The Oesophagaus is a tube that starts in the neck, traverses through the chest and joins the stomach in the upper abdomen. It transports food from mouth into the stomach. In cancer of the oesophagus (food pipe), malignant (cancerous) tumour arises in the innermost lining of the tube. It then progresses outwards, lengthwise and circumferentially to cause progressively increasing difficulty in swallowing. Two most common form of cancer oesophagus are squamous cell carcinoma and adenocarcinoma; latter generally involved lower part of the oesophagus near stomach.
Tobacco and heavy alcohol use are known to increase the risk of developing cancer of the oesophagus. People with long standing reflux disease and anaemia (women in particular) also have increased risk of developing cancer of the oesophagus.
Though tobacco, alcohol and long standing reflux are risk factors for cancer of oesophagus, it is known to occur in people who are not addicted to tobacco or alcohol. Reflux could be probable cause in some as often this disorder is under investigated and under diagnosed
The most common signs of esophageal cancer are painful or difficult swallowing and weight loss. A doctor should be consulted if any of the following problems occur:
- Painful or difficult swallowing
- Weight loss
- Pain behind the breastbone
- Hoarseness and cough
- Indigestion and heart burn
- Black stools or blood in vomit
The following tests and procedures are necessary for confirming the diagnosis:
- Barium Swallow: A series of x – rays of the esophagus and stomach. The patients drinks a liquid that contains barium (a silver white metallic compound). The liquid coats the esophagus and x ray is taken.
- Oesophago-Gastro-Duodenoscopy: This involves introducing a flexible telescope through the mouth to visualize esophagus and stomach. A biopsy may be done at the same time if tumour is seen at endoscopy.
- CT Scan with Contrast: This is computerized imaging of chest and abdomen done after intravenous and oral contrast. This gives information about the location, extent and spread of spread disease and hence helps in planning treatment.
- PET CT Scan Whole Body: This is combination of CT scan entire body and PET. It involves giving a special dye before scanning. The dye (FDG) helps in identifying the spread of disease and thus is more accurate for staging of disease and planning of treatment.
The treatment depends on the stage of cancer. Cancer of the esophagus is staged from I to IV; stage I is early, localised cancer and stage IV is when cancer has spread to other organ such as lung, liver bone, etc., or neighbouring structures, such as tracheo-bronchial tree, nerves or aorta.
- Surgery is the treatment of choice in medically fit person.
- Radiation+Chemotherapy are usually prescribed in patients who cannot with stand major surgery due to coexisting medical illnesses or for those who are not willing for surgery.
Induction Treatment Followed By Surgery: Downstaging of disease is done with chemotherapy alone or combination of chemotherapy and radiation therapy. Later may be associated with increased side effects. This is followed by reassessment of the disease status. If adequate downstaging is achieved surgery is preferred.
Radiation Combined With Chemotherapy
: Those patients who are medically unfit to go through surgery are treated with combination of radiation therapy and chemotherapy or radiation alone.
Stage IV (Presence of Metastasis)
- Stenting with self expanding stent
- Palliative radiation therapy
- Palliative chemotherapy
- Supportive care alone – for very sick patients whose life expectancy is few weeks
In early stages when the cancer is very superficial endoscopic resection of disease (EMR - Endoscopic Mucosal Resection) can be done.
Amongst many other factors, the stage of cancer at the time of diagnosis is the most important determinant for cure. Cure rates are best when tumour is localised and superficial without having spread to lymph glands. The risk of recurrence of cancer increases with advancing stage. In stage IV, where cancer has already spread to other organs, disease is not curable. The risk of recurrence after successful treatment is maximum during the first two years; after 5 years the risk becomes negligible.
Difficulty in swallowing is the most common complain with which patient present. Difficulty in swallowing occurs when lumen of the oesophagus is almost completely blocked; this occurs very late in the course of disease. Early symptoms such as long standing retrosternal burning, painful swallowing and blood in vomiting should not be ignored and investigated by endoscopy.