Oesophageal Adenocarcinoma

Oesophageal adenocarcinoma is a type of cancer that begins in the glandular cells of the lower part of the food pipe, where it meets the stomach. This cancer has become more common in recent decades, especially in the United States and western Europe, and most often affects men over the age of 50.

Table of contents

• What is oesophageal adenocarcinoma
• Causes and risk factors
• Symptoms
• Diagnosis
• Staging
• Treatment
• Nutrition and eating
• Living with oesophageal cancer

What is oesophageal adenocarcinoma

Oesophageal adenocarcinoma is one of the two main types of oesophageal cancer. It starts in glandular cells, which are cells in the lining of the oesophagus that produce and release fluids such as mucus^[1]. These cancerous cells typically form in the lower part of the oesophagus, near the stomach^[1].

The oesophagus is a long, muscular tube that moves food and liquid from the throat to the stomach. It is part of the upper digestive system and sits in the chest, behind the windpipe and heart^[8]. The oesophagus has several layers of tissue, and cancer begins in the inner lining and can spread outward through the other layers as it grows^[1].

• Oesophagus (lower part)
• Gastroesophageal junction

This type of cancer has risen dramatically over the last few decades and is now more common than squamous cell carcinoma in the United States and western Europe^[2]. The increase has been most notable among white men^[8]. Most adenocarcinomas are located in the distal oesophagus, which is the part closest to the stomach^[8].

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Causes and risk factors

The exact cause of oesophageal adenocarcinoma is not known, but several risk factors have been identified that increase the chance of developing this cancer^[4].

The most important risk factor is Barrett’s oesophagus, a condition in which the cells lining the lower part of the oesophagus have changed or been replaced with abnormal cells. A high percentage of oesophageal adenocarcinoma cases arise from Barrett’s oesophagus^[9]. Barrett’s oesophagus is characterized by metaplasia, which means that normal cells have been replaced by a different type of cell^[9].

There is a strong association with chronic gastroesophageal reflux disease (GERD), commonly known as heartburn, which is considered the main cause of Barrett’s oesophagus^[9]. Long-term acid reflux from the stomach into the oesophagus damages the lining and can lead to these abnormal cell changes over time^[4].

Obesity is another significant risk factor. Being overweight or having obesity may cause inflammation in the oesophagus that could progress to cancer^[5]. Tobacco use, including smoking and smokeless tobacco, increases risk^[4]. While heavy alcohol use is a risk factor for squamous cell oesophageal cancer, its role in adenocarcinoma is less clear^[8].

Age is an important factor. Oesophageal cancer typically affects people between 50 and 60 years old, and it is more frequently seen in males^[9]. In the United States, the median age at diagnosis is 68 years^[8].

Symptoms

Oesophageal adenocarcinoma often does not cause symptoms early on. Most people do not notice symptoms until the cancer is at an advanced stage^[1]. This happens because the oesophagus is very flexible and stretches to make room as the tumor grows^[5]. Eventually, as the tumor becomes larger, it starts to block the opening of the oesophagus^[5].

The most common early symptom is difficulty swallowing, also called dysphagia^[9]. This may progress from trouble swallowing solid foods to difficulty with liquids as the tumor grows^[1]. Swallowing may also become painful.

Other symptoms that may develop include:

• Unintentional weight loss^[1]
• Chest pain, pressure or burning^[1]
• Pain behind the breastbone or between the shoulder blades^[4]
• Worsening indigestion or heartburn^[1]
• Hoarseness or chronic cough^[4]
• Vomiting or coughing up blood^[5]

There is often a history of chronic gastroesophageal reflux disease when symptoms appear^[9]. Because these symptoms can be caused by many other conditions, it is important to see a doctor if you experience any of them, especially if they persist^[1].

Diagnosis

Diagnosing oesophageal adenocarcinoma involves several tests and procedures. The diagnosis is confirmed by taking a sample of tissue for examination under a microscope^[2].

A healthcare professional will begin with a physical exam and health history to check general signs of health and ask about past illnesses and treatments^[4]. A chest X-ray may be taken to look at the organs and bones inside the chest^[4].

The key diagnostic test is an endoscopy, also called an esophagoscopy or upper endoscopy. During this procedure, a thin, flexible tube with a camera and light at the end (called an endoscope) is inserted through the mouth or nose, down the throat, and into the oesophagus^[4]. This allows the doctor to look inside the oesophagus and check for abnormal areas^[1].

During the endoscopy, the doctor can perform a biopsy, which means removing a small sample of tissue using special cutting tools passed through the endoscope^[10]. The tissue sample is then sent to a laboratory to be examined under a microscope to look for cancer cells^[10]. This is how the diagnosis is confirmed^[9].

Another test that may be used is a barium swallow study, where you drink a white liquid called barium before having X-rays taken. The barium coats the oesophagus and makes it easier to see changes on the X-rays, such as a growth that could be cancerous^[10].

Staging

After oesophageal adenocarcinoma is diagnosed, additional tests are done to determine how far the cancer has spread. This process is called staging^[2]. Staging is important because it helps doctors decide on the best treatment approach.

Imaging studies are the main tools used for staging^[2]. These may include:

• Computed tomography (CT) scan of the neck, chest, and abdomen to identify the primary tumor and any spread to lymph nodes or organs such as the liver, lungs, and bones^[9]
• Positron emission tomography (PET) scan, sometimes combined with CT (CT-PET), to look for cancer throughout the body^[9]
• Endoscopic ultrasound (EUS), which uses sound waves during an endoscopy to see how deep the tumor has grown into the wall of the oesophagus and to check nearby lymph nodes. This is particularly valuable for early cancers^[9]
• Laparoscopy, a surgical procedure using a small camera inserted through tiny cuts in the abdomen, may be used in selected cases for further staging^[9]

Adenocarcinoma of the oesophagus is staged differently than squamous cell carcinoma. The staging system takes into account the size and location of the tumor, whether cancer has spread to lymph nodes, whether it has spread to distant parts of the body, and the grade of the cancer (how abnormal the cells look under a microscope)^[7].

There are five main stages for adenocarcinoma of the oesophagus, numbered from 0 to 4. Generally, the higher the stage number, the more the cancer has spread^[7]. Stage 0 is the earliest stage, where cancer is only in the inner lining. By stage 4, the cancer has spread to distant parts of the body^[7].

Treatment

Treatment for oesophageal adenocarcinoma depends on several factors, including the stage of the cancer, the grade (how abnormal the cells look), and the patient’s overall health^[2]. When the cancer is confined to the oesophagus and nearby lymph nodes, and the patient is fit enough, treatment may be given with the aim to cure^[9].

Surgery is the most common treatment when the cancer has not spread^[13]. The main surgical procedure is called an esophagectomy, where all or part of the oesophagus is removed^[13]. This is usually done through an incision in the chest (transthoracic resection), and occasionally a neck incision is needed^[9]. In selected cases, surgery may be done without opening the chest (transhiatal esophagectomy)^[9].

For patients diagnosed with very early cancers, particularly those being monitored for Barrett’s oesophagus, endoscopic surgery may be used instead of open surgery. This involves removing the tumor through an endoscope, often combined with a technique called radiofrequency ablation (RFA) to destroy abnormal tissue^[9].

Chemotherapy uses anti-cancer drugs to destroy cancer cells^[13]. It may be given before surgery to shrink the tumor, after surgery to kill any remaining cancer cells, or as the main treatment for advanced cancer^[13].

Radiation therapy uses high-energy waves similar to X-rays to kill cancer cells^[13]. Chemoradiotherapy, which combines chemotherapy with radiation therapy, may be used on its own as the main treatment or before surgery^[13]. Several clinical trials support the use of chemotherapy or chemoradiotherapy before and after surgery^[9].

Targeted therapy and immunotherapy are newer types of treatment that may be used for oesophageal adenocarcinoma^[1]. Targeted drugs such as trastuzumab work against specific features of cancer cells, while immunotherapy drugs like nivolumab help the body’s immune system fight cancer^[13].

For patients who have difficulty swallowing, treatments are available to make eating easier. A self-expandable metallic stent may be placed in the oesophagus to keep it open^[23]. Other options include hypofractionated radiotherapy, a type of radiation given in higher doses over fewer sessions^[23].

When a cure is not possible, treatment focuses on helping people live longer, easing symptoms, and maintaining quality of life^[1]. This is called best supportive care or palliative care^[23].

Nutrition and eating

Oesophageal cancer and its treatments often cause problems with eating and swallowing. Good nutrition is a key part of the treatment plan and recovery^[24]. Most people with this cancer have trouble getting enough nutrition and maintaining a normal weight^[24].

A dietitian should be part of the healthcare team and can help manage eating problems and suggest ways to cope with diet difficulties^[18]. A speech and language therapist may also be involved to assess swallowing and teach exercises to help with swallowing difficulties^[18].

When swallowing is difficult, several strategies can help:

• Eat small amounts more often throughout the day^[18]
• Choose soft, moist foods that are easier to swallow^[18]
• Eat slowly and chew food well^[18]
• Take sips of a drink between mouthfuls to help food pass through^[18]
• Use sauces, cream, and gravies to moisten food^[18]
• Process or blend foods to make them softer^[18]

It is important to eat foods high in calories and protein to maintain weight and strength^[24]. Examples include whole milk, cheese, yogurt, eggs, beans, nut products, and meat. Liquid food supplements may be helpful and can be prescribed by a doctor^[18].

If eating by mouth becomes too difficult, other options are available. A feeding tube may be placed through the nose into the stomach, or directly into the stomach or small intestine through the skin over the belly^[24]. Patients can learn how to use these tubes at home. In some cases, nutrition may be given through an IV (intravenous) line, called parenteral nutrition^[24].

After surgery, eating may return to normal after a few months, though for some people this can take up to two years^[18]. The stomach may be smaller after surgery, causing people to feel full quickly. Eating smaller meals more frequently can help^[24].

Living with oesophageal cancer

Coping with oesophageal cancer can be difficult, both physically and emotionally^[19]. Help and support are available through various means.

Many people experience a range of emotions after being diagnosed with cancer, including feeling shocked, frightened, confused, angry, sad, or numb^[19]. These feelings are normal and may come and go, sometimes leaving people feeling exhausted^[19].

Getting information about the type of cancer and its treatment can help people feel more able to cope and make decisions^[19]. It is important to ask doctors and nurses to explain things again if needed, as taking in a lot of new information can feel overwhelming^[19]. Bringing someone along to appointments can help remember what was said and remind you what questions to ask^[19].

Talking to friends and family about the cancer can provide help and support, though some people may find this difficult^[19]. Some patients prefer to talk to someone outside their own circle, such as a counselor or cancer information nurse^[19].

The physical changes caused by oesophageal cancer and its treatments, such as weight loss, can affect how people feel about themselves and their relationships^[19]. Eating problems can make social events and eating out with friends much harder^[18].

Tiredness, also called fatigue, is common during treatment and for some months afterward^[19]. Resting but also doing some gentle physical activity can help manage fatigue^[19].

It is important to tell the doctor or specialist nurse about any symptoms so they can help control them^[19]. For people with advanced cancer, community cancer nurses or symptom control nurses can provide support at home. Local hospice services may also help with complementary therapies, counseling, short stays for symptom management, or to give caregivers a break^[19].

After treatment, regular follow-up appointments are usually scheduled to check how the patient is doing and address any problems or concerns^[13]. These appointments are an important part of ongoing care^[22].