Understanding cancer of the esophagus, the causes, symptoms, testing, stages and survival statistics

1. Cancer of the Esophagus
www.aboutcancer.com

2. 2014 Data for Esophagus
Cancer
New Cases Cancer Deaths
18,170 (1.1%) #19 15,450 (2.6% )
Life Time Risk of developing this cancer is
0.5%
5 Year Survival Rate is 17.5%

3. Incidence and Mortality over the Last
30 Years for Esophagus Cancer

4. Trends in 5 Year Survival Rates for
Adenocarcinoma of the Esophagus

5. Esophagus Cancer by Gender
in 2014
16000
14000
12000
10000
8000
6000
4000
2000
0
Gender
Male
Female
14,660
3,510
81%
19%

6. Esophagus Cancer Median Age
at Diagnosis
Year of Data Male Female
1998 – 2002 68 73
2000 - 2004 67 73
2002 – 2006 67 73
2005 – 2009 66 72

7. Age – Adjusted SEER Incidence
Rates for 2000 - 2011
25
20
15
10
5
0
Age 20-49 Age 50 - 64 Age 65-74 Age 75 +
Rates per 100,00

8. In the US where there is no routine screening
for esophagus cancer, most patients present
with advanced stages
Nearly 50% are advanced beyond local-regional
Less than 60% with local-regional can
undergo a curative resection
70-80%of resected specimens show spread
to the lymph nodes

9. National Data 2004-2010
Esophagus Cancer from SEER
Stage Incidence Survival/5y
Local 21% 39.6%
Regional 30% 21.1%
Distant 37% 3.8%

10. Risk Factors
• Tobacco use.
• Heavy alcohol use.
• Barrett esophagus
• Older age.
• Being male.
• Being African-American.

11. Two most common forms of esophageal
cancer are named for the type of cells that
become malignant
Squamous cell carcinoma 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
Adenocarcinoma 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.

12. In the 1960’s squamous cancer accounted for
more than 90% of cases but over the last two
decades adenocarcinoma has dramatically
increased and is now over 60% in the US
Tumors at the esophagogastric junction and
proximal 5 cm of the stomach that extend into
the EGJ or esophagus are classified and staged
as esophageal cancers (the so-called Siewert III
EGJ tumors).
All other tumors with an epicenter in the
stomach >5 cm from the EGJ, or those within 5
cm or the EGJ without extension into the
esophagus are staged as gastric cancers.

13. Squamous Cancer
• Now only accounts for less than
30% of cases in the US
• Tobacco and Alcohol are the
major risk factors

14. Adenocarcinoma
• now most common type in the US, esp in
white men
• Obesity and a high Body Mass Index
(BMI) are high risk factors, very high BMI
risk is 7.6 X higher
• GERD (gastroesophageal reflux) high
risk
• Barrett’s esophagus increases the risk to
30 – 60 X higher

15. Trends in the US for Esophagus
Cancer
Adenocarcinoma white males
Squamous white males
Adenocarcinoma black males
1980 1985 1990 1995 2000 2005

16. Trends for Adenocarcinoma in the US
White males
Black males
White females Black females
1980 1985 1990 1995 2000 2005

17. Epidemiology of Esophagus Cancer in the US
Squamous Adenocarcinoma
New cases per Year ~ 7,000 ~10,000
Male : Female 3:1 7:1
Black : White 6:1 1:4
Most Common Site Middle Distal
Major Risk Factor Smoking, alcohol Barrett’s

18. Barrett’s Esophagus – Columnar Cells Extend Above the GE Junction

19. Barrett’s Esophagus
• Replacement of normal esophageal lining
cells (stratified squamous) with cells that
predispose to cancer (metaplastic columnar
epithelium)
• Due to chronic GERD (gastroesophageal
reflux)
• Median age at diagnosis is 55y
• Predisposed to getting adenocarcinoma of
the lower esophagus

20. Barrett’s and Cancer
• Estimates of the annual cancer incidence
in patients with Barrett's esophagus have
ranged from 0.1 to 2.0 percent.
• Although the risk of developing
esophageal cancer is increased at least
30-fold above that of the general
population, the absolute risk of
developing cancer is low.

21. Barrett’s and Cancer
• Cancer incidence was 6.3 per 1000 person-years.
When only studies with well defined
criteria for the diagnosis of Barrett's esophagus
were included, the rate was 5.0 per 1000
person-years.
• For high-grade dysplasia the corresponding
pooled estimate for cancer incidence was 10.2
per 1000 person-years.
• The incidence of mortality was 3.0 per 1000
person-years due to esophageal
adenocarcinoma and 37.1 per 1000 person-years
due to other causes.

22. Screening for Barrett’s from the AGA
(American Gastroenterological Association)
Age 50 years or older
Male sex
White race
Chronic GERD
Hiatal hernia
Elevated body mass index
Intra-abdominal distribution of body fat

23. Screening for Barrett’s from the ACP
(American College of Physicians)
In men older than 50y with GERD symptoms
for more than 5 years plus:
Nocturnal reflux symptoms
Hiatus hernia
Elevated body mass index
Tobacco use
Intra-abdominal distribution of fat

24. Signs and Symptoms of
Esophagus Cancer
• Difficulty and pain with swallowing
• Pressure or burning in the chest
• Indigestion or heartburn
• Vomiting
• Frequent choking on food
• Unexplained weight loss
• Coughing or hoarseness
• Pain behind the breastbone or in the
throat

25. Esophagus Anatomy
23- 25 cm from
pharynx to the
stomach. Often
locations are
measured form the
teeth at the time of
endoscopy and the
first 15 cm are
before the
esophagus begins.

26. The esophagus is
roughly from C6 to T11

29. Primary Site Based on
Proximal Edge of Tumor
Anatomic Esophageal Distance
name location from teeth
Cervical Upper 15 to < 20cm
Thoracic Upper 20 to < 25cm
Middle 25 to < 30cm
Lower 30 to < 40cm
Abdominal Lower 40 to 45 cm
EGJ/Cardia 40 to 45 cm

30. Lymph nodes
from the
esophagus

31. Lymph Nodes at Risk for GE
junction

33. Staging and Diagnostic
Studies

34. Accuracy in Identifying Lymph Node
Spread, Comparing CT with EUS
(endoscopic ultrasound) or EUS + FNA (fine
needle aspirate biopsy)
Test Sensitivity Specificity
CT 29% (17 – 44%) 89% (72 – 98%)
EUS 71% (56 – 83%) 79% (59 – 92%)
EUS + FNA 83% (70- 93%) 93% (77 – 99%)

35. Endoscopic Ultrasound and
Peri-esophageal Lymph Nodes
Benign Malignant

36. Sensitivity in Detecting Nodes/
Mets
Test Site Sensitivity Specificity
EUS celiac N 85% 96%
other N 80% 70%
CT regional N 50% 83%
abdom N 42% 93%
Mets 52% 91%
PET regional N 57% 85%
Mets 71% 93%

41. Cross Section Anatomy
Heart
Esophagus
Lung
Lung

42. Cross Section Anatomy of the Esophagus

43. Cross Section Anatomy of the Chest

44. Reading a CT Scan near the Esophagus

45. Normal CT of the Esophagus

46. CT Squamous Cancer in the
Upper Esophagus

47. CT Adenocarcinoma Lower
Esophagus

48. CT and PET Scan
CT Scan PET Scan

49. PET Scan: Large Squamous Cancer of the
Upper Esophagus

50. PET Scan Mid Esophagus
Cancer

51. PET Scan Lower Esophagus Cancer

52. Endoscopic Ultrasound

53. Endoscopic Ultrasound

54. Endoscopic Ultrasound

55. Endoscopic Ultrasound

56. Staging System: T N M
T = depth of the tumor into the wall of the
esophagus
N = number of lymph nodes spread
M = distant metastases (spread to other
parts of the body)

57. Layers of
the
Esophagus

58. Layers of the Esophagus
epithelium
Lamina propria
Muscularis mucosa
Submucosa
Muscularis
propria
Adventitia

59. Layers of the Esophagus
g. Stratified epithelial lining
f. Mucous membrane
e. Muscularis mucosa
d. submucosa
c. Transverse muscle
b. Longitudinal muscle
a. Fibrous covering

60. Layers of the Esophagus
Mucosa
Submucosa
Muscle
Epithelial
Lamina
Propria
Muscular
mucosa

61. Epithelial
Basement
Membrane
Lamina Propria
Muscular mucosa
Layers of the Mucosa
T is = epithelial only
T1a = through the
basement membrane
into lamina propria or
muscularis mucosa
T1b = into submucosa
Submucosa

62. Layers of the Esophagus
Muscle
Mucosa
Submucosa

64. T = Tumor

65. N = Nodes , M =
Metastases

67. Staging System, T and N for
Esophagus Cancer
Tis T1
T1
submucosal
intramucosal
aorta
T3 T4
T2
N0
N1
1-2 nodes
Mucosa
N2
3-6 nodes
N3
7+nodes
Submucosa
Muscularis
propria

76. Survival by Stage NCDB
National Data 2003- 2006
Stage Number Survival/5y
I 3,786 (12%) 47.6%
II 7,324 (24%) 25.1%
III 7,444 (24%) 13.8%
IV 11,975 (39%) 3.3%

77. Squamous Cancer – Survival after Esophagectomy
Years
Stage 0
Stage I
Stage II
Stage III

78. Squamous Cancer – Survival after Esophagectomy
Stage Ia
Stage 0
Stage Ib
Stage IIA
Stage IIB
Stage IIIA
Stage IIIB
Stage IIIC

79. Squamous Cancer
Survival after Esophagectomy
Stage 5 Y 10 Y
I 62% 51%
Ia 71% 58%
Ib 60% 50%
II 47% 37%
IIa 53% 43%
IIb 42% 33%
III 20% 16%
IIIa 25% 20%
IIIb 17% 14%
IIIc 14% 12%

80. Adenocarcinoma – Survival after Esophagectomy
Years
Stage 0
Stage I
Stage II
Stage III

81. Adenocarcinoma – Survival after Esophagectomy
Years
Stage 0
Stage IA
Stage IB
Stage IIA
Stage IIB
Stage IIIA
Stage IIIB
Stage IIIC

82. Adenocarcinoma
Survival after Esophagectomy
Stage 5y 10Y
I 73% 61%
Ia 77% 67%
Ib 63% 51%
II 41% 33%
IIa 50% 37%
IIb 40% 30%
III 20% 17%
IIIa 25% 20%
IIIb 17% 14%
IIIc 13% 12%

83. Cancer of the Esophagus
www.aboutcancer.com