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“FOOD PIPE (Esophagus) CANCER AND SURGICAL TREATMENT”

What is esophageal cancer? It is a cancer caused by tissues that cover the esophagus (the tubular muscle tissue that allows the passage of food from mouth to stomach). There are 2 types of this cancer: squamous cell cancer (squamous cell cancer) and adenocarcinoma arising from secretion and mucus-secreting structures.

Estimated new cases and deaths (Esophageal cancer, America, 2013):

 
New cases: 17,990
Deaths: 15,210

FOOD PIPE


It is a tubular muscle structure located in the thorax, behind the trachea.
It is about 25-28 cm long. It is an important part of the digestive system. Foods are carried from mouth to stomach through the esophagus.

  

There are many anatomical floors in the esophagus wall:


Inner part: This covering part (mucosa) is wet, facilitates the passage of food to the stomach.
Submucosa: The secretory cells in the submucosa secrete mucus, which provides the wetness of the innermost lining of the esophagus.
Muscle layer: This muscle layer contracts (peristaltic movements) to transport food to the stomach.
Outer layer: The outer layer wraps around the esophagus.

Cancer Cells

Cancer is caused by cells in the esophagus, as in other organs.

Normal cells grow and divide in need or during a normal aging and damage process. Sometimes, this process goes wrong. New cells are formed even when there is no need.

Mass (tumor) tissues begin to form as a result of this excessive, unnecessary and abnormal uncontrolled cell proliferation.

These tumors can sometimes be benign (benign; not cancer) and sometimes malignant (malignant):

Benign tumors:

• They rarely threaten life• They are removable and usually do not grow again• They do not spread to other parts of the body.• They do not invade the surrounding tissues.

Malignant tumors (cancer):

• They may threaten life and can spread to other parts of the body• May invade neighboring organs and tissues. Sometimes they can be removed, but they can grow again.

Esophageal cancer can go to remote areas and progress. They can spread through the blood and lymph vessels. * After spreading, they can settle and grow in other tissues and organs and cause destruction in their location.

Esophageal cancer also has its own cancer cells (metastasis) in the organs and tissues where it spreads. * This is treated as esophagus cancer.

Esophageal Cancer Types


In 2013, 18,000 Americans will be diagnosed with esophagus cancer.

They are named according to the way they appear under the “microscope”:


Adenocarcinoma: About 12,000 Americans will be diagnosed with adenocarcinoma in 2013. It is the most common of esophageal cancers in America. It mostly occurs in the lower part of the esophagus. The escape of the stomach acid to the esophagus (reflux) plays a role. If there is Barret esophagus or obesity, it is more common in them.


Squamous cell cancer: In 2013, approximately 6000 Americans will have squamous cell cancer. This type of cancer is more common in other parts of the world. It usually appears in the upper parts of the esophagus. It is more common in those who consume a lot of cigarettes and alcohol.

NOTE: ** If you smoke CIGARETTE, be sure to contact a specialist. It is never too late to quit smoking. Quitting smoking is very helpful in cancer treatment. You also reduce the risk of developing other cancers **.

TESTS

When esophageal cancer is detected, “additional tests” are needed to determine the most appropriate treatment.

Tumor grading test (grading) Pathological examination is performed on the biopsy piece taken from the tumor tissue.

“Grade (grade)” determines how different tumor tissue differs from normal esophagus cells. High-grade tumors grow faster. They spread more often.

Doctors evaluate grading along with other factors.

Staging tests” show the prevalence of esophageal cancer (whether or not there is another organ and tissue involvement).

When cancer cells spread, they usually hold adjacent lymph nodes. It may also spread to many areas, such as the liver, lungs, or bones.

These staging tests:

  • CT (Computed Tomography)
  • PET (Positron Emission Tomography)
  • EUS (Endoscopic Ultrasonography)
  • Esophagography

Stages

Doctors express the stages of esophageal cancer in Roman numbers (I, II, III, and IV).

Stage I refers to “early stage cancer” and Stage IV refers to “advanced stage cancer”. In advanced stage, cancer has spread to other organs and / or tissues of the body.


The stage of esophageal cancer depends on:

  • How deep has the esophagus wall kept?
  • The location of the tumor (upper, middle or lower esophagus part)
  • Spread of cancer cells into lymph nodes and / or distant organs

 

Stage I-II (Adenocarcinoma)


Stage IA
The cancer caught the inner layers of the esophagus. It is grade 1 or 2.
Stage IB
Cancer has invaded the esophagus wall and is Grade 3. Or, it held the muscle layer of the esophagus and is Grade 1-2.
Stage IIA
The cancer has invaded the muscular layer of the esophagus and is Grade 3.
Stage IIB
The cancer held the outer layer of the esophagus. Or the cancer did not invade the outer layer, but several adjacent lymph nodes.

Stage I-II (squamous cell esophageal cancer)


Stage IA
Cancer has affected both the interior and the wall, Grade 1.
Stage IB
Cancer has caught the esophagus wall and is Grade 2-3. Or cancer held the muscle layer or outer part of the lower part of the esophagus, Grade 1.
Stage IIA
The cancer is in the upper and middle esophagus and has involved the muscular and outer layer of the esophagus and is Grade 1. Or the cancer is in the lower part of the esophagus and has caught the muscle and outer layer of the esophagus and is Grade 2-3
Stage IIB
The cancer is located in the upper and middle part of the esophagus, involves the muscle or outer layer of the esophagus and is Grade 2-3. Or the cancer did not involve the esophagus but several adjacent lymph nodes were involved.


Stage III and IV (Both types of esophagus cancer)


Stage IIIA

Any of the following:
Cancer did not hold the outer layer and cancer cells are located in adjacent 3-6 lymph nodes.
• Or it held the outer layer and is also located in the neighboring 1-2 lymph nodes.
• Or the cancer has crossed the esophagus wall and has retained tissues such as the adjacent diaphragm or pleura (pulmonary membrane). There are no cancer cells in the lymph nodes.


Stage IIIB
Cancer cells have involved the outer layer of the esophagus, and cancer cells are located in adjacent 3-6 lymph nodes.


Stage IIIC
Any of the following:
Cancer has caught adjacent tissues and cancer cells are located in approximately 6 adjacent lymph nodes.
Or, cancer cells are found in more than 7 and 7 adjacent lymph nodes.
Or the cancer has caught the trachea or adjacent organs and cannot be removed by surgery.


Stage IV
Esophageal cancer has spread to distant organs such as the liver, lungs, or bone.

TREATMENT


Treatment options:


• Surgery

• Chemotherapy
• Radiation Therapy
• Targeted Treatments

You and your doctor should make a good “treatment plan”. The “appropriate” treatment plan for you depends on the type and stage of the cancer.

Probably more than one treatment will be applied. For example, Radiation therapy and / or Chemotherapy will be applied before and / or after surgery.

Your doctor will also apply treatment for any side effects you may experience at any stage of the treatment.


Doctors who treat esophageal cancer:


The treatment team consists of the following specialists:


• Gastroenterology Specialist

• Thoracic Surgery Specialist
• Medical Oncology Specialist
• Radiation Oncology Specialist


“Make an effort to find experienced specialist doctors”.

The treatment team also include:


– Oncology nurse,

  • Social worker,
  • Dieticians,
  • Respiratory therapist,
  • Speech pathologist,
  • There is also a pain specialist (algology specialist).

The treatment team will explain the entire treatment process, what to do, the side effects to experience and how to deal with it in detail.

Side effects depend on the stage of the disease, treatment options, dose administered, etc. may differ from patient to patient, depending on the patient.

It is difficult to control esophageal cancer with today’s treatment options. For this reason, many doctors refer their patients to “clinical research” groups where new treatment options are tried. This approach is an important treatment option.

You can ask your doctor about your treatment:


• What are my treatment options? Which do you suggest for me? Why?

• What is the expected benefit of each treatment option?
• What are the possible side effects of each treatment? How are side effects treated?
• What can I do to prepare for treatment?
• Do I have to stay in the hospital? For how long?
• What are the treatment costs? Does my insurance cover?
• How will my treatment affect my normal activities?
• Is it okay for me to join the treatment research group?


Second opinion


You may want to get a second opinion about diagnosis and treatment options before starting treatment. You can discuss with many doctors about treatment options, side effects and outcomes.
Your doctor will meet this situation with understanding*. Many insurance companies actually want you to get a second opinion.


Don’t get worried that your treatment is delayed because getting a second opinion will take you some time. But still share this with your doctor; because in some cases it may be necessary to start treatment quickly.

SURGERY

Surgery is a good option in “early-stage esophageal cancer”. The surgeon removes the cancerous part of the esophagus (usually covering 8-10 cm above and below the cancer), and adjacent lymph nodes.


If part of the stomach is also removed, the surgeon then prepares the stomach in tube form, which is combined with the remaining esophagus either in the rib cage or on the neck (with appropriate suturing techniques).

Or, part of the colon or small intestine is used to connect (anastomose) the stomach and the rest of the esophagus.


If the entire stomach has to be removed, the surgeon uses a part of the intestine to provide the connection between the remaining esophagus and the intestine.


During surgery, the surgeon inserts a feeding tube into the small intestine.

Thanks to this tube, you are fed in the healing process.


You may have pain due to surgery. The treatment team will give you the appropriate medicine for pain control. Always talk to your doctor about how to control pain before surgery.


Your doctor and treatment team will closely monitor and provide treatment for lung or other foci of infection, respiratory problems, bleeding, leakage from sutures, and other problems that require treatment.


Recovery time after surgery varies from person to person. Hospital stay is usually “1 week or longer”. The recovery process will continue after leaving the hospital.


Get help from your doctor and dietitian about post-surgery nutrition.

About surgery, you can ask your doctor about:


– Do you suggest me surgery? What type of surgery?

– How will I feel after the surgery?
– How do I check if I have pain?
– How long will I stay in the hospital?
– Will I have problems while eating? Will I need a special diet?
– Will I need a feeding tube? How do I maintain it?

– Who will help me when I have a problem?
– Will there be a permanent side effect?

When can I return to my normal activity?

RADIATION THERAPY

 Radiotherapy can be used in all stages of esophageal cancer.  * Cells in the throat and chest in the treatment area are affected.

 Radiotherapy is used before or after surgery or to the surgical site.  Chemotherapy is usually given with Radiotherapy.

 Radiotherapy effects:

To destroy cancer,

 Facilitates patient swallowing by shrinking the tumor,

 · It provides relief of cancer-related pain that has spread to bone or other tissues.

 Two types of Radiotherapy are applied (some patients receive both treatments):

 External Radiotherapy: The rays come from a large device from the outside.  It does not hurt.  It kills cancer cells.  Each treatment session is less than 20 minutes.  It is usually applied 5 days a week and for many weeks.

 “Brachytherapy” in which the radioactive substance is in the body: The patient is relieved with medication.  A tube is placed in the esophagus.  Radiation is given through the tube.  No radioactive material remains in your body after the tube is removed.  Treatment takes 1-2 days.  Therefore, you need to stay in a private room in the hospital.

Side effects vary depending on the type of radiotherapy, the dosage administered and the region it is administered.

Sore throat, cough, and shortness of breath can be seen due to External Radiotherapy.  You may feel stuck and burning in your throat while swallowing.  Swallowing can be painful after weeks.  Your doctor will plan treatment, and after radiotherapy is completed, these side effects usually disappear.

It dries and reddens on the skin (at the irradiation area) connected to External Radiotherapy.  

Sometimes there is tension and itching on the skin. Ask your doctor what you can use.  Your skin will recover after completing treatment.

In the last weeks of treatment, there will usually be fatigue due to External Radiotherapy.  Rest is good, but many patients say it is good to do physical exercise; you can do short walks, light stretching movements and yoga.

The esophagus may contract years after both radiotherapy.  If this happens, the dishes begin to hang on and consult the gastroenterology Specialist.

 You can ask your doctor about radiotherapy:

 When will the treatment begin?  When will it end?  How often will I be treated?

 How will I feel during the treatment?  Can I drive while coming and going to treatment?

 What should I consider before, during and after treatment?

 How do we know that the treatment works?

 What side effects should I expect?  What should I tell you?

 Are there permanent side effects?

NUTRITION

 “Good and proper nutrition” is very important before, during and after treatment.  The right amount of calories and protein must be taken to maintain body weight and strength.  Good food makes you feel good and you have more energy.

On the other hand, esophageal cancer and its treatment make feeding difficult and it is difficult to prevent weight loss.  There may be no desire to eat for many reasons.  Nausea and difficulty swallowing and the foods you have eaten before will now cause you discomfort.

Unless you can eat by mouth, you will be fed in other ways.  Radiotherapy will primarily shrink cancer, which will facilitate swallowing.  Or sometimes metal or plastic stents can be placed inside the esophagus, which keeps the esophagus open.  Another option is to provide your diet through a feeding tube.  Sometimes feeding will be made through the vascular access.

 Nutrition after surgery

 If your stomach is removed during the surgery, “dumping syndrome” may develop.  There may be cramps, nausea, flatulence, bloating and dizziness after meals.

 If dumping syndrome develops, it will be appropriate to be in contact with your doctor and dietician.

Some tricks (dumping syndrome):

  • Eat at least 6 small meals every day
  • Sit upright for at least 30 minutes during and after meals
  • Chew food very well
  • Eat solid foods, eat liquid foods between meals
  • Do not eat very sweet foods and beverages

 After surgery, ask your doctor if you need food supplements such as calcium, vitamin B12.

 Ask your dietitian:

 What should I do to not lose weight?

 How will I know if I have enough calories and protein?

 What are the sample foods that can meet my needs?

 How can I add my favorite foods to my diet without causing digestive problems?

 What are the foods and drinks I shouldn’t buy?

Follow-up

After esophageal cancer treatment, you should regularly go to the controls every 3-6 months.  If you have any problems, you should definitely consult your doctor.

Esophageal cancer may recur.  It may recur within the rib cage or another part of the body, such as the liver.

Problems related to the side effects of cancer treatment can also be detected in the controls.

Physical exams, blood tests, plain radiography and computed tomography, endoscopy and other necessary tests are performed in the controls.

TARGETED TREATMENTS

  In patients with esophageal cancer, “targeted therapy” can be applied when the cancer spreads very rapidly.  This treatment can block the growth and spread of esophageal cancer cells.

This treatment is also given intravenously.  It gets into the bloodstream and affects cancer cells throughout the body.

Your doctor will follow the side effects during treatment.  You may experience diarrhea, abdominal pain, burning, joint pain, a feeling of stinging in the hands and feet, or problems with the heart.  Most side effects will disappear when treatment is finished.

You can ask your doctor about chemotherapy and targeted therapies:

What drugs do you recommend to me?  How will they work?

What are the possible side effects?  What can be done?

When will the treatment begin?  When will it end?  How often will I be treated?

 How will we understand that the treatment is effective?

 Will there be a permanent side effect?

SUPPORT SOURCES

 The appearance of your cancer will change your life and the lives of those close to you.  It is very normal that you need help when fighting cancer.  With the whole treatment process, many concerns will arise about your family and your business life.

The people you can get help from your environment are:

  • Doctors, nurses, other healthcare professionals
  • Social workers, consultants
  • Support groups;  cancer patients, family members

 

Cancer Treatment Research Studies

  If necessary, it is best to share the need to participate in such studies and what research studies you can participate in.  It is not always true that you will benefit from these studies.

Note the following:

How protected is your security?

 Who pays for the clinical trials?

 What should you think if you want to take part in a clinical trial?

 What should you ask your doctor?

 

REMEMBER!  “EARLY DIAGNOSIS SAVES LIFE”

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