Signs and Symptoms of Esophageal Cancer

In most cases, cancers of the esophagus are discovered because of the symptoms they cause. Diagnosis in people without symptoms is rare and usually accidental (because of tests done to check other medical problems). Unfortunately, most esophageal cancers do not cause symptoms until they have reached an advanced stage, when a cure is less likely.

Dysphagia: The most common symptom of esophageal cancer is difficulty swallowing, or dysphagia, with the sensation of food getting stuck in the throat or chest. The opening of the esophagus is often narrowed to about half of its normal width. Therefore, dysphagia is commonly a late symptom caused by a large cancer that might not be curable.

When swallowing becomes difficult, people often change their diet and eating habits without realizing it. They chew their food more carefully and slowly. As the cancer continues to grow, however, this stops working and they start to eat softer foods that pass through the esophagus more easily. The foods that typically get stuck are bread and meat. The inability to swallow may lead some people to avoid solid food completely and eat a liquid diet. Eventually, even liquids are not able to pass. To help pass food through the esophagus, the body makes more saliva. This causes some people to complain of bringing up lots of thick mucus or saliva.

Pain: In rare cases, people can have mid-chest pain or discomfort, a slight sensation of pressure, or burning. However, because these symptoms can be associated with many common problems, such as heartburn, they are often overlooked. Painful swallowing is usually a late sign of a large cancer blocking the opening of the esophagus. This pain can occur a few seconds after swallowing food or liquid as it reaches the tumor and cannot pass it.

Weight loss: About half of patients with esophageal cancer complain of unintended weight loss. This happens because they cannot swallow enough food and nutrients to maintain their weight. Early in the disease, this may go unnoticed. Cancer also can cause a decreased appetite and can affect a person's metabolism.

Other symptoms: Hoarseness, hiccups, pneumonia, and high blood calcium levels are usually signs of more advanced cancer of the esophagus. Sometimes the cancer will bleed. If there is enough blood, stools may turn black. Of course, this can occur with other cancers and with some benign (noncancerous) diseases and does not always indicate esophageal cancer.

If you have any of the following symptoms, please see a doctor right away for appropriate examination and diagnosis:

• dysphagia (a feeling of food getting stuck in your throat or chest)
• significant weight loss without dieting
• avoidance of solid food because of pain when you swallow
• hiccups and dysphagia together

If you have certain symptoms or if the results of screening tests (in high-risk individuals without symptoms) suggest that you may have esophageal cancer, your doctor will use one or more of the methods explained below to find out if esophageal cancer or another disease is present.

History and Physical Examination

The doctor will take a complete history (medical interview) to check for risk factors and symptoms. The physical exam will provide information about signs of esophageal cancer and other health problems.

Barium Swallow or Upper Gastrointestinal (GI) X-rays

Esophageal cancers grow from the wall of the esophagus into the opening of the esophagus, creating a tumor or bump inside the esophagus. A barium swallow test can show irregularities in the normally smooth surface of the esophageal wall. Barium in liquid form is used to coat the esophagus wall before the x-ray is taken, allowing the x-ray to show the esophagus clearly.

A barium swallow test is often the first diagnostic test in people with trouble swallowing. It can be used to identify both early and advanced cancers, although early cancers (before symptoms occur) are often found by accident while having the test for another reason. In the barium x-ray, early cancers can look like small round bumps. They also can appear as a flat, raised area called a plaque. These masses will cause the barium to coat the affected area of the esophagus unevenly. Advanced cancers look like large irregular areas and cause a narrowing of the width of the esophagus. A barium swallow test cannot be used to determine how far a cancer may have spread outside of the esophagus.

A barium swallow test can also be used to diagnose one of the more serious complications of esophageal cancer called a tracheoesophageal fistula. This occurs when the tumor destroys the tissue between the esophagus and the trachea (windpipe) and creates a hole connecting the swallowing and breathing tubes. This leads to frequent coughing and gagging, and can be repaired with surgery or an endoscopy procedure.

Upper Endoscopy

An upper endoscopy is a procedure involving the use of an endoscope, which is a flexible, very narrow tube with a video camera and light on the end. During an upper endoscopy procedure, the patient is sedated (made sleepy) to allow for this narrow tube to pass through the mouth and into the esophagus and stomach. The camera is connected to a television set, allowing the doctor to see abnormalities in the wall of the esophagus clearly.

Endoscopy is an important test for diagnosing esophageal cancer. It permits the doctor to view the cancer through the scope. A biopsy (tissue sample) can be taken through the endoscope for laboratory testing to determine whether cancer is present and, if so, its type (squamous cell cancer or adenocarcinoma). If the esophageal cancer is blocking the opening (called the lumen) of the esophagus, then certain instruments can be used to help enlarge the opening to help food and liquid pass. This endoscopic examination can give the surgeon information about the size and spread of the tumor and whether the tumor can be completely removed.

Computed Tomography (CT)

The CT scan is a procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures of the part of your body being studied as it rotates around you. A computer then combines these pictures into an image of a slice of your body.

CT scans are not usually used to make the initial diagnosis of esophageal cancer, but they are helpful when determining the extent, called the stage, of the cancer. CT scans show the esophagus clearly and often can confirm the location of the esophageal cancer. CT scans can also show the organs next to the esophagus, as well as lymph nodes (bean-sized collections of immune cells that help fight infections and cancers) and distant organs where the cancer might have spread. The CT scan can help to determine whether surgery is a good treatment option.

After the first set of pictures is taken, you may be asked to drink 1 or 2 pints of a radiocontrast agent, or dye, to help outline the intestine so that certain areas are not mistaken for tumors. You need to be sure to let your doctor know if you are having any difficulty swallowing.

A contrast dye may be injected through an intravenous (IV) line. This helps outline structures in the body better. A second set of pictures is then taken.

The drink and the injection can cause some flushing. Some people are allergic and get hives; rarely, more serious reactions like trouble breathing and low blood pressure can occur. It is important to tell the doctor if you have ever had a reaction to any contrast agent used for x-rays.

CT scans are more inconvenient than regular x-rays because they take longer and require you to lie still on a table while they are being done. But just like other computerized devices, CT scans are getting faster and the stay might be pleasantly short. Also, some people feel a bit confined by the ring they have to lie in when the pictures are being taken.

CT scans can also be used to guide a biopsy needle precisely into a suspected metastasis, or spot to which the cancer has spread. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is in the mass. A fine-needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about one-half inch long and less than 1/8-inch in diameter) is removed and examined under a microscope.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross-sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body. A contrast material might be injected just as with CT scans but is used less often.

MRI scans are also very helpful in looking at the brain and spinal cord. MRI scans are a little more uncomfortable than CT scans. First, they take longer -- often up to an hour. Also, you have to be placed inside tube-like equipment, which is confining and can upset people with a fear of enclosed spaces. To stay calm, try keeping your eyes closed. Thinking of pleasant, relaxing mental images has also been shown to be helpful in making the time pass quickly. You should also feel free to ask for anti-anxiety medicines if you think this will help you. Finally, if you have a strong fear of enclosed areas, you can seek out a facility that has an open MRI. Many cities have at least one MRI center that has an open MRI (there is not an enclosed tube).

The MRI machine also makes a thumping noise like a washing machine that you may find annoying. Some places provide headphones with music to block this out. Although most people have little difficulty managing the MRI experience, you should feel free to discuss any concerns you have with your doctor or nurse. While you are in the MRI you will be able to talk to the technician throughout the procedure.

Endoscopic Ultrasound

This is a procedure that, according to recent studies, might be even more accurate than CT scans and upper endoscopy in determining an esophageal cancer's size and stage, or how far it has spread into nearby tissues. An endoscope with a small ultrasound probe attached to its end is used. The probe sends very sensitive sound waves that penetrate deep into tissues. The sound waves that bounce off the normal tissues and the cancer are picked up by the probe and determine how deeply the tumor has invaded into the esophagus. This is the same technology that doctors use to examine the fetus in a pregnant woman. It is harmless and can detect small abnormal changes very well.

Endoscopic ultrasound can help determine how much of the tissue next to the esophagus (including nearby lymph nodes) is affected by the cancer. This helps surgeons decide which tumors can be surgically removed and which cannot.

Bronchoscopy

This procedure is similar to an upper endoscopy except in this instance the doctor looks into the trachea (windpipe) and bronchi (tubes leading from the trachea to the lung). This allows the doctor to determine whether the cancer has grown into these structures. The patient is sedated for this procedure.

Positron Emission Tomography

In this test, radioactive glucose (sugar) is injected into your vein. Because cancers use sugar much faster than normal tissues, the cancerous tissue takes up the radioactive material. A scanner can spot the radioactive deposits. This test is useful for spotting cancer that has spread to nearby lymph nodes and sites distant from the esophagus. It may be a useful test for staging the cancer.

Thoracoscopy and Laparoscopy

These procedures allow the doctor to see lymph nodes and other organs near the esophagus inside the chest (by thoracoscopy) or the abdomen (by laparoscopy) through a hollow lighted tube. The surgeon can operate instruments through the tube and remove lymph node samples and biopsy organs to see whether they contain cancer cells. This information is often important in deciding whether or not a person is likely to benefit from surgery. These procedures require you to be in the hospital and undergo general anesthesia.

Biopsy

During an endoscopy or other procedure, the doctor will remove a small piece of tissue. This tissue is then examined by a pathologist (a doctor who specializes in diagnosing cancer with a microscope). He or she examines the tissue to determine whether cancer cells are present and if so, their type. It usually takes a couple of days to get the results of a biopsy.

Revised: 08/04/2006