Esophageal Cancer

1. What is Esophagus? Where is it located?

The esophagus is a muscular tube that transports saliva, liquids and food from the mouth to the stomach. When the patient is upright, the esophagus usually between 25 to 30 centimeters long. The muscular layers hat form the esophagus are pinched together at both ends by sphincter muscles, to prevent food or liquids leaking from the stomach back into the esophagus or mouth. When the patient swallows, the sphincters temporarily relax to allow passage. The esophagus passes close to the trachea (breathing tube) and the left atrium (a section of the heart). This means that problems with the esophagus, such as eating something too hot, can sometimes feel like a pain close to or in the heart or throat. Like any other part of the body, the esophagus can be damaged. Heartburn and cancer are both problems affecting the esophagus.

2. What is esophageal cancer?

The wall of esophagus is made up of several layers and the esophageal cancer generally starts from the inner layer and its spreads both inwards and outwards. Very seldom the tumors and cancer arise from the middle muscular layers of esophagus.

3. Why have I developed esophagus cancer?

There are two main types of esophageal cancer. One type is squamous cell carcinoma. Squamous cells line the inner esophagus, and cancer developing from squmaous cells can occur along the entire esophagus. The other type is called adenocarcinoma. This is cancer that develops from gland cells. The risk factor for squamous cells causes includes smoking, tobacco and heavy use of alcohol. People who are infected with human papilloma virus are also at increased risk. Those who suffers from achlasia cardia (a benign esophageal disease), chronic scarring of the esophagus due to prior corrosive injury, or Tylosis (a rare genetic disorder) are also at risk. The risk factors for adenocarcinoma are less well understood. People who have Barret's esophagus, an abnormal lining of the bottom part of the esophagus that is related to acid reflux problem, are at increased risk as one people who have long standing acid reflux problem alone.

4. What are symptoms of the esophagus cancer?

Early on there may be no symptoms. In more advanced cancers, symptoms of esophageal cancer include.
  • Difficulty or pain when swallowing
  • Weight loss
  • Pain in the chest, behind the breastbone
  • Coughing
  • Hoarseness
  • Indigestion and heartburn
5. What are investigations will I subjected to?

To diagnose esophageal cancer, your doctor will review your symptoms, medical history, and examine you. In addition, he or she may order certain blood tests and X-rays.
Tests for esophageal cancer may include.
  • Barium swallow X-ray- In which you drink a liquid that coats your esophagus. This makes the esophagus stand out on the x-ray so that your doctor can identify certain problems.
  • Endoscopy- The doctor passes an endoscope, a thin, lighted tube, down your throat into your esophagus to examine it. Endoscopic ultrasound uses sound waves to provide more information about the extent of tumor involvement in nearby tissues.
  • Biopsy- During an endoscopy, the doctor can take cells or tissue from your esophagus. The cells are examined under a microscope for the presence of cancer.
Other tests, including computed tomography (CT) scans, positron emission tomography (PET) scan, thoracoscopy, and laparoscopy, may be performed to determine if the cancer has spread, or metastasized, outside of the esophagus. This process is called "staging". The doctor needs this information in order to plan your treatment.

6. Are there different types of esophagus cancer?

There are two main types of esophageal cancer. One type is squamous cell carcinoma. Squamous cells line the inner esophagus, and cancer developing from squamous cells can occur along the entire esophagus. The other type is called adenocarcinoma. This is cancer that develops from gland cells. To develop adenocarcinoma of the esophagus are replaced by glands cells. This typically occurs in the lower esophagus near the stomach and is believed to be largely related to acid exposure to the lower esophagus.

7. At what stage is the cancer?

Accurate staging of the cancer is based on Histopathology and will be possible only after surgery. Based on clinical and radiological findings, esophagus cancer can be broadly classified into

Stage I : The cancer is detected only in the top layers of cells lining the esophagus.
Stage II : The cancer involves deeper layers of the lining of the esophagus or it has spread to nearby lymphnodes. However, the cancer has not spread to other parts of the body.
Stage III : The cancer has spread into the wall of the esophagus or has spread to tissues or lymphnodes near the esophagus. However, it has not spread to other parts of the body.
Stage IV : The cancer has spread to other parts of the body, such as the liver or lungs.

8. Now that I have been diagnosed o have esophagus cancer, how will I be treated?

The treatment of any cancer depends on part on the stage of cancer at the time it is diagnosed, other consideration include the overall condition of the patient and specific symptoms the patient is having. In early stages, surgery to remove the majority of esophagus is the main form of therapy. Many patients also receive chemotherapy (intra venous drug therapy) and radiotherapy (X-ray treatment). After surgery although there is little information to prove that these additional treatment are useful. Many cancer centers are investigating the usefulness of giving chemotherapy or combined with radiotherapy prior to surgery for patients who are potentially curable.

For patients who are found to have cancer spread to other organs or who, for some other reasons can't have surgery, combined chemotherapy and radiotherapy are the most common treatment. Since swallowing difficulty are not always immediately relieved by this combined therapy, other means to improve to swallowing are available like stenting (Placement of flexible tube).

9. Which kind of surgery is done for esophageal cancer?

The type of surgery for Esophageal cancer depends on location and type of tumor. In squamous cell cancer, almost full length of esophagus is removed along with lymph nodes and anastomosis (joining of tube) is done in the neck. In adenocaricnoma (which is located at lower part of esophagus in almost all cases) upper part of esophagus is preserved and anastomosis is made inside the chest.

In our centre we are pioneering Thoracolaparoscopic esophagectomy in which mobilization of food pipe in chest and stomach tube formation in abdomen is one by key hole method (Laparoscopy Esophagectomy) Recent published data has shown equal oncological results and better short term results (in term of faster recovery, short ICU stay and less blood loss) as compared to open surgery.

There is not much role of surgery in cancer of esophagus for the palliative purpose. To improve swallowing in non operative cases esophageal stenting (putting a tube in esophagus) is an option.

10. Are there any alternatives besides surgery?

To date, surgery is the only proven curative option for esophageal cancer.

11. How do I prepare myself for surgery?

The preparation is generally similar to any major surgery. If you are a smoker it is absolutely essential to stop smoking. Breathing exercises using the incentive spirometer and football bladder should be started. Follow the anaesthetist's advice regarding continuation of medications if you are on any. A high protein diet is prepared to improve nutrition.

12. How major is the surgery? What are the possible complications?

Esophagectomy with lymphadenectomy and other esophagus surgeries are deemed as major surgeries with a risk of complications (up to 20%) and a very small risk of death (<4). This means that if 100 people are operated, less 4 of them have a chance of death. The complications of Esophagectomy (removal of the food pipe and lymph nodes and joining back (anastomosis) the healthy stomach tube include:
  • Leak of anastomosis
  • Bleeding from the anastomosis
  • Prolonged vomiting
  • Horsiness of voice
13. For how long do I stay in the hospital?

In an uncomplicated case, hospital stay after surgery is -14 days. This may be longer when there are complications.

14. Will I need any further treatment after surgery?

The decision about adjuvant treatment is based on the final histopathology report which will be available approximately 7-10 days following surgery. If any of the lymphnodes are positive and your general condition is good enough then you may be referred to the medical (GI) oncologist for consideration for chemotherapy or in some cases.

15. What will be my survival after surgery? Are there any chances of the cancer coming back?

The survival depends on the stage of the disease. The average 5 year survival after curative surgery for esophagus cancer is 25=35%. This means that 25-35 out of a 100 people with esophagus cancer will survive and be disease-free at the end of 5 years. As of date there is no foolproof way of predicting which patients will have recurrence and which patient will not.

16. Are there any special precautions I need to tale to prevent cancer from coming back?

There are no proven precautions, but it is logical to exercise regularly, avoid using tobacco, drink alcohol in moderation and maintain a good diet. Following Esophagectomy, since the size of the stomach is now reduced, you should eat smaller meals of regular intervals.

17. How frequently should I follow up after surgery?

After completion of treatment you will be advised to follow-up once in 3-4 months in the first 2 years. Then the frequency will be reduced to once in 6 months for the next 2-3 years. Subsequent follow up you will be once a year. During each follow-up you will be asked to do certain blood tests. You may also be advised to get an ultrasound or CT scan of the abdomen and chest done.