Oesophageal Cancer

Oesophagus (gullet) is a tube-like organ of 25 to 30cm long, running from the throat to the stomach. Gullet does not have digestive function. It keeps wriggling for carrying food to the stomach for digestion.

Malignant tumour in the gullet is called oesophageal cancer. Malignant transformation of cells occurs when genetic mutation in the gullet tissue cells leads to uncontrolled growth and invasion of adjacent tissues. Depending on the type of cells, it is classified into squamous cell carcinoma and adenocarcinoma. In general, squamous cell carcinoma usually affects neck (upper part) and chest (middle part) while adenocarcinoma commonly affects the junction of gullet and stomach (lower part).

There are no definite causes of oesophageal cancer so far, but it may be related to the following:

• Aged 60 or above.
• Heavy drinker.
• Smoker.
• Fond of preserved or smoked food.
• Like to drink very hot liquid or soups.
• Inadequate consumption of fruits and vegetables.
• Acid reflux.
• Certain rare diseases (such as achalasia) and inherited gene mutations (such as PTEN and Peutz-Jeghers syndrome (PJS)).

The first symptom experienced by most oesophageal cancer patients is progressive difficulty in swallowing, but patients may not be aware of it and change their eating habits unconsciously. Since the patient cannot eat properly, he/she will lose weight and malnutrition will be resulted. When people experience difficulty in swallowing, weight loss for unknown reason and heartburn, they should consult doctor as soon as possible.

The early stage symptoms include:

• Difficulty in swallowing dry solid food.
• Discomfort and pain in the chest during eating.
• If tumour appears in the upper part of the gullet (near the throat), there will be a feeling of discomfort in the throat or something in the throat when swallowing.
• If tumour appears in the middle part of the gullet (near the chest), there will be pain behind the chest bones or back pain during eating.
• If tumour appears in the lower part of the gullet (where it connects with the stomach), there will be a bloated feeling in the abdomen.

The symptoms of later stage oesophageal cancer include:

• Difficult swallowing will intensify. Gradually, patient can only eat semi-liquid food. Finally, patient may not be able to swallow liquid or saliva.
• Tumour in the gullet disturbs normal digestion in the stomach. Patient may feel nausea or even vomit and have regurgitation (bringing food back up).
• Cough after eating.
• Hoarseness.
• Other symptoms caused by spreading of the tumour to other parts of the body such as feeling of a mass in throat, bone pain, difficulty in breathing and right upper abdominal pain.

Risk factors for oesophageal cancer includes:

• Advancing age;
• Gender: Oesophageal cancer is more common in men;
• Smoking;
• Alcohol drinking; and
• Being overweight and obese.

In general, adopting a healthy lifestyle through regular physical activities, maintaining a healthy body weight and waist circumference, having well balanced diet and avoiding smoking and alcohol consumption may lower risk of oesophageal cancer.

If people have difficulty in swallowing, feeling painful or burning in the gullet when eating, or feeling something near the throat and chest, they should consult a doctor even though these symptoms are not necessarily resulted from oesophageal cancer. Referral to specialist for treatment will be made if needed.

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   Oesophagogastroduodenoscopy (OGD)

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   Barium swallow and meal examination

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   Computerised tomography (CT) scan

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   Endoscopic ultrasonography

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   Bronchoscopy

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   Positive emission tomography scan (PET scan)

   PET is an advanced isotope imaging technology for detecting spread of cancer cells in other parts of the body.

If tumour is confined to an area or has not spread to the organs nearby, with an aim to eradicate the tumour and taken into account patient's overall health status, doctors will recommend the following treatment solutions. Generally, radiotherapy and chemotherapy are more suitable for tumour in the upper part of gullet while all of the below solutions can be considered for treatment of tumour in middle and lower part of the gullet.

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   Surgery

2. anchor

   Radiotherapy

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   Radiotherapy and synchronous chemotherapy

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   Surgical removal after synchronous chemotherapy with radiotherapy

If there is sign that the tumour has spread far away or intruded into the main artery, or the patient is very weak, doctor can only perform palliative care to relieve the swallowing problem and maintain his/her quality of life.

Palliative treatment

• Tube feeding by placing a plastic tube via the nose or abdomen wall into the stomach for feeding.
• Gullet expansion by using a stent to expand part of the gullet to help swallowing.
• By-pass surgery by connecting a portion of colon or small intestine to the upper part of the gullet bypassing the obstructing tumour.
• Feeding through nasogastric tube / gastrostomy tube for nutritional support.
• Treatment by cancer drugs can reduce exacerbation of the disease among patients with better overall health status. Chemotherapy is most commonly used at present while targeted therapy can only be used in combination with chemotherapy for a small number of esophageal cancer patients with HER2 status. Besides, the use of immunotherapy is still under development, and is only effective on certain patients after failing of chemotherapy treatment.

When it is not under control, the gullet tumour itself will continue to grow, making swallowing more difficult and causing serious weight loss and malnutrition. Tumour will also spread to the lymph nearby, leading to hoarseness. It may also spread to organs nearby, causing fistula (an abnormal connection or passageway between two organs or vessels) between gullet and trachea. If fistula is formed, the food and drinks the patient takes in may enter into lungs through the trachea and cause coughing and repetitive pneumonia.

Possible short-term complications after surgical removal include poor healing or leakage of connected part between gullet and stomach, pain or infection in the wound. Patients may also have complications like acid reflux and narrowing of the anastomosis after recovery.

Possible side effects in early radiotherapy include pain and difficulty in swallowing, redness and peeling skin at treated area and mild cough. Patients may have trouble swallowing, pulmonary and cardiac functions compromised after recovery.

During chemotherapy, patients will have compromised immunity. Patients who present fever, chills and easy bleeding should seek for immediate medical attention. Furthermore, chemotherapy may also cause transient hair loss and patients’ appetite and digestive function will also be affected temporarily. The side effects of chemotherapy generally will gradually be subsided over time. Patients could refer to information leaflet of specific drug for more information.

1. Regular follow-up

   Regular follow-ups are arranged for a patient to monitor his or her conditions and symptoms of recurrence. Should there be any new symptom, the doctor must be notified as soon as possible.

2. Diet

   • Some patients with severe malnutrition need nutrition supplement through gastric catheter or even intravenous infusion.
   • Ask for good nutrition supplement advice from dietitian.
   • Treatment may affect appetite. Patient should choose what he/she likes to eat and the dishes that can enhance appetite. Meal should be delicious and light for better digestion and absorption. Food that is too greasy should be avoided.
   • Removal of stomach makes the patient feel full even he/she only eats a little. Patient should eat less and more frequently. Patient should not have ill-balanced diet or even overeating.
   • Relaxing environment, pleasant mood and slow down while eating.

3. Exercises

   Avoid over-exhaustion during recovery. However, patients should do appropriate exercises (e.g. walking, jogging, playing Tai Chi) to enhance physique and anti-cancer capability.

4. Maintain good habits and pay attention to health

   Patients should quit smoking and avoid alcohol intake. Besides, having timely follow-up appointments with other chronic co-morbidities can help with long-term rehabilitation.

5. Listen to patients’ inner voice

   Patients have worked hard throughout the treatment process and to adapt to changes in their own body. It is advised talking to the people around you and seek for professional help if patients can't get out of the low mood persistently.

• Centre for Health Protection
• Cancerinformation.com.hk
• Hong Kong Alliance of Patients' Organisation Limited
• Hong Kong Cancer Fund
• Hong Kong Cancer Registry
• The Hong Kong Anti-Cancer Society
• Regeneration Society Ltd

1. Introduction

   The oesophagus or stomach cannot be imaged by plain X-ray alone. Intake of contrast medium that contains barium compounds is, therefore, required for the diagnosis of suspected pathology.

2. Preparation before the procedure

   • Adult patients should fast for 8 hours before the examination. Children aged between 3 to 12 years should also fast for 8 hours before the examination. Light supper only in the evening before the examination.
   • Please inform staff before the examination if the patient is pregnant or suspects pregnancy.
   • Paediatric patients should be accompanied by parents or relatives.
   • Smoking should be discontinued or restricted.
   • Diabetic patients should consult clinician concerned for the adjustment of drug dosage if necessary.

3. Procedure

   • The examination is performed by a radiologist and it usually takes about 30 minutes to 1 hour.
   • Under fluoroscopic guidance, the radiologist will instruct the patient to take a suitable amount of oral contrast medium that contains barium compounds. A series of X-rays are then taken.
   • Patients should follow the instructions of the staff during the examination. Various positions may be adopted to facilitate the flow of contrast medium within the oesophagus and stomach for optimal examination.

4. After the procedure

   • Eat or drink as usual after the examination and increase fluid intake if not contraindicated.
   • Stool will appear white in colour for a few days.

5. Risk and complication

   • Abdominal discomfort due to distension of the stomach.
   • Aspiration of contrast medium into the lung.
   • Leakage of contrast medium due to any unexpected perforation.
   • Constipation after taking the barium contrast.

6. Remarks

   For further information please contact your doctor.

1. Introduction

   Oesophagectomy refers to the resection of the oesophagus, which is mainly performed for malignancy of the oesophagus. Occasionally, oesophagectomy is also indicated in benign condition like perforation and non-malignant narrowing (e.g. corrosive stricture). Following oesophagectomy, the stomach is the organ of choice to be pull-up to regain the continuity of the gastro-intestinal tract. However, in selected cases, a segment of the large bowel is required to work as the conduit for reconstruction.

2. Preparation before the procedure

   • Optimize pulmonary function:
     • Stop smoking.
     • Treat existing chest infection if any.
     • Vigorous breathing and coughing exercise.
   • Nutritional support
     • Enteral feeding is encouraged if possible. Otherwise, parental nutrition will be considered.

3. Procedure

   • The operation is carried out under general anesthesia with selective ventilation of the lungs. Epidural anesthesia or patient-control-anesthesia is frequently applied to reduce post-operative pain in view of the thoracotomy wound.
   • Conventionally, oesophagectomy includes three phases:
     • Surgical resection of the oesophagus.
     • Mobilization of the stomach keeping with it the blood supply.
     • Anastomosis to maintain the continuity.
   • Open surgical approach results in incisions over abdomen, chest and perhaps, neck as well. Nowadays, laparoscopic and thoracoscopic dissection can be performed as minimal invasive procedures.

4. After the procedure

   After surgery, ICU care for ventilatory support and monitoring is the routine practice. Early ambulation and early oral feeding is advisable depending on the progress of recovery.

5. Risk and complication

   Oesophagectomy is an ultra-major operation that takes at least 5-6 hours to be completed. Post-operative intensive care is absolutely indicated. Specific complications related to oesophagectomy include:

   • Intra-operative bleeding in view of the extensive field of dissection and the nearby major vessels.
   • Anastomotic leakage because of tension to anastomosis and / or impaired blood supply.
   • Chylothorax as a result of damage to lymphatic system.
   • Chest infection or pneumonia. The majority of patients developing this complication are heavy smokers with poor ventilator function. The thoracotomy wound and single lung ventilation further impair the pulmonary recovery. Indeed, sputum retention and chest complication is still one of the most likely causes of surgical failure.

6. Remarks

   For further information please contact your doctor.