) solids, but dysphagia for liquids usually follows within a few weeks. Processing food causes pain, but more persistent pain indicates that the adjacent structures of the esophagus are also affected. The swallowing problems result in a loss of appetite (anorexia) and weight loss. The tumor causes a blockage in the esophagus (oesophageal obstruction), causing the patient to have difficulty swallowing saliva. Hoarseness, sore throat, pain behind the breastbone, a persistent cough and coughing up blood are also common symptoms of an adenocarcinoma of the esophagus. Finally, the lymph nodes are swollen (lymphadenopathy).

Diagnosis of disease and examination of the degree of cancer

Physical examination

In addition to the present symptoms, the doctor finds no abnormal results in the early stages. If metastases are present, the patient does have swollen lymph nodes. In addition, during the physical examination, the doctor notices an enlarged liver (hepatomegaly) when the cancer has spread to the liver.

Diagnostic research

Endoscopy
An endoscopy (internal examination of the inside of the body) provides histological or cytological evidence of the presence of the cancer; 90% of esophageal carcinomas (cancer on the skin, mucous membranes and organs) can be confirmed with this technique.

Barium swallow test
In addition, it is sometimes useful to perform a barium swallow test. This is useful to rule out other conditions that have dysphagia as a symptom, such as achalasia. In addition, this makes it easy to detect strictures in the esophagus.

CT scan or MRI scan
In addition to the endoscopy, a CT scan of the thorax (chest) and upper abdomen is necessary, because this gives the doctor an image of the volume of the tumor and any metastases. An MRI scan is also useful for this, but it is less good for detecting lung metastases.

Endoscopic ultrasound
Furthermore, an endoscopic ultrasound has an accuracy of almost 90% for assessing the depth of the tumor and 80% for assessing metastases to the lymph nodes. A fine needle aspiration of the lymph nodes improves the accuracy of this test.

Laparoscopy
A diagnostic laparoscopy is an internal examination of the abdominal wall, which is useful when the tumor is located in the cardia (gastric entrance: transition between esophagus and stomach), and to look for metastases in the peritoneum (peritoneum).

Bronchoscopy
An internal examination of the airways (bronchoscopy) is necessary to detect metastases in the trachea or tracheal branches (bronchi).

PET scan
Finally, a PET scan (Positron emission tomography) is sometimes necessary. The doctor performs this when he suspects that an adenocarcinoma has created distant metastases.

Differential diagnosis

Achalasia, a common esophageal stricture (which also causes swallowing problems) and stomach cancer are conditions that the doctor wants to rule out when he conducts tests for adenocarcinoma of the esophagus.

Treatment of adenocarcinoma of the esophagus

The treatment of adenocarcinoma depends on the age and general health of the patient and the stage of the disease. Various treatment options are possible.

Surgery

Surgery offers the best chance of cure and is only possible when the tumor is still within the esophageal wall (grade 1). Surgery in this group gives an 80% survival rate if postoperative pathology confirms the grade of the cancer. Patients receive careful preoperative examinations to evaluate the patient’s general health.

Chemotherapy

Patients who are in grade 2 to 3 of the disease sometimes receive chemotherapy, which extends their lifespan.

Palliative therapy

Palliative therapy is often the only treatment option. Occasionally, the doctor performs surgery to insert a metal stent into the esophagus so that the patient is still able to drink fluids and eat soft foods. Brachytherapy (internal radiation) prolongs patency after stenting. An endoscopic laser destroys part of a growing tumor, and alcohol injections may also be useful. In this way the doctor relieves the symptoms of dysphagia, but repeated treatments are often necessary.

Photodynamic therapy

Photodynamic therapy is a treatment in which the doctor administers a light-sensitive drug to the patient. This is a treatment that is especially useful in patients who are in the early stages of the disease, but the results are not effective for everyone.

Other support

Nutritional support (dietary adjustments), as well as psychological support for the patient and his family, are vital in this serious disease.

Prognosis form of esophageal cancer

Direct invasion of surrounding structures and metastases to the lymph nodes are more common than disseminated metastases in esophageal adenocarcinoma. The five-year survival rate for grade 1 tumor (low grade, least serious) is 80%. At grade 2 the five-year survival is 30%, at grade 3 it is 18% and in the final stage (grade 4, high grade) the five-year survival has dropped to 4%. 70% of patients are already in stage 3 or 4 of the disease at diagnosis, so that overall survival is 27% after 1 year and approximately 10% after 5 years.

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