The oesophagus is the muscular tube that connects the bottom of the neck with the stomach, carrying food though the chest. The muscles in the tube push lumps of chewed food downward. The cells lining the oesophagus are mainly squamous cells, which are flat. However, the cells in the bottom part of the oesophagus can change into ones that are similar to those found in the stomach if, over time, acid reflux/ heartburn has been present.
There are therefore two main types of oesophageal cancer: Squamous Cell Cancer and Adenocarcinoma.
Symptoms of oesophageal cancer
The first symptom is usually difficulty in swallowing, first to very solid, dry foods, but then progressing to less solid food. There may be a sensation of the food sticking that goes away with drinking fluids to force the food past an obstruction. Weight loss and a reduced appetite are also possible.
Chest pain is possible, and sometimes coughing immediately after swallowing can occur if an abnormal connection between the swallowing tube and the breathing tube (trachea) has been made by the tumour.
Treatment of oesophageal cancer
The treatment of oesophageal cancer depends on the aim of therapy, which in turn is decided on by considering the stage of the disease and how well the patient is.
When the tumour is only at the oesophagus, then it may be possible to aim to cure the disease.
The exact treatment then depends on the type of oesophageal tumour present.
For most adenocarcinomas, an operation is required. Furthermore, unless the tumour is very small, then the potential success of the treatment may be improved by a 2 to 3 month course of chemotherapy before the operation.
The operation itself is major and removes the whole oesophagus, either through incisions in the abdomen and left neck, or through on in the abdomen and the side of the chest. It is important this sort of surgery is done in a centre where it is performed routinely, and by a specialised surgeon. Patients also should be fit for such a major operation.
After the operation, the details of the resected specimen are considered and further chemotherapy may be given, particularly if it was given before the operation. Some oncologists recommend a combination of chemotherapy and radiotherapy, particularly if the 'safety margin' around the tumour is narrow.
For Squamous Cell Carcinomas, if the tumour is small and the patient is fit, then an operation as described above is usually offered. In larger tumours that are still potentially curable, then a combination of chemotherapy and radiotherapy given at the same time may be chosen. It has been shown that the success rate of chemoradiotherapy may be the same as surgery. The radiotherapy is given on a daily basis, Monday to Friday, for 5 to 5 1/2 weeks. The chemotherapy is given at the beginning and towards the end of the radiotherapy course. The usual drugs used are Cisplatin and 5-Flourouracil. Chemoradiotherapy is quite tough treatment which has a number of side effects, including tiredness, sore swallowing and nausea and vomiting. Regular blood tests need to be done as well.
Sometimes the aim of the treatment is to control the disease as well as possible, aiming to help the patient live as long as possible as well as possible. Primarily, the aim is to ease symptoms and maximise quality of life, but not to cure.
The best way of improving severe swallowing difficulties is by placing a stent across any obstruction in the oesophagus. A stent is an expandable tube that can be placed within the tumour and will then hold open the tube to allow food to pass down. If the obstruction is very tight, or the tumour is very high or low in the oesophagus, placing a stent is not possible. However, when it can be used, it improves swallowing problems relatively quickly.
If a stent cannot be placed, then a feeding tube may need to be placed directly through the abdominal wall into the stomach. This allows liquid food to be given, maintaining the patients nutrition if they cannot swallow. It also allows medicines to be given as required.
Radiotherapy can be given to help improve swallowing. The treatment is usually given over 1 to 3 weeks, either daily or twice a week. The treatment has relatively few side effects but can take a few weeks to have an effect on the tumour to improve swallowing.
Chemotherapy can also be given to shrink the tumour and attempt to treat cancer that may have spread to other places. Chemotherapy has a number of side effects and the potential benefit must be carefully weighed against the disadvantages.
Other ways of treating oesophageal tumours to open any obstructions and improve swallowing include laser treatment that may vaporise the tumour and 'brachytherapy'. This is where radiotherapy can be given from a narrow tube placed inside the oesophagus, so the treatment is delivered very close to the tumour whilst minimising the dose to nearby organs.