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There are several cancers that can arise in the esophagus, but the most common are squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma is typically related to smoking, where esophageal adenocarcinoma is related to gastroesophageal reflux disease, or GERD. There has been a significant rise in the incidence of esophageal adenocarcinoma in the last 35 years, especially in the United States. This rise has reached an approximate 700% increase over this time frame and correlates with the use of acid-suppressing medications such as Proton Pump Inhibitors, or PPIs (Protonix, Prevacid, Dexilant, etc.). There are several hypotheses for the correlation, but the most widely accepted hypothesis is that the lining of the esophagus is exposed to the intestinal secretions, such as acid and bile, causing the lining to attempt to accommodate this harsh environment. The esophagus lining begins to change to appear like the stomach lining. However, this change is disorganized and can result in premalignant (pre-cancer) changes.

The premalignant changes progress in a well-known pathway, and in this sequence:


The correlation with the rise in the incidence of esophageal adenocarcinoma mirrors the rise in the use of PPIs. Use of PPIs for long periods of time masks symptoms by taking away heartburn while the esophagus still endures the harsh environment present in the stomach and with the presence of bile. Gastroesophageal reflux disease progresses over time, and will often wear out the effects of PPIs. Surgery should be considered when a patient reaches this point. It has been shown that surgical intervention can reverse the premalignant changes, or halt its progression.

Diagnosis

Diagnosis of esophageal adenocarcinoma is made with a biopsy. These biopsies are obtained with an upper endoscopy. This is why patients with long-standing GERD or symptoms should have an upper endoscopy performed.

The appearance of esophageal cancer at the bottom of the esophagus seen with endoscopy

Treatment

The treatment of esophageal adenocarcinoma varies based on its stage. When caught early, and the cancer is confined to the innermost layer of the esophagus exposed to stomach acid and intestinal bile, it can be treated with endoscopic methods only. Once cancer grows further into the esophageal wall, surgical intervention needs to be considered, and possibly chemotherapy with radiation.

Endoscopic treatment – Treatment of choice for high-grade dysplasia, Carcinoma in situ, and T1a cancer

    • Endoscopic mucosal resection (EMR) – resecting portions of the lining of the esophagus, or mucosa, containing cancer.
    • Endoscopic mucosal dissection (ESD) – resecting the lining of the esophagus, or mucosa, in one single piece.
    • Endoscopic ablation (BARRX) – using radiofrequency ablation to burn the lining of the esophagus, or mucosa, containing cancer.

Esophagectomy (removing the esophagus) - This procedure is performed when the cancer is performed in several cases and is at the discretion of the surgeon.

    • Possible indications include Carcinoma in situ and high-grade dysplasia, and T1a cancer but endoscopic treatments are preferred.
    • T1b and T2 cancer.
    • T3 and T4, positive lymph nodes will usually require chemotherapy and radiation, followed by esophagectomy.

​Depth of tumor invasion