The esophagus is a hollow tube that carries food and liquids from your throat to your stomach. Early esophageal cancer usually does not cause symptoms. Later, you may have symptoms such as:

• Painful or difficult swallowing
• Weight loss
• A hoarse voice or cough that doesn't go away

You're at greater risk for getting esophageal cancer if you smoke, drink heavily, or have acid reflux. Your risk also goes up as you age.

Your doctor uses imaging tests and a biopsy to diagnose esophageal cancer. Treatments include surgery, radiation, and chemotherapy. You might also need nutritional support, since the cancer or treatment may make it hard to swallow.

General Information About Esophageal Cancer

KEY POINTS

• Esophageal cancer is a disease in which malignant (cancer) cells form in the tissues of the esophagus.
• Smoking, heavy alcohol use, and Barrett esophagus can increase the risk of esophageal cancer.
• Signs and symptoms of esophageal cancer are weight loss and painful or difficult swallowing.
• Tests that examine the esophagus are used to diagnose esophageal cancer.
• Certain factors affect prognosis (chance of recovery) and treatment options.

Esophageal cancer is a disease in which malignant (cancer) cells form in the tissues of the esophagus.

The esophagus is the hollow, muscular tube that moves food and liquid from the throat to the stomach. The wall of the esophagus is made up of several layers of tissue, including mucous membrane, muscle, and connective tissue. Esophageal cancer starts on the inside lining of the esophagus and spreads outward through the other layers as it grows.

The two most common forms of esophageal cancer are named for the type of cells that become malignant (cancerous):

• Squamous cell carcinoma: Cancer that forms in the thin, flat cells lining the inside of the esophagus. This cancer is most often found in the upper and middle part of the esophagus, but can occur anywhere along the esophagus. This is also called epidermoid carcinoma.
• Adenocarcinoma: Cancer that begins in glandular 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.

The Human Digestive System

The process of digestion begins in the mouth with the intake of food (Figure 16.4). The teeth play an important role in masticating (chewing) or physically breaking food into smaller particles. The enzymes present in saliva also begin to chemically break down food. The food is then swallowed and enters the esophagus—a long tube that connects the mouth to the stomach. Using peristalsis, or wave-like smooth-muscle contractions, the muscles of the esophagus push the food toward the stomach. The stomach contents are extremely acidic, with a pH between 1.5 and 2.5. This acidity kills microorganisms, breaks down food tissues, and activates digestive enzymes. Further breakdown of food takes place in the small intestine where bile produced by the liver, and enzymes produced by the small intestine and the pancreas, continue the process of digestion. The smaller molecules are absorbed into the blood stream through the epithelial cells lining the walls of the small intestine. The waste material travels on to the large intestine where water is absorbed and the drier waste material is compacted into feces; it is stored until it is excreted through the anus.

Figure 16.4 The components of the human digestive system are shown.

Digestive Processes

The processes of digestion include six activities: ingestion, propulsion, mechanical or physical digestion, chemical digestion, absorption, and defecation.

The first of these processes, ingestion, refers to the entry of food into the alimentary canal through the mouth. There, the food is chewed and mixed with saliva, which contains enzymes that begin breaking down the carbohydrates in the food plus some lipid digestion via lingual lipase. Chewing increases the surface area of the food and allows an appropriately sized bolus to be produced.

Food leaves the mouth when the tongue and pharyngeal muscles propel it into the esophagus. This act of swallowing, the last voluntary act until defecation, is an example of propulsion, which refers to the movement of food through the digestive tract. It includes both the voluntary process of swallowing and the involuntary process of peristalsis. Peristalsis consists of sequential, alternating waves of contraction and relaxation of alimentary wall smooth muscles, which act to propel food along (Figure 23.5). These waves also play a role in mixing food with digestive juices. Peristalsis is so powerful that foods and liquids you swallow enter your stomach even if you are standing on your head.

Figure 23.5 Peristalsis Peristalsis moves food through the digestive tract with alternating waves of muscle contraction and relaxation.

Digestion includes both mechanical and chemical processes. Mechanical digestion is a purely physical process that does not change the chemical nature of the food. Instead, it makes the food smaller to increase both surface area and mobility. It includes mastication, or chewing, as well as tongue movements that help break food into smaller bits and mix food with saliva. Although there may be a tendency to think that mechanical digestion is limited to the first steps of the digestive process, it occurs after the food leaves the mouth, as well. The mechanical churning of food in the stomach serves to further break it apart and expose more of its surface area to digestive juices, creating an acidic “soup” called chyme. Segmentation, which occurs mainly in the small intestine, consists of localized contractions of circular muscle of the muscularis layer of the alimentary canal. These contractions isolate small sections of the intestine, moving their contents back and forth while continuously subdividing, breaking up, and mixing the contents. By moving food back and forth in the intestinal lumen, segmentation mixes food with digestive juices and facilitates absorption.

In chemical digestion, starting in the mouth, digestive secretions break down complex food molecules into their chemical building blocks (for example, proteins into separate amino acids). These secretions vary in composition, but typically contain water, various enzymes, acids, and salts. The process is completed in the small intestine.

Food that has been broken down is of no value to the body unless it enters the bloodstream and its nutrients are put to work. This occurs through the process of absorption, which takes place primarily within the small intestine. There, most nutrients are absorbed from the lumen of the alimentary canal into the bloodstream through the epithelial cells that make up the mucosa. Lipids are absorbed into lacteals and are transported via the lymphatic vessels to the bloodstream (the subclavian veins near the heart). The details of these processes will be discussed later.

In defecation, the final step in digestion, undigested materials are removed from the body as feces.

In some cases, a single organ is in charge of a digestive process. For example, ingestion occurs only in the mouth and defecation only in the anus. However, most digestive processes involve the interaction of several organs and occur gradually as food moves through the alimentary canal (Figure 23.6).

Figure 23.6 Digestive Processes The digestive processes are ingestion, propulsion, mechanical digestion, chemical digestion, absorption, and defecation.

The esophagus is a tubular organ that connects the mouth to the stomach. The chewed and softened food passes through the esophagus after being swallowed. The smooth muscles of the esophagus undergo peristalsis that pushes the food toward the stomach. The peristaltic wave is unidirectional—it moves food from the mouth the stomach, and reverse movement is not possible, except in the case of the vomit reflex. The peristaltic movement of the esophagus is an involuntary reflex; it takes place in response to the act of swallowing.

Ring-like muscles called sphincters form valves in the digestive system. The gastro-esophageal sphincter (or cardiac sphincter) is located at the stomach end of the esophagus. In response to swallowing and the pressure exerted by the bolus of food, this sphincter opens, and the bolus enters the stomach. When there is no swallowing action, this sphincter is shut and prevents the contents of the stomach from traveling up the esophagus. Acid reflux or “heartburn” occurs when the acidic digestive juices escape into the esophagus.

Figure 16.5 (a) Digestion of food begins in the mouth. (b) Food is masticated by teeth and moistened by saliva secreted from the salivary glands. Enzymes in the saliva begin to digest starches and fats. With the help of the tongue, the resulting bolus is moved into the esophagus by swallowing. (credit: modification of work by Mariana Ruiz Villareal)

The esophagus is a muscular tube that connects the pharynx to the stomach. It is approximately 25.4 cm (10 in) in length, located posterior to the trachea, and remains in a collapsed form when not engaged in swallowing. As you can see in image below, the esophagus runs a mainly straight route through the mediastinum of the thorax. To enter the abdomen, the esophagus penetrates the diaphragm through an opening called the esophageal hiatus.

Passage of Food through the Esophagus

The upper esophageal sphincter, which is continuous with the inferior pharyngeal constrictor, controls the movement of food from the pharynx into the esophagus. The upper two-thirds of the esophagus consists of both smooth and skeletal muscle fibers, with the latter fading out in the bottom third of the esophagus. Rhythmic waves of peristalsis, which begin in the upper esophagus, propel the bolus of food toward the stomach. Meanwhile, secretions from the esophageal mucosa lubricate the esophagus and food. Food passes from the esophagus into the stomach at the lower esophageal sphincter (also called the gastroesophageal or cardiac sphincter). Recall that sphincters are muscles that surround tubes and serve as valves, closing the tube when the sphincters contract and opening it when they relax. The lower esophageal sphincter relaxes to let food pass into the stomach, and then contracts to prevent stomach acids from backing up into the esophagus. Surrounding this sphincter is the muscular diaphragm, which helps close off the sphincter when no food is being swallowed. When the lower esophageal sphincter does not completely close, the stomach’s contents can reflux (that is, back up into the esophagus), causing heartburn or gastroesophageal reflux disease (GERD).

Histology of the Esophagus

The mucosa of the esophagus is made up of an epithelial lining that contains non-keratinized, stratified squamous epithelium, with a layer of basal and parabasal cells. This epithelium protects against erosion from food particles. The mucosa’s lamina propria contains mucus-secreting glands. The muscularis layer changes according to location: In the upper third of the esophagus, the muscularis is skeletal muscle. In the middle third, it is both skeletal and smooth muscle. In the lower third, it is smooth muscle. As mentioned previously, the most superficial layer of the esophagus is called the adventitia, not the serosa. In contrast to the stomach and intestines, the loose connective tissue of the adventitia is not covered by a fold of visceral peritoneum. The digestive functions of the esophagus are identified in image.

The esophagus is a muscular tube about ten inches (25 cm.) long, extending from the hypopharynx to the stomach. The esophagus lies posterior to the trachea and the heart and passes through the mediastinum and the hiatus, an opening in the diaphragm, in its descent from the thoracic to the abdominal cavity. The esophagus has no serosal layer; tissue around the esophagus is called adventitia.

There are two sub site descriptions for the esophagus and they are not equivalent.

Sub Site Description 1

Cervical

• Cervical begins at the lower end of pharynx (level of 6th vertebra or lower border of cricoid cartilage) and extends to the thoracic inlet (suprasternal notch); 18 cm from incisors.

Thoracic

• Upper thoracic: from thoracic inlet to level of tracheal bifurcation; 18-23 cm.
• Mid thoracic: from tracheal bifuraction midway to gastroesophageal junction; 24-32 cm.
• Lower thoracic: from midway between tracheal bifurcation and gastroesophageal junction to GE junction, including abdominal esophagus; 32-40 cm.

Abdominal

• Considered part of lower thoracic esophagus; 32-40 cm.

Sub Site Description 2

• Upper third (10% of esophageal cancers)
• Middle third (40%)
• Lower third (50%)

The figure below illustrates the correlation between sub site descriptions of the esophagus.

Smoking, heavy alcohol use, and Barrett esophagus can increase the risk of esophageal cancer.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors include the following:

• Tobacco use.
• Heavy alcohol use.
• Barrett esophagus: A condition in which the cells lining the lower part of the esophagus have changed or been replaced with abnormal cells that could lead to cancer of the esophagus. Gastric reflux (heartburn) is the most common cause of Barrett esophagus.
• Older age.

Signs and symptoms of esophageal cancer are weight loss and painful or difficult swallowing.

These and other signs and symptoms may be caused by esophageal cancer or by other conditions. Check with your doctor if you have any of the following:

• Painful or difficult swallowing.
• Weight loss.
• Pain behind the breastbone.
• Hoarseness and cough.
• Indigestion and heartburn.
• A lump under the skin.

Tests are used to screen for different types of cancer when a person does not have symptoms.

Scientists study screening tests to find those with the fewest harms and most benefits. Cancer screening trials also are meant to show whether early detection (finding cancer before it causes symptoms) helps a person live longer or decreases a person's chance of dying from the disease. For some types of cancer, the chance of recovery is better if the disease is found and treated at an early stage.

There is no standard or routine screening test for esophageal cancer.

Although there are no standard or routine screening tests for esophageal cancer, the following tests are being used or studied to screen for it:

Esophagoscopy

A procedure to look inside the esophagus to check for abnormal areas. An esophagoscope is inserted through the mouth or nose and down the throat into the esophagus. An esophagoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.

Biopsy

The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. Taking biopsy samples from several different areas in the lining of the lower part of the esophagus may detect early Barrett esophagus. This procedure may be used for patients who have risk factors for Barrett esophagus.

Brush cytology

A procedure in which cells are brushed from the lining of the esophagus and viewed under a microscope to see if they are abnormal. This may be done during an esophagoscopy.

Balloon cytology

A procedure in which cells are collected from the lining of the esophagus using a deflated balloon that is swallowed by the patient. The balloon is then inflated and pulled out of the esophagus. Esophageal cells on the balloon are viewed under a microscope to see if they are abnormal.

Chromoendoscopy

A procedure in which a dye is sprayed onto the lining of the esophagus during esophagoscopy. Increased staining of certain areas of the lining may be a sign of early Barrett esophagus.

Fluorescence spectroscopy

A procedure that uses a special light to view tissue in the lining of the esophagus. The light probe is passed through an endoscope and shines on the lining of the esophagus. The light given off by the cells lining the esophagus is then measured. Malignant tissue gives off less light than normal tissue.

Tests that examine the esophagus are used to diagnose esophageal cancer.

The following tests and procedures may be used:

• Physical exam and health history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• Esophagoscopy: A procedure to look inside the esophagus to check for abnormal areas. An esophagoscope is inserted through the mouth or nose and down the throat into the esophagus. An esophagoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer. When the esophagus and stomach are looked at, it is called an upper endoscopy.

• Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. The biopsy is usually done during an esophagoscopy. Sometimes a biopsy shows changes in the esophagus that are not cancer but may lead to cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis and treatment options depend on the following:

• The stage of the cancer (whether it affects part of the esophagus, involves the whole esophagus, or has spread to other places in the body).
• Whether the tumor can be completely removed by surgery.
• The patient’s general health.

When esophageal cancer is found very early, there is a better chance of recovery. Esophageal cancer is often in an advanced stage when it is diagnosed. At later stages, esophageal cancer can be treated but rarely can be cured. Taking part in one of the clinical trials being done to improve treatment should be considered.

Examination of the esophagus using an esophagoscope. An esophagoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue to be checked under a microscope for signs of disease.

After esophageal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the esophagus or to other parts of the body.

The process used to find out if cancer cells have spread within theesophagus or to other parts of the body is called staging. The informationgathered from the staging process determines the stage of the disease. It isimportant to know the stage in order to plan treatment.The following tests and procedures may be used in the staging process:

• Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the body, usually through the mouth or rectum. For esophageal cancer, the endoscope is inserted through the mouth. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. A biopsy may also be done. This procedure is also called endosonography.
• CT scan (CATscan): A procedure that makes a series of detailed pictures of areas inside the body, such as the chest, abdomen, and pelvis, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography,computerized tomography, or computerized axial tomography.
• PET scan (positronemission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. A PET scan and CT scan may be done at the same time. This is called a PET-CT.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• Thoracoscopy: A surgical procedure to look at the organs inside the chest to check for abnormal areas. An incision (cut) is made between two ribs and a thoracoscope is inserted into the chest. A thoracoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node samples, which are checked under a microscope for signs of cancer. In some cases, this procedure may be used to remove part of the esophagus or lung.
• Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples to be checked under a microscope for signs of disease.
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs, such as those in the neck, and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

• Tissue. The cancer spreads from where it began by growing into nearby areas.
• Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
• Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

• Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
• Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if esophageal cancer spreads to the lung, the cancer cells in the lung are actually esophageal cancer cells. The disease is metastatic esophageal cancer, not lung cancer.

The grade of the tumor is also used to describe the cancer and plan treatment.

The grade of the tumor describes how abnormal the cancer cells look under a microscope and how quickly the tumor is likely to grow and spread. Grades 1 to 3 are used to describe esophageal cancer:

• In grade 1, the cancer cells look more like normal cells under a microscope and grow and spread more slowly than grade 2 and 3 cancer cells.
• In grade 2, the cancer cells look more abnormal under a microscope and grow and spread more quickly than grade 1 cancer cells.
• In grade 3, the cancer cells look more abnormal under a microscope and grow and spread more quickly than grade 1 and 2 cancer cells.

The following stages are used for squamous cell carcinoma of the esophagus:

Stage 0 (High-grade Dysplasia)

In stage 0, cancer has formed in the inner lining of the esophagus wall. Stage 0 is also called high-grade dysplasia.

Stage I squamous cell carcinoma of the esophagus

Stage I is divided into stages IA and IB, depending on where the cancer has spread.

• Stage IA: Cancer has spread into the mucosa layer or thin muscle layer of the esophagus wall. The cancer cells are grade 1 or the grade is not known.

• Stage IB: Cancer has spread:
  • into the mucosa layer, thin muscle layer, or submucosa layer of the esophagus wall. The cancer cells are any grade or the grade is not known; or
  • into the thick muscle layer of the esophagus wall. The cancer cells are grade 1.

Stage II squamous cell carcinoma of the esophagus

Stage II is divided into stages IIA and IIB, depending on where the cancer has spread.

• Stage IIA: Cancer has spread:
  • into the thick muscle layer of the esophagus wall. The cancer cells are grade 2 or 3 or the grade is not known; or

  • into the connective tissue layer of the esophagus wall. The tumor is in the lower esophagus; or

  • into the connective tissue layer of the esophagus wall. The cancer cells are grade 1. The tumor is in either the upper or middle esophagus.

• Stage IIB: Cancer has spread:
  • into the connective tissue layer of the esophagus wall. The cancer cells are grade 2 or 3. The tumor is in either the upper or middle esophagus; or

  • into the connective tissue layer of the esophagus wall. The grade of the cancer cells is not known, or it is not known where the tumor has formed in the esophagus; or

  • into the mucosa layer, thin muscle layer, or submucosa layer of the esophagus wall. Cancer is found in 1 or 2 lymph nodes near the tumor.

Stage III squamous cell carcinoma of the esophagus

Stage III is divided into stages IIIA and IIIB, depending on where the cancer has spread.

• Stage IIIA: Cancer has spread:
  • into the mucosa layer, thin muscle layer, or submucosa layer of the esophagus wall. Cancer is found in 3 to 6 lymph nodes near the tumor; or
  • into the thick muscle layer of the esophagus wall. Cancer is found in 1 or 2 lymph nodes near the tumor.

• Stage IIIB: Cancer has spread:
  • into the thick muscle layer or the connective tissue layer of the esophagus wall. Cancer is found in 1 to 6 lymph nodes near the tumor; or

  • into the diaphragm, azygos vein, pleura, sac around the heart, or peritoneum. Cancer may be found in 0 to 2 lymph nodes near the tumor.

Stage IV squamous cell carcinoma of the esophagus

Stage IV is divided into stages IVA and IVB, depending on where the cancer has spread.

• Stage IVA: Cancer has spread:
  • into the diaphragm, azygos vein, pleura, sac around the heart, or peritoneum. Cancer is found in 3 to 6 lymph nodes near the tumor; or

  • into nearby structures, such as the aorta, airway, or spine. Cancer may be found in 0 to 6 lymph nodes near the tumor; or

  • to 7 or more lymph nodes near the tumor.

• Stage IVB: Cancer has spread to other parts of the body, such as the liver or lung.

The following stages are used for adenocarcinoma of the esophagus:

Stage 0 (High-grade Dysplasia)

In stage 0, cancer has formed in the inner lining of the esophagus wall. Stage 0 is also called high-grade dysplasia.

Stage I adenocarcinoma of the esophagus

Stage I is divided into stages IA, IB, and IC, depending on where the cancer has spread.

• Stage IA: Cancer has spread into the mucosa layer or thin muscle layer of the esophagus wall. The cancer cells are grade 1 or the grade is not known.

• Stage IB: Cancer has spread:
  • into the mucosa layer or thin muscle layer of the esophagus wall. The cancer cells are grade 2; or
  • into the submucosa layer of the esophagus wall. The cancer cells are grade 1 or 2 or the grade is not known.

• Stage IC: Cancer has spread:
  • into the mucosa layer, thin muscle layer, or submucosa layer of the esophagus wall. The cancer cells are grade 3; or
  • into the thick muscle layer of the esophagus wall. The cancer cells are grade 1 or 2.

Stage II adenocarcinoma of the esophagus

Stage II is divided into stages IIA and IIB, depending on where the cancer has spread.

• Stage IIA: Cancer has spread into the thick muscle layer of the esophagus wall. The cancer cells are grade 3 or the grade is not known.

• Stage IIB: Cancer has spread:
  • into the connective tissue layer of the esophagus wall; or
  • into the mucosa layer, thin muscle layer, or submucosa layer of the esophagus wall. Cancer is found in 1 or 2 lymph nodes near the tumor.

Stage III adenocarcinoma of the esophagus

Stage III is divided into stages IIIA and IIIB, depending on where the cancer has spread.

• Stage IIIA: Cancer has spread:
  • into the mucosa layer, thin muscle layer, or submucosa layer of the esophagus wall. Cancer is found in 3 to 6 lymph nodes near the tumor; or
  • into the thick muscle layer of the esophagus wall. Cancer is found in 1 or 2 lymph nodes near the tumor.

• Stage IIIB: Cancer has spread:
  • into the thick muscle layer of the esophagus wall. Cancer is found in 3 to 6 lymph nodes near the tumor; or
  • into the connective tissue layer of the esophagus wall. Cancer is found in 1 to 6 lymph nodes near the tumor; or

  • into the diaphragm, azygos vein, pleura, sac around the heart, or peritoneum. Cancer may be found in 0 to 2 lymph nodes near the tumor.

Stage IV adenocarcinoma of the esophagus

Stage IV is divided into stages IVA and IVB, depending on where the cancer has spread.

• Stage IVA: Cancer has spread:
  • into the diaphragm, azygos vein, pleura, sac around the heart, or peritoneum. Cancer is found in 3 to 6 lymph nodes near the tumor; or

  • into nearby structures, such as the aorta, airway, or spine. Cancer may be found in 0 to 6 lymph nodes near the tumor; or

  • to 7 or more lymph nodes near the tumor.

• Stage IVB: Cancer has spread to other parts of the body, such as the liver or lung.

Esophageal cancer can recur (come back) after it has been treated.

The cancer may come back in the esophagus or in other parts of the body.