Esophageal carcinoma

Squamous cell carcinoma is the most common malignant tumor of the esophagus, followed by adenocarcinoma. Symptoms of esophageal cancer include progressive dysphagia and weight loss. The diagnosis of "esophageal cancer" is established by endoscopy followed by CT and endoscopic ultrasound to verify the stage of the process. Treatment for esophageal cancer depends on the stage and generally includes surgical treatment with or without chemo- and radiotherapy. Long-term survival is observed in a small percentage of cases, except for patients with limited lesions.

Annually, approximately 13,500 cases of esophageal cancer and 12,500 deaths are diagnosed in the United States.

[1], [2], [3], [4],

What causes esophageal cancer?

Squamous cell carcinoma of the esophagus

About 8,000 cases are diagnosed annually in the United States. The disease is more typical for the regions of Asia and South Africa. In the United States, squamous cell carcinoma occurs 4-5 times more often among black people than whites, and 2-3 times more often among men than women.

The primary risk factors are alcohol abuse and the use of tobacco in any form. Other factors include achalasia, human papillomavirus, chemical burns with alkali (resulting in stricture), sclerotherapy, Plummer-Vinson syndrome, irradiation of the esophagus and esophagus membranes. Genetic factors are unclear, but in patients with keratodermia (palmar and plantar hyperkeratosis), autosomal dominant diseases, esophageal cancer at the age of 45 years is found in 50%, and at age 55 - in 95% of patients.

Adenocarcinoma of the esophagus

Adenocarcinoma affects the distal esophagus. The incidence increases; it is 50% of esophageal cancer in people with white skin color and is 4 times more common in people with white skin color than in blacks. Alcohol is not an important risk factor, but smoking contributes to the development of the tumor. Adenocarcinoma of the distal esophagus is difficult to differentiate with adenocarcinoma of the cardiac part of the stomach due to tumor germination in the distal esophagus.

Most adenocarcinomas develop in the Berretta's esophagus, which is a consequence of chronic gastroesophageal reflux disease and reflux esophagitis. At the Berretta's esophagus, the cylindrical, glandular, intestinal mucosa replaces the multilayered flat epithelium of the distal esophagus during the healing phase with acute esophagitis.

[5], [6]

Other malignant tumors of the esophagus

Rarer malignant tumors include spindle-cell carcinoma (a poorly differentiated version of squamous cell carcinoma), a warty carcinoma (a well-differentiated version of squamous cell carcinoma), pseudosarcoma, mucoepidermoid carcinoma, adenoplasco cell carcinoma, a cylinder (adenocystic carcinoma), primary ovarian carcinoma, choriocarcinoma, carcinoid tumor, sarcoma and primarily malignant melanoma.

Metastatic esophageal cancer accounts for 3% of esophageal cancer. Melanoma and breast cancer can metastasize into the esophagus; other sources include cancer of the head and neck, lungs, stomach, liver, kidneys, prostate, testis and bones. These tumors usually affect the free connective tissue stroma around the esophagus, whereas the primary cancers of the esophagus begin with the mucosa or submucosa.

Symptoms of esophageal cancer

The initial stages of esophageal cancer usually proceed asymptomatically. Dysphagia occurs when the lumen of the esophagus becomes less than 14 mm. First, the patient has difficulty swallowing solid food, then semi-solid and, finally, liquid food and saliva; this sustained progression presupposes a malignant growth process, not a spasm, a benign Schatzky ring or a peptic stricture. There may be chest pain, usually radiating to the back.

Weight loss, even if the patient has a good appetite, is almost universal. The compression of the recurrent laryngeal nerve can lead to paralysis of the vocal cords and hoarseness. Compression of sympathetic nerves can lead to the appearance of Horner's syndrome, and nerve compression elsewhere can cause back pain, hiccup or diaphragm paralysis. Pleural pleura with pleural effusion or metastasis to the lungs can cause dyspnea. Intraluminal growth of the tumor can cause pain when swallowing, vomiting, vomiting with blood, melena, iron deficiency anemia, aspiration and cough. The appearance of fistulas between the esophagus and the tracheobronchial tree can lead to an abscess of the lung and pneumonia. Other abnormalities can include upper vena cava syndrome, cancerous ascites and bone pain.

Characteristic lymphatic metastasis in the internal jugular, cervical, supraclavicular, mediastinal and celiac nodes. The tumor usually metastasizes into the lungs and the liver and sometimes to distant areas (eg, bones, heart, brain, adrenals, kidneys, peritoneum).

Diagnosis of esophageal cancer

Screening tests are currently not available. Patients with suspected esophageal cancer should complete endoscopy with cytology and biopsy. Despite the fact that the passage of barium can demonstrate obstructive lesion, endoscopy is necessary for biopsy and tissue research.

Patients with an identified cancer should complete a chest CT scan and an abdominal CT scan to determine the extent of the tumor. In the absence of signs of metastasis, an endoscopic ultrasound is required to determine the depth of tumor germination into the esophagus wall and regional lymph nodes. The obtained data allow to determine the therapy and prognosis.

Basic blood tests should be performed, including a general blood test, electrolytes and functional liver tests.

[7], [8]

Treatment of esophageal cancer

Treatment of esophageal cancer depends on the stage of tumor growth, size, location and wishes of the patient (many refrain from aggressive treatment).

General principles of treatment of esophageal cancer

In patients with 0.1 and at stages of the disease, a good result is achieved by surgical resection; chemo- and radiotherapy is not required. At IIb and III stages only surgical treatment is not enough because of low survival rate; the effectiveness of the operation and survival increase with preoperative (supplementary) use of radiation and chemotherapy to reduce the volume of the tumor before resection. Palliative combined treatment of esophageal cancer, including radiation and chemotherapy, is indicated in patients who have refused surgical treatment or who have contraindications. The effectiveness of only radiation or chemotherapy is very small. Patients with stage IV disease need only palliative therapy and do not require surgical treatment.

Stages of esophageal cancer

Stage	Tumor (maximum invasion)	Metastases in regional lymph nodes	Remote metastases
0	Tis	N0	M0
I	T1	N0	M0
IIa, b	T2 or T3	N0	M0
III	T3 or T4	N1	M0
IV	Any T	Any N	M1

¹ Classification of TNM: Tis - carcinoma in situ; T1 - own plate or submucosa; T2 - actually the muscle layer; TK - adventitia; T4 - adjacent structures. N0 - no; N1 - are available. M0 - no; M1 - are available.

After treatment, patients are screened for repeated endoscopic and CT examinations of the neck, chest and abdomen every 6 months for 3 years, and then once a year.

Patients with the Berretta esophagus need intensive long-term treatment of esophageal-gastric reflux disease and endoscopic observation to control malignant degeneration in the range of 3 to 12 months, depending on the degree of metaplasia.

Surgical treatment of esophageal cancer

For treatment, a single block should be resected with removal of the entire tumor at a level of unchanged tissues distal to and proximal to the tumor, as well as all potentially affected lymph nodes and a partially proximal part of the stomach containing the distal path of the lymphatic outflow. The operation requires additional mobilization of the stomach to the top with the formation of esophagogastro-anastomosis, the mobilization of the small or large intestine. Pyloroplasty provides mandatory drainage of the stomach, since removal of the esophagus is necessarily accompanied by bilateral vagotomy. Such extensive surgical intervention is poorly tolerated by patients older than 75 years, especially with concomitant underlying cardiac or pulmonary pathologies [ejection fraction less than 40%, or FE ^ (forced expiratory volume in 1 second) <1.5 l / min]. In general, the operational mortality rate is approximately 5%.

Complications of the operation include anastomosis failure, fistulas and strictures, biliary gastroesophageal reflux and dumping syndrome. Burning pain behind the sternum due to reflux of bile after distal esophagectomy may be more pronounced than the usual symptoms of dysphagia, and require a reconstructive operation with Ru-sarinostomy to remove bile. Interposition of the segment of the small or large intestine into the breast cavity can cause a violation of blood supply, torsion, ischemia and gangrene of the intestine.

External radiation therapy

Radiation therapy is usually used in combination with chemotherapy in patients with questionable efficacy of surgical treatment, as well as with concomitant pathology. Radiation therapy is a contraindication in patients with tracheoesophageal fistulas, as the wrinkling of the tumor leads to an increase in fistula. Similarly, in patients with vascular tumor germination, massive bleeding can develop when it is wrinkled. In the early stages of radiotherapy, edema can lead to deterioration of the esophagus, dysphagia and pain when swallowing. This problem may require dilatation of the esophagus or a preliminary imposition of a percutaneous gastrostomy for feeding. Other side effects of radiation therapy include nausea, vomiting, anorexia, malaise, esophagitis, excess production in the mucus esophagus, xerostomia (dry mouth), strictures, radiation pneumonitis, radiation pericarditis, myocarditis and myelitis (inflammation of the spinal cord).

[9], [10], [11]

Chemotherapy

Tumors are poorly sensitive only to chemotherapy. The effect (defined as a decrease in tumor size by> 50%) is observed in 10-40%, but overall the effectiveness is slight (small compression of the tumor) and temporary. Differences in the effectiveness of drugs are not noted.

Usually used in combination of cisplatin and 5-fluorouracil. At the same time, several other drugs, including mitomycin, doxorubicin, vindesine, bleomycin and methotrexate, are also quite active in squamous cell carcinoma.

[12], [13], [14], [15]

Palliative treatment of esophageal cancer

Palliative treatment of esophageal cancer is aimed at reducing esophageal obstruction, sufficient for oral nutrition. Complaints with esophageal obstruction may be significant and include salivation and recurrent aspiration. Treatment options include dilation procedures (bougie), oral stenting, radiotherapy, laser photocoagulation and photodynamic therapy. In some cases, cervical esophagostomy is required, with the removal of inostasis for nutrition.

The effectiveness of dilatation of the esophagus persists a little more than a few days. A flexible metal loop for stenting is more effective for maintaining the patency of the esophagus. Some plastic-coated models can be used to close tracheoesophageal fistulas, and some models with a valve that prevent reflux if a stent is to be placed near the lower esophageal sphincter.

Endoscopic laser coagulation can be effective in dysphagia, as it burns through the tumor the central canal and can be repeated if necessary. Photodynamic therapy involves the administration of sodium porpher, a derivative of hematoporphyrin, which is captured by tissues and acts as an optical sensitizer. When activated by a laser beam aimed at the tumor, this substance releases cytotoxic singlet oxygen, which destroys the tumor cells. Patients receiving this treatment should avoid sun exposure for up to 6 weeks after treatment, as the skin also becomes sensitive to light.

Supportive treatment of esophageal cancer

Nutritional support by enteral or parenteral nutrition increases the sustainability and feasibility of all therapies. Endoscopic or surgical intubation for feeding provides longer-lasting nutrition in case of esophageal obstruction.

Since almost all cases of cancer of the esophagus are fatal, care at the end of life should be aimed at seeking to reduce the manifestations of the disease, especially pain and inability to swallow saliva. At some point, most patients need significant doses of opiates. Patients should be advised in the course of illness to make administrative decisions and make notes of their wishes in case of neglect of the process.

What is the prognosis of esophageal cancer?

Esophageal cancer has a different prognosis. It depends on the stage of the disease, but, as a rule, it is not completely satisfactory (5 years of survival: less than 5%) due to treatment of patients with already started disease. In patients with mucosal-restricted cancer, survival is approximately 80%, which is reduced to less than 50% in submucosal lesions, 20% with the proliferation of the process on the actual muscle envelope, 7% in affection of adjacent structures and less than 3% with distant metastases.