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Esophageal cancer :

Esophageal cancer forms inside the esophagus - a hollow, muscular tube about 10 inches long that carries food and drink from the mouth to the stomach.

Cancer can develop when cells in the lining of the esophagus begin to grow and divide abnormally, forming a tumour. Tumours typically start in the innermost layer of the esophagus. They can eventually metastasize (spread) to the lymph nodes and other organs.

Your treatment will depend on the stage of your cancer. You may have surgery, Chemotherapy, Radiation therapy or some combination of these. Endoscopic therapy is also available today for precancerous conditions and very early-stage cancer. Your treatment options will vary based on how localized or advance your disease is.

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Symptoms :

In many cases, esophageal cancer is diagnosed after a person begins to notice symptoms. However, early-stage cancer often has no warning signs.

Some of the most common symptoms of esophageal cancer include:

  • Difficulty swallowing (as the tumour grows, the esophagus narrows)
  • Chest pain or discomfort, such as pressure or a burning sensation
  • Weight loss and lack of appetite (often related to difficulty swallowing)
  • Hoarseness
  • Persistent cough
  • Hiccups
  • Pneumonia
  • Bone pain
  • Bleeding in the esophagus

Types of Esophageal Cancer :

Most esophageal cancers can be classified as one of two types: adenocarcinoma or squamous cell carcinoma. A third type of esophageal cancer, called small cell carcinoma, is very rare. These different types of cancer begin in different kinds of cells in the esophagus. They develop in unique ways and call for approaches to treatment that are unique to each person.

  • Squamous Cell Carcinoma : It is the most common form of esophageal cancer in Indian subcontinent. It begins when squamous cells (thin, flat cells lining the inside of the esophagus) begin to grow uncontrollably. Squamous cell carcinoma of the esophagus is strongly linked with smoking and drinking too much alcohol.
  • Adenocarcinoma : Adenocarcinoma is the most common form of esophageal cancer in the United States, making up more than half of all new cases. It starts out in glandular cells, which are not normally present in the lining of the esophagus. These cells can grow there due to a condition called Barrett's esophagus, which increases a person's chance of developing esophageal cancer. Adenocarcinoma occurs mainly at the lower end of the esophagus and the upper part of the stomach.
  • Small Cell Carcinoma : A third, rarer type of esophageal cancer is small cell carcinoma. It begins in neuroendocrine cells, a type of cell that releases hormones into the bloodstream in response to signals from nerves.

Diagnosis :

Before you start any treatment, we'll help you understand your disease clearly. Our doctor will discuss your medical history and give you an overall health exam. We will probably take a sample of the tumour so we can look at the tissue under a microscope.Before you start any treatment, we'll help you understand your disease clearly. Our doctor will discuss your medical history and give you an overall health exam. We will probably take a sample of the tumour so we can look at the tissue under a microscope.

We may also look at the tumour with endoscopic ultrasound, MRI, or CT and PET scans. Getting an accurate diagnosis is the first step toward getting the best cancer care.

Biopsy :

A biopsy is when your doctor looks at your actual tissue. Biopsies for esophageal cancer are usually done with an endoscope (a thin, lighted tube) that lets your doctor see the inside of the esophagus. After you take an anaesthetic to relax you, your doctor puts the endoscope through your mouth and into your esophagus, giving a clear picture of the esophagus and what's inside it.

Your doctor will take a small sample of tissue from the tumour so it can be looked at. After the biopsy, a doctor who specializes in esophageal cancer looks at the cells under a microscope and does other tests to learn more about the tumour.

Stages of Esophageal Cancer :

If a tissue sample from the tumour shows that you have esophageal cancer, the next step is to find out if the cancer has spread, and if so, how far. This process, called staging, is important in deciding which treatment will be best for you.

Staging the tumour requires one or more tests, including:

  • CT scans of the chest and upper gastrointestinal tract
  • A combined PET and CT scan, which allows our doctors to measure and analyse the location of tumours.
  • An endoscopic ultrasound, which uses an endoscope with a small ultrasound probe at its tip to measure how thick the tumour is and see whether the cancer has spread to the wall of the esophagus or the lymph nodes.
  • Bronchoscopy, an endoscopy procedure that can see whether the cancer has entered the windpipe or airways.
  • Interventional radiology or surgical biopsies if suspicious areas are identified outside the esophagus.
Your cancer may be staged as follows after imaging results:
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  • Stage 0: The cancer is found in only the top lining of the esophagus.
  • Stage IA: The cancer is in only the top layers of the esophagus.
  • Stage IB: Either of these conditions:
    • The cancer is in the top layers of the esophagus, but the tumour cells are less differentiated.
    • The tumour is in the third layer of the esophagus, but it has not spread to the lymph nodes or other parts of the body.
  • Stage IIA: Any of these conditions:
    • The tumour is in the third layer of the esophagus. Cancer cells have spread into but not through the muscle wall of the esophagus.
    • The tumour is in the outer layer of the upper or middle part of the esophagus.
    • The tumour is in the outer layer of the lower part of the esophagus.
  • Stage IIB: Any of these conditions:
    • The tumour is in the outer layer of the upper or middle part of the esophagus. The tumour cells are less differentiated.
    • The tumour is in the outer layer of any part of the esophagus.
    • The tumour is in any part of the esophagus, and cancer cells have spread into the lining of the esophagus and underneath layers. Cancer has also spread to 1 or 2 lymph nodes near the tumour.
  • Stage IIIA: Any of these conditions:
    • The tumour is in any part of the esophagus, and cancer cells have spread into the lining of the esophagus and underneath layers. Cancer cells have also spread to 3 to 6 lymph nodes near the tumour.
    • The tumour is in any in any part of the esophagus and has grown into the third layer of the esophagus. Cancer cells have spread to 1 or 2 lymph nodes.
    • Cancer has spread beyond the esophagus to nearby tissue but not to lymph nodes or other areas of the body.
  • Stage IIIB: Any of these conditions:
    • The tumour is in any part of the esophagus and has grown into the third layer of the esophagus. It has also spread to 3 to 6 lymph nodes.
    • The tumour is in any part of the esophagus, has grown into the outer layer of the esophagus and to either 1 to 2 or 3 to 6 lymph nodes.
    • The tumour is in any part of the esophagus and has spread to structures surrounding the esophagus. It has either spread to no lymph nodes or only 1 to 2 lymph nodes.
  • Stage IVA: Either of these conditions:
    • The tumour is in any part of the esophagus and has spread to nearby structures. It may also have spread to up to 3 to 6 lymph nodes.
    • The cancer has spread to 7 or more regional lymph nodes.
  • Stage IVB: The cancer has spread to other parts of the body.

Treatment for Esophageal Cancer :

We will develop a comprehensive care plan for you based on the type of condition you have, your age, the presence of other illnesses, and the condition of your overall health. We discuss your options with you at length before deciding on a course of surveillance or treatment.

Our team approach is particularly important in esophageal cancer, which is often best managed using a combination of chemotherapy, radiation therapy and surgery. It enables us to coordinate your treatment using many different strategies.

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Surgery for Esophageal Cancer :

Surgery is an important part of treatment for many people with esophageal cancer. Surgery depends on several important factors, including:

  • Whether the cancer is adenocarcinoma or squamous cell carcinoma (squamous cell carcinoma can sometimes be managed with chemotherapy and radiation therapy alone)
  • The size of the tumour
  • How deeply the cancer has spread into the wall of the esophagus.
  • Whether the cancer has spread to the lymph nodes or other organs
  • Your overall health

For most patients, surgery is not the first treatment, since esophageal cancer isn't usually diagnosed until it is advanced. You may first receive a combination of chemotherapy and radiation therapy to shrink the tumour and make it easier to remove.

Esophagectomy :

In an esophagectomy, the goal is to remove all of the tumour in order to prevent it from returning or spreading.

Your surgeon removes the tumour, part of the esophagus, tissue around the tumour, and lymph nodes where cancer cells may have spread. The stomach is then attached to the remaining part of the healthy esophagus. When the stomach is not available or if it needs to be removed because it also has cancer, portions of the large or small intestine may be used instead so you can eat.

For an Esophagectomy, we can use open surgery or a minimally invasive technique, depending on your case.

Minimally Invasive Surgery - We do many operations for esophageal cancer using minimally invasive techniques, including robotic-assisted surgery. Minimally invasive surgery uses small cuts. Its benefits include:

  • Less damage to healthy tissue during an operation
  • Shorter hospitalization time
  • Less pain
  • Fewer complications, particularly in older patients

Chemotherapy for Esophageal Cancer :

Chemotherapy is a drug, or combination of drugs, that goes through the body to kill cancer cells wherever they are. Chemotherapy is an important part of treating esophageal cancer because in most cases people only find the disease after it has spread to other organs. Chemotherapy drugs can shrink the tumour in the esophagus as well as cancerous growths in other areas of the body.

Chemotherapy is used in both adenocarcinoma and squamous cell carcinoma of the esophagus.

Combining Chemotherapy with Other Approaches:

In many people with squamous cell carcinoma of the esophagus, chemoradiation drives the cancer into remission (meaning that although there are no signs of cancer, it is not necessarily cured).

If chemoradiation alone cannot control the cancer, or if you have adenocarcinoma, we may give chemotherapy and radiation to shrink the tumour and make it easier to remove. When used before surgery, this is called induction chemotherapy or neoadjuvant chemotherapy.

The mix of chemotherapy, radiation therapy, and surgery is known as trimodality therapy, and support for this approach is growing. Chemoradiation followed by surgery offers good results for many esophageal cancer patients who have small tumours that have not spread.

Chemotherapy before surgery improves treatment for esophageal cancer in several ways:

  • It can reduce the risk that the cancer will recur after the tumour has been removed.
  • It can shrink the tumour, making it easier to remove the cancer in its entirety.
  • It can improve a person's ability to swallow, often after just two cycles of treatment if a tumour is blocking the esophagus.

Chemotherapy is typically given with radiation therapy for six to ten weeks before surgery.

Radiation Therapy for Esophageal Cancer :

Radiation therapy for esophageal cancer is the use of high-energy beams to shrink or get rid of tumours.

We don't usually use radiation therapy alone to treat esophageal cancer, but it can be important in combination with chemotherapy and surgery. Often, you will begin treatment for esophageal cancer with four to six weeks of radiation therapy along with chemotherapy. This combination treatment is sometimes called chemoradiation.

In some cases, chemoradiation is the primary therapy, and surgery is used only if the tumour does not have a complete response to the chemoradiation. In other cases, chemoradiation just shrinks the tumour before surgery.

Radiation therapy can also be used to relieve pain. For example, it can shrink a tumour so you can swallow better, or it can eliminate spots where the cancer has spread in other parts of the body.