Esophageal cancer

Radiation therapy plays a central role in the treatment of esophageal cancers

BioXmark® has been demonstrated valuable as fiducial marker to guide treatment precision.

Facts about esophageal cancer

Esophageal cancer is the sixth and ninth leading cause of cancer related deaths among men and women, respectively. Worldwide, there are estimated to be 455,800 new esophageal cancer cases and 400,200 related deaths annually and both numbers are rapidly increasing[1,2]. Esophageal cancer is among the most aggressive of the gastrointestinal cancers with an overall 5-year survival rate ranging from 15 to 25%[1]. The incidence rate of esophageal cancer displays huge international variation (more than 21-fold)[2]. The highest rates are found in Eastern Asia and in Eastern and Southern Africa and the lowest rates are found in Western Africa. Esophageal cancer is 3 to 4 times more common in men than in women[3].

Cancers of the esophagus typically occur in one of two histological forms; squamous cell carcinomas (SCC) and adenocarcinoma (AC), arising from the stratified squamous epithelium and from the columnar glandular epithelium, respectively[4]. SCC is the most common histological type of esophageal cancer worldwide, but in Australia, the UK, the US, and some western European countries the incidence of AC now exceeds that of SCC[1].

Clinical presentation and diagnosis

Dysphagia (difficulty swallowing) is the most common symptom of SCC accompanied by weight loss. A history of smoking and alcohol intake while gastro esophageal reflux are the primary risk factors for AC[1].

Esophagogastroduodenoscopy is required to obtain biopsies and conforming cancer diagnosis on a histological level. When histology is confirmed, staging of the disease is essential to offer the patient the best treatment option. The staging process can include history, clinical examination, CT of chest and abdomen, PET, endoscopic ultrasound and bronchoscopy[1].

Surgical treatment

Esophagectomy is considered the cornerstone of the curatively intended treatment of non-metastatic esophageal cancer irrespective of histology. However, definitive chemoradiotherapy is considered an option for patients unwilling to or unfit for undergoing major surgery[1,5].

Neoadjuvant and adjuvant treatment

If the cancer is locally advanced, but still resectable, surgery alone gives unsatisfying survival due to a high recurrence rate. Multiple studies have demonstrated benefit of giving chemotherapy or chemoradiotherapy before surgery (neoadjuvant treatment). In the Western world, chemoradiotherapy is considered the golden standard based on the results of the multicenter CROSS trial[1,5].

Non-surgical treatment

Locally advanced and unresectable, metastatic and recurrent esophageal cancers are treated with systemic chemotherapy long life and with local therapies such as radiation and stents to treat dysphagia. For most patients this treatment is considered palliative with the aim of prolonging life and maximizing quality of life. A smaller number of patients with locally advanced disease initially considered unresectable will respond to the chemoradiation to an extent making subsequent resection possible – so-called conversion surgery. As mentioned above, a number of patients will also receive chemoradiotherapy with a curative intent but the rate of recurrence is very high[1,5].

How can BioXmark® add value in the treatment of patients with esophageal cancer?

As described above, radiation therapy plays a central role in esophageal cancer treatment and application of  BioXmark® as fiducial marker has been demonstrated valuable to guide treatment precision. Dr. de Blanck and colleagues from Rigshospitalet, Denmark, found it safe and feasible to implant BioXmark® in patients with cancers in the esophagus and the gastro-esophageal junction, using standard endoscopic equipment. Furthermore, they found that BioXmark® remained positionally stable and visible[6]. This supported the findings by Machiels et al. from Amsterdam University Medical Center that BioXmark® is feasible to implant, safe, visible (on both ultrasound and CT) and positionally stable in patients with esophageal cancers[7].

Besides the features supporting customizable applicability as a fiducial marker in esophageal cancers, as a liquid, BioXmark® has other unique advantages, including that several markers can be implanted in one uninterrupted procedure.

For more information about BioXmark®, see BioXmark®.


  1. Pennathur A, Gibson MK, Jobe BA, Luketich JD. Oesophageal carcinoma. The Lancet. 2013 Feb;381(9864):400–12.

  2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2018 Nov;68(6):394–424.

  3. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012: Global Cancer Statistics, 2012. CA: A Cancer Journal for Clinicians. 2015 Mar;65(2):87–108.

  4. Zhang Y. Epidemiology of esophageal cancer. WJG. 2013;19(34):5598.

  5. Watanabe M, Otake R, Kozuki R, Toihata T, Takahashi K, Okamura A, Imamura Y. Recent progress in multidisciplinary treatment for patients with esophageal cancer. Surg Today. 2020 Jan;50(1):12–20.

  6. de Blanck SR, Scherman-Rydhög J, Siemsen M, Christensen M, Baeksgaard L, Irming Jølck R, Specht L, Andresen TL, Persson GF. Feasibility of a novel liquid fiducial marker for use in image guided radiotherapy of oesophageal cancer. Br J Radiol. 2018 Dec;91(1092):20180236.

  7. Machiels M, Voncken FEM, Jin P, Dieren JM van, Bartels-Rutten A, Alderliesten T, Aleman BMP, Hooft JE van, Hulshof MCCM. A Novel Liquid Fiducial Marker in Esophageal Cancer Image Guided Radiation Therapy: Technical Feasibility and Visibility on Imaging. Practical Radiation Oncology. 2019 Nov 1;9(6):e506–15.