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Cervical Esophageal Cancer

Diagnosing Cervical Esophageal Cancer

Getting to a diagnosis begins with a history and physical examination. If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that your lesion is cancer, your doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer. You might undergo some anti-reflux medications, try changing your diet, try speech therapy or receive special tests such as an esophagram or a modified barium swallow test.

At some point, if your doctor is not certain of a diagnosis, and if symptoms aren’t getting better (and definitely if symptoms are getting worse), your doctor should raise the possibility of starting a cancer work-up. Like with most cancers in the head and neck, this will include some combination of biopsy and imaging tests.

Be sure to bring all reports and images from any prior treatment with you to your appointment with your head and neck cancer specialist.

Imaging

Imaging refers to radiologic studies, or scans, that create pictures of the structures inside your head and neck. In general, for small tumors that are easily evaluated on physical examination, imaging might not be necessary. For larger tumors, or tumors in locations that are difficult to examine (including most tumors of the hypopharynx), your doctor will probably order some sort of imaging to get more information about the tumor location and possible spread to regional lymph nodes. [link to 2.1.1 Imaging]

Your imaging will probably include an esophagram because it is quick and easy and gives a great deal of information.

  • Esophagram (also called a barium swallow): This is basically a moving X-ray taken while you swallow a special liquid (usually barium) that lights up in the X-ray images. As you drink the liquid, the technician will take pictures of the liquid moving down your esophagus. Normally, there should be a smooth line of liquid going down your throat. If there is a tumor in the cervical esophagus, there will be a little indentation (or even a complete blockage in the case of a large tumor) instead of a smooth line of liquid going down into your stomach.

Also, other imaging can help your doctor determine the location and extent of the tumor, how it relates to major structures in the head and neck and, in some cases, evidence of invasion into bone and/or nerves.

The two main imaging techniques used in the U.S. are computed tomography (CT) scans and magnetic resonance imaging (MRI) scans. Ultrasound is a quick and inexpensive way to get information about disease that is in lymph nodes in the neck. PET scans are studies that look at the function of cells in the body, and they are being used more and more in oncology. PET scans can be combined with other imaging methods such as CT scans to get more detailed information.

CT Scan: This is a quick series of X-rays that can show very good detail of the anatomy. It is helpful in seeing the extent of the main tumor mass and what structures it has invaded. It can also help detect spread into the neck.

  • Advantages: A CT scan is a quick test that is readily available and gives a great deal of useful information.
  • Disadvantages: A CT scan involves radiation, and the images can be degraded by movement and dental work. It only shows late changes associated with invasion into nerves (such as destruction of the bone where the nerve enters the skull).
  • Important points: A CT scan looking for throat tumors should be done with a contrast dye that is injected into your veins, unless there is some reason that you cannot receive contrast. Allergies to iodine and shellfish are common indications that a patient may be allergic to contrast dye.
  • What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. CT scans are typically open, so you shouldn’t feel enclosed. You will then get an injection of contrast, and soon after, the scanner will start moving and taking pictures; this part should only take one or two minutes. Try not to swallow, speak or move during this quick test.

MRI: This test uses magnets to create a picture of the inside of the neck. It is good for showing more subtle details of how extensive the main tumor mass is. It can also help pick up spread of cancer to lymph nodes in the neck.

  • Advantages: There is no radiation involved, and the details of the soft tissues are better than that of a CT scan.
  • Disadvantages: An MRI takes much longer than a CT scan and is more expensive. Some people feel enclosed inside the MRI machine and may require sedation to get through the study.
  • Important points: This test should be done with and without contrast injected into your veins, unless there is some reason you can’t have contrast. Closed MRI machines usually give better pictures than open MRI machines.
  • What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. Due to the strength of the magnets, you will be instructed to remove any metallic objects and to change into a hospital gown before entering the room where the scanner is located. You will then enter the scanner, and the MRI machine will start moving and taking pictures. This can take 30 to 60 minutes, depending on how the scan is done. Try to stay as still as possible throughout the test.

Positron Emission Tomography (PET): Doctors are still studying the most appropriate uses of PET scans for head and neck cancer. The main uses of PET scans at this point are to see if there is spread to sites in the neck or other parts of the body or to help find a primary tumor when the only evidence of cancer is a lymph node that has cancer in it. It is often combined with a CT scan (or in some cases an MRI) to help pinpoint the location of active cells.

Neck ultrasound: An ultrasound is a way to look at vessels, structures and lymph nodes all over the body, particularly in the neck and thyroid gland. You are not exposed to any radiation, and it doesn’t hurt. Basically, a technician or a radiologist will place some cold jelly over the area that is being examined and rub a plastic probe over the area to take pictures. The technician can see enlarged lymph nodes and nodules deep in the neck and describe details about them such as whether they have fluid inside, have a lot of blood vessels around and so on. At the same time that the ultrasound is being performed, a doctor can place a needle into a lymph node or nodule and draw off cells (this is an ultrasound-guided biopsy).

Chest X-ray: This is a quick, inexpensive and easy way to look for signs of spread of cancer into the lungs or the possibility of a different cancer in the lungs. Some doctors will recommend a chest X-ray every year as follow-up if you have had a head and neck cancer. This is because patients who have had head and neck cancer are at a higher risk of getting lung cancer as well.

Finally, some special considerations with esophageal cancer that are different from other head and neck cancers are that you will probably get a chest and abdominal CT scan with both IV contrast as well as contrast for you to drink. You may also be referred for a pelvic CT scan.

Biopsy

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of the suspicious lesion in your throat. The biopsy report is extremely important for determining your diagnosis and treatment plan.[link to 2.1.2 Biopsies]

When performing a biopsy on a neck mass, your doctors should test for certain viruses such as human papillomavirus (HPV) and Epstein-Barr Virus (EBV). They can also test for proteins related to these viruses (e.g. P16 as it relates to HPV infection). Cancerous lymph nodes that have the HPV virus (or P16 protein) are very likely to be related to a primary cancer in the oropharynx. A positive HPV or P16 test should make your doctor spend extra time and effort looking for a small or hidden tumor somewhere in the oropharynx.

If you have a biopsy done in the operating room, your surgeon will likely send the piece of tissue to the pathologist for an intraoperative evaluation with a “Frozen Section.” In a frozen section evaluation, the pathologist rapidly freezes the biopsy piece and tries to make an immediate diagnosis. The aim of this intraoperative consultation is really just to determine if the biopsy was sufficient to make a diagnosis or if another biopsy should be performed while you are still asleep under anesthesia. The final result of the pathology will be available after the biopsy piece is evaluated completely by the pathologist in a few days.

Biopsy of cervical esophageal lesions

At some point, you will need a biopsy of the suspicious lesion in your esophagus. Typically, you will undergo endoscopy with biopsy. Exactly how the endoscopy is done will be up to your physician. The three general ways to biopsy a suspicious area in the cervical esophagus are:

  • Transnasal esophagoscopy with biopsy: While not all doctors will do this, it is technically possible to use a special flexible noodle-like camera (a little longer than the flexible laryngoscope) and look past the pharynx into the esophagus. Actually, with most of these special cameras, it may even be possible to take a tiny biopsy right in the office. You should talk to your doctor to see if this is an option.
  • Flexible esophagoscopy with biopsy: With this technique, you will receive some sedation (but not be knocked out completely). A specialist will put a flexible camera into your mouth and look down into your esophagus. He or she will then be able to look at the entire esophagus and biopsy any areas that look suspicious.
  • Rigid esophagoscopy with biopsy: With this technique, a surgeon will take you to the operating room and give you general anesthesia with a breathing tube. He or she will first thoroughly feel your neck while you are asleep and then look inside your mouth and throat, including the larynx, to make sure there are no other suspicious areas. The doctor will then move on to the rigid esophagoscopy. For this procedure, a metal tube is carefully placed into your mouth and down into your esophagus. It gives your surgeon an excellent view of where the tumor starts and ends and allows him or her to take biopsies.

Endoscopic ultrasound, with or without fine needle aspiration biopsy (FNAB): This should be performed prior to any treatment to help assign you a cancer stage. This test will allow your team to get a better sense of the depth of invasion of the tumor (T stage), as well as to look at any abnormal lymph nodes in the region around the esophagus (N stage). In some cases, the ultrasound might even identify signs of spread around organs near the esophagus and give an M stage.5Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Esophageal and Esophagogastric Junction Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.

Endoscopic ultrasound is typically performed by a gastroenterologist with special training in this technique. You will be sedated, and a camera with an ultrasound will be passed through your mouth into your esophagus. Like an ultrasound of other parts of your body, sound waves are used, and the specialist can gather a lot of information about the tumor in your esophagus and lymph nodes around it. Actually, the specialist can even use a small needle and take biopsies of surrounding areas, including suspicious lymph nodes, to see if the cancer has spread anywhere.

Bronchoscopy: According to the current National Comprehensive Cancer Network® (NCCN®) Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Esophageal and Esophagogastric Junction Cancers, you should undergo a bronchoscopy for esophageal cancers that are above where the trachea enters the lungs.5Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Esophageal and Esophagogastric Junction Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org. In this procedure, typically done by a thoracic surgeon, pulmonary doctor or sometimes a head and neck surgeon, you are sedated, and a camera is inserted through your mouth, through your vocal cords, into your windpipe and into your lungs. This is the best way to see if the tumor in the cervical esophagus is going through the wall into the trachea (which would put the cancer into T4b).

 

References

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5 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Esophageal and Esophagogastric Junction Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.

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7 Vinik, A. I., Thompson, N., Eckhauser, F., & Moattari, A. R. (1989). Clinical features of carcinoid syndrome and the use of somatostatin analogue in its management. Acta Oncologica, 28(3), 389-402.

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