Title:

Oesophagus Cancer

Word Count:
1918

Summary:
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. 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.

Keywords:
cancer, oesophagus, therapy, diagnosis

Article Body:
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.