Cancer arising in the food pipe or oesophagus (long, hollow muscular tube that connects throat to stomach) is known as cancer oesophagus. In USA it accounts for 1% of cancers, however in India it is much more common and is ranked as 6th most common cancer. It is much more common in men than women. Tobacco, alcohol, drinking very hot liquids, Barrett’s oesophagus, gastro-oesophageal reflux disease (GERD), obesity and achalasia cardia are some of the risk factors for cancer oesophagus. Cancer oesophagus usually arise in the inner lining of the oesophagus and can be – squamous cell carcinoma, adenocarcinoma or other rare types (lymphoma, sarcoma, melanoma, small cell carcinoma).
What are the symptoms of oesophageal cancer?
Oesophageal cancer often does not cause any specific symptoms until advanced stages. The symptoms include: difficulty in swallowing (dysphagia), heartburn, unintentional weight loss, chronic cough, hoarseness of voice, vomiting or bleeding.
However, having these symptoms does not mean that you have cancer oesophagus but you should see your doctor if you continue to have these symptoms or if you have been diagnosed to have Barrett’s oesophagus (precancerous condition).
What is the preoperative work up?
Based on your symptoms, other relevant medical history and physical examination your doctor may recommend investigations to reach a diagnosis.
The objectives of investigations for a patient with suspected gastric cancer include:
1. Establish diagnosis
2. Assess fitness for major surgery
3. Meticulous preoperative staging to determine the extent of cancer and select patients who are candidates for surgery Upper GI Endoscopy (UGIE) is an initial and essential investigation for diagnosis of gastric cancer. Biopsies (usually 6-8) are taken from any suspicious tissue.
In patients where the biopsy is confirmatory of oesophagus cancer, further investigations are performed to determine the stage of the disease so as to plan appropriate treatment. These would usually include:
a. Abdominal CT scan of the whole abdomen and pelvis (with oral and intravenous contrast) is the preferred imaging investigation to detect spread to other abdominal organs such as the liver. It also provides reasonable information regarding the tumor (T stage) and surrounding lymph nodes (N stage).
b. High resolution CT scan of chest (with or without contrast) is performed to exclude spread of cancer deposits in lungs.
c. Positron emission tomography (PET) scan is recommended in patients with loco-regionally advanced tumors with no evidence of metastatic disease on initial CT scan.
Is there a role for endoscopic ultrasound (EUS)?
Upper GI endoscope with mounted ultrasound is used to perform EUS examination. In patients with oesophagus cancers, EUS provides more accurate information regarding the T (tumor) stage and N (surrounding lymph nodes) stage as compared to abdominal CT scan.
What is meant by stages of the cancer oesophagus?
The most widely used staging system for cancer stomach is American Joint Committee on cancer (AJCC) staging system which includes TNM classification of the cancer. The TNM system indicates size of the tumor (T), lymph node involvement (N) and distant metastases to lymph nodes outside specified regional nodes or other organs (M). The stages of cancer are documented as roman numerals from 0 to IV. The stage of the cancer indicates the likely treatment and survival.
Stage 0: Cancer is confined only to epithelium (inner lining of oesophagus) also known as high grade dysplasia.
Stage IA, IB, IIA: Cancer likely confined to oesophagus and has not spread to draining lymph nodes or to other organs.
Stage IIB, IIIA, IIIB: Cancer has spread either to draining lymph nodes of adjacent organs but no spread to distant organs.
Stage IV: Cancer has spread to distant organs such as liver therefore cure is no longer possible. Such patients are candidates for palliative management only.
Patients with stage 0, I & II are potentially resectable. Most of the patients with Stage III are resectable except for those in whom cancer has grown to involve windpipe (trachea), aorta, spine or other vital structures.
What are the treatment options?
a. Chemoradiotherapy in patients with resectable cancer
Preoperative chemoradiotherapy (neoadjuvant) in these patients is now the standard of care and has been shown to improve the rate of surgical clearance of the cancer, recurrence rates and overall survival. The optimal timing of surgery after completion of chemoradiotherapy is 7-8 weeks. In select patients with cancer involving upper part of the oesophagus chemoradiotherapy without surgery may be the main treatment (i.e. definitive chemoradiotherapy).
The detailed chemotherapy and chemoradiotherapy protocols are beyond the scope of current discussion.
b. Curative surgery
Surgery to remove cancer following chemotherapy & radiotherapy is the standard of care except for select patients with small T1 tumors where surgery alone may be considered.
The surgery for oesophagus cancer is known as radical oesophagectomy which involves removal of either small part or most of the oesophagus along with short segment of proximal stomach. The remaining part of upper oesophagus is then connected to the stomach either in the chest or neck depending on the location and stage of the tumor. The surgery can be performed by traditional open surgery using either transthoracic or transhiatal approach. Surgery may also be accomplished by minimally invasive techniques (laparoscopic or robot assisted).
At specialized centers, the surgery can be accomplished with acceptable morbidity and mortality rate ranging up to 40% and 3-8% respectively. The main complications immediately following surgery include pneumonia, change in voice owing to nerve injury (recurrent laryngeal nerve), bleeding, anastomotic leak, stricture of the anastomosis or reflux of bile.
c. Palliative management
Palliative management is indicated for patients in whom curative therapy is not feasible either because of advanced cancer or fraility of the individual. It is aimed at preventing or relieving the symptoms to improve patient’s health related quality of life. Such patients benefit from a multidisciplinary consultation / management. Endoscopic stenting / dilatation for cancers with obstruction or endoscopic feeding gastrostomy may be performed for feeding. In patients where endoscopic procedure is not feasible surgical feeding jejunostomy may be considered. For patients who present with persistent / recurrent tumor bleeding the treatment options are endoscopic/ angiographic embolization/ surgery.
If after chemoradiotherapy no residual tumor is detected on investigations – can I avoid surgery?
It is well documented that after chemoradiotherapy up to 10-30 % patients may have clinical complete response i.e. no residual tumor is evident on investigations. However not all patients with clinical complete response are actually cured and, in many such patients tumor may recur over time. Therefore, current evidence is to proceed with surgery in all such patients. Studies are being conducted on the topic, which may give further direction for management of these patients.
What are the outcomes following curative surgery?
Five-year survival of up to 47% has been reported from European centers of excellence following multimodality treatment comprising of neoadjuvant chemoradiotherapy and surgery.
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