ESOPHAGEAL CANCER

Best Cancer Surgeon in Bangalore | Esophageal Cancer

The esophagus or food pipe is a muscular tube, which connects the throat with the stomach. The foods and liquids that we swallow travel to the stomach through the esophagus. The wall of the esophagus has four linings, starting with inner most mucosal lining to the outermost adventia layer. Cancer of the esophagus usually starts on the innermost lining of the esophagus, called the mucosal layer, but some start in the other layers as well.  In the earlier stages, the cancer is usually limited to the inner lining, but with time, it starts spreading, initially into the outer layers and eventually into the surrounding lymph nodes. The cancer becomes more advanced and beyond surgical treatment when it spreads through the blood vessels into lungs, liver and other distant organs. The treatment very much depends on the staging of cancer and this is discussed below.

Esophageal Cancer | Best Cancer Surgeon in Bangalore

Symptoms of Esophageal cancer

Esophageal cancer may manifest itself through one or more of the following symptoms:

  • The tumor, as it grows, can block the passage to the stomach. Hence patients may have difficulty in swallowing, especially hard foods, and sometimes even liquids
  • Choking on food or even liquids
  • Pressure or burning sensation in the chest
  • Heartburn or indigestion
  • Vomiting blood
  • Unexplained and sudden weight loss
  • Pain in the throat or behind the breastbone
  • Frequent coughing or hoarseness of speech
  • Due to bleeding, may present as anemia (low hemoglobin) on the blood test

Some people suffering from early-stage esophageal cancer do not have any of these symptoms. On the other hand, the symptoms may be indicative of other medical conditions apart from cancer. Hence, it is always recommended that you consult a doctor when you experience any persistent changes in your body.

Risk Factors For Esophageal Cancer:

The following are some of the risk factors associated with development of esophageal cancer:

  • Gender: Men are more likely to develop (3 times higher risk) compared to women
  • Age:  The incidence of cancer is seen between 50-70 years of age
  • Tobacco: From snuffing tobacco to chewing tobacco to smoking cigarettes and cigars all increase the risk of developing esophageal cancer.
  • Alcohol: Heavy drinking over a period of time increases the risk
  • Obesity: BMI greater than 25 (Asia) and greater than 30 (rest of the world) increase the risk of developing adenocarcinoma, especially in the lower one third of esophagus
  • Diet/ Nutrition: diet low in high fiber (fruits and vegetables), and diet low in certain vitamins and minerals can also increase the risk. There is also weak association of eating processed meats and developing cancer
  • Hot liquids: Drinking hot liquids greater than 65deg C has been correlated to developing squamous cell cancer of the upper third of esophagus due to damage caused by hot liquids to the mucosal lining
  • GERD/ Barrett’s esophagus: This condition is associated with change in the lining of the lower esophagus due to chronic acid exposure or GERD. Less than 1 percent of patient’s with Barrett’s proceed to develop adenocarcinoma, but risks increase when other risk factors like smoking, alcohol abuse and obesity are in the mix
  • Familial: Inherited disorders like Tylosis are also linked to developing SCC in esophagus
  • Others: Conditions like Plummer-Vinson syndrome, previous caustic injury to esophagus, achalasia and HPV infection are also linked with developing cancer in the esophagus

Diagnosis

There are many tests that diagnostic specialists employ. The tests are based on the symptoms, age, general health of the patient and his or her medical history. However, the following two tests are usually the best ways to confirm that a patient is suffering from cancer:

  • Endoscopy:An endoscope is a tiny video camera fitted to a slender, flexible tube. The endoscope is inserted into the esophagus via the throat, and the doctor carefully examines the mucosal lining of the esophagus, stomach and the duodenum. The procedure is very safe, and is usually less than 10 minutes. Mostly it is carried out with a throat spray, and the patient can return to normal activities within few hours. If any abnormalities or changes are noted on the examination, the doctor will proceed to take a sample/ biopsy from the concerned area.
  • Biopsy: A biopsy is only way to confirm cancer. The tissue is sent to a pathologist, who views it under a microscope and confirms if there are any cancerous cells present in the tissue

There are predominantly two types of cancer: Adenocarcinoma (ACC) and Squamous cell carcinoma (SCC).

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Staging

If the endoscopy and biopsy confirms cancer, the doctor will recommend further tests to stage the cancer, and determine if the cancer is surgically removable as this offers best chance of cure. The most common tests used are:

  1. CT Scan: A computer tomography or CT scan comprises of a number x-ray images taken from various angles of the affected body part. A computer then combines the x-ray images into a single, detailed three-dimensional image to know more the tumour. Sometimes, a special dye is injected into the veins to show contrast and better detail. A CT scan measures the size of the tumor and the extent of its spread.
  1. PET Scan:A positron emission tomography or PET scan is generally conducted along with the CT scan; sometimes the combined tests are called PET-CAT scan. It is a technique used to create internal images of organs and tissues. A radioactive sugar substance is injected into the patient. Since cancer cells consume energy more actively than normal cells, the scanner easily detects the sugar agent, and through it, identify the extent of the cancer. PET-CT is now the preferred radiological
  1. Endoscopic Ultra Sound (EUS):

The doctor may sometimes recommend EUS to stage the cancer, and take biopsies from surrounding lymph nodes. This test is similar to the endoscopy test, with a specialized ultrasound probe fitted to the end of an endoscope.

 

Types of Treatment

Cancer management is the domain of a multidisciplinary (MDT) team, which consists of surgeons, oncologists, radiologists and radiation therapists. The MDT team will review all the tests, and based on patient’s health, age and staging of cancer, will recommend the most appropriate treatment going forward. 

If the cancer is localized and not spread, surgery is recommended as this is the most effective form of treatment. If there is spread or advanced disease, the patient may be recommended to undergo pre-operative chemoradiotherapy to downstage the cancer and proceed to surgery few weeks later. In certain cases of SCC of the upper one third of esophagus, definitive chemoradiotherapy may be used instead of surgery, and the surgeon will discuss that accordingly. The surgeon will discuss all the options with the patient and family before proceeding with the treatment plans.

Gastrointestinal Endoscopic Mucosal Resection (EMR)

EMR is a non-invasive surgical procedure that is performed in cases of small and early-stage cancers, which are localized to the lining of the esophagus without any lymphnode spread. The EMR removes the cancerous cells and some surrounding healthy tissue from the upper lining of the esophagus. The surgery is performed with the help of an endoscope, and is usually a day-case procedure carried out under sedation. Depending on biopsy results of the EMR specimen, the patient will either undergo regular surveillance or proceed to surgical resection (oesophagectomy) if the biopsy shows advanced features.

Esophagectomy (SURGERY) 

Esophagectomy is the definitive treatment for esophageal cancers, and offers the bet chance of cure. If the cancer is prevalent in the lower part of the esophagus where it connects with the stomach, part of the stomach is removed along with the lower, cancerous part of the esophagus. The stomach is then connected with what is left of the food pipe.

For tumours that affect the upper or middle section of the esophagus, the surgery will remove most of the esophagus to be sure of eradicating all the cancerous cells. In these cases, the stomach is pulled up into the chest region to reconnect with the remaining part. If much of the esophagus has to be removed and the stomach cannot be pulled up to that extent, the surgeon may use part of the intestine. The main principles of esophagectmy are:

  • Removal of the cancerous lesion in the esophagus with adequate margins to achieve a R0 resection
  • Remove the draining lymphnodes of the esophagus
  • Perform a safe anastomosis/ joint between the remaining esophagus and the stomach

Types of Esophagectomies

The type of esophageal surgery depends on the location of the cancer, its stage, i.e. the extent to which it has spread, and the number of incisions required.

Open Esophagectomy: This is the standard open procedure, in which the operation is conducted through incisions in the abdomen and chest (IVOR-LEWIS), or (MCKEOWN) if neck incision is used. IVOR- LEWIS surgery is predominantly for lower and middle third esophageal cancers, and MCKEOWN is for upper third cancers.

Minimally Invasive Esophagectomy (Laparoscopic / Robotic Surgery) 

MIS esophagectomy is gaining popularity around the world, and is recommended depending on the stage of the cancer. In this, the surgeon creates small tiny holes in the abdomen and chest to insert a camera which transmits images of the affected areas on a TV screen. Tiny surgical instruments are then inserted through the other cuts to carry out the procedure. This type of surgery requires a high level of skill, and experience. Since the surgery is minimally invasive, there is less postoperative pain compared to the open surgery, and can also lead to the the patient go home early.

Robotic surgery is the next level up from laparoscopic surgery, which offers the surgeon clearer pictures and higher magnification to carry out the procedure more efficiently. Only few centers offer robotic surgery, and require a dedicated team to carry it out.

Post-Operative Recovery:

Recovery is very much dependent on the patient’s age, health and any pre-morbid conditions. Patient usually stays in the hospital for 7-10 days with the first few days in ICU. The main risks of the operation include:

  • Anastomotic leak
  • Conduit (the pulled up stomach) necrosis
  • Chest infection
  • Bleeding
  • DVT/PE
  • Pain and wound issues
  • Mortality (dying from the operation within 30 days- low risk)
  • Cardiovascular events (heart attack, stroke etc)

The risks are usually low, and will be specifically explained by the surgeon taking into account patient’s health and ECOG performance status. 

Once home, the main focus is nutrition and recovery. Most of the patient’s will have feeding tube (jejunostomy) inserted into the intestine, to aid feeding at the time of surgery. This is needed as patient will not be able to consume his normal calories in the initial few weeks, and the tube helps with maintaining the nutritional intake until oral intake improves. The tube usually stays for 6-8 weeks, and then removed in the clinic without any issues.

Survival Figures:

In cancer surgery, two definitions are used: DFS  ( Disease/ cancer free survival) and OS ( Overall survival).  Cancer survivorship depends not only on the stage of cancer, but also on the patient’s pre operative health. The figures vary from country to country, and hence, the patient is rigorously followed up post surgery with regular radiological examinations and blood tests to look out for recurrence. It is essential that patients and their family members are educated to look out for signs and symptoms of recurrence, and gain prompt medical input