Close

Cervical Esophageal Cancer

If an adult in your life has cervical esophageal cancer, you may want to learn more about it. This page contains information about cervical esophageal cancer, its types and what to expect.

First, you should understand what cancer is. Cancer is a disease caused by abnormal cells that grow too rapidly. Our bodies are made of cells so tiny you need a microscope to see them. Cancer cells don’t look or act like normal cells, and they don’t allow our normal cells to work properly. There are many different types of cancer that can grow anywhere in the body.1 Krause CJ, Carey TE, Ott RW, Hurbis C, McClatchey KD, Regezi JA. Human squamous cell carcinoma. Establishment and characterization of new permanent cell lines. Arch Otolaryngol. Nov 1981;107(11):703-710.

The cervical esophagus is the top part of the feeding tube (esophagus) that extends from the bottom of the throat (hypopharynx) to the thoracic esophagus (part of the esophagus that leads to the stomach). Because it starts in the neck, cervical esophageal cancer will be grouped with throat cancers by many doctors.

In the U.S., most esophageal cancers are adenocarcinomas and are located in the lower part of the esophagus. Here we are focusing on cervical (or upper) esophagus cancers. These are almost always squamous cell carcinomas, though there have been reports of adenocarcinoma in the cervical esophagus as well.1 Krause CJ, Carey TE, Ott RW, Hurbis C, McClatchey KD, Regezi JA. Human squamous cell carcinoma. Establishment and characterization of new permanent cell lines. Arch Otolaryngol. Nov 1981;107(11):703-710.

Understanding the anatomy

To understand cervical esophageal cancer, you need a basic understanding of the anatomy (parts) of the head and neck.

The throat is made up of many different parts. The esophagus is a muscular tube that carries food and liquids from the throat into the stomach. It is located behind the breathing tube (trachea, or windpipe).

04a_throat_overview CROP

The esophagus is divided into three parts, going from top to bottom: the cervical esophagus, thoracic esophagus and abdominal esophagus. Because the cervical esophagus is in the neck, many people still consider this in the general category of throat cancer.

30_1_esophagus_regions

  • Cervical esophagus: This part of the esophagus extends from the hypopharynx to the sternal notch (the indentation in the middle of the neck between the two collarbones). It starts 16 centimeters from the teeth and ends where the esophagus enters the chest (approximately 20 centimeters from the teeth).
  • Thoracic esophagus: This part of the esophagus extends from the sternal notch down to where the stomach and esophagus join. It stretches approximately 20 to 40 centimeters from the teeth. It is divided into upper, middle and lower thoracic esophagus.
  • Abdominal esophagus: This part of the esophagus extends from the esophagus/stomach junction and five centimeters below. Cancers in the uppermost part of the stomach are fairly similar to esophageal cancer (in type and the way they behave), so they are often grouped here. Whether to call a tumor here a stomach cancer or an esophageal cancer is open to debate.

In front of the cervical esophagus is the trachea (windpipe). Behind the cervical esophagus is the tissue covering the spine. Beside the cervical esophagus is the carotid sheath, which protects important mechanisms for communication between the brain and body, as well as for transportion of blood to and from the head. Also, the thyroid gland curves around from the front of the neck and can sit beside the cervical esophagus as well.

The layers of the esophagus are important to know, because understanding how deeply the cancer has invaded is important for determining the stage of the cancer.

30_esophagus_layers

  • Mucosa: This is the inner lining of the esophagus. The mucosa has three layers:
    • Epithelium: The mucosa of the esophagus is lined with squamous epithelium. Cells that turn cancerous in this layer lead to squamous cell carcinoma. In the lower part of the esophagus, the squamous cells can be replaced with gland-like cells and lead to adenocarcinoma.
    • Lamina propria: This is a thin line of tissue just below the epithelium. If the cells invade past this layer, then we can call it cancer (T1 or greater).
    • Muscularis mucosa: This is a really thin layer of involuntary muscle.
  • Submucosa: This layer has mainly mucous glands that keep the esophagus lubricated and help food pass down the tube easily. There are also loose connective tissues, blood vessels and nerves in this layer.
  • Muscularis propria (also called the external muscle layer): This is a thicker layer of muscle than the thin muscularis mucosa. This muscle layer is responsible for the coordinated movement of food from the cervical esophagus all the way down to the stomach.
  • Adventitia: This is the outermost layer of the esophagus. Once cancer cells invade into the adventitia, it’s a T3 cancer (an advanced stage cancer). If the cells spread outside of this layer, they can get into some of the structures outside of the esophagus, and this can be much more challenging to cure.

Another important factor in esophageal cancer anatomy is regional lymph nodes. While lymph nodes for other head and neck cancers are located in the face or the neck, esophageal regional lymph nodes are in the lower neck and in the chest.

  • Supraclavicular zone: These are lymph nodes in the central part and the sides of the neck just above the collar bones. This includes lymph nodes in the sternal notch.
  • Superior mediastinal / aortic / inferior mediastinal / pulmonary nodes: These lymph nodes are in the chest and are best evaluated by thoracic and gastrointestinal specialists using imaging and endoscopic ultrasound.

Causes of cervical esophageal cancer

You may want to know what caused the cervical esophageal cancer. The short answer is that we don’t know. You can be sure that you did nothing to cause it. Also, it is not contagious (you can’t catch it).

By far the most common contributor to cervical esophageal cancer is using tobacco, particularly smoking it. Drinking too much alcohol also adds to the risk of developing cancer of the cervical esophagus.

Major factors that increase the chance of developing cervical esophageal cancer include:

  • Tobacco: Smoking cigarettes, cigars or pipes and using chewing tobacco greatly increase the chance of getting cervical esophageal cancer.2 Moore C. Smoking and cancer of the mouth, pharynx, and larynx. JAMA: the journal of the American Medical Association. Jan 25 1965;191(4):283-286.
  • Alcohol: Drinking too much alcohol is strongly related to getting cervical esophageal cancer. And if one both smokes and drinks heavily, the risk more than doubles.3 Pelucchi C, Gallus S, Garavello W, Bosetti C, La Vecchia C. Cancer risk associated with alcohol and tobacco use: focus on upper aero-digestive tract and liver. Alcohol research & health: the journal of the National Institute on Alcohol Abuse and Alcoholism. 2006;29(3):193-198.
  • Exposure to radiation in the past: Being exposed to radiation through previous treatment for another disease, certain working conditions or even a natural disaster can increase the chances of some cancers of the esophagus.4 Little MP. Cancer after exposure to radiation in the course of treatment for benign and malignant disease. The lancet oncology. Apr 2001;2(4):212-220.
  • Plummer-Vinson Syndrome: This condition, more common in women, is associated with low iron and low blood counts (anemia), along with webs of tissues in the throat that cause difficulty with swallowing.5 NCCN Guidelines version 2.2012. Esophageal and esophagogastric junction cancers. Principles of Endoscopic Staging and Therapy. NCCN 2013.

Other factors that can increase the risk of developing cancer of the cervical esophagus include:

  • Drinking hot liquids or foods frequently
  • A history of drinking poisons such as lye
  • Certain viruses or bacteria
  • Certain diet factors such as nitrosamine or some vitamin deficiencies
  • Celiac disease
  • Genetic factors

Signs and symptoms of cervical esophageal cancer

In many cases, cervical esophageal cancers get quite large before patients become aware of symptoms. The most common symptom is increasing difficulty with swallowing, but many other symptoms can also be present including:6 Modlin IM, Shapiro MD, Kidd M. An analysis of rare carcinoid tumors: clarifying these clinical conundrums. World J Surg. 2005 Jan;29(1):92-101.

  • Pain or difficulty with swallowing in the throat: This can occur because a tumor is in the way of swallowing, so it becomes difficult or painful to swallow. Also, there can be ulceration (an area of dead cells) and bleeding as the tumor grows, causing pain.
  • Weight loss: As it becomes more and more difficult to swallow solid foods, patients often develop fairly severe weight loss. Weight loss is caused from the cancer using up lots of nutrients and because patients aren’t eating as much.
  • A lump in the neck: This will be a symptom of cervical esophageal cancer if it has spread to lymph nodes in the neck. This can be the first symptom that brings a patient to the doctor.
  • Ear pain (particularly on one side, with no other ear problems): Ear pain, also known as otalgia, happens because the nerves of the throat reach the brain through the same pathway as one of the nerves in the ear. Therefore, the brain might think a pain in the throat is coming from the ear. This is called referred pain. For this reason, unexplained ear pain that doesn’t go away should be checked by a specialist. It is important to understand that most causes of ear pain are due to simple problems such as middle ear infection, dysfunction of the Eustachian tube or TMJ pain due to a problem in the joint located in front of the ear.

Other possible symptoms might include:

  • A hoarse voice
  • Coughing when drinking liquids
  • Feeling like there’s something stuck in the throat
  • Bleeding (coughing or vomiting blood)

These symptoms sound scary but don’t jump to conclusions. A person could have one or more of these symptoms but NOT have cervical esophageal cancer. There are several non-cancerous causes of the same symptoms. That’s why the patient needs to see a specialist.

What will happen at the doctor visit

Step 1: History

First, the doctor will listen to the patient talk about his or her health. The doctor will probably ask many questions, too.

The doctor might ask some of these questions:

  • How long has the problem been there?
  • Is it getting worse, better or staying the same?
  • Does it come and go?
  • Have you tried anything to make it better?
  • Is it painful?
  • Do you have numbness or tingling anywhere in your face or mouth?
  • Do you have any lumps or bumps in your neck?
  • Are you losing weight?
  • Do you have any other medical conditions?
  • Have you had any surgeries in the past?
  • What medications do you take? And do you have any allergies?
  • Have you ever been exposed to radiation in the head and neck?
  • What do you (or did you) do for a living?
  • Do you have a family history of cancer?

Step 2: Physical Exam

Next, the doctor will look at and feel the patient’s head and neck. The throat typically requires a specialist to examine it because it is not easy for a general doctor to see and feel. In general, the specialist might do some of the following:

  • Feel the neck extensively and carefully to check for any lumps or bumps
  • Look inside the ears
  • Look inside the front of the nose
  • Check the cranial nerves, do some simple hearing tests and test sense of touch all over the face

Step 3: Reviewing Tests

After getting background information and doing a physical exam, the doctor will look at the results of any tests the patient has already had.

Step 4: Suggestions

Finally, the doctor will make suggestions about next steps. This will probably include more tests and doctor visits.

Diagnosing cervical esophageal cancer

If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less worried that the lesion is cancer, the doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

However, if the doctor is worried, he or she may choose one or more of the following actions.

Imaging

Imaging refers to radiologic studies, or scans, that make pictures of the structures inside the head and neck. In general, imaging might not be necessary for small tumors that can be easily seen by the doctor. For larger tumors, or tumors in locations difficult to examine, the doctor will probably order some sort of imaging to get more information about the tumor location to see if the tumor has spread to nearby lymph nodes. An important reason to get a scan for sinonasal tumors is to see if there is any evidence of spread into nearby structures. Spread into other structures will influence what treatment the doctor recommends.

Some surgeons also say getting some imaging (pictures of the inside of the head and neck) will lower the chance of surprises in the operating room. Imaging will also give some clues about whether the tumor is really cancer. This will prepare the patient and the surgeon for what to expect during surgery.

There are many different kinds of imaging scans. The doctor may recommend more than one kind of scan to see a better picture of the tumor.

The two main types of imaging used in the U.S. are CT scans and MRI scans.

CT SCAN MRI
 CT Scan  MRI
Advantages A computed tomography (CT) scan is a quick test that shows a great deal of useful information. A CT scan can show the size of the tumor and how far it has spread. It can help a surgeon plan an operation. Magnetic resonance imaging (MRI) is better at showing how the tumor has spread to body parts around it. The patient will not be exposed to radiation during an MRI.
Disadvantages A CT scan uses radiation, which can be dangerous. The pictures might not be clear if the patient moves or has a lot of dental work. Also, a CT doesn’t show damage to nearby body parts as clearly unless the damage is moderate to severe. An MRI takes a lot longer than a CT scan. It requires the patient to lie perfectly still for almost an hour. The patient can’t have an MRI if he or she has metal implants.

For most head and neck cancers, if imaging is required, the doctor will likely start with a CT scan with contrast. Other tests might include an MRI and/or a positron emission tomography (PET) scan.

Biopsy

A biopsy is the main way to find out if a growth is cancer. For a biopsy, the doctor takes out a small piece of the lump or the entire tumor. Another doctor, called a pathologist, then looks at the sample under a microscope to see if it is cancer. Doctors often do biopsies because they can usually be done quickly and safely. The doctor can sometimes do a biopsy during the first visit with very little risk.

Fortunately, biopsies of the skin are more straightforward than for other sites, mainly because they are easier to get to. Typically, skin cancers can be biopsied in the office with a little numbing medicine. It usually takes only a few seconds to do a biopsy. The tissue is then sent to a pathology doctor to see if it is cancer and, if so, what type and how far it has spread.

A biopsy can help the doctor plan the surgery if he or she decides it is needed. A biopsy can also prevent unnecessary surgery.

As good as biopsies sound, there are a few problems. First, biopsies are not 100 percent accurate. A biopsy could show that a growth is NOT cancer when it really is; this is called a false-negative biopsy. A false-positive is also possible when the biopsy seems to show that a growth is cancer but more testing shows it isn’t. Sometimes doctors can’t be completely sure a tumor is cancerous from a biopsy.7 Key C and Meisner ALW. Chapter 3: Cancer of the Esophagus, Stomach, and Small Intestine. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.

Determining the type of cervical esophageal cancer

After the tumor has been closely looked at, the doctor will need to figure out what type of cancer it is. He or she may be able to tell from biopsy results. The doctor may also want a second opinion from a specialist to be sure. Remember, not all lumps and bumps inside the throat are cancer. Some growths are benign (non-cancerous), and some tumors are on the border between benign and malignant (cancerous).

  • Squamous cell carcinoma: These are by far the most common cervical esophageal cancers.1 Krause CJ, Carey TE, Ott RW, Hurbis C, McClatchey KD, Regezi JA. Human squamous cell carcinoma. Establishment and characterization of new permanent cell lines. Arch Otolaryngol. Nov 1981;107(11):703-710. They arise from cells lining the upper part of the cervical esophagus.
  • Adenocarcinoma: This type of cancer is from the gland-type cells in the esophagus. Adenocarcinoma is very rare in the cervical esophagus. It is much more common in the lower third of the esophagus.

Rare cancers found in the cervical esophagus include:

  • Lymphoma: Lymphoma is cancer of the lymphatic system, which includes lymph nodes, lymph channels, lymphatic fluid and lymphoid tissue. The throat is lined with lymphoid cells. Some major sites of lymphoid tissue include the adenoids in the nasopharynx and palatine tonsils and lingual tonsils in the oropharynx. This is why lymphoma might appear as a lump in the throat area.
  • Carcinoid: This very slow-growing tumor is only rarely found in the esophagus, particularly the cervical esophagus (the most common site for this type of tumor is the appendix). Carcinoid tumor is a neuroendocrine tumor, meaning the tumor cells can secrete hormones into the blood stream. It is typically a benign tumor but can occasionally become cancerous.

Although extremely rare, these cancers can also develop in the cervical esophagus:

  • Sarcomas such as leiomyosarcoma, liposarcoma, rhabdomyosarcoma
  • Malignant fibrous histiocytoma
  • Peripheral Neuroectodermal Tumor (PNET)
  • Cancer spread from another site

The doctor will determine the treatment for the cancer based on the category (type), grade (abnormality) and stage (severity) of the tumor.

Determining the grade of the tumor

Pathologists will typically report on the grade of the tumor. This is a qualitative interpretation by the pathologist of how much the cancerous cells resemble normal tissue from that site. There are a number of different grading systems that might be used. The most common is as follows:

  • GX: Grade cannot be assessed
  • G1: Well differentiated
  • G2: Moderately differentiated
  • G3: Poorly differentiated
  • G4: Undifferentiated

Differentiation refers to how closely the cells taken from a tumor or lesion resemble normal cells from the healthy tissue surrounding the tumor. “Well differentiated” means that the cells look similar to normal cells in that area. “Undifferentiated” means the cells look nothing like normal cells in that area.

While it is important to report the tumor’s grade, few doctors use this information to make decisions regarding treatment or prognosis for this particular cancer type.

Determining the stage of the cancer

The final step before treatment is identifying the stage or the extent of the cancer. This will be determined by studying the physical exam, imaging studies, laboratory work and biopsies.

Like with all cancers of the head and neck, doctors in the U.S. use the AJCC Cancer Staging Manual (7th Ed) to figure out the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumor mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

T stage: the main tumor

Based on a physical examination and review of any imaging, the doctor should be able to assign a T stage that falls within one of the following categories.

31_esophagus_Tstages

Tx The doctor is unable to assess the main tumor.
T0 The doctor is unable to find the main tumor.
Tis(HGD) High grade dysplasia (HGD) is abnormal cells that have not invaded deeper cell layers. This term has replaced the term carcinoma in situ for columnar mucosa in the GI tract.
T1a The tumor has invaded the lamina propria or muscularis mucosae.
T1b The tumor has invaded the submucosa.
T2 The tumor has invaded the muscularis propria.
T3 The tumor has invaded the adventia.
T4a A resectable tumor has invaded the pleura, pericardium or diaphragm.
T4b An unresectable tumor has invaded other structures such as the aorta, spine, trachea, etc.

N stage: spread of cancer to the lymph nodes in the neck

Next, the doctor will use all the available information to figure out the N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the lymph nodes.
N1 The cancer has spread to one or two lymph nodes in the region.
N2 The cancer has spread to three to six lymph nodes in the region.
N3 The cancer has spread to seven or more lymph nodes in the region.

M stage: spread of cancer outside the head and neck

Finally, the doctor will identify an M stage. The M stage is based on an examination of the entire body.

M0 No evidence of distant (outside the head and neck) spread.
M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.).

The cancer stage

After TNM staging, the doctor can assign a cancer stage based on the following chart.

For squamous cell carcinomas:

Stage T N M Grade Tumor Location
0 Tis (HGD) N0 M0 1, X Any
IA T1 N0 M0 1, X Any
IB T1 N0 M0 2-3 Any
T2-3 N0 M0 1, X Lower, X
IIA T2-3 N0 M0 1, X Upper, middle
T2-3 N0 M0 2-3 Any
IIB T2-3 N0 M0 Any Any
T1-2 N1 M0 Any Any
IIIA T1-2 N2 M0 Any Any
T3 N1 M0 Any Any
T4a N0 M0 Any Any
IIIB T3 N2 M0 Any Any
IIIC T4a N1-2 M0 Any Any
T4b Any M0 Any Any
Any N3 M0 Any Any
IV Any Any M1 Any Any

For adenocarcinomas (which are very rare in the cervical esophagus):

Stage T N M Grade
0 Tis (HGD) N0 M0 1, X
IA T1 N0 M0 1-2, X
IB T1 N0 M0 3
T2 N0 M0 1-2, X
IIA T2 N0 M0 3
IIB T3 N0 M0 2-3
T1-2 N1 M0 Any
IIIA T1-2 N2 M0 Any
T3 N1 M0 Any
T4a N0 M0 Any
IIIB T3 N2 M0 Any
IIIC T4a N1-2 M0 Any
T4b Any M0 Any
Any N3 M0 Any
IV Any Any M1 Any

The clinical stage

Once the tests are completed, and before deciding on a treatment plan, the patient should be given a clinical stage that looks like this:

CLINICAL STAGE
Site Esophagus
Subsite Cervical Esophagus
Type Squamous Cell Carcinoma
cT cT3
cN cN1
cM cM0
cStage 1

Deciding on a treatment plan

Like with all cancers in the head and neck, there are three general treatment options:

Let’s look at the types of treatments available.

Surgery

The main treatment for almost all cervical esophageal cancers is complete surgical removal of the tumor. The surgeon will cut out the tumor plus a little bit of normal tissue around it to be sure to get all the cancer. Another doctor, called a pathologist, will look at the entire tumor under a microscope to identify a more exact stage for the tumor. This report, called the pathologic stage, can help the doctor decide if radiation and/or chemotherapy are needed.

Radiation

Radiation therapy kills cancer cells with high-energy radiation such as X-rays or gamma rays. Radiation may be used as a main treatment for tumors that cannot be easily removed. The surgeon will use radiation alone or radiation with chemotherapy, depending on the characteristics of the tumor. Radiation is also often used after surgery to lower the chances that the tumor will come back.

Chemotherapy

Chemotherapy, or “chemo,” uses drugs to kill cancer cells. It is especially helpful when:

  • Cancer has spread beyond the head and neck.
  • There is a T3 or T4 tumor in which surgery cannot remove all of the tumor.
  • There is a T3 or T4 tumor that has certain bad features found under the microscope, such as intermediate or high grade.
  • There are close edges.
  • There is growth into nerves.
  • There is spread into lymph nodes.
  • There is growth into lymphatics or vessels.

Determining the prognosis

The prognosis is a prediction of how the treatment will turn out. How likely is it that a person with cancer will be cured? Will the cancer come back? How will life change? These are the big questions on most people’s minds when they find out that someone they love has cervical esophagus cancer.

Prognosis is based on many factors, and a survival rate is an estimate based on large populations of patients who have been given a similar stage of their cervical esophageal cancer. There are many specific factors unique to each patient that may influence treatment success.

The following aspects of the cancer may affect the prognosis.

Stage of Cancer This is the most important factor that affects the chances of being cured.
Grade of Cancer This is particularly important for adenocarcinoma.7 Key C and Meisner ALW. Chapter 3: Cancer of the Esophagus, Stomach, and Small Intestine. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.
Depth of Invasion Some studies have shown that how deep the tumor goes into the esophageal wall can be associated with survival.8 Mariette C, Balon J-M, Piessen G, Fabre S, Van Seuningen I, Triboulet J-P. Pattern of recurrence following complete resection of esophageal carcinoma and factors predictive of recurrent disease. Cancer. 2003;97:1616-1623.
Type of Cancer Squamous cell carcinoma of the esophagus has a slightly worse prognosis than adenocarcinoma (12 percent survival at five years versus 15 percent at 5 years).7 Key C and Meisner ALW. Chapter 3: Cancer of the Esophagus, Stomach, and Small Intestine. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.

What to expect after treatment is completed

When the person in your life who has cancer has completed treatment, he or she will need to follow up closely with the doctor. Follow-up doctor visits and testing are to make sure the cancer doesn’t come back or to catch it quickly if it does. In general, a person should have regularly scheduled doctor’s visits every one to three months for the first year, every two to six months in the second year and every four to eight months in the third to fifth year. In addition, the doctor will order scans to help in the monitoring process. After making it past the first five years, the person can then see the doctor once a year.


References

1 Krause CJ, Carey TE, Ott RW, Hurbis C, McClatchey KD, Regezi JA. Human squamous cell carcinoma. Establishment and characterization of new permanent cell lines. Arch Otolaryngol. Nov 1981;107(11):703-710.

2 Moore C. Smoking and cancer of the mouth, pharynx, and larynx. JAMA: the journal of the American Medical Association. Jan 25 1965;191(4):283-286.

3 Pelucchi C, Gallus S, Garavello W, Bosetti C, La Vecchia C. Cancer risk associated with alcohol and tobacco use: focus on upper aero-digestive tract and liver. Alcohol research & health: the journal of the National Institute on Alcohol Abuse and Alcoholism. 2006;29(3):193-198.

4 Little MP. Cancer after exposure to radiation in the course of treatment for benign and malignant disease. The lancet oncology. Apr 2001;2(4):212-220.

5 NCCN Guidelines version 2.2012. Esophageal and esophagogastric junction cancers. Principles of Endoscopic Staging and Therapy. NCCN 2013.

6 Modlin IM, Shapiro MD, Kidd M. An analysis of rare carcinoid tumors: clarifying these clinical conundrums. World J Surg. 2005 Jan;29(1):92-101.

7 Key C and Meisner ALW. Chapter 3: Cancer of the Esophagus, Stomach, and Small Intestine. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.

8 Mariette C, Balon J-M, Piessen G, Fabre S, Van Seuningen I, Triboulet J-P. Pattern of recurrence following complete resection of esophageal carcinoma and factors predictive of recurrent disease. Cancer. 2003;97:1616-1623.

Important: Privacy Update

Your privacy and the protection of your personal information is important to the THANC (Thyroid, Head and Neck Cancer) Foundation and the Head & Neck Cancer Guide (HNCG). For this reason, we have updated our privacy policy to align with the GDPR (General Data Protection Regulation).

Please click below to see an updated privacy policy that describes how we collect and use your personal information and respect your privacy.

Privacy Policy