Research Article - Otolaryngology Online Journal (2017) Volume 7, Issue 3
Esophageal Carcinoma in Indonesia
- *Corresponding Author:
- Agus Surono MD, Faculty of Medicine, University Gadjah Mada, Indonesia, Tel: +62274518717, Email: [email protected]
Received date: July 17, 2017; Accepted date: August 03, 2017; Published date: August 10, 2017
Esophageal cancer is included in seven out of the ten malignancies resulting in death in the world. The incidence of esophageal cancer in Indonesia is estimated still low and there has been little research on the characteristics of esophageal cancer. The objective of this study was to determine the characteristics of patients with esophageal carcinoma. This was a retrospective descriptive study of data obtained from medical records of patients with esophageal carcinoma who had been treated at the tertiary hospital from 2012 to 2014. Most patients were males (75%) and aged from 61–65 years (30%). The histopathologic type was squamous cell carcinoma in 35% of cases and adenocarcinoma in 65%; 65% of carcinomas were moderately differentiated. Sixty percent of the esophageal carcinomas originated in the distal third of the esophagus. No metastases were identified in 85% of cases, whereas metastases were detected in the remaining 15%. The most common characteristics of Indonesian patients with esophageal carcinoma were male and age 61–65 years, the most common histopathologic type was adenocarcinoma, and most cancers were locally advanced at diagnosis.
Esophageal cancer is serious and life threatening, being the seventh most frequent cause of cancer mortality worldwide. Its prevalence varies from 30 to 800 cases per 10,000, the highest prevalence occurring in Iran, Russia, and China . There were 13,900 new cases in the United States in 2003, the incidence being higher in African Americans (13/100,000) than in other ethnic groups. Esophageal cancer occurs more commonly in men, the male to female ratio being 3:1. The risk of esophageal cancer increases with age, the average age at diagnosis being 67 years . The incidence of esophageal cancer is low in Indonesia and there has been negligible research on its prevalence and characteristics.
The most common histopathologic types of esophageal cancer are squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma is the commonest, accounting for about 60% of all esophageal carcinoma and usually causing death within five years of diagnosis . Squamous cell carcinoma most frequently occurs between the upper and middle thirds of the esophagus, whereas about 75% of adenocarcinomas originate in the lower esophagus . The diagnosis of esophageal cancer is established by the history and findings on physical examination, endoscopy, ultrasonography, barium esophagography, thoracic and abdominal multi-slice computer tomography, and tumor biopsy . Esophageal cancer is highly malignant and has a poor prognosis, even with early diagnosis and treatment, the average of 5 year survival rate being 10% . Because the incidence of esophageal cancer is increasing, further study concerning its characteristics is needed.
Patients and Methods
This was a retrospective descriptive study of data obtained from the medical records of patients with esophageal cancer who had been treated at tertiary hospital, Yogyakarta, Indonesia from January 2012 to December 2014, and had met the inclusion. The inclusion criteria were age 45 years and older and histopathologic confirmation of esophageal squamous cell carcinoma or adenocarcinoma. Patients with incomplete data were excluded.
Of the 20 patients who had been treated with esophageal carcinoma in hospital from 2012 to 2014 identified by a search of medical records, 15 (75%) were males and five (25%) females. Three of these patients (15%) were aged 41–50 years, five (25%) 51–60, eight patients (40%) 61–70, and four (20%) >70 (Table 1). Seven (35%) of the patients had squamous cell carcinoma and another 13 (65%) with adenocarcinoma. The most common site was the lower third of the esophagus (12 cases; 60%), followed by the upper and middle third of the esophagus (both four cases; 20%). Five of the cancers (25%) were classified as well differentiated, 13 (65%) were moderately differentiated, and two (10%) poorly differentiated. Most patients had localized disease, 17 cases (85%) having no identified metastases and three cases (15%) metastases (two to the liver [10%] and one [5%] to the lungs (Table 2).
|Age (years old)|
|α. 40-50||3 (15)|
|β. 51-60||5 (25)|
|χ. 61-70||8 (40)|
|δ. >70||4 (20)|
Table 1: Relevant patient characteristics.
|Squamous Cell Carcinoma|
|1. Well differentiated||3 (15)|
|2. Moderately differentiated||3 (15)|
|3. Poorly differentiated||1 (5)|
|1. Well differentiated||2 (10)|
|2. Moderately differentiated||10 (50)|
|3. Poorly differentiated||1 (5)|
|1. Upper third||4 (20)|
|2. Middle third||4 (20)|
|2.Lower third||12 (60)|
|No metastasis||17 (85)|
|With metastasis (liver and lung)||3 (15)|
Table 2: Characteristics of esophageal cancers.
Ten men (50%) and three women (15%) had adenocarcinoma and five men (25%) and two women (10%) squamous cell carcinoma. In the 61–70 year age group, five patients (25%) had adenocarcinoma and three (15%) squamous cell carcinoma (Table 3).
|Variable||SCC (%)||AC (%)||Total (%)|
|α. Male||5 (25)||10 (50)||15 (75)|
|β. Female||2 (10)||3 (15)||5 (25)|
|Age (years old)|
|α. 41-50||2 (10)||1 (5)||3 (15)|
|β. 51-60||2 (10)||3 (15)||5 (25)|
|χ. 61-70||3 (15)||5 (25)||8 (40)|
|δ. >70||0||4 (20)||4 (20)|
Table 3: Age and sex versus histopathologic type of esophageal cancer.
This study aimed to provide an overview of the basic characteristics of esophageal carcinoma at tertiary hospital, including histopathologic features, prime tumor location, and presence of metastasis. We found the disease was commoner in male than female patients, the ratio being 3:1. This is in accordance with the findings of a previous study, which have also reported a male to female ratio of 3:1 . The higher incidence in men may be related to the higher frequency of smoking habit. Previous research has shown that smoking is associated with an increased risk of esophageal cancer of squamous cell carcinoma type . The risk of esophageal cancer correlates directly with the number of cigarettes smoked per day and the duration of smoking . Most study patients with esophageal carcinoma were more than 60 years old, which is consistent with a report that esophageal cancer occurs most commonly in the fifth to sixth decade of life . There were more cases of esophageal adenocarcinoma (13 cases, 65%) than squamous cell carcinoma (seven cases, 35%). The incidence of squamous cell carcinoma has reportedly been declining during the last 20 years, whereas that of adenocarcinoma has increased in parallel with the increased prevalence of obesity, which can result in increased intraabdominal pressure and consequent gastroesophageal reflux . The most frequent location of esophageal cancer is reportedly the lower esophagus [6-8]; 12 of our patients (60%) had cancers in this location. Most adenocarcinoma of the esophagus occurs in the distal part of esophagus as a consequence of the columnar epithelial metaplasia that can replace the squamous epithelium during healing after reflux esophagitis; dysplasia can subsequently develop in these cells.
Most esophageal cancers in our series were locally advanced but without metastases; this being true of 17 patients (85%), whereas three (15%) had metastases. The high incidence of locally advanced disease is likely attributable to the absence of symptoms in the early stages. About 90% of patients with esophageal cancer present with difficulty swallowing (dysphagia) as their chief symptom; such dysphagia is characteristically progressive . In the present study, three patients (15%) had metastases, two cases (10%) in the liver and one (5%) in the lungs, which is consistent with the earlier research showing that the hematogenous metastases occur is the liver, lungs, and bones in that order . Because patients often present with late stage disease that is relatively unresponsive to treatment, the prognosis is poor.
Patients with esophageal carcinomas who attended tertiary hospital were mostly males, aged 61-70 years, had adenocarcinoma, and their cancers were most commonly located in the lower third of the esophagus and were locally advanced. Further study of risk factors, early diagnosis, and therapeutic strategies is needed, ideally involving multiple centers.
Declaration of Conflicting Interests
The authors declare that there are no conflicts of interest
This research did not receive specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
- Lin SH, Chang JY (2010) Esophageal cancer: Diagnosis and management. Chin J Cancer 29:843–854.
- Enzinger PC, Mayer RJ (2003) Esophageal Cancer. N Engl J Med. 349:2241–2252.
- Brown LM, Hoover R, Silverman D, Baris D, Hayes R, et al. (2001) Excess incidence of squamous cell esophageal cancer among US black men: Role of social class and other risk factors. Am J Epidemiol 153:114–122.
- Siewert JR, Stein HJ, Feith M,Bruecher BL, Bartels H, et al. (2001) Histologic tumor type is an independent prognosticparameter in esophageal cancer: Lessons from more than 1,000 consecutive resections at a single center in the Western World. Ann Surg 234:360–369.
- Allum WH, Griffin SM, Watson A, Colin-Jones D (2002) Guidelines for the management of esophageal and gastric cancer. Gut 50:1-23.
- Camilleri P. (2005) Esophageal carcinoma: A review of current practice in the United Kingdom. Malta Med J17:14-15.
- Koshy M, Esiashvilli N, Landry J, Thomas CR Jr, Matthews RH, et al. (2004) Multiple management modalities in esophageal cancer: Epidemiology, presentation and progression, work-up, and surgical approaches. Oncologist 9:137-146.
- Zhang Y (2013) Epidemiology of esophageal cancer. World J Gastroenterol 19:5598–5606.
- Javle M, Ailawadhi S, Yang GY, Nwogu CE, Schiff MD, et al. (2006) Palliation of malignant dysphagia in esophageal cancer: A literature-based review. J Support Oncol 4:365-373.
- Turkyilmaz A, Eroglu A, Aydin Y, Yilmaz O, Karaoglanoglu N, et al (2009) Survival in esophageal cancer patients with hematogenous distant organ metastases. Turk J Med Sci 39:415-421.