Oesophagus Cancer

Copyright 2006 Radoslaw Pilarski
Epidemiology
Cancer of the oesophagus is one of the cancers of the digestive tract of the most serious prognosis. Incidence and death rates are higher for populations other than the white race (5-years long survival rate in the United States in years 1992 - 1999 equalled 15% for the white race and 9%for others). As far as the incidence rate is concerned, the cancer is classified on the 13th position among men and on the 29th position among women. As far as the death rate is concerned, it is classified on the 12th and 25th positions respectively.
The following regions are characterized by the highest incidence rate: north Iran, southern republics of the former USSR and the north of China - over 100 for 100,000 (Asian belt of cancer of the oesophagus). Medium incidence rate - Sri Lanka, India, South Africa, France, Switzerland: 10-50 for 100,000; low - Europe, Japan, Great Britain, Canada - under 10 for 100,000.
Increasing tendency for adenocarcinoma (before 1980, it constituted about 15%, nowadays it's about 35-37%) - in the USA and in Europe. The incidence rate of cancer of the cardia area is also increasing.
Etiology
Tobacco use - increases the risk of adenocarcinoma, no connection with the occurrence of squamous carcinoma. Alcohol abuse - increases the risk of squamous carcinoma. Joint effects of tobacco and high-proof spirits use increase the risk of cancer of the oesophagus about 100 times. Obesity - increases the risk of the incidence about 2 times. Diet poor in fruit increases the risk of squamous carcinoma about 2 times. Lack of carotene, selenium, E vitamin, scarcity of hot meals and consumption of spoiled fruit have influence on the incidence of adenocarcinoma and squamous carcinoma.
Culturally inclined dietary habits increase the risk of incidence in Asia, south Africa, south America and the Middle East; in Europe and in the USA these are tobacco use and alcohol abuse.
Additional risk factors: Tylosis Plantaris, Plummer syndrome / Vinson and Patterson / Kelly, Achalasia, Pre-existing presence of caustic substances, Pre-existing cancers of respiratory and digestive tract, Barrett's oesophagus Infections of Helicobacter Pyroli and Human Papilloma Virus.
Symptoms Dysphagia, often preceded by discomfort of swallowing lasting several months, and loss of weight are the first symptoms in 90% of patients. Difficulties with swallowing may not be perceptible even if the narrowing of the oesophagus reaches 66%. There are 4 degrees of dysphagia: I grade - ability to swallow solids, II grade- ability to swallow ground food III grade - ability to swallow liquids only IV grade - aphagia
The following symptoms appear frequently: bringing up food, stomachaches and pneumonia. In more advanced cases: bloodstained vomit, blood spitting (because of tracheoesphageal fistula), retrosternal aches (infiltration of mediastinum structures), hoarseness, and cough (invasion of tracheal lymph nodes and infiltration of recurrent laryngeal nerve).
Natural course of the illness
Phase I - initial - is reversible thanks to prevention methods. It may last up to 30 years, it is characterized by a low or advanced metaplasia of epithelium cells, then it results in dysplasia, hyperchromasia and dyscariosis of nuclei. Phase II - results in carcinoma in situ (pre-invasion cancer). It is clinically asymptomatic and may last for a long time. Afterwards, cancer permeates basement membrane and assumes an infiltrative character. In clinical terms, it is the first degree of advanced cancer. Phase III - II and III grade of advanced cancer. Clinical symptoms: increasing dysphagia, narrowing of the inside diameter of the oesophagus visible in radiological examination. Phase II clinical - no metastases to regional lymph nodes, III - metastases are present. Phase IV - IV degree of advanced cancer. Terminal phase, it lasts for a short time, remote metastases are possible, often a non-operational cancer.
Classification
TNM classification Size of tumour TX primary tumour cannot be assessed T0 no evidence of the primary tumour Tis carcinoma in situ T1 tumour affects lamina propria of the mucosa or submucosa T2 tumour affects muscularis propria T3 tumour affects tunica adventitia T4 tumour infiltrates adjacent structures Lymph nodes NX regional lymph nodes cannot be assessed N0 regional lymph nodes are not affected N1 regional lymph nodes are affected Remote metastases M0 absent M1 remote metastases are present (including visceral nodes)
Classification of the American Joint Committee on Cancer Abbreviations mentioned above are used in the description: 0 grade Tis, N0, M0; I grade T1, N0, M0; IIA grade T2, N0, M0 or T3, N0, M0; IIBgrade T1, N1, M0 or T2, N1, M0; III grade T3, N1, M0 or T4, any N, M0; IV grade any T, any N, and M1.
Diagnostics
Diagnostically basic tests: Thorough subjective test with medical history. Radiological examination of the oesophagus with contrast medium, together with stomach and duodenum tests - narrowing or change of the oesophageal axis may signify the presence of a tumour and it estimates the usefulness of the stomach to be joined. Double contrast use is advisable in order to reveal smaller changes that are invisible during tests with single contrast use.
Diagnostically additional tests: Aspirational biopsy of palpable cervical nodes in order to exclude metastases beyond the chest. Oesophagoscopy with a sample taken to histopathological tests - estimates the cancer macroscopally (it can be assigned to one of the following groups: convex, ulcerating, superficial, egzofitic and mixed) and microscopally, it is localized precisely against the physiological narrowing of the oesophagus, and regarding the distance from the upper incisors; one should pay attention to changes in the area of the pharyngeal muscle connection of squamous and column epithelinum and diaphragm hiatus, presence or absence of satellite changes such as erosions, Barrett's oesophagus or esophagitis. In the case of unambiguous test results, toluidine blue or Lugol's iodine should be used. Bronchoscopy should always be conducted if there is a possibility of resection of upper or middle part of the oesophagus in order to exclude trachea's and bronchial tree infiltration. CT of the chest and the upper abdomen in order to localize metastatic changes. Esophageal ultrasonography (EUS) as a confirmation of the afflicting of mediastinal lymph nodes. MRI - its precision is comparable to CT. PET with 18F - fluorodeoxyglucose (FDG) according to initial tests detects the tumour and presence of the regional metastases with a greater precision than CT, it certainly works better in the detection of the presence of remote metastases. PET with 11C-methacholine - detects with greater precision presence of small metastatic foci in the mediastinal area; according to some tests, best results are achieved by PET together with combined use of FGD and 11C-methacholine.
Preoperative tests: Test of cardiovascular system function - ECG, in some justified cases echocardiography, exercise test, arteriography of carotid artery, Doppler's USG of carotid arteries. Test of respiratory system function - spirometrical and gasometrical tests; assessment of vital lung capacity, one-second tense tidal volume, Tiffeneau-test. Kidneys and liver function test determination of urea level, creatinine, creatinine clearance, level of sodium, potassium, chloride and calcium ions, level of transaminases GOT, GPT, bilirubin, alkaline phosphatase, hepatic tests. Determination of the complete albumin level and albumin found in plasma. Assessment of the degree of undernourishment and dehydration assessment of the thickness of a skin fold, Determination of the general state of a patient scales of Karnofsky and WHO.
Qualification to operation: General state according to Karnofsky's scale at least 80, according to WHO - not more than 1. Normal functioning of bone marrow (RBC 3.5 mln/1ml, PLT 100thous/1ml). Normal functioning of kidneys (indicator/gauge of creatinine clearance >50l l/min). No remote metastases (M0). Treatment
Surgery
Surgery usually consists in a removal of the tumour together with a part or the whole of the oesophagus and surrounding lymph nodes and tissues. Then, the remaining part of the oesophagus is joined to the stomach in the cervical area in order to preserve swallowing ability. Sometimes, endoprostheses are used, however, usually only of stomach or intestine . An additional joint of the stomach directly to the intestine may be carried out in order to facilitate passage of food from the stomach to the intestine. It should be remembered that this type of surgery depends mainly on the general state of a patient and the stage of cancer development.
Main methods used in surgery are presented below:
Transhiatal esophagectomy (m. Orringer). 1. Upper part of abdomen and lower part of neck are opened, no direct invasion in the chest. 2. Oesophagus is dissected with care from mediastinal structures and then removed. 3. Subsequently, stomach is connected with the cervical part of the oesophagus (end-to-end esophagogastrostomy) carried in the site of anterior mediastinum. Transmediastinal esophagectomy (m. Akiyama). 1. Chest is opened on the left and right side (more often on the right side, with the tumour in the upper and middle part of the oesophagus, and taking into consideration the aortic arch; more often on the left if the tumour is localized in the joint of the oesophagus and the stomach). 2. Incision in the sixth left intercostal area exposes anterior mediastinum. 3. Semicircular incision of the diaphragm, 1 inch from the costal arch, exposes upper part of abdomen. 4. Oesophagus is removed with perioesophageal nodes and nodes of lesser curvature of the stomach 5. Substitute is made mainly from stomach: a) with incision made on the right side, laparotomy is additionally performed in order to prepare stomach and to place in the site in the anterior mediastinum or in the retrosternal area, b) with incision made on the left side, stomach is pulled under the aortic arch and joined to cervical stump of the oesophagus. Esophagectomy en bloc. 1. It consists in excision of the tumour with a wide margin including surrounding structures in the background together with pleura and with pericardium in front. 2. Lymphatic vessels placed between the oesophagus, aorta and thoracic duct are excised en bloc. 3. Anterior mediastinum excision guarantees complete removal of nodes from the split of trachea to oesophageal hiatus. 4. Hepatic, visceral, left gastric nodes and nodes of lesser curvature of the stomach, parahiatal and retroperitoneal, which reduces the number of local post operational metastases to less than 10%. Esophagectomy en bloc with tripolar lymphadenectomy It consists in additional excision of cervical nodes.
Radiotherapy
Radiotherapy treatment consists in the use of highly energetic rays in order to destroy cancerous cells. Radiotherapy may be provided from an external or an internal source (brachytherapy, it consists in introduction of a pipe with radiating material into the inside diameter of the oesophagus). Radiotherapy may only be used together with chemotherapy, as an alternative treatment method, if the stage of cancer or other factors do not allow to carry out a surgery. It can be used either alone or together with chemotherapy, before surgery is performed. In palliative treatment, radiotherapy also plays an important role.
Chemotherapy
Pharmaceutical treatment consists in anti-cancerous medicines use, usually administered intravenously affecting cancerous cells by circulation around/ in the body. It can be used together with radiotherapy, as an alternative way of treatment to surgery and preoperatively.
In the phase of controlled clinical tests, other ways of treatment are possible, such as laser therapy or photodynamic therapy (PDT).
Palliative treatment
Over 70% of the diagnosed patients cannot be qualified for surgical treatment because of the extensiveness of cancerous changes. Palliative treatment is intended to improve the general state of a patient, decrease ailment and difficulties swallowing. The following methods are applied: Palliative resection Evasive connections - creation of a bridge evading a narrowing or a closure of the inside diameter of the oesophagus. Oesophageal prostheses. Gastric and intestinal fistula, including microfistula of small intestine - enabling feeding directly to the inside diameter of the intestine. Mechanical widening of the narrowing. Self-widening Stent's mass. Laser therapy - a surgery consisting in introducing a fiberscope with a laser light into the oesophagus, with breaks lasting several days, which enables exfoliation of cells and widening of the inside diameter of the oesophagus. The most popular laser: Nd Yag laser.