ESOPHAGEAL CANCER
Cancer of the esophagus is the ninth most common cancer in the world and has the poorest prognosis because when it is found clinically, the tumor is usually in an advanced stage.
Q. What is esophageal cancer?
Esophageal cancer begins in the cells that line the inside of the esophagus. Over time, cancer can penetrate deeper into the layers of the esophagus wall. Because the esophagus has no serosa, the tumor quickly invades through the nearby organs.
Cancer cells that can spread by breaking down the original tumor, can also enter the blood vessels or lymph vessels around the esophagus. Then quickly spread to the lymph nodes in the early stage of the disease and spread to far away-tissues such as lungs, liver, and bones.
Q. What is the incidence of esophageal cancer?
Esophageal cancer is the ninth most common cancer and the sixth most common cause of cancer deaths worldwide.
The Globocan estimates that 604,100 new cases of esophageal cancer (9.3% in men and 3.6% in women) occurred in the world in 2020, and 544,067 people died of the disease.
The disease occurs in men 3 to 4 times more than in women. According to Globocan, there were 3,281 new cases and 3,080 people that died from the disease in Vietnam.
Q. What are the symptoms of esophageal cancer?
Early-stage esophageal cancer causes no symptoms. As cancer progresses, the most common symptoms are:
Difficulty swallowing (dysphagia): a feeling of food getting caught in the esophagus and possible vomiting. Dysphagia increases gradually from solid to liquid food. Usually, when dysphagia appears, the disease is in a late stage.
Vomiting: appears when difficulty swallowing is developing. Vomiting can occur during a meal, right after eating. The vomit is freshly eaten food that does not contain any gastric juice, and there may be a little blood in the vomit.
Increased salivation: When difficulty swallowing increases, the saliva can hardly reach the stomach, so the patient always has to spit.
Weight loss: the patient is thin, depressed, and anemic.
Symptoms show that the tumor has spread beyond the esophagus:
Shortness of breath
Cough
Choking
Hoarseness (A hoarse voice that does not go away within two weeks)
Pain (Pain on swallowing: feeling pressure behind the sternum when swallowing, chest or back pain, epigastric abdominal pain).
Q. What is the cause of esophageal cancer?
The cause of esophageal cancer is still unclear.
Esophageal cancer occurs when cells in the lumen of the esophagus grow incorrectly (mutate) in their DNA. Mutations cause cells to grow and divide uncontrollably. Abnormal cells accumulate as a tumor in the esophagus, which can invade nearby structures and spread to other parts of the body.
There are two main types of esophageal cancer:
Squamous cell carcinoma. It has accounted for 95% of primary esophageal cancer. This is a type of esophageal cancer that begins in the squamous cells that are flat, thin cells that line the surface of the esophagus. It usually develops in the upper and middle part of the esophagus.
Adenocarcinoma. It has accounted for 2.5-8% of primary esophageal cancer. This type begins in the cells of mucus-secreting glands in the lower part of the esophagus, where the esophagus connects with the stomach.
Other types. It is rare, accounting for less than 1%, including small cell cancer, melanoma, lymphoma, sarcomas and choriocarcinoma.
Q. What are the risk factors of esophageal cancer?
Smoking
Drink alcohol
Diet low in fruits and vegetables. Food and drink are high in nitrite and nitrate (a source of nitrosamine, a carcinogen). The habit of eating and drinking a lot of hot foods and substances that rub against the esophageal lining.
Morbid obesity
Gastroesophageal reflux disease (GERD)
Barrett's esophagus
Achalasia that is not treated
Plummer-Vinson syndrome: common disease in women, hypochromia, atrophic glossitis, esophagitis with difficulty swallowing.
Esophageal diverticulum
Burns of the esophagus due to chemicals
Radiation therapy to the chest or upper abdomen
Q. What are the complications of the disease?
As esophageal cancer progresses, it can cause complications such as:
Obstruction of the esophagus. Cancer can make it difficult or impossible for food or fluids to pass through your esophagus.
Pain.
Bleeding. Although bleeding is usually gradual, oozing can be sudden and severe.
Q. How is esophageal cancer diagnosed?
Tests and diagnostic procedures include:
X-ray
Endoscopy. It helps to accurately determine the location, shape of the tumor, the degree of narrowing of the esophagus, the ulceration and swelling of the tumor's surface. Endoscopy also allows a tumor biopsy to confirm the diagnosis.
The following tests contribute to the evaluation of the pre-operative period.
Ultrasound through endoscopy
CT scan
PET scan
Chest laparoscopy
H. What are the stages of esophageal cancer?
When you are diagnosed with esophageal cancer, your doctor will determine the disease's extent (stage) for appropriate treatment options.
Cancer of the esophagus has four stages from I – IV (see).
Q. How is esophageal cancer treated?
The treatments you choose are based on the type of cancer cell, the disease stage, your overall health, and patient preference.
Surgery
Tumor removal surgery can be used alone or in combination with other methods.
Endoscopic therapies. If the tumor is tiny, confined to the mucosa of the esophagus it will be endoscopically removed by mucosal dissection (EMR) or submucosa (ESD).
Part or all of the esophagus may be removed. When the tumor spreads through to the submucosa, the esophagus is removed and reconstructed in several ways. Esophageal removal with lymphadenectomy will have a better survival prognosis. However, there are many complications such as infection, bleeding, anastomotic leak, and etc...
Surgery to remove the esophagus can be done with either open surgery or laparoscopic surgery. The surgery performed depends on your overall condition, the surgeon's experience, and expertise.
Methods of treatment of complications
When the disease progresses, congestion complications may:
Relieve esophageal obstruction: stent through endoscopy, or by-pass. Other options include radiation therapy, chemotherapy, laser therapy, and photodynamic therapy.
Providing nutrition. Open your stomach or small intestine with a feeding tube, where nutrients are delivered directly to your stomach or small intestine.
Chemotherapy
Chemotherapy drugs are usually given before or after surgery in people with esophageal cancer. Chemotherapy may also be combined with radiation therapy.
In people with cancer that has spread beyond the esophagus, chemotherapy may be used alone to help reduce the signs and symptoms caused by cancer.
The side effects of chemotherapy drugs depend on the medication you are taking.
Radiotherapy
Radiation therapy is often combined with chemotherapy in people with esophageal cancer. It can be used before or after surgery. Radiation therapy is also used to relieve advanced esophageal cancer complications, such as when a tumor grows large enough to block the esophagus.
Side effects of radiation to the esophagus include skin burning reactions, painful or difficult swallowing, and accidental damage to nearby organs such as the heart and lungs.
Targeted drug therapy
Targeted therapy is a treatment that targets specific genes, proteins, or tissue environments that contribute to cancer cell growth and survival. This approach is intended to prevent cancer cells' growth and spread while limiting damage to healthy cells.
Alternative treatment (palliative)
Palliative therapy can help you cope with the symptoms of the disease and the side effects of cancer treatment. For example, a person with esophageal cancer may experience pain from cancer treatment or from a growing tumor. Your doctor may try to control your pain by treating the cause or by using medicine. However, the pain can persist and palliative therapy can help you cope with the pain. Possible methods are acupuncture, massage, and relaxation techniques.
Q. How can esophageal cancer be prevented?
You can take steps to lower your risk of esophageal cancer:
Quitting smoking. If you don't use tobacco, don't start.
Drink alcohol in moderation. If you drink alcohol, limit yourself to no more than one can of beer a day if you're a woman or two a day if you're a man.
Eat more fruits and vegetables. Add a variety of colorful fruits and vegetables to your diet.
Maintain a healthy weight. If you are overweight or obese, have strategies to help you lose weight slowly and steadily.
Q. How to detect esophageal cancer early?
Early detection of esophageal cancer by screening. The purpose of screening is to detect cancer at an early stage, which can be completely cured to help people live longer and healthier lives.
At present, there is no testing and screening strategy. However, people at high risk of esophageal cancer, such as Barrett's esophagus, are often closely monitored for early and precancerous cancers.
Q. What is the prognosis of the disease?
Usually, esophageal cancer is a treatable but rarely curable disease because patients often come in a late stage.
Patients with severe Barrett's esophagus and those with few cancer cells have relatively successful results.
The overall 5-year survival rate ranges from 5% to 30%. Results are particularly low because patients typically arrive at a late stage when cancer has spread.
The prognosis for squamous cell carcinoma and adenocarcinoma are the same.
Feb 13, 2021
HUNG M. DO, MD, Ph.D