2. Esophageal cancer - a malignant tumor emanating from the
mucous membrane of the esophagus makes up a significant part
of all diseases of this organ. The main symptoms of this disease
are: progressive impairment of swallowing (first solid food, then
liquid) and unintentional weight loss. As of 2012, esophageal
cancer was the eighth most common cancer in the world, with
456,000 new cases during the year. In men, esophageal cancer
occurs about 3 times more often than in women.
3. Etiology
The main risk factors that can cause esophageal cancer include:
Consuming hot, rough, and poorly chewed foods
Drinking alcohol
Frequent drinking of hot drinks (tea, coffee)
Smoking
Barrett's esophagus
Esophagitis
Diverticulitis
Thermal and chemical burns of the esophagus, accompanied by
the formation of scars
Leukoplakia
4. Tumor growth types
There are 3 types of esophageal cancer:
Exophytic (nodular, mushroom, papillomatous -
growth into the lumen of the organ)
Endophytic (ulcerative)
Infiltrative sclerosing (circular form)
5. Histological forms
Most often (97-99% of cases), squamous cell
carcinoma with keratinization and without
keratinization is found. There are also glandular
forms of esophageal cancer and tumors originating
from dystopic epithelium. The international
classification also includes small cell carcinoma,
adenoacanthoma, and carcinosarcoma. [7]
Undifferentiated cancers are also rarely found.
6. Metastasis
Metastasis of esophageal cancer is due to the developed lymphatic network
of the esophagus. Metastases spread to the adjacent lymphatic vessels, and
then to the lymph nodes. Cancer of the cervical esophagus metastasizes to
the deep cervical lymph nodes, cancer of the upper thoracic and middle
thoracic esophagus affects paraesophageal, tracheobronchial and posterior
mediastinal lymph nodes with metastases; cancer of the lower thoracic and
abdominal regions spreads to the subphrenic, paraesophageal, paracardial
lymph nodes, as well as to the lymph nodes along the lesser curvature of
the stomach and the left gastric artery. In addition, metastases are found in
the lymph nodes of the lesser omentum, along the left gastric artery, and in
the cervical and supraclavicular lymph nodes.
Distant metastases affect the liver, lungs, and skeletal system.
7. Clinical classification
According to TNM classification:
T - primary tumor
Tх - insufficient information to assess the primary tumor
T0 - no primary tumor found
Tis - carcinoma in situ.
T1 - the tumor invades the wall of the esophagus up to the submucosa
T2 - the tumor invades the wall of the esophagus to the muscle layer
T3 - the tumor invades the wall of the esophagus to the adventitia.
T4 - the tumor process spreads to neighboring organs
N - regional lymph nodes
Nx - insufficient data to assess regional lymph nodes
N0 - no metastases to regional lymph nodes were found
N1 - metastases to regional lymph nodes are detected
M - distant metastases
Mx - insufficient information to determine distant metastases
M0 - distant metastases not found
M1 - distant metastases are detected
8. In accordance with the Russian classification, esophageal cancer is
divided into 4 stages:
Stage 1 - a small neoplasm affects the mucous membrane and the
submucosa of the esophageal wall, but does not narrow the lumen of the
esophagus and its muscle layer does not grow. No metastases (T1N0M0)
Stage 2 - tumor masses penetrate into the muscular membrane of the
esophagus and narrow the lumen, but do not leave the organ. Single
metastases are found in regional lymph nodes (stage 2A: T2N0M0,
T3N0M0; stage 2B: T1N1M0, T2N1M0)
Stage III - all layers of the esophageal wall are involved in the tumor
process, as well as the peri-esophageal tissue or serous membrane, but
neighboring organs are not affected. Numerous metastases are found in
regional lymph nodes (T3N1M0, T4 any N M0)
Stage IV - cancer affects all layers of the esophagus wall and spreads
to neighboring organs. Metastases are found in regional and distant lymph
nodes (any T, any N, M1)
9. Clinical picture
The clinical symptoms of esophageal cancer can be divided into three
groups: primary or local symptoms caused by damage to the walls of the
esophagus; secondary symptoms resulting from the spread of the tumor
process to neighboring organs and tissues; general symptoms caused by
intoxication and malnutrition.
Primary symptoms include dysphagia, chest pain, chest fullness,
regurgitation, and increased salivation. Almost all of these symptoms
indicate a fairly large spread of the pathological process along the
esophagus.
Typical symptoms of esophageal cancer are caused by obstruction. The
most striking of them is dysphagia - the difficulty in passing food
through the esophagus. Dysphagia is caused by a narrowing of the organ
lumen by a growing tumor (mechanical dysphagia), but sometimes it
depends on spasm in the overlying parts of the esophagus (reflex
dysphagia).
10. In most cases, dysphagia increases gradually. At first, there are subtle
delays in the passage of solid food through the esophagus. The patient, as
it were, feels a solid lump of food moving along the esophagus. The
narrowing progresses, and soon the patient is forced to drink solid food
with a sip of water or refuse to take second courses. In the future, after a
few weeks or months, semi-liquid food ceases to pass, and then liquid.
This sequential development of dysphagia is not always observed.
Sometimes, as a result of the disintegration of the tumor or drug
treatment, the patency of the esophagus is partially or completely restored.
The improvement in the condition does not last long, and soon the
dysphagia begins to progress again.
11. DIAGNOSTICS
At LISOD, effective diagnosis is based on a comprehensive examination. The first in
this series is the endoscopic examination of the esophagus: a flexible endoscope is
inserted into the esophagus, with the help of which a full examination of the entire
mucosa is performed; if necessary, a biopsy is taken - a small piece of tissue for
histological examination.
To find out the extent of the tumor (the degree of involvement of other tissues and
organs in it), i.e. determining the stage of the disease, use additional research methods:
computed tomography of the chest and abdomen;
ultrasound examination of the abdominal cavity;
chest x-ray;
a unique for Ukraine transesophageal ultrasound examination of the walls of the
esophagus and structures of the mediastinum with a possible biopsy of the formations
located in the immediate vicinity of the esophagus;
bronchoscopy;
video laparoscopy and video thoracoscopy;
laboratory research.
12. LISOD uses a modern research method - PET-CT. This
study is prescribed for patients who are indicated for
radical treatment, as well as for patients who have
undergone neoadjuvant chemotherapy. PET-CT is also
used to accurately plan radiation therapy, to assess the
outcome of treatment and to identify possible recurrence
of the disease.
The use of a number of diagnostic measures allows
specialists to identify the extent of the spread of the
disease and begin complex treatment.
13. TREATMENT
Treatment for esophageal cancer depends on the extent of the tumor and the underlying
pathology. Often, esophageal cancer is detected too late for radical treatment.
In such cases, we offer procedures aimed at improving the quality of life of patients:
placement with an endoscope of a special tube (stent) in the esophagus in order to allow
the passage of food and liquid;
radiation therapy aimed at shrinking the tumor;
expansion (bougienage) of the esophagus or argon plasma destruction of the esophageal
tumor.
These methods are aimed at eliminating esophageal stenosis - closure of it by a tumor -
and associated severe symptoms such as dysphagia, vomiting, and weight loss.
Patients without pronounced concomitant diseases, with a localized tumor, are offered
surgical intervention, which gives a good chance of recovery.
The operation involves removing most of the swollen esophagus and connecting the
remainder to the stomach. Surgery is often accompanied by pre- or postoperative
chemotherapy and radiation therapy. In LISOD, the most complex operations on the
esophagus are performed using a low-traumatic laparoscopic method.
14. SYMPTOMS
Signs of esophageal cancer usually do not appear until the growth is of sufficient
size. The most common symptom is difficulty swallowing solid food. But after a
while, even swallowing liquid becomes difficult. A tumor of the esophagus is
also characterized by other signs.
Any of the following symptoms should be considered as a serious reason for
seeking medical attention and a comprehensive examination:
pain in the center of the chest;
vomiting;
pain when swallowing;
hoarseness and persistent cough (it happens if the tumor spreads to the trachea
and larynx);
weight loss;
signs of gastrointestinal bleeding: vomiting of blood or a mass that resembles
coffee grounds;
black feces (melena).
15. PREVENTION
Quitting smoking and drinking alcohol can reduce the incidence of
squamous cell carcinoma of the esophagus. At least 90% of this type of
cancer is associated with alcohol and tobacco abuse.
Esophageal adenocarcinoma is a common complication of Barrett's
esophagus, affecting more than 20% of people with reflux symptoms.
People with frequent reflux symptoms (heartburn or belching) should
have regular endoscopic examinations.
Patients with Barrett's esophagus should undergo endoscopy in order to
identify precancerous changes in the esophageal mucosa and receive
quality adequate treatment. They also need treatment for
gastroesophageal reflux, which includes diet and lifestyle changes.
