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Esophageal cancer

Esophageal cancer ranks 7th among the most commonly occurring cancers. It manifests with symptoms like weight loss, difficulty swallowing, and pain. Factors such as smoking and excessive alcohol consumption increase the risk of esophageal cancer. While lung cancer is the most frequently observed cancer in our country with 30,000 to 40,000 new cases each year, esophageal cancer sees around 4,000 to 5,000 new cases annually.

What is esophageal cancer?


Cancers that occur in the esophagus, a tube approximately 25-30 cm in length that extends from the neck to the stomach, are referred to as esophageal cancer.


What are the symptoms of esophageal cancer?


The most significant symptom of esophageal cancer is difficulty in swallowing. Among the symptoms of esophageal cancer, there can be a sensation of food getting stuck and painful swallowing. When the tumor does not block 60-70% of the esophagus, it generally doesn't show symptoms. Esophageal cancer symptoms often appear late, leading to the detection of tumors in advanced stages.


In elderly individuals, excessive saliva production during sleep and pain while swallowing can be the initial signs of esophageal cancer.


Depending on the location where the tumor develops, the symptoms of esophageal cancer can vary:


Difficulty in swallowing is a common symptom for esophageal cancer regardless of the area where it emerges.

For esophageal cancer occurring near the neck region, another symptom might be hoarseness of voice.

Esophageal cancer in the middle chest area might manifest as cough.

If it appears in the lower region closer to the stomach, severe reflux can be a symptom.


Although rare, sometimes bleeding can be seen among the symptoms of esophageal cancer. This bleeding is more akin to intestinal bleeding rather than blood coming from the mouth.


The symptoms of esophageal cancer can differ based on the stages:


In Stage 1, esophageal cancer might not show any symptoms. Diagnosis at Stage 1 is often incidental or through screenings.

In Stage 2, difficulty in swallowing can be a symptom. Although rare at this stage, a sensation of food getting stuck and intestinal bleeding can also occur.

In Stage 3, severe difficulty in swallowing is a significant symptom. Patients might become unable to consume solid food. Excessive salivation is more common in elderly individuals.

In Stage 4, symptoms of esophageal cancer can vary based on the location of metastasis. Significant weight loss is among the initial symptoms in Stage 4 esophageal cancers. If the tumor affects the airway, coughing might occur. If it spreads to the liver, side pains can be experienced. Bone pain might occur if it spreads to the bones.


What are the causes of esophageal cancer?


The causes of esophageal cancer also vary based on the cell type.


Among the causes of squamous cell esophageal cancer:


Alcohol and tobacco use

Consuming excessively hot beverages

Consuming burned or smoked foods


Adenocarcinoma esophageal cancers, on the other hand, are generally associated with reflux. Approximately 20% of the population experiences reflux, but not every reflux patient will develop esophageal cancer. Prolonged reflux (acid and bile) combined with alcohol and tobacco use can lead to Barrett's esophagus. Barrett's esophagus is a significant risk factor for esophageal cancer.


A significant portion of the causes of esophageal cancer can be prevented. Additionally, some rare cases are attributed to certain diseases and genetic factors.


A diet high in meat consumption and frequent consumption of charred foods prepared on the grill are risk factors for esophageal cancer, similar to stomach and colon cancer.


How is esophageal cancer diagnosed?


The diagnosis of esophageal cancer is conducted through endoscopic examination. Visualizing the inside of the esophagus using endoscopic imaging might be sufficient for the doctor to make a diagnosis. However, to confirm the diagnosis of esophageal cancer, the tissue sample obtained needs to be examined pathologically.


To determine the stage of esophageal cancer, which indicates how far it has progressed into the esophageal wall, an endoscopic ultrasound imaging method called EUS is used. EUS provides important information in determining the stage of esophageal cancer.


Furthermore, every patient undergoing treatment or esophageal cancer surgery is required to undergo Computed Tomography (CT) and Positron Emission Tomography (PET CT) scans.


What are the treatment methods of esophageal cancer?


Treatment of esophageal cancer varies based on its stage and the location within the esophagus.


For adenocarcinoma or squamous cell carcinoma (stage 3), a treatment approach called chemoradiotherapy is used. This involves combining chemotherapy with a moderately high dose of radiation therapy. Substantial responses can be obtained from this treatment. Patients who become suitable for surgery after chemoradiotherapy undergo surgical removal of the esophageal cancer.


In stage 4 esophageal cancers, surgery is generally not feasible. Patients in this group receive chemotherapy and radiation therapy as treatment.


For stages 1-2-3 of esophageal cancer, treatment is planned based on the location of the tumor.


Treatment for Cervical Esophageal Cancers:

In cases where cancer is situated in the cervical part of the esophagus (neck region), surgery is usually not the preferred treatment. Research indicates that there is no significant difference between surgery and chemoradiotherapy in treating cervical esophageal cancers.


Chemoradiotherapy has shown considerable success in treating cancers that occur in the cervical region of the esophagus.


However, surgery is preferred when chemotherapy and radiation therapy are insufficient.

Tumors originating in the cervical region of the esophagus are located behind the vocal cords and the thyroid, partially involving the pharynx and trachea. Consequently, patients who undergo these surgeries need to breathe through the neck for the remainder of their lives.


In esophageal cancer surgeries, where part of the esophagus is removed, the remaining portion can be reconstructed using a segment of the small or large intestine. In some cases, the entire esophagus can be replaced with a segment from the stomach, extending from the base of the tongue to the stomach.


Treatment for Thoracic Esophageal Cancers:


In the case of tumors occurring in the middle of the esophagus (thoracic region), treatment is determined based on whether the tumor is above or below the division point of the trachea. If the tumor is above the trachea, chemoradiotherapy is preferred. If the tumor is below the trachea, surgery is preferred.


Surgery for thoracic esophageal cancer involves removing the entire esophagus along with at least 16 lymph nodes. Subsequently, a new esophagus can be constructed using a segment of the stomach, enabling the patient to receive nutrition through their mouth.


Treatment for Proximal Esophageal Cancers:


For cancers in the upper region of the esophagus, treatment is planned according to whether the tumor has spread to the stomach.


In cases where the tumor has invaded 2 cm or more into the stomach, surgery involves removing a significant portion of the esophagus along with the entire stomach. Patients then require a new esophagus constructed from either the small or large intestine. These patients need to follow a specific diet regimen and consume small, frequent meals. Nevertheless, they can generally consume a wide variety of foods.


FREQUENTLY ASKED QUESTIONS ABOUT ESOPHAGEAL CANCER

Who is More Prone to Esophageal Cancer?


In Turkey, particularly due to dietary habits, squamous cell carcinoma, also known as squamous-type esophageal cancer, is more commonly observed in the Eastern regions such as Erzurum, Ağrı, Kars, Van, Bitlis, and Muş. Drinking very hot tea and having a diet low in vegetables but rich in meat play a significant role in the prevalence of esophageal cancer in these areas. Squamous cell carcinoma of the esophagus is more frequent in the region starting from the eastern part of Turkey, including the area referred to as the Turkic Republics, and extending to China, compared to the global average. The mountainous and cold nature of this region contributes to the excessive consumption of hot beverages. The consumption of hot beverages, when combined with smoking and alcohol, further increases the incidence of esophageal cancer.


Esophageal cancer is typically a disease of individuals aged 60 and above, with rare occurrences below this age range. While more common in males, due to the consumption of hot tea in the Eastern provinces, it can also occur in females at nearly the same rate. Esophageal cancer is rarely seen in the younger population, but it can be more common in families with a history of esophageal or colon cancer.


What are the types of esophageal cancer?


Esophageal cancer is classified based on the type of cells it originates from and the region where it develops. Esophageal cancer is generally divided into two main types: squamous cell carcinoma and adenocarcinoma.


Squamous Cell Carcinoma: Squamous cell carcinoma of the esophagus is a cancer that arises from the thin layer of flat cells lining the inside of the esophagus. In Turkey, squamous cell carcinoma is more commonly observed.


Adenocarcinoma: Adenocarcinoma of the esophagus occurs in the lower region of the esophagus where the mucosa (inner lining) is exposed to stomach acid and bile. Over time, these cells transform, resembling glandular cells and the inner lining of the stomach. Adenocarcinoma is more frequently seen in Western countries compared to squamous cell carcinoma.


In addition to these two main types, there are very rare types of esophageal cancer that originate from muscle tissues.


Esophageal cancer can also be classified based on its location within the esophagus:

  1. Cervical Esophagus (Neck)

  2. Thoracic Esophagus (Chest)

  3. Lower End - Near Stomach Entrance


Due to the damage caused by stomach acid and bile reflux being closer to the stomach, adenocarcinoma of the esophagus is usually found at the entry to the stomach or in the lower portion of the esophagus. On the other hand, squamous cell carcinoma often occurs in the upper or middle part of the esophagus.


Can Esophageal Cancer Be Detected Through a Blood Test?


Esophageal cancer cannot be determined through a blood test.


What Should Be Done for the Early Diagnosis of Esophageal Cancer?


There is no screening program for the early diagnosis of esophageal cancer in Turkey. However, among the precautions that can be taken personally, undergoing endoscopic examinations is a priority.


For patients with Barrett's esophagus (BARRETT) developed due to reflux, regular annual endoscopic follow-up is important to detect any potential esophageal cancer at an early stage.

Routine endoscopic screenings in Eastern provinces where squamous cell (Squamous) esophageal cancer is prevalent are of vital importance for early diagnosis.


What Are the Stages of Esophageal Cancer?


Esophageal cancer consists of 4 stages.


Esophageal cancer stage 1: Due to the late onset of symptoms, diagnosing stage 1 esophageal cancer is quite challenging. The disease is confined to the inner lining of the esophagus and hasn't reached the muscle layer. In the treatment of stage 1 esophageal cancers, it is possible to remove only the affected lining through an endoscope inserted through the mouth, rather than completely removing the esophagus.


Esophageal cancer stage 2: In stage 2, the disease has breached the lining and reached the muscle tissue of the esophagus.


Esophageal cancer stage 3: The tumor is not very large. The disease is present in the esophagus but has also spread to nearby lymph nodes. In the treatment of stage 3 esophageal cancers, chemotherapy and radiotherapy are initially administered. The aim is to shrink the tumor and lymph node involvement. If regression is achieved, surgical removal of the tumor becomes necessary.


Esophageal cancer stage 4: In stage 4 esophageal cancers, the tumor has metastasized to distant parts of the body. Esophageal cancer most commonly metastasizes to the liver, bones, lungs, and lymph nodes near the stomach entrance. At this point, the opportunity for surgery is limited. Treatment involves chemotherapy.


Which department and doctor should be consulted for esophageal cancer?


A significant portion of esophageal cancer patients undergo a treatment process that involves the collaboration of multiple departments. In cases of esophageal cancer, which require a multidisciplinary treatment approach, in addition to thoracic and esophageal surgery, departments such as gastroenterology, medical oncology, radiation oncology, and general surgery can work together. The support of the diet and nutrition department is crucial during this process. In cases that require specialized microsurgery (such as constructing the esophagus from the small intestine), support is also obtained from the Department of Aesthetic, Plastic, and Reconstructive Surgery. Since there are highly specialized surgical approaches in the treatment of esophageal cancer, it is important to choose hospitals with experienced doctors and adequate infrastructure in this field.


How is Esophageal Cancer Surgery Performed?


Unlike intestinal surgeries, a part of the esophagus cannot be cut and rejoined with the remaining part. When the esophagus is removed during surgery, a new esophagus must be constructed in its place. The main goal is to ensure the continuity of the digestive tract. When the esophagus is removed, the stomach, small and large intestines, or rarely, the esophagus can be reconstructed from the skin.


In very rare cases where the tumor is not removed, lateral intestinal continuity can be established to allow the patient to eat. Thanks to advancing technology, this situation can now be addressed by placing a stent.


In cases where a completely blocked tumor cannot be removed and a stent cannot be placed, nutrition can be provided by placing a tube into the stomach (gastrostomy) to directly deliver food to the stomach.


How is minimally invasive esophageal cancer surgery performed?


The majority of esophageal cancer surgeries (80-90%) at our Esophageal Diseases Center are performed using minimally invasive techniques. Globally, minimally invasive esophageal cancer surgeries are conducted through 6 incisions in the chest area and 4 incisions in the abdominal area. At Memorial Ataşehir Hospital's Esophageal Diseases Center, minimally invasive esophageal cancer surgery can be performed through 3 abdominal incisions and a single incision in the chest. The abdominal portion of the surgery takes 45 minutes to 1 hour, while the chest portion takes 1 to 1.5 hours. Minimally invasive esophageal cancer surgery reduces complications by minimizing bleeding, surgical time, and trauma.


What are the risks of esophageal cancer surgery?


Esophageal cancer surgery is one of the most critical surgical procedures. The most significant risk is leakage at the junction between the esophagus and the stomach or the new reconstructed esophagus. Hoarseness is also a potential risk in esophageal cancer surgery. However, this risk is less than 10%, and hoarseness is generally temporary. Prolonged hoarseness can be resolved with a minor procedure. As an outcome of major surgery, pneumonia, cardiac arrhythmias, and lymphatic leaks might occur.


Is esophageal cancer fatal?


Cancer evokes thoughts of death in people's minds. Therefore, doctors frequently encounter the question "Does esophageal cancer kill?" The majority of patients with Stage 1 and Stage 2 esophageal cancer, as well as a portion of those with Stage 3 that can be operated on, have a chance of overcoming the disease. However, esophageal cancer is a disease that progresses without clear symptoms. Symptoms become distinct only in Stage 4.


There isn't a general answer to the question of whether esophageal cancer kills. Each case comes with individual conditions. Factors such as the tumor type, stage, and location, as well as the patient's age and the presence of accompanying illnesses, contribute to the variation in lifespan.


Regardless of these factors, research indicates the following 5-year survival rates for esophageal cancer:


Stage 1 esophageal cancer: 80-90%

Stage 2 esophageal cancer: 50-60%

Stage 3 esophageal cancer: 30-40%

Stage 4 esophageal cancer: 5%


If the disease doesn't recur within the first 2-3 years after treatment, it generally does not reoccur at all. That's why the initial 2-3 years after treatment are crucial.


Are there any herbal treatments for esophageal cancer?


There is no herbal treatment for esophageal cancer. However, consuming a diet rich in vegetables is important, and consuming anti-inflammatory foods like onions, garlic, and turmeric can provide support in fighting against cancer.


Foods high in sugar such as molasses, honey, sugary compotes, and desserts should be avoided. Instead, it's important to consume a diet rich in protein and vegetables.


What to pay attention to after esophageal cancer surgery?


After esophageal cancer surgery, patients need to pay attention to their diet. Consuming anti-inflammatory foods and avoiding sugar while prioritizing quality sleep, exercise, and regular health check-ups is crucial.


Acidic beverages should be avoided after esophageal cancer. Patients need to use gastric protective medications for the rest of their lives.


Due to absorption issues following surgery, where food directly enters the stomach, patients might experience a 10% weight loss and occasional diarrhea depending on the type of food. To avoid these issues, it's recommended to stay away from foods like honey, molasses, and syrupy desserts. Eating small amounts frequently is necessary. Patients are usually advised to limit the quantity rather than the variety of food.


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