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Esophageal Cancer Treatment in India

Esophagus cancer

Esophageal cancer occurs when cancer cells develop in the esophagus, a tube-like structure that runs from your throat to your stomach. Food goes from the mouth to the stomach through the esophagus. The cancer starts at the inner layer of the esophagus and can spread throughout the other layers of the esophagus and to other parts of the body

Esophageal cancer has been categorized into two types that include –

Adenocarcinoma: This type of esophageal cancer starts in the glandular tissue in the lower part of the esophagus. The stomach and the esophagus appear together in this lower part of esophagus.

Squamous Cell Carcinoma: Squamous cell carcinoma begins in the squamous cells lining the esophagus. This type of esophageal cancer typically occurs in the middle and upper part of the esophagus.

Causes of Esophageal Cancer

There are a number of factors which increase a person’s risk of developing esophageal cancer. They include:

  • Gastroesophageal reflux disease (GERD), in which contents and acid from the stomach back up into the esophagus, significantly increase the risk of adenocarcinoma of the esophagus.
  • Smoking or other use of tobacco.
  • Heavy alcohol use.
  • Barrett’s esophagus, a condition that affects the lower part of the esophagus and can lead to esophageal cancer

Symptoms of Esophageal Cancer

Early on there may be no symptoms. In more advanced cancers, symptoms of esophageal cancer include:

Stages of Esophageal Cancer

Staging of squamous cell carcinoma of the esophagus

There are separate staging systems for the two most common types of esophageal cancer: squamous cell carcinoma and adenocarcinoma. The staging system for each is described below.

Stage 0: This is the same as Tis cancer, in which cancer is found in only the top lining of the esophagus (Tis, N0, M0, G1).

Stage IA: This is the same as T1 cancer, in which the cancer is located in only the 2 inside layers of the esophagus (T1, N0, M0, G1).

Stage IB: Either of these conditions:

  • The cancer is located in only the 2 inside layers of the esophagus, but the tumor cells are less differentiated (T1, N0, M0, G2 or G3).
  • The tumor is located in the lower part of the esophagus, and the cancer has spread to either of the 2 outer layers of the esophagus, but not to the lymph nodes or other parts of the body (T2 or T3, N0, M0, G1).

Stage IIA: Either of these conditions:

  • The tumor is located in the upper or middle part of the esophagus, and the cancer is in either of the 2 outer layers of the esophagus (T2 or T3, N0, M0, G1).
  • The tumor is located in the lower part of the esophagus, and the cancer is in either of the 2 outer layers of the esophagus. The tumor cells are less differentiated (T2 or T3, N0, M0, G2 or G3).

Stage IIB: Either of these conditions:

  • The tumor is located in the upper or middle part of the esophagus, and cancer is in either of the 2 outer layers of the esophagus. The tumor cells are less differentiated (T2 or T3, N0, M0, G2 or G3).
  • Cancer is in the inner layers of the esophagus and has spread to 1 or 2 lymph nodes near the tumor (T1 or T2, N1, M0, any G).

Stage IIIA: Any of these conditions:

  • Cancer is in the inner layers of the esophagus and has spread to 3 to 6 lymph nodes near the tumor (T1 or T2, N2, M0, any G).
  • Cancer is in the outside layer of the esophagus and has spread to 1 or 2 lymph nodes (T3, N1, M0, any G).
  • Cancer has spread beyond the esophagus to nearby tissue but not to lymph nodes or other areas of the body (T4a, N0, M0, any G).

Stage IIIB: Cancer is in the outside layer of the esophagus and in 3 to 6 lymph nodes (T3, N2, M0, any G).

Stage IIIC: Any of these conditions:

  • Cancer has spread beyond the esophagus into nearby tissue. Cancer is also in 6 or less lymph nodes (T4a, N1 or N2, M0, any G).
  • Cancer has spread beyond the esophagus into nearby tissue and cannot be removed by surgery (T4b, any N, M0, any G).
  • Cancer has spread to 7 or more lymph nodes but not to distant parts of the body (any T, N3, M0, any G).

Stage IV: Cancer has spread to another part of the body (any T, any N, M1, any G).

Staging of adenocarcinoma of the esophagus

For adenocarcinoma, doctors use the T, N, and M classifications, as well as the grade (G).

Stage 0: This is the same as Tis cancer, in which cancer is found in only the top lining of the esophagus (Tis, N0, M0, G1).

Stage IA: This is the same as T1 cancer, in which the cancer is located in either of the 2 inside layers of the esophagus only (T1, N0, M0, G1 or G2).

Stage IB: Either of these conditions:

  • The cancer is located in either of the 2 inside layers of the esophagus only, and the tumor cells are poorly differentiated (T1, N0, M0, G3).
  • The cancer has spread to an outer layer of the esophagus but not to the lymph nodes or other parts of the body (T2, N0, M0, G1 or G2).

Stage IIA: Cancer is in an outer layer of the esophagus, and the cells are poorly differentiated (T2, N0, M0, G3).

Stage IIB: Either of these conditions:

  • Cancer is in the outside layer of the esophagus but not beyond (T3, N0, M0, any G).
  • Cancer is in an inner layer or the muscularis propria of the esophagus and has spread to 1 or two lymph nodes (T1 or T2, N1, M0, any G).

Stage IIIA: Any of these conditions:

  • Cancer is in the inner layers of the esophagus and has spread to 3 to 6 lymph nodes near the tumor (T1 or T2, N2, M0, any G).
  • Cancer is in the outside layer of the esophagus and has spread to 1 or 2 lymph nodes (T3, N1, M0, any G).
  • Cancer has spread beyond the esophagus to nearby tissue but not to lymph nodes or other areas of the body (T4a, N0, M0, any G).

Stage IIIB: Cancer is in the outside layer of the esophagus and in 3 to 6 lymph nodes (T3, N2, M0, any G).

Stage IIIC: Any of these conditions:

  • Cancer has spread beyond the esophagus into nearby tissue. Cancer is also in 6 or less lymph nodes (T4a, N1 or N2, M0, any G).
  • Cancer has spread beyond the esophagus into nearby tissue and cannot be removed by surgery (T4b, any N, M0, any G).
  • Cancer has spread to 7 or more lymph nodes but not to distant parts of the body (any T, N3, M0, any G).

Stage IV: Cancer has spread to another part of the body (any T, any N, M1, any G).

Recurrent: Recurrent cancer is cancer that has come back after treatment. It may come back in the esophagus or in another part of the body

Diagnosis of Esophageal Cancer

In addition to a physical examination, the following tests may be used to diagnose esophageal cancer:

  • Barium swallow, also called an esophagram. The patient swallows a liquid containing barium and then a series of x-rays are taken.. Barium coats the surface of the esophagus, making a tumor or other unusual changes easier to see on the x-ray. If there is an abnormal looking area, your doctor may recommend an upper endoscopy and biopsy to find out if it is cancerous.
  • Upper endoscopy, also called esophagus-gastric-duodenoscopy, or EGD. An upper endoscopy allows the doctor to see the lining of the esophagus. A thin, flexible tube with a light and video camera on the end, called an endoscope, is passed down the throat and into the esophagus while the patient is sedated.. If there is an abnormal looking area, a biopsy will be performed to find out if it is cancerous. An endoscopy using an inflatable balloon to stretch the esophagus can also help widen the blocked area so that food can pass through until treatment begins.
  • Endoscopic ultrasound. This procedure is often done at the same time as the upper endoscopy. During anultrasound, sound waves provide a picture of the wall of the esophagus and nearby lymph nodes and structures. The ultrasound is used to find out if the tumor has grown into the wall of the esophagus, how deep the tumor has grown, and whether cancer has spread to the lymph nodes or other nearby structures.
  • Similar to an upper endoscopy, the doctor passes a thin, flexible tube with a light on the end into the mouth or nose, down through the windpipe, and into the breathing passages of the lungs. A bronchoscopy may be performed if a patient’s tumor is located in the upper two-thirds of the esophagus to find out if the tumor is growing into the person’s airway.
  • Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. A biopsy is the removal of a small amount of tissue from the suspicious area for examination. A pathologist then analyzes the sample(s).
  • Molecular testing of the tumor. Your doctor may recommend running laboratory tests on a tumor sample to identify specific genes, proteins, and other factors unique to the tumor. Results of these tests will help decide whether your treatment options include a type of treatment called targeted therapy.
  • Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan can also be used to measure the tumor’s size. Usually, a special dye called a contrast medium is given before the scan to provide better detail. This dye is generally injected into a patient’s vein.
  • Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. MRI can also be used to measure the tumor’s size. A contrast medium is usually injected into a patient’s vein to create a clearer picture.
  • Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

Treatment of Esophageal Cancer

Treatment of esophageal cancer depends on many factors, including the stage of the cancer and the overall health of the patient.

  • Surgery . Part or all of the esophagus may be removed.

Surgery for palliative care

In addition to surgery to treat the disease, surgery may be used to help patients eat and relieve symptoms caused by the cancer. This is called palliative surgery. To do this, surgeons and gastroenterologists (doctors who specialize in the gastrointestinal tract) can:

  • Put in a percutaneous gastrostomy or jejunostomy, also called a feeding tube, so that a person can receive nutrition directly into the stomach or intestine. This may be done before chemotherapy and radiation therapy is given to make sure that the patient can eat enough food to maintain his or her weight and strength during treatment.
  • Create a bypass, or new pathway, to the stomach if a tumor blocks the esophagus but cannot be removed with surgery; this procedure is rarely used.
  • Radiation therapy. Kills cancer cells with radiation.
  • Chemotherapy. Powerful drugs that target cancer cells throughout the body. Typically used in combination withradiation therapy and/or surgery.

  Endoscopic therapy

The following treatments use an endoscope (see Diagnosis) to treat esophageal cancer and to manage side effects caused by the tumor.

  • Endoscopy and dilation. This procedure expands the esophagus. It may have to be repeated if the tumor grows.
  • Endoscopy with stent placement. This procedure uses an endoscopy to insert a stent in the esophagus. An esophageal stent is a metal, mesh device that is expanded to keep the esophagus open.
  • Photodynamic therapy. Photodynamic therapy is a palliative or supportive care option used to make swallowing easier, especially for people who cannot or choose not to have surgery, radiation therapy, or chemotherapy. In photodynamic therapy, a light-sensitive substance is injected into the tumor and stays longer in cancer cells than in healthy cells. A light is then aimed at the tumor, destroying the cancer cells. Although photodynamic therapy may relieve swallowing problems for a short period of time, it does not cure esophageal cancer.
  • This type of palliative treatment helps kill cancer cells by heating them with an electric current. This is sometimes used to help relieve symptoms by removing a blockage caused by the tumor.
  • This is a type of palliative treatment that uses an endoscope with a probe attached that can freeze and remove tumor tissue. It can be used to reduce the size of a tumor to help a patient swallow better

 Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.