Esophageal cancer
Food pipe (esophagus) cancer

Esophagus, is a hollow muscular tube (the food pipe) that runs between your throat and the stomach. It carries the food you swallow from mouth to your stomach through movements known as peristalsis. The wall of the esophagus is made of several layers of tissue.

In esophageal cancer, a malignant tumor forms in the inner lining of the esophagus and then it advances and spreads. It is found more commonly in men than women.

You might be surprised to know that esophageal cancer is the sixth most common cause behind cancer deaths globally.

Types of esophagus cancer

Esophageal cancer can be divided into subtypes based on microscopic examination (histopathology) and location of tumor in the esophagus.

• Histopathology: Adenocarcinoma and squamous cell carcinoma
• Location: Upper, mid and lower esophageal cancer

Risk factors for Esophageal Cancer

Any factor causing long term chronic irritation to the mucous lining of esophagus is thought to induce cancerous changes in the cells.

These factors include:

• Smoking
• Gastroesophageal reflux disease (GERD)
• Obesity
• Alcohol intake
• Drinking very hot liquids

Symptoms of Esophageal Cancer

These cancers like most other gastrointestinal cancers are asymptomatic in initial stages.

The symptoms when occur would include:

• Difficulty in swallowing (Dysphagia)

• Unintentional weight loss

• Chest pain

• Worsening indigestion or heartburn

Diagnosis of Esophageal Cancer

Diagnosis of esophageal cancer is established by doing an endoscopy. Endoscopy is a procedure in which a flexible thin tube with camera is passed and esophagus is seen from inside. If any abnormality is seen then a small sample from it is obtained called as biopsy and examined under microscope confirming the diagnosis.

Determining extent of disease (staging)

The cancer cells can break away from the primary tumour and spread through the body in three ways: via the bloodstream, the lymphatic system, or directly through the tissue. The spread could be local, through the layers of the oesophagus, to the adjacent lymph nodes and nearby organs, or it could be distant, to the liver, lungs, and peritoneum, which is known as metastasis.

Staging is finding out the extent of the disease. After the diagnosis of oesophagus cancer, tests are done to find out how much the tumour has spread. These tests include:

Computed tomography (CT) scan: This involves placing the patient in a scanner and using X-rays to image the inside of the chest and abdomen from all sides. The resulting computer-processed images provide an accurate representation. Contrast injected into the blood enhances these images.

Positron emission tomography (PET) scan: Cancer cells take up a larger amount of glucose. Here, injected radioactive glucose (18F-fluorodeoxyglucose; FDG) binds to the tumour, and then the patient is imaged. The images are computer-processed and combined with CT images, giving us a CT image with bright tumours.

Endoscopic ultrasound (EUS): It is a procedure that combines endoscopy and ultrasound to obtain detailed images of the digestive tract and surrounding organs including lymph nodes. EUS provides high-resolution images and can precisely target areas for tissue sampling.

Bronchoscopy: It is a procedure that allows us to view the inside of the airways and lungs using a thin, flexible tube called a bronchoscope, which is passed through the nose or mouth into the lungs. It can directly visualize the trachea and bronchi, assess tumour invasion, and obtain tissue samples if needed.

This work-up helps assign a stage to the tumour, broadly classifying them into:

• Localised - Tumour is limited to the organ in which it started.
• Regional spread - The tumour has spread to nearby lymph nodes and/or has come out of the wall of the organ in which it started.
• Distant spread - The tumour has spread to organs away from the organ of origin, called metastasis.

TNM (Tumour, Node and Metastasis) classification

TNM classification, developed by the American Joint Committee on Cancer (AJCC), is used for the exact classification of the stage. It is based on the following three key elements and spans from I to IV.

1. The extent (size) of the tumour (T): How far has cancer grown into the layers of the oesophageal wall? Has cancer reached nearby structures or organs?
2. The spread to nearby lymph nodes (N): Has cancer spread to nearby lymph nodes? And to how many?
3. The spread (metastasis) to distant sites (M): Has cancer spread to distant lymph nodes or distant organs such as the liver or lungs?

Numbers and letters after T, N and M give further details. The higher the number, the more advanced the tumour. Combined Information from T, N and M assigns an overall stage, a process called stage grouping.

The oesophageal cancer stage ranges from I to IV. Stages I to III are localized diseases and stage IV is advanced cancer (metastatic disease).

Chances of recovery from cancer (prognosis) depend on the stage of the disease at the time of diagnosis. The lower the stage, the better the long-term prognosis.

The definite stage is determined after surgery by histopathological examination of the removed cancer specimen. It is called surgical staging. The stage determined by imaging tests is the clinical stage.

Treatment of Esophageal Cancer

Treatment will depend upon the stage of the tumour and the fitness of the patient to undergo a major surgical procedure.

Treatment of localized cancer

Upper oesophagal cancers are treated with radiation and chemotherapy.

Middle and lower oesophagal cancers are treated with surgery. For advanced tumours, a combination of chemotherapy, radiotherapy, and surgery, known as a multimodal treatment, is often used to achieve the best results. The current standard of care for squamous cell cancers involves administering chemotherapy or chemoradiotherapy first (neoadjuvant treatment) followed by surgery. For adenocarcinoma only chemotherapy is administered before surgery.

Chemotherapy is the use of special drugs to kill cancer cells. Radiotherapy is the use of high-powered X-ray beams to kill cancer cells.

Treatment of advanced cancer

Palliative treatment is aimed at relieving symptoms and improving the patient's quality of life. This type of treatment is considered when the tumour is too advanced or widespread. A patient unfit for major surgery is also treated with palliative intent. Difficulty in swallowing (dysphagia) is treated by inserting an oesophagal stent. Chemotherapy can provide symptomatic relief and help prolong life.

Surgery for Esophageal Cancer

Surgery involves esophagectomy, which is a procedure of removing part or most of the esophagus along with lymph nodes and reconstructing the same using another part of gastrointestinal tract, most commonly stomach.

There are two ways to do a esophagectomy:

• Open, and
• Laparoscopic (thoracoscopic) or Robotic

In open surgery, a long incision is required over the chest and abdomen to do the surgery.

Minimally invasive surgery for esophageal cancer

The laparoscopic and thoracoscopic approach or robotic approach uses minimally invasive techniques to do the same surgery with tiny incisions. This entails the insertion of special long thin surgical tools through these small holes. In robotic surgery, there is a robotic interface between the patient and the surgeon. Minimally invasive surgery results in faster recovery and reduced pain compared to conventional open surgery. This requires expertise. Make sure your surgeon is skilled and has done many of these operations.

Robotic surgery for esophageal cancer

Robotic surgery combines the skill and expertise of a surgeon with the vision, precision, and flexibility of robotic technology. The robotic system features a 3D high-definition camera system for clear and enhanced vision with depth perception. It comprises a surgical console, where the surgeon sits, and robotic arms equipped with surgical instruments. The tiny wristed instruments can bend and rotate in ways the human hand cannot, allowing the surgeon to operate in tight spaces.

During robotic surgery, the surgeon makes minor cuts in the abdomen and inserts special tubes called ports. The robotic arms are connected to these ports, and the instruments mounted on these robotic arms go through the ports to do the surgery. A slender camera is also inserted through one port to show the surgeon a clear view of the inside. The surgeon controls the robotic arms from a console nearby, and an assistant helps by changing the instruments and aiding as needed.

Prognosis (survival rate) of Esophageal Cancer

According to the SEER data, the percentages of people who live for at least five years after being diagnosed with esophageal cancer is 48.8% for localized cancer to the esophagus, 27.7% for cancer that has spread regionally, and 5.6% with distant cancer spread.

Stay Alert! Stay Healthy!
Wish you a speedy recovery!