Esophageal Cancer

Esophagogastroduodenoscopy (EGDS) is a fundamental examination for the diagnosis of esophageal cancer. It consists of the introduction of a thin flexible tube with a camera on the end (endoscope) through the mouth to directly visualize the esophagus. During endoscopy, tissue samples (biopsy) may be taken for histological examination.

Chest and abdominal X-rays with a transit study, along with computed tomography (CT) scans, provide detailed images of the esophagus and surrounding structures, helping to assess the extent of the tumor.

This procedure combines endoscopy with ultrasound to obtain high-resolution images of the walls of the esophagus and surrounding lymph nodes.

This examination provides information on the tumor’s ability to absorb labeled glucose and allows more confident localization of disease sites and extent, particularly in cases where findings from CT scans are uncertain.

It is a endoscopic examination of the airways (trachea and bronchi) and is used to evaluate, in selected cases, direct involvement of these structures by esophageal neoplasia.

Ear, Nose, and Throat (ENT) examinations are used to rule out, in cases of esophageal squamous cell carcinoma, the presence of synchronous tumors in the oral cavity, which share common risk factors for esophageal disease, such as cigarette smoking and alcohol consumption.

Blood tests can provide information about the patient’s overall health and assess the function of various organs. Tumor markers, specifically CEA and CA 19-9, are also measured; although they are not specific to esophageal cancer and may be elevated in other conditions, they can serve as general indicators of tumor activity but cannot be used as definitive diagnostic tests for esophageal cancer.

Histologic examination is a process in which a pathologist carefully examines samples taken during an endoscopy under a microscope to identify any cellular abnormalities that may indicate the presence of esophageal cancer. They are, therefore, defined:

• The type of tumor (adenocarcinoma or squamous cell carcinoma)
• The “histological grade” or grading: describes the appearance of tumor cells under the microscope and indicates the degree of cell differentiation and how quickly they can grow
• biomarkers, i.e., assessment by immunohistochemical techniques of protein expression on tumor cells on the biopsy that represent a prognostic and/or predictive factor for response (e.g., PDL1, HER2 only in selected cases)

Endoscopic treatment is often considered for early esophageal cancers, particularly carcinoma in situ or superficial tumors. These treatment options include:

• Endoscopic Mucosal Resection (EMR): an endoscopic procedure to remove superficial or precancerous lesions of the esophagus without the need of open surgery
• Endoscopic Dissection Stretched to the Submucosa (ESD): an advanced endoscopic technique to remove larger, invasive tumors that extend to the submucosa of the esophagus

The surgical approach is based on esophagectomy, which is the partial or total surgical removal of the esophagus. This procedure can be performed through a traditional open incision or using minimally invasive techniques, such as laparocopic, thoracoscopic or robotic surgery. Depending on the location of the tumor, the surgery may involve the abdomen, chest, and in some cases, the neck.

Because esophagectomy is a highly complex procedure, it is essential to carefully select patients who can safely tolerate the surgery and to ensure thorough preoperative preparation. For this reason, esophagectomy is performed only in centers with experienced multidisciplinary teams and a high volume of such procedures each year.

After removing the portion of the esophagus affected by the tumor, the esophageal tract must be reconstructed, typically using a portion of the stomach (esophago-gastric anastomosis) or another section of the intestine. Regional lymph nodes are also removed during the procedure to evaluate the extent of the tumor and reduce the risk of metastatic spread.

Chemotherapy can be used in several settings in the treatment of esophageal cancer, including:

• • Neoadjuvant treatment: administered before surgery to shrink the tumor and improve the likelihood of a successful outcome.
• • Adjuvant treatment: given after surgery to eliminate any remaining cancer cells and reduce the risk of recurrence.
• • Perioperative treatment: administered both before and after surgery.
• • Palliative treatment: used when the tumor has metastasized to other organs, aiming to relieve symptoms, improve quality of life, and extend survival.

Radiation therapy uses high-energy beams to destroy cancer cells. In the treatment of esophageal cancer, it can be combined with chemotherapy as neoadjuvant therapy before surgery to shrink the tumor or as adjuvant therapy after surgery to reduce the risk of local recurrence.

For inoperable tumors, radiation therapy may be used alone or alongside chemotherapy with a curative intent.

In patients with locally advanced esophageal cancer, it can also be employed palliatively to alleviate pain or difficulty swallowing (dysphagia).

Esophageal cancer staging is essential to determine the extent of disease and plan treatment. Using diagnostic test results, a stage is assigned to the tumor, such as stage 0 (carcinoma in situ) to stage IV (distant spread). Specifically:

• Endoscopic Mucosal Resection (EMR): an endoscopic procedure to remove superficial or precancerous lesions of the esophagus without the need of open surgery
• Endoscopic Dissection Stretched to the Submucosa (ESD): an advanced endoscopic technique to remove larger, invasive tumors that extend to the submucosa of the esophagus

The surgical approach is based on esophagectomy, which is the partial or total surgical removal of the esophagus. This procedure can be performed through a traditional open incision or using minimally invasive techniques, such as laparocopic, thoracoscopic or robotic surgery. Depending on the location of the tumor, the surgery may involve the abdomen, chest, and in some cases, the neck.

Because esophagectomy is a highly complex procedure, it is essential to carefully select patients who can safely tolerate the surgery and to ensure thorough preoperative preparation. For this reason, esophagectomy is performed only in centers with experienced multidisciplinary teams and a high volume of such procedures each year.

After removing the portion of the esophagus affected by the tumor, the esophageal tract must be reconstructed, typically using a portion of the stomach (esophago-gastric anastomosis) or another section of the intestine. Regional lymph nodes are also removed during the procedure to evaluate the extent of the tumor and reduce the risk of metastatic spread.

Chemotherapy can be used in several settings in the treatment of esophageal cancer, including:

• • Neoadjuvant treatment: administered before surgery to shrink the tumor and improve the likelihood of a successful outcome.
• • Adjuvant treatment: given after surgery to eliminate any remaining cancer cells and reduce the risk of recurrence.
• • Perioperative treatment: administered both before and after surgery.
• • Palliative treatment: used when the tumor has metastasized to other organs, aiming to relieve symptoms, improve quality of life, and extend survival.

Radiation therapy uses high-energy beams to destroy cancer cells. In the treatment of esophageal cancer, it can be combined with chemotherapy as neoadjuvant therapy before surgery to shrink the tumor or as adjuvant therapy after surgery to reduce the risk of local recurrence.

For inoperable tumors, radiation therapy may be used alone or alongside chemotherapy with a curative intent.

In patients with locally advanced esophageal cancer, it can also be employed palliatively to alleviate pain or difficulty swallowing (dysphagia).

Endoscopic treatment is often considered for early esophageal cancers, particularly carcinoma in situ or superficial tumors. These treatment options include:

• Endoscopic Mucosal Resection (EMR): an endoscopic procedure to remove superficial or precancerous lesions of the esophagus without the need of open surgery
• Endoscopic Dissection Stretched to the Submucosa (ESD): an advanced endoscopic technique to remove larger, invasive tumors that extend to the submucosa of the esophagus

The surgical approach is based on esophagectomy, which is the partial or total surgical removal of the esophagus. This procedure can be performed through a traditional open incision or using minimally invasive techniques, such as laparocopic, thoracoscopic or robotic surgery. Depending on the location of the tumor, the surgery may involve the abdomen, chest, and in some cases, the neck.

Because esophagectomy is a highly complex procedure, it is essential to carefully select patients who can safely tolerate the surgery and to ensure thorough preoperative preparation. For this reason, esophagectomy is performed only in centers with experienced multidisciplinary teams and a high volume of such procedures each year.

After removing the portion of the esophagus affected by the tumor, the esophageal tract must be reconstructed, typically using a portion of the stomach (esophago-gastric anastomosis) or another section of the intestine. Regional lymph nodes are also removed during the procedure to evaluate the extent of the tumor and reduce the risk of metastatic spread.

Chemotherapy can be used in several settings in the treatment of esophageal cancer, including:

• • Neoadjuvant treatment: administered before surgery to shrink the tumor and improve the likelihood of a successful outcome.
• • Adjuvant treatment: given after surgery to eliminate any remaining cancer cells and reduce the risk of recurrence.
• • Perioperative treatment: administered both before and after surgery.
• • Palliative treatment: used when the tumor has metastasized to other organs, aiming to relieve symptoms, improve quality of life, and extend survival.

Radiation therapy uses high-energy beams to destroy cancer cells. In the treatment of esophageal cancer, it can be combined with chemotherapy as neoadjuvant therapy before surgery to shrink the tumor or as adjuvant therapy after surgery to reduce the risk of local recurrence.

For inoperable tumors, radiation therapy may be used alone or alongside chemotherapy with a curative intent.

In patients with locally advanced esophageal cancer, it can also be employed palliatively to alleviate pain or difficulty swallowing (dysphagia).

Due to the high number of cases treated each year, the Candiolo Cancer Institute is a national reference center  for the care of esophageal cancer. This extensive experience allows us to manage even the most complex cases, always using a personalized approach, tailored to the clinical and individual profile of each patient.

Establishing a treatment plan always begins with an accurate and timely diagnosis. Patients have access to state-of-the-art imaging technologies that enable precise assessment of disease extent.

Additionally, the Institute provides advanced laboratory investigations, including molecular and genomic analyses, which are essential for identifying the biological characteristics of the cancer and guiding therapeutic decisions.

When appropriate, surgery is performed using minimally invasive techniques (laparoscopic or thoracoscopic), which minimize operative trauma, promote faster recovery, and enhance postoperative quality of life. All treatment decisions are made within the GIC (MDT), ensuring a coordinated and integrated approach.

As an IRCCS (Scientific Institute for Research, Hospitalization, and Healthcare), the Candiolo Cancer Institute combines clinical care with a strong focus on scientific research. Patients can be considered for participation in active clinical trials, offering access to innovative therapies not yet available in standard practice. This integration of care and research is a distinctive strength that translates into tangible benefits for patients.

The Multi Disciplinary Team (GIC or MDT) supports the patient at every stage, from diagnosis to treatment and follow-up, addressing nutritional needs, psychological well-being, and reintegration into daily life. The scheduling of checkups, visits, and treatments is organized to ensure continuity and peace of mind, always prioritizing the human dimension of care.