indiacancer.org - Cancer of the Esophagus

	Cancer of the Esophagus

		What is the esophagus?
		What is cancer of the esophagus?
		How does cancer of the esophagus present?
		How is cancer of the esophagus detected?
		What are staging and grading?
		How is esophageal cancer treated?
		What are the side effects of treatment for esophageal cancer?
		What is the importance of follow up?

What is the Esophagus?

The esophagus is located in the upper part of the digestive system and it is a hollow tube which acts as a conduit between the mouth or the oral cavity and the stomach. It helps in carrying food and liquid from the mouth to the stomach.

The esophagus passes through the neck behind the windpipe or the trachea through the chest wall, where it lies right at the back in the center of the chest cavity and into the abdomen through an opening in the diaphragm, which is a thin muscle which helps in breathing and separates the chest or the thorax from the abdomen. The moment it enters the abdomen it takes a sharp angle to the left and becomes continuous with the stomach.

Cancer of the Esophagus

What is cancer of the Esophagus?

Cancer of the esophagus is a cancer which is found arising from the tissues of the esophagus.

If the cancer is coming from the upper part of the esophagus, then it is usually a squamous type of cancer or a squamous carcinoma. This is because the lining of the upper part of the esophagus is made of flat scaly cells called squamous cells.

If it is arising from the lowest part of the esophagus, then it is usually an adenocarcinoma because here the lining of the esophagus is just like the lining of the stomach and it is made of glandular cells.

How does cancer of the Esophagus present?

The most common symptoms of esophageal cancer are different grades of difficulty in swallowing.

There may be pain associated with swallowing or there may be no pain at all. The pain may also be felt behind the breast bone. The difficulty in swallowing may become so complete that the patient regurgitates or vomits out whatever food he has swallowed almost immediately after the meal is over.

There also may be vomiting of blood which is known as hematemesis and the patient may show extreme loss of weight. No other cancer causes so much loss of weight as cancer of the esophagus because of this obstruction to swallowing and absolute lack of entry of any nutrition into the body. This difficulty in swallowing is known as dysphagia.

How is cancer of the Esophagus detected?

Besides the significant and obvious history given by the patient, the doctor may also perform a series of imaging investigations for the esophagus such as-

A barium swallow in which an x-ray is taken after the patient is made to drink a liquid containing barium sulfate which makes the esophageal lining opaque and easier to see on the x-ray. The tumor may show particular characteristics.

The doctor may also try to directly visualize the lesion by performing an investigation called an esophagoscopy. The esophagoscope is a fiberoptic self-illuminated tube which is introduced through the oral cavity and into the esophagus. It is usually done with the patient conscious, with just his posterior pharyngeal wall or posterior throat wall anesthetized by a local anesthetic spray. The patient is asked to assist the esophagoscope passing into his esophagus by swallowing every time the doctor pushes the 'scope further down. The more the patient is relaxed for this investigation, the easier it is for the patient. Once the doctor is directly able to visualize the lesion with the oesophagoscope he takes a small piece of tissue from the lesion. This is known as a biopsy, which is to be studied for positive histopathological diagnosis under a microscope by a pathologist. The doctor also tries to see if the esophagoscope can negotiate the tumor and pass beyond the tumor in order to find out what is the extent of invasiveness or the thickness of the disease. If the esophagoscope cannot negotiate the obstruction caused by the tumor, then it is known as an obstructing carcinoma of the esophagus.

The doctor may also order other imaging investigations including a chest x-ray which is important to find out whether there has ever been any aspiration or not. Aspiration is the passage of food or liquid down the wrong way, that is into the breathing apparatus, because the obstruction in the esophagus causes pooling of food and liquids right up to the top. This may result in pneumonia.

The doctor also may order a CT scan of the chest to find out if there are any lymph nodes which are involved in the region of the mediastinum, which is the central part of the chest cavity. (Lymph nodes are small bean-shaped structures, which act as stations for drainage of lymph, a clear watery fluid, which courses through out the body in transparent, thin tubes called lymph channels or lymphatics, from various organs).

The doctor also may order an ultrasonography of the abdomen to find out if there is evidence of metastasis to the abdomen.

What are staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs.

The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive.

Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome.

Staging may require additional imaging tests such as CT Scan of the brain, Sonography of the abdomen, Bone scan or chest X-ray. These are terms with which you must become familiar, if you are dealing with any form of cancer.

Carcinoma in situ. In this, the lesion is still very very early and is only found in the first layer of cells lining the esophagus and has not reached the basement membrane, which is the bottom firm layer of the mucosal lining.

Stage 1. Cancer is found in only a small part of the esophagus and has not spread to adjacent tissues, lymph nodes, or other organs.

Stage 2. Cancer is found in a large segment of the esophagus and has spread to all sides of the esophagus and may have spread to the local lymph nodes as well. But it has not spread to adjacent organs.

Stage 3. Cancer is spread to the lymph nodes near the esophagus and also to the tissues and organs near the esophagus but has not shown any signs of distant spread.

Stage 4. Cancer has spread to distant parts of the body.

Recurrent esophageal cancer. This is a disease which has come back after the primary therapy for the esophageal cancer is over. It may recur in the esophagus itself or in other parts of the body.

How is Esophageal cancer treated?

	A lot depends on the patient's constitution, the grade of his disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes an an oncosurgeon and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy may become an add on. Treatment strategies. Surgery is the bastion of treatment for carcinoma of the esophagus. The surgery to remove the esophagus is called an oesophagectomy. There are several ways of doing the oesophagectomy. The opening may be made only in the abdomen or only in the chest or both in the chest and the abdomen. This also depends on the location of the esophageal cancer, whether it is in the upper-third, middle-third or lower-third. The doctor removes the offending segment of the esophagus along with a reasonable healthy margin and then joins the esophagus remnant to the stomach so that the patient can still swallow. The stomach is converted into a narrow tube, much in the shape of the esophagus. Lymph nodes in the surrounding area to the esophagus are also removed to find out if they show any signs of metastasis which is the spread of cancer. The joining of the esophagus to the stomach may take place in the chest which is usual or it may take place in the neck. If the lesion in the esophagus is very high, then the anastomosis or the joining takes place with almost the top of the esophagus or the pharynx (the throat) with the stomach when the entire esophagus has been removed. Instead of the stomach, a portion of the intestine may also be interposed between the parts which are far away from each other. The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer. Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after. Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used. Internal radiation is also given for esophageal cancer. When radiation is used to treat cancer of the esophagus, a plastic tube or a dilator may be kept inside the esophagus to keep it patent. This is called intraluminal intubation and dilatation.There are many types of tubes available in the country and in the world. Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the esophagus is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy. This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks). Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after. Carcinoma in situ esophageal cancer. The option to be entertained: Surgery to remove the tumor.
	Stage 1 esophageal cancer. One of the following options may be entertained:
					An oesophagectomy.
					Chemotherapy plus radiation.
					Surgery with or without radiation and finally chemotherapy and radiation therapy with surgery.
	Stage 2 esophageal cancer. One of the following treatment options may be entertained:
					An oesophagectomy.
					Chemotherapy plus radiation therapy. Surgery may be performed after the other therapies are completed.
	Stage 3 esophageal cancer. One of the following options may be entertained.
					Surgery to remove the tumor to relieve pain, discomfort and dysphagia. This is strictly a palliative surgery.
					Chemotherapy plus radiation therapy. Surgery may be performed after other therapy is completed and there is evidence of reasonable response.
	Stage 4 esophageal cancer. One of the following treatment options may be entertained:
					Radiation therapy with or without insertion of an intraluminal tube to keep the esophagus patent.
					Removal of the tumor or dissolution of the central part of the tumor to make the esophagus patent again using laser or electrical current or diathermy.
					Finally palliative chemotherapy with palliative radiotherapy.
	Recurrent esophageal cancer. The treatment is always palliative and surgery or radiation may be used to relieve pain or discomfort.

What are the side effects of treatment for Esophageal cancer?

	Surgery for esophageal cancer should be undertaken only in institutes which are experienced in this kind of surgery. The surgery can be very morbid in the wrong hands and it is one of the technically more difficult surgeries to perform. Often the result of surgery may also not be favorable if done by inexperienced hands. Unfortunately, treatment for cancer does cause damage to healthy tissues Please ask the clinician about any possible side effects before any form of treatment commence. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist (chemotherapist) will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. The better psychologically prepared the patient is, the better are his or her chances of having decreased side effects. The patient should drink large quantities of liquids while therapy is in progress, and preferably avoid uncooked or raw food. Water for drinking should be filtered or boiled. Any relative or person who has any infection such as common cold should be asked to desist from coming close to the patient.

What is the importance of follow up?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination ), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.