Cancerous tumors of the esophagus develop from the epithelium of the mucous membrane. In such cases, the tumor is called carcinoma. Doctors diagnose squamous cell and adenomatous forms of oncology much less frequently. which occur in the second stage of growth, requires immediate surgical intervention.

Epidemiology of the disease

According to statistics, the highest incidence rates of esophageal cancer are observed among the population of the Asian belt (Syria, China, Japan, Siberia, Middle Eastern countries). According to scientists, this demographic picture is explained by the peculiarities of the cuisine of the peoples of this region.

Causes

The reliable cause of the development of a tumor of the esophageal mucosa has not been established to date. Researchers point to the significant role of mechanical, thermal and chemical damaging factors in carcinogenesis. Thus, coarse, salty and peppery foods can cause chronic inflammation of the epithelial layer of the esophagus. Esophagitis has the ability to transform into cancer over time.

Recent studies by Chinese scientists have revealed the presence of papillomatous viral infection in tumor tissues of the esophagus. Experts assume the etiological role of the papilloma virus in the formation of carcinoma of the digestive tract.

Oncologists also identify the following risk factors:

1. Congenital anomalies of the esophagus (gastro-esopharyngeal reflux disease, achalasia and hiatal hernia).
2. Tobacco smoking and abuse of strong alcoholic beverages.
3. Frequent consumption of spicy foods.
4. Deficiency of vitamins and minerals.

Esophageal cancer: first symptoms in men and women

The first symptoms of esophageal cancer in women and men occur when the passage of food through the digestive canal is disrupted. Conventionally, signs of oncology of this localization are divided into three categories:

General symptoms

Includes chronic low-grade fever, weakness, fatigue, decreased performance, loss of appetite and rapid loss of body weight.

Local symptoms

Manifest in the form of dysphagia (complicated passage of a bolus of food). Patients complain of a feeling of a “foreign body” behind the sternum and difficulty swallowing food. In oncological practice, it is customary to distinguish four degrees of dysphagia:

1. At the first stage, the patient has difficulty passing solid food through the esophagus.
2. The second stage is characterized by problems while eating porridge-like foods.
3. The third stage is accompanied by blocking the passage of fluid.
4. At the fourth stage, complete obstruction of the esophagus is diagnosed in a cancer patient.

The first symptoms of esophageal cancer in men and women at the local level also include pain. Pain in the initial period of the disease is periodic and, as a rule, occurs after eating. In the future, the pain syndrome becomes constant; such pain can only be relieved with the help of narcotic painkillers.

Symptoms of metastatic spread

They occur after the germination of oncology into neighboring systems and the penetration of cancer particles into the lymphatic or circulatory systems. Another is pain in the area of ​​the secondary cancer focus.

This disease is very rarely diagnosed in childhood. The first symptoms of esophageal cancer in children are similar to the symptoms of oncology in adult patients.

Diagnosis of esophageal cancer

Establishing a diagnosis of esophageal cancer begins with an X-ray, which determines the cause of dysphagia. X-ray of the esophagus in such cases is carried out using contrast agents, which makes it possible to identify the location and size of the malignant neoplasm. Further examination includes endoscopy, during which the oncologist examines the condition of the mucous membrane using a special optical device.

The final diagnosis is made based on the results of a biopsy. This study consists in the surgical removal of a small area of ​​pathological tissue for cytological and histological analysis. Biopsy sampling is usually performed during endoscopy. Tumor samples are subjected to microscopic examination. As a result, the doctor determines the tissue affiliation and stage of growth of oncology.

Treatment

The only treatment for cancer of the esophagus is surgery, which can be supplemented with radiation treatment using gamma rays.

Depending on the location of the tumor, surgery is performed in the following ways:

1. Radical surgery to excise the entire esophagus. This intervention is very traumatic. The postoperative survival rate in this case does not exceed 5%.
2. Removal of the lower third of the esophagus. Indicated when the tumor is located in the cardia of the stomach. Such an operation, compared with a complete extirpation, provides a more favorable outcome of therapy.
3. Partial excision of the esophagus followed by plastic surgery of the lost organ. This operation is by far the most widely used.

In modern oncology clinics, endoscopic operations are also often used, during which the excision of pathological tissues is performed by a laser. This technique improves the accuracy of tumor removal.

The esophagus is carried out in two stages:

1. Prior to surgery, radiological exposure of a malignant neoplasm stabilizes.
2. In the postoperative period, gamma radiation neutralizes residual cancer cells and thus prevents the formation of recurrence.

Cancer of the esophagus, the first symptoms which indicate an inoperable form of oncology, undergoes symptomatic treatment with the use of radiation and cytotoxic therapies.

Esophageal cancer is a malignant tumor that develops as a result of degeneration and accelerated cell division of the epithelial layer of the organ. The histological basis of the tumor is squamous epithelium (with or without keratinization).

Basal cell, colloid and glandular tumors develop much less frequently - with abdominal localization of the process. The process is localized more often in the middle third of the organ. Clinically, the tumor is manifested by increasing symptoms of dysphagia and, as a result, the development of cachexia - an extreme degree of exhaustion.

ICD-10 code: C 15 Malignant neoplasm of the esophagus.

Causes that can cause the development of the oncological process

The following causes are distinguished in the development of esophageal cancer:

• lifestyle features (consumption of hot food, water with a high content of salt and minerals, smoking, alcohol);
• developmental anomalies - tylosis (a rare genetically determined disease, manifested by a violation of the development of squamous epithelium), sideropenic syndrome.
• - chronic esophagitis, esophageal ulcers, polyps, (a disease characterized by the replacement of squamous epithelium with glandular epithelium, characteristic of the stomach).

What are the morphological forms of esophageal cancer

The danger of any tumor is determined by how differentiated its constituent cells are.

In cancer of the esophagus, there are two main forms of pathology:

• The non-keratinized form is the uncontrolled growth of undifferentiated cells. These forms are highly malignant. They grow rapidly and metastasize early. Non-carcinogenic forms of squamous cell carcinoma are considered the most malignant tumors.
• Keratinizing cancer is an accumulation of highly differentiated and moderately differentiated cells, so the malignancy of this form of cancer is lower.

Stages of the cancer process in the esophagus

There are V degrees of cancer process.

Grade 0 is the appearance of a cancer cell, it is impossible to clinically identify this stage (the words "degree" and "stage" in oncology are now used as synonyms).

Table 1. Characteristics of stages of development of esophageal cancer

Process characteristics	Stage I	Stage II	Stage III	IV stage
Histological characteristics of the stage	The tumor grows deep into the mucous membrane, but does not affect the muscular layer	The mucous and muscular lining of the esophagus is affected. There is a narrowing of the lumen	Swallowing problems, weight loss, and other signs of cancer are prominent. The tumor has grown through all layers of the esophagus	The tumor grows into all membranes of the organ
Metastases to regional lymph nodes	No	Single metastases may occur*	Multiple metastases	Multiple metastases
Metastases to distant lymph nodes	No			Eat
Damage to anatomically close organs (trachea, bronchi, vagus nerve, heart)	Does not affect	Does not affect	The tumor grows into nearby organs
Damage to anatomically distant organs (kidneys, liver)	Does not affect			Metastases to distant organs

*For stage 2 esophageal cancer, there are 2 substages:

• II A – no metastases;
• II B – metastases are in the nearest lymph nodes.

How do symptoms of esophageal cancer manifest in women?

The earliest symptoms of esophageal cancer are: weakness, loss of appetite. But patients usually do not go to the doctor with these complaints.

The first symptom of concern is increasing dysphagia (impaired swallowing of food). There are several degrees of dysphagia:

1. the patient has difficulty swallowing solid food;
2. difficulties arise when swallowing food diluted with liquids;
3. difficulty swallowing liquid food;
4. the patient cannot swallow anything.

Dysphagia is accompanied by increased salivation.

As the tumor grows and goes beyond the anatomical limits of the organ, the following, already late, signs appear.

Late clinical manifestations include:

• pain first appears when eating, and then becomes constant, the nature of the pain is different, localized in the front, in the upper part of the sternum, or behind, in the interscapular region;
• patients complain of a “lump” behind the sternum;
• when moving to the stomach - constant belching, followed by regurgitation mixed with blood, nausea, vomiting;
• with tumor invasion into the trachea – change in voice timbre;
• when a neoplastic formation grows into the bronchi, aspiration pneumonia often develops, and a sharp hacking cough appears;
• Growth into the mediastinum is characterized by the phenomenon of mediastinitis (inflammation of the mediastinal tissue.

In the terminal stage, the clinic is joined by organs affected by metastasis (liver, bones, lungs).

How does esophageal cancer spread?

Tumor cells are able to move throughout the body, thereby affecting nearby organs, lymph nodes and distant organs.

Ways of spread of cancer cells in the human body:

1. Local spread is the growth of a cancer tumor into organs located in anatomical proximity (heart, trachea, recurrent nerve, bronchi).
2. Hematogenous spread (through the blood) - cancer cells enter the bloodstream and attach to other organs (the kidneys and liver are most often affected).
3. Lymphogenic type of spread is the most important route of metastasis, occurring through the lymphatic vessels. Metastases (secondary tumors) in the lymph nodes closest to the organ are detected already when the tumor has invaded the submucosal layer. In many ways, the localization of metastasis depends on the location of the tumor.

If the tumor is located above the bifurcation (branching) of the trachea, metastasis occurs in the supraclavicular lymph nodes and mediastinal lymph nodes. With distal localization (below the branching) of esophageal cancer, metastasis occurs in the lymphatic collectors of the peritoneum.

But due to the characteristics of the lymphatic system of the esophagus and the presence of retrograde lymphatic flow, metastases at any location of the cancer process can be detected in various lymph nodes.

Measures for early detection of esophageal tumors

The most effective are considered to be preventive examinations periodically conducted among patients at risk. Not only are they examined by a physician, but they also undergo an esophagoscopy and, if necessary, a biopsy is taken.

Patients at risk include:

• with a genetic predisposition;
• with Barrett's disease and other precancerous pathologies;
• with long-term non-healing ulcers of the esophagus of various etiologies.

Diagnosis of esophageal cancer

The diagnosis of esophageal cancer is considered established if cancer cells are found in a biopsy taken from the patient's esophagus. All other examination methods are aimed at clarifying the localization and prevalence of the process. This is necessary to draw up a plan for the management of the patient, the choice of a rational method of treatment.

X-ray examination is done for all patients with diseases of the esophagus:

• on the x-ray, the narrowing of the esophagus is clearly visible, the presence of ulcers and fistulas, characteristic of the cancerous process, is determined;
• according to the radiograph, it is possible to determine the position of the cancerous defect relative to other structures and organs;
• the study allows you to assess the patency of the esophagus and its propulsive function (the ability to peristaltic movements);
• determine the presence of other diseases of the esophagus.

Esophagoscopy allows not only to take a targeted biopsy of the mucosa for histological examination, but also to examine the affected area in detail, to identify areas of necrosis, ulceration, and bleeding in it.

Esophageal cancer is a malignant disease that develops from epithelial cells of the mucous membrane of the walls of the esophagus. This type of cancer most often affects older people over 55 years of age. It occurs more often in men than in women. The reason for this is smoking and alcohol abuse, which increase the risk of pathology.

There are countries where this disease is more common. These include Japan, part of the regions of China, some regions of Siberia, Iran, and the states of Central Asia. This is explained by the fact that the population consumes a lot of spicy food, spices and marinades, and vegetables and fruits are consumed much less. According to statistics, dark-skinned people are much less likely to develop esophageal cancer than fair-skinned people.

The human esophagus is located between the 6th cervical and 11th thoracic vertebrae, connects the pharynx with the stomach and delivers food to the place of digestion. This muscular tube is hollow inside. The esophagus and stomach are separated by a sphincter that prevents food from moving back. In an adult, the esophagus is about 41-43 cm long, up to an average of 25 cm in diameter. Anatomically, it consists of three sections: upper (cervical), middle (thoracic) and lower (abdominal). The walls of the esophagus consist of three layers of tissue: muscle, mucosa and connective tissue. In the abdominal part of the distal esophagus there are hormonally active glands and islets of ectopic gastric epithelium, which are of great importance in the development of peptic ulcers and various structures.

Diseases and pathologies of the esophagus

Esophageal cancer begins to form in the cells of the epithelium of the inner mucosa (carcinoma), as it develops, it spreads to other layers. The first symptom of a neoplasm is the appearance of difficulty in swallowing food, caused by a narrowing of the lumen of the esophagus.

Submucosal formation of the esophagus - what is it? Oncology or submucosal malignant neoplasm (MS) of the esophagus is considered rare, but the most complex phenomenon. The disease can be both benign and malignant. Tumors are formed from different layers of the walls of the esophagus; each neoplasm has a personal classification based on the type of tissue structure (histology).

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Main types of tumors:

• epithelial - formed from epithelial tissue, skin, mucous membrane. This type is characterized by the appearance of neoplasms of benign and malignant types (squamous cell carcinoma, adenocarcinoma);
• non-epithelial - considered the most common. Such neoplasms are very diverse (blastoma, leiomyoma, hemangioma,);
• mixed - this type of tumor leads to damage to all layers of the walls of the organ, is characterized by rapid decay and is replaced by ulcers (malignant lymphoma, carcinosarcoma).

Experts consider squamous cell carcinoma the most aggressive and malignant cancer, which develops very quickly. There are several types of this cancer:

1. highly differentiated (keratinizing) – this is a mature form in which tumor cells retain the ability to keratinize and develop in the form of a “pearl”;
2. moderately differentiated - intermediate form, occurring most often;
3. low-differentiated (non-keratinizing) – an immature form in which the epithelial cells of the tumor grow chaotically, have pronounced atypicality, and infiltrates occur.

Types of cancer

According to the structure, esophageal cancer is divided into two main forms:

• carcinoma (squamous cell carcinoma) - formed from epithelial cells lining the esophageal mucosa, most often found in the upper and middle parts of the esophagus;
• – occurs in the glandular cells of the mucous membrane, is often located in the lower part of the esophagus, and can transform into malignant tumors of the pharynx, larynx, tonsils, palate, and lips.

Other types of esophageal cancer (lymphoma, sarcoma, melanoma, chorionic carcinoma) occur in very rare cases. Among malignant tumors, leiomyoma is the most common (in 60-75% of cases).

According to the characteristics of tumor growth, esophageal cancer is also divided into 2 types: exophytic (the neoplasm grows into the lumen of the esophagus) and endophytic (the neoplasm develops in the thickness of the tissue or in the submucosal layer). Particularly unfavorable prognosis for infiltrative-stenosing form of tumor growth.

Causes

Cancer can arise from many causes:

Signs

At an early stage, the patient most often does not feel signs of the disease. Early symptoms include dysphagia (trouble swallowing pieces of food). There is a feeling that food is stuck in the upper third of the esophagus and the desire to drink it with plenty of water. This is explained by the fact that there is a partial blockage of the lumen of the esophagus. The tumor causes a spasm of the walls of the esophagus, the patient feels a sore throat, there is pain when swallowing (odynophagia) and cough.

As the tumor develops, it further blocks the lumen of the esophagus. A person can no longer eat normally, refuses solid foods, begins to eat mashed potatoes, cereals, soups. With the growth of the tumor, the lumen becomes narrower, more problems appear in a patient with esophageal cancer. Now he can only swallow liquids (juice, milk, broth). The patient almost completely loses the ability to eat, loses weight, the body begins to deplete. The person experiences a constant feeling of hunger and becomes weaker.

If the stagnation of food occurs above the narrowing of the lumen of the esophagus, then there is an eructation of mucus and saliva, vomiting appears. When pain occurs behind the ribs, radiating to the area between the shoulder blades and there is abundant salivation when eating, it means that esophagitis has developed, that is, the tumor has begun to grow into adjacent organs and lymph nodes. In the case when the neoplasm is located in the area of ​​​​the cardia (the place where the esophagus passes into the stomach), the initial manifestation of the disease is frequent belching of air, bad breath, and difficulty swallowing.

When a malignant tumor grows beyond the boundaries of the digestive system, swelling of the larynx may appear, the airways are compressed, and it becomes difficult to breathe. The neoplasm can also penetrate the nerve trunks, whose nerve fibers from the esophagus pass through the spinal cord. The patient begins to cough, his voice becomes hoarse, and Horner's syndrome develops. are severe pain and dysfunction of adjacent organs. A symptom of advanced esophageal cancer is weight loss (occurs in the later stages of the disease, when it is most often impossible to help the patient; the patient is severely exhausted before death).

In case of esophageal cancer, metastases can spread through the lymphogenous route (to the lymph nodes of the mediastinum and supraclavicular region) and through the bloodstream (affect the lungs, xiphoid process of the sternum, liver, brain). Metastasis is rarely the leading cause of death in patients with esophageal cancer. The main factor is the progressive depletion of the body due to the development of the primary neoplasm

Important! If you find suspicious signs, you should immediately consult a doctor. If the disease is identified and diagnosed at an early stage, the chances of cure can be increased.

Stages of cancer

Stage 1 – the tumor is localized only in the mucosa and submucosa, there is no growth into the muscle layer, there are no metastases or narrowing of the lumens of the esophagus. The prognosis is very good - survival rate for 5 years is about 80%.

Stage 2 – the neoplasm has spread into the muscle layer, there is a slight narrowing of the lumen. The tumor does not extend beyond the esophagus; minor metastases are noted in the adjacent lymph nodes. Survival rate for three years is 70%.

Stage 3 – the disease affects all layers of the walls of the esophagus, the tumor spreads to the adjacent serosa and to the peri-esophageal tissue. The tumor has not yet grown into adjacent organs, but there are significant metastases in the lymph nodes. How long do patients with stage 3 live? Life expectancy up to three years 55%. Only a quarter of patients survive to the 5-year mark.

Stage 4 – the tumor spreads not only to all layers of the walls of the esophagus, but also grows into nearby organs. Metastases are observed in distant organs and lymph nodes. 15-20% of patients survive up to three years. Not a single person achieves a five-year survival rate.

Everything about diagnosing esophageal cancer

To determine the exact type of disease, a thorough examination of the patient is necessary. The following types of studies are prescribed:

To clarify the diagnosis, in some cases, osteoscintigraphy (to identify metastases in the bones), laparoscopy, bronchoscopy, videolaparoscopy and videothoracoscopy are performed. PET (positron emission tomography) can also be used - a modern study prescribed for patients who are contraindicated for radical treatment or who have undergone chemotherapy. This study is recommended when planning the use of radiation therapy, to evaluate treatment results and detect relapses.

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*Only upon receipt of data on the patient’s disease, a representative of the clinic will be able to calculate an accurate estimate for treatment.

Treatment

Treatment methods for this disease depend on the general condition of the patient’s body, the location of the tumor, its size, the degree of penetration into the walls of the esophagus and neighboring tissues, and the presence of metastases.

Doctors of different specializations participate in the selection of individual treatment: oncologist, gastroenterologist, surgeon, radiologist. Most often, surgical removal of the tumor and adjacent tissues, radiotherapy and chemotherapy are combined. Chemotherapy and radiation sessions can be prescribed both before and after surgery.

There are two main types of surgical intervention: radical and palliative operations (for inoperable esophageal cancer). Surgical treatment is applicable in cases where the tumor is localized in the lower or middle third of the esophagus. The advantage of the operation is that the lumen of the esophagus is restored and normal nutrition is established. During surgery, a part or the entire organ is removed and the consequences caused by cancer are corrected. In some cases, the upper part of the stomach has to be removed. To replace the organ, a fragment of intestine is used or a gastrostomy is formed. When the lumen of the esophagus is blocked by a neoplasm, a plastic or metal esophageal stent is installed to maintain the passage of food.

Gastrostomy is most often used for cancer of the middle portion of the esophagus. A hole is made in the anterior wall of the peritoneum into the stomach, into which a probe is inserted (for feeding through it). The organ is then completely removed. Along with this, lymph nodes affected by the tumor are often removed. If the operation is successful and there are no metastases, after about a year, an artificial organ is created from part of the small intestine.

In surgery, another method of esophageal cancer surgery is used - bypass surgery, used in cases where, due to the patient’s health condition, it is impossible to install a stent. During bypass surgery, the stomach is pulled up and connected to the esophagus above the location of the tumor, as if going around it.

Endoscopic operations are less traumatic. This method is used in the early stages of the disease. An endoscope with a camera, laser, or surgical loop at the end is inserted into the esophagus through the mouth. Using special flexible instruments, bougienage is performed (to expand the lumen of the esophagus).

In some cases, radiation therapy, used either independently or before or after surgery, gives a positive result. The tumor is irradiated with ionizing radiation, which leads to a slowdown in the growth and division of malignant cells. Gamma therapy is not dangerous for healthy tissues adjacent to the tumor, since it mainly affects the affected cells. Photodynamic – which uses drugs that are absorbed by cancer cells. When tumor cells are irradiated with special light, the drug becomes active and destroys the affected cells.

Using radiation therapy together with chemotherapy usually gives very good results. Neoplasms become much smaller, and the risk of metastases decreases. This method of treatment is used in cases where surgery is not possible.

Chemotherapy is the effect of drugs on tumor cells that stop the development of the tumor and promote the death of its cells.

And the combined method is when a course of radiation therapy along with chemotherapy is carried out about a month before surgery. Such a scheme significantly increases the chances of a positive result from treatment.

After treatment, the patient should be under the supervision of a doctor, regularly examined, and periodically undergo repeated examinations. This will help monitor the condition of the body and promptly detect the return of the disease (relapse).

Folk remedies

Folk treatment with celandine, which is known for its antitumor effect, is widespread. But remember that many plants are toxic. Without medical care, patients die from this type of cancer much more often and faster. For this reason, folk remedies can only be used as an auxiliary part of treatment and only as prescribed by the attending physician.

Attention! It is necessary to promptly begin treatment of oncology at the initial stage, since large tumors can completely block the lumen of the walls of the esophagus, leading to obstruction and other complications.

Cancer Prevention

Basic principles of esophageal cancer prevention:

• undergo regular medical examinations and preventive examinations;
• quitting smoking and drinking strong alcoholic beverages;
• proper balanced nutrition;
• detection and treatment of precancerous diseases such as achalasia of the esophagus.

Malignant tissue damage to the esophagus (cancer) is a widespread disease in older people.

Among the oncologist's patients with this diagnosis, there are more men; up to the age of thirty, there are only isolated cases of atypical degeneration of esophageal cells into cancer cells.

Concept and statistics

A malignant neoplasm occurs as a result of an abnormal degeneration of normal cells. Most often the lower and middle parts of the organ are affected.

The disease is manifested by an increasing violation of the swallowing process, which ultimately leads to the fact that the patient cannot swallow even the softest food. The consequence of this is severe weight loss.

At the initial stages of tumor development, it can be detected only by one of the instrumental methods, that is, by ultrasound diagnostics, CT, endoscopy. In the final stages, it is not yet possible to completely defeat cancer.

The diagnosis is made only after a histological analysis of the biomaterial taken from the tumor. A neoplasm in the esophagus can also be benign, so do not panic until the diagnosis is confirmed.

Esophageal cancer, like any malignant degeneration, in the last stages grows into adjacent organs - the trachea, bronchi, blood vessels. Metastases can appear both within the sternum and in distant organs.

Classification

Oncologists use several classifications of esophageal cancer, division into types is necessary to select the most effective treatment tactics.

According to the characteristics of the growth of the neoplasm, cancer affecting the esophagus is divided into:

• Exophytic. The tumor with this type of cancer grows only in the lumen of the organ and rises above the mucous layer.
• Endophytic. The tumor forms in the thickness of the tissue or in the submucosal layer.
• Mixed tumors affect all layers of the walls, are characterized by the appearance of ulceration and rapid decay.

Based on their structure, esophageal cancer is usually divided into:

• – atypical cells are formed from squamous epithelial cells.
• . Rarely seen. The tumor begins to form from gland cells that secrete mucus. This form of cancer is more difficult to tolerate compared to squamous cell cancer. Adenocarcinoma in most patients is found in the lower esophagus adjacent to the stomach.

In relatively rare cases, there are other types of cancerous lesions of the esophagus. These include sarcoma, melanoma, chorionic carcinoma, lymphoma.

Squamous cell carcinoma is divided into two types:

• Surface– one of the most favorable forms of esophageal cancer in terms of prognosis. A malignant lesion manifests itself in the form of a plaque or erosion growing on the wall of the esophagus. This pathological change does not reach large sizes.
• Deeply invasive. Captures tissue located deep in the esophagus. Looks like a deep ulcer or mushroom. With this type of lesion, metastases quickly appear in the bronchi, trachea and heart muscle.

Upon visual examination, squamous cell carcinoma in the esophagus resembles a growth that surrounds the organ from the inside in the form of a ring. As the tumor grows into the lumen of the organ, its diameter narrows, which leads to the appearance of the main clinical picture of the disease.

The photo shows pictures of squamous cell carcinoma of the esophagus with endophytic growth

Sometimes squamous cell carcinoma forms as a polyp.

Conducted studies have established that squamous cell carcinoma in women usually begins in the lower parts of the organ and moves to the upper parts. In men, cancer primarily forms where the esophagus meets the stomach.

Squamous cell cancer of the esophagus is also usually divided into keratinizing and non-keratinizing cancer.

• Non-keratinizing cancer disrupts the functioning of the organ due to a pronounced narrowing of the lumen. This form is manifested by disturbances when swallowing food and saliva, and periodic regurgitation.
• Keratinizing form a cancerous tumor leads to changes in the surface of the mucous layer. The cells become keratinized and this makes the walls of the esophagus dry, which greatly aggravates all manifestations of the disease. The tumor grows quickly, but does not receive the necessary nutrition due to the slow formation of blood vessels in it. The consequence of this process is the appearance of zones of necrosis, which during endoscopy are determined as areas with ulcerative lesions.

The prognosis for survival of patients with cancer in the esophagus depends on the stage of the pathology.

In the first stages, the oncologist can give a greater chance of a favorable outcome of the disease after complex treatment. The five-year survival rate of patients reaches 80%. Patients are allowed to continue working if their profession does not involve heavy physical work.

In advanced cases, that is, when distant metastases are already detected, esophageal cancer is difficult to respond to even modern treatment methods.

Causes

It is impossible to single out one main reason leading to the formation of cancer cells in the walls of the esophagus.

The disease can occur under the influence of many provoking factors, and the risk of its development increases many times over if the human body is simultaneously affected by a whole group of negative conditions.

Most often, esophageal cancer is diagnosed:

• In people whose smoking experience is estimated at tens of years. contains carcinogenic substances that settle on the walls of the esophagus and lead to abnormal changes in epithelial cells. It has been established that in people who smoke, malignant neoplasms of the esophagus develop 4 times more often.
• With alcohol abuse. Drinks containing burn the esophagus, and this leads to an atypical proliferation of squamous epithelium. In chronic alcoholics, esophageal cancer is detected 12 times more often.
• With improper and irrational nutrition. The development of esophageal cancer is influenced by constant consumption of pickled, too spicy and hot foods. Eating foods containing mold and lack of fresh plant foods in the diet has an adverse effect. The listed dietary habits are typical for residents of Central Asia, Japan, China, and some regions of Siberia, therefore in these areas the number of patients with esophageal cancer is tens and hundreds of times higher.
• After thermal and chemical burns of esophageal tissue. A burn can also be a consequence of constantly eating too hot food. If concentrated alkalis are accidentally ingested, a cancerous tumor may be detected several years later.
• In people with vitamin deficiencies. The mucous layer of the esophagus needs vitamins such as A and E in sufficient quantities; they participate in creating the natural protective barrier of the organ. If vitamin deficiency is observed for a long time, then the cells of the organ cease to perform their function and degenerate.

There is also a hereditary predisposition to the development of a cancerous tumor in the esophagus. Scientists were able to isolate a mutation in the p53 gene, which leads to the production of an abnormal protein. This protein disrupts the natural defenses of esophageal tissue against cancer cells.

In the blood of many patients with malignant tumors of the esophagus, they are detected, so it can be suggested that this microorganism can also give impetus to cell degeneration.

Esophagitis and a condition such as can precede the development of a cancerous lesion. Esophagitis is characterized by the constant casting of hydrochloric acid into the esophagus, which irritates the walls of the organ.

Stomach diseases and obesity lead to esophagitis. Barrett's esophagus is a complication of esophagitis and is manifested by the replacement of stratified epithelium with a cylindrical one.

Symptoms

The formation of a cancerous tumor in the esophagus is indicated by such signs as difficulty in swallowing food and saliva, gradual weight loss up to cachexia, and increasing weakness.

Early metastasis is detected with a malignant neoplasm of the esophagus in the mediastinum, in some areas of the neck, and in the supraclavicular region. The appearance of metastases does not affect life expectancy in esophageal cancer, since a significant deterioration in the patient's condition is more to blame for rapid and earlier exhaustion.

Diagnostic measures

If a cancerous lesion of the esophagus is suspected, the oncologist prescribes a series of examinations, on the basis of which the final diagnosis is determined.

• with a contrast agent. This examination allows you to detect narrowing of the esophagus, the location of the tumor, its size, and thinning of the walls.
• . Using an endoscope, the doctor examines the entire esophagus, all data is displayed on a computer screen, which allows you to determine the cause of impaired swallowing or other manifestations of the disease. During endoscopy, if necessary, a tissue sample is taken for histology.
• Bronchoscopy is necessary to identify metastases in the bronchi, trachea, and vocal cords.
• one of the most accurate diagnostic methods. A layer-by-layer examination of the walls of the esophagus makes it possible to determine to what depth the tumor has grown and whether there are metastases in nearby tissues.
• Ultrasound is prescribed to detect metastases in internal organs.
• – special proteins, the level of which increases during the development of cancer cells. Tumor markers are divided into groups, each of which indicates a specific type of cancer. A cancerous tumor of the esophagus is characterized by the presence in the blood of tumor markers such as CA 19-9, Tumor marker 2, and squamous cell carcinoma antigen.

It must be remembered that tumor markers in certain situations can also appear in a healthy body, so their determination does not provide a reason to accurately diagnose cancer.

How to treat esophageal cancer?

The doctor selects treatment methods for esophageal cancer for his patient, guided by the stage of the pathology, the size of the tumor, and the patient’s age. Surgical methods, chemotherapy, and radiation are used. Radiation sessions and chemotherapy may be prescribed before and after surgery.

Surgery involves removing part of the esophagus or the entire organ with tumor-altered tissue. If necessary, part of the stomach is also removed. The esophagus is replaced with part of the intestine or a gastrostomy is formed. There are several types of surgeries performed on patients with esophageal cancer.

Operation

For esophageal cancer, the following types of operations are most often used:

• Operation Osawa Garlock. During the operation, an incision is first made in the abdominal cavity and passed along the midline. Usually the beginning of the incision is the navel, and the end is the 7th rib or the angle of the scapula from the side of the sternum. The tissue is dissected and the esophagus is isolated, cutting the pleura. During the operation, the stomach is removed into the pleural cavity. The detected tumor is examined, removed from it by about 8 cm and removed along with the esophagus using a Fedorov clamp. The stomach is fixed in the diaphragm, its food opening.
• Torek's operation. From the lateral approach, an incision is made on the right, the skin and tissue are dissected along the sixth intercostal space. First, the organ is isolated, then the cardia is expanded by widening the hole. A suture is placed at the end of the isolated esophagus, catgut and silk threads are used. At the second stage, the patient’s position is changed and he is placed on his back. The neck and area from the collarbone to the deltoid muscle are treated with iodine. From the side of the pleural cavity, the esophagus is isolated. The tumor is cut off along with part of the esophagus. Wounds on the neck and chest area are sutured in layers.
• Lewis operation. Resection is carried out in two stages. First, an abdominal approach is made through the midline of the abdomen, after which a revision is performed. A right thoracotomy is then performed with the patient in the left lateral position. The detected tumor is removed along with the esophagus, all lymph nodes must be punctured and the abdominal cavity must be examined for bleeding. It is necessary to install drainage tubes in the pleural cavity and only after this the suturing is performed. The Lewis operation is the most commonly used procedure for esophageal cancer because it is performed in one go. With this type of surgery, it is possible to perform plastic surgery of a partially removed esophagus. Lewis operation is prescribed if there are no metastases.

Diet

Proper nutrition is important during the recovery period for esophageal cancer.

It is necessary to select dishes in such a way that they fully provide the body with all the components necessary for the normal functioning of internal organs. In this case, you should avoid eating rough food.

• Eating pureed food. This facilitates its passage through the esophagus and increases the absorption of nutrients.
• Dishes should not contain particles that could block the narrowed lumen.
• The total weight of food consumed per day should not exceed 3 kg.
• The amount of liquid is limited to 6 glasses, and the liquid included in soups is also taken into account.
• The number of meals should be at least 6. In this case, the portions should be small.
• The temperature of the food should be medium. Excessively hot and cold foods increase discomfort.

Almost all patients with esophageal cancer experience nutritional deficiencies, which negatively affects the functioning of internal organs and their mental state.

Therefore, it is necessary to adhere to the proposed nutritional principles constantly. The doctor may also recommend a course of use of vitamin-mineral complexes, which will have a positive effect on overall well-being and reduce the likelihood of developing anemia and hypovitaminosis.

Is it possible to cure the pathology?

Esophageal cancer detected at an early stage of development can be cured with combination treatment. In advanced cases, no more than 8 months pass from the appearance of obvious signs of the disease to death. The patient's life at this time is supported by radiation therapy sessions.

How long do patients live and survival prognosis?

The survival rate of patients with a cancerous tumor in the esophagus after surgery, courses of radiation therapy and chemotherapy is:

• At the first stage of cancer, about 90%.
• At the second stage – 50%.
• On the third – no more than 10%.

The most favorable prognosis is in the detection of superficial squamous cell carcinoma. An unfavorable course is observed if cancer forms in the middle section. This is due to the fact that such a tumor quickly grows into the trachea and lungs.

Prevention

With the preventive goal of preventing esophageal cancer, it is necessary to abandon all bad habits and always adhere to proper nutrition.

Food should be fortified, plant foods must be present in the diet, spicy and pickled dishes should be limited.

It is necessary to eliminate precancerous conditions of the esophagus in time and undergo a complete examination if even the slightest symptom appears, indicating changes in the functioning of the organ.

Particular attention should be paid to their health by those people whose relatives had a history of cancer of the esophagus.

The following video will tell you about the prevalence, diagnosis and treatment of esophageal cancer:

Video about surgery to remove esophageal cancer using a new technique:

The most common histological type of esophageal cancer is squamous cell carcinoma, but there is currently a trend towards an increase in the incidence of esophageal adenocarcinoma, especially in young people and Caucasians. This trend is particularly pronounced in the United States, where adenocarcinoma accounts for 50% of esophageal cancer cases.

Causes of esophageal cancer

In Western countries, the main risk factors are smoking and alcohol consumption: heavy smokers and alcohol drinkers have a risk of esophageal cancer 100 times greater than the average population.

Other etiological factors include the following:

• Berrett's syndrome (with severe epithelial dysplasia, esophageal cancer develops in every second patient);
• hyperkeratosis of the palms;
• chronic iron deficiency anemia;
• exposure to certain chemicals and radiation;
• achalasia cardia.

Obesity contributes to the appearance of gastroesophageal reflux and the development of columnar cell metaplasia of the esophageal mucosa (Berrett's syndrome), which may partly explain the increased incidence of esophageal adenocarcinoma.

Mostly MEN get sick (5 times more often than women), especially alcoholics who eat irregularly, have bad teeth, and are mostly aged 50-60 years and older. Clinically, only rarely is a connection established with certain precancerous diseases, inflammation of the esophagus (with Achilles chlorosis), and scars after chemical burns.

Pathological anatomy. In men, esophageal cancer begins at the cardia itself, moving to the stomach, and at the border of the middle and lower third of the esophagus; in women, more often in the upper part of the esophagus, starting from the hypopharynx. Typically, a ring-shaped tumor sharply narrows the lumen of the esophagus, sometimes spreading along it. In addition to the main form with a narrowing of the lumen as a result of cancer infiltration and contraction of fibrous tissue, an ulcerating form and cancer in the form of a polyp are distinguished.

Microscopically, esophageal cancer mostly consists of squamous epithelium, has a very malignant growth, giving early metastases to the lymph nodes in the neck or in the mediastinum, even with rare superficial spread of the main tumor, which does not spread to the submucosa and muscular lining of the esophagus.

Prognosis of esophageal cancer

Overall, the 5-year survival rate is about 16%; even in the early stages it does not exceed 50-80%, and with metastases to the lymph nodes it drops below 25%. For locally advanced tumors, the 5-year survival rate after surgery or radiation therapy is 5-10%; the combination of surgery with radiation and chemotherapy can increase it to 25-27%.

The growth of an esophageal tumor is accompanied by invasion of neighboring organs. Cancer cells also spread along the wall of the esophagus through the lymphatic vessels, up to the cervical and celiac lymph nodes. Hematogenous metastases occur in the lungs, liver and other organs. Esophageal-bronchial and esophageal-pleural fistulas with recurrent pneumonia and abscesses can form. Tumor growth into the orta threatens death from massive bleeding.

Epidemiology of esophageal cancer

The incidence varies greatly from country to country, with the highest rates in China, Singapore, Iran, South Africa, France and Puerto Rico. In the United States in 2006, 14,550 people became ill with esophageal cancer and 13,770 died (7th place in mortality from malignant neoplasms in men). Over the past 25 years, the incidence of adenocarcinoma of the distal esophagus and esophagogastric junction has increased significantly. Over the past 30 years, the incidence of esophageal adenocarcinoma in men has increased, while the incidence of squamous cell carcinoma has decreased.

Squamous cell carcinoma in 10-15% of patients comes from the upper third of the esophagus, in 35-40% - from the middle and in 40-50% - from the lower. Adenocarcinoma in most cases arises from the lower third of the esophagus, often against the background of columnar cell metaplasia of the epithelium. Esophageal cancer often develops against the background of another tumor of the respiratory tract and upper gastrointestinal tract; on the other hand, synchronous or metachronous cancer of this location is found in 5-12% of patients with esophageal cancer.

Other, rarer esophageal tumors include glandular squamous, mucoepidermoid, verrucous, small cell, pseudosarcomatous, carcinoid, melanoma, lymphoma, carcinosarcoma, and squamous papilloma. Occasionally, invasion of the esophagus by a tumor of the lung or thyroid gland, as well as metastases into the esophagus, occur.

Risk factors for esophageal cancer

Alcohol abuse and smoking contribute to the development of esophageal cancer - probably due to constant irritation of the mucous membrane. The risk of esophageal cancer is also increased by cicatricial strictures of the esophagus after an alkali burn, achalasia of the cardia, ionizing radiation, a history of head and neck tumors, Plummer-Vinson syndrome, hereditary keratoderma, celiac cylindrocellular metaplasia of the epithelium (Barrett's esophagus). Squamous cell carcinoma accounts for less than half of esophageal cancers. Adenocarcinoma used to account for less than 10% of esophageal cancers, but has now grown to more than two-thirds in the United States. It usually develops from metaplastic columnar epithelium, in rare cases - from the glands of the esophagus. Gastric adenocarcinoma may also spread to the esophagus. Reflux esophagitis is considered the main risk factor for adenocarcinoma of the esophagus (according to some reports, the risk increases by 8 times). In cylindric metaplasia, the risk of malignant transformation is 0.8% per year. M-cholinoblockers, calcium antagonists, nitrates, theophylline and its analogues, as well as obesity (due to increased intra-abdominal pressure) can contribute to the development of reflux esophagitis and, thus, adenocarcinoma.

Symptoms and signs of esophageal cancer

The most common complaint is increasing dysphagia for less than a year: first, swallowing of solid foods is impaired, then soft and liquid. Substernal pain, usually constant and radiating to the back, indicates that the tumor has spread beyond the esophagus. Characterized by decreased appetite and sudden weight loss. Iron deficiency anemia is sometimes observed due to bleeding from the tumor, but severe bleeding is rare. If the recurrent laryngeal nerve is affected, hoarseness may develop. If the tumor blocks the lumen of the esophagus, aspiration of the contents of the esophagus is possible and, as a result, aspiration pneumonia and pleural effusion. Horner's syndrome, enlarged cervical lymph nodes, hepatomegaly, bone pain, paraneoplastic syndromes (hypercalcemia, hypersecretion of ACTH and gonadotropic hormones) are also possible.

The main triad of symptoms is difficulty swallowing, regurgitation, pain.

Difficulty swallowing (dysphagia) represents the first symptom; First, the esophagus gets stuck with uneven dense food (potatoes, bread, apples), then the edges become mushy. The patient cannot eat quickly, feels a foreign body in the esophagus, a “feeling of a stake”, stagnation of food, and less often, pain when passing a bolus of food. Short periods of improvement in swallowing due to tumor disintegration are common. Finally, swallowing liquids also becomes difficult.

The impact of the blockage is regurgitation or esophageal vomiting (regurgitation) soon after eating, especially after drinking liquids; when the lumen is completely closed, sometimes with an admixture of blood or with fragments of tumor tissue; there is salivation. Pain usually occurs in the late period of the disease when the tumor spreads to adjacent tissues or when the esophagus is perforated; usually the pain is of a constant type, rarely colicky, located deep and posteriorly, sometimes of extreme strength, without typical irradiation. Often striking is the almost complete absence of complaints, especially if thirst is quenched; Appetite usually drops sharply early on. Weakness, emaciation, dehydration, decreased skin turgor, and pallor increase, although the composition of the blood changes little.

X-ray examination with a liquid barium suspension reveals a cancerous narrowing, usually asymmetrical with an area where there is no peristalsis. With cerebral cancer, a filling defect is visible, with uneven edges corresponding to the lumpy surface of the tumor and without noticeable expansion above the narrowing. Cancer may be complicated by spasm with its usual x-ray signs along the upper border of the tumor. With scirra, a circular defect with a moderate expansion of the esophagus above the tumor is often found.

Course, forms and complications of esophageal cancer

The onset is usually gradual, the course is progressive, and cachexia develops late. With superficial esophageal cancer, the first sign of the disease may be metastases to the lymph nodes in the neck or in the liver. Death occurs more often 3-9 months after the onset of the disease, usually from bronchopneumonia; with scirrhosis later - up to 2 years.

When the tumor is located near the cardia, in addition to impaired swallowing, anemia and cachexia develop early, and referred angina is also observed, as with primary gastric cancer localized in the cardia.

Other signs and complications of esophageal cancer include persistent hiccups, especially when the cancer is located in the lower part of the esophagus; aphonia or hoarse voice - due to compression of the recurrent nerve by a tumor or metastases; profuse, even fatal bleeding during ulceration. When the esophagus is perforated, an esophageal-bronchial or esophageal-tracheal fistula often forms, causing severe coughing and the risk of suffocation; the fistula leads to secondary purulent infection of the lungs or to acute putrefactive mediastinitis, which often accelerates death. Possible perforation into the pleura, aorta, pericardium, and corrosion of the vertebrae.

Diagnosis and differential diagnosis of esophageal cancer

Early diagnosis is complicated by the fact that patients, as a rule, consult a doctor six months after the first mild symptoms they ignore. In the presence of severe dysphagia, one should think first of all about esophageal cancer, especially if a patient over 50 years of age begins to complain of difficulty swallowing first solid and then soft and liquid foods and if the symptoms have been present for less than a year and are associated with pain (long-term dysphagia is more often scar or other benign origin). In 2/5 of all cases, dysphagia is caused by this very serious disease. A detailed examination of the patient may reveal metastases in the neck or liver. Esophagoscopy with biopsy is difficult to perform, but provides a definitive diagnosis, which cannot be said about the previously used unsafe diagnostic probing of the esophagus. X-ray examination is usually of decisive importance, and should begin with plain radiography, which allows identifying a foreign body and an extra-esophageal tumor of the mediastinum.

The differential diagnosis should exclude:

1. mediastinal tumor, including aortic aneurysm and bronchogenic cancer, however, only rarely giving severe dysphagia;
2. idiopathic dilatation of the esophagus with a characteristic x-ray pattern of narrowing in the form of a narrow symmetrical funnel, with significant expansion and a large layer of fluid above the barium sediment;
3. inflammatory-cicatricial narrowing, easily recognized if there are appropriate indications in the anamnesis;
4. X-ray forms that are difficult to distinguish from cancer: tuberculosis of the esophagus (usually with an active pulmonary process), syphilitic lesions, and peptic ulcer of the esophagus, often occurring together with spasm; however, patients with syphilis often have cancer rather than a specific lesion;
5. anemic esophagitis with Achilles chlorosis (the so-called Plemmer-Vinson syndrome) with symptoms of excessive keratinization, focal desquamation of the epithelium and degeneration of the underlying muscle tissue of the esophagus (also tongue, hypopharynx).

Patients, usually women aged 40 years and over, complain of pain in the mouth and tongue, dysphagia, sometimes to the point of complete inability to swallow unsoaked solid food; however, the tube passes freely into the stomach. There are other signs of severe Achilles chlorosis - a smooth red tongue, cracks in the corners of the mouth. This esophagitis can lead to cancer of the esophagus and stomach. The same esophagitis and glossitis can be observed with hookworm anemia, sprue and malignant anemia. Normal esophageal spasm is limited, as seen on an x-ray screen when a barium pill is swallowed, to the upper or lower end of the esophagus. It is accompanied by a sensation of a foreign body in the throat, when the patient cannot swallow solid food. This spasm is of reflex origin in case of damage to adjacent organs - tuberculous, syphilitic, cancerous ulcers of the larynx, with peptic ulcers of the stomach and duodenum, with cholelithiasis, inflammation of the uterus, etc. - or predominantly of a central nervous origin in patients with psychasthenia for fear of getting cancer (cancerophobia), hysteria, epilepsy, chorea; also observed in tetanus and rabies. The probe passes into the stomach freely. The spasm can be seen through an esophagoscope. Less commonly, the spasm may involve most of the esophagus. Relieved by atropine and psychotherapy.
The so-called globus hystericus - hysterical spasm of m. crico-pharyngeus - with a sensation of a lump in the throat. Swallowing is completely free. It is observed more often in emotionally unstable teenage girls.

In another form of neurogenic dysphagia, patients, usually young, who are afraid of getting esophageal cancer or tuberculosis, do not experience the sensation of esophageal obstruction, but chew food until they tire, being confident in the impossibility of swallowing both solid and liquid food. Treatment has to be carried out with persuasion, re-instilling in patients the skill of swallowing.

Diagnosis of esophageal cancer

X-ray contrast examination of the esophagus usually done first. Small, flattened tumors can sometimes be identified using double contrast. Most often, the examination reveals an uneven narrowing of the lumen, sometimes thickening is visible in the upper part of the tumor. However, it is extremely difficult to distinguish a tumor from a cicatricial stricture of the esophagus using radiography.

Endoscopy allows you to directly examine the tumor. A flexible endoscope, unlike a rigid one, can be inserted into the fundus of the stomach to examine the area of ​​the esophagogastric junction and cardia. A biopsy and brush scraping are taken for histological and cytological studies.

CT used to assess the extent of tumors that have spread beyond the esophageal mucosa.

Endoscopic ultrasound, which allows a detailed study of the structure of the esophageal wall, is the most accurate method for assessing the depth of invasion and identifying metastases in regional lymph nodes. Since the tumor originates from the mucosa and successively invades the deeper layers of the esophageal wall, TNM classification is recommended. Category T describes the depth of invasion of the primary tumor, N - metastases to lymph nodes, M - distant metastases.

MRI makes it possible to obtain vertical and horizontal sections of the body. In diagnosing esophageal cancer, MRI does not provide advantages over CT.

PAT can be useful for identifying distant metastases.

Thoracoscopy and laparoscopy help assess the local spread of the tumor, as well as the condition of the regional, celiac and gastric lymph nodes.

Stages and prognosis. The main prognostic factor is the TNM stage of the tumor. The risk of relapse and survival are clearly related to the depth of invasion, lymph node involvement, and the presence of distant metastases. Tumors of stages T1-2N0M0 can be cured with surgery. Invasion of the adventitia or serosa (stage T3), as well as metastases to regional or distant lymph nodes (stage T4), greatly worsens the prognosis.

Diagnosis and determination of the stage of the tumor process

If dyspepsia and dysphagia appear in people over 50 years of age, fibroesophagogastroduodenoscopy with biopsy should be performed.

Fluoroscopy with a barium swallow allows you to clarify the extent of the tumor. Using CT, it is possible to clarify the relationship of the tumor to neighboring organs and tissues, in particular to the aorta and tracheal bifurcation, and also to exclude regional and distant metastases.

Endoscopic ultrasound allows one to assess the depth of tumor growth into the wall of the esophagus in approximately 85% of patients.

For low-lying tumors of the esophagus, in some cases it is advisable to perform laparoscopy to exclude metastases in the abdominal cavity.

Currently, PET plays an important role in identifying distant metastases.

The stage of the tumor process is assessed in accordance with the TNM system.

Esophageal cancer treatment

Treatment depends on the stage of the tumor. The main method remains surgery, sometimes in combination with radiation and chemotherapy. For inoperable tumors, radiation therapy is performed, since squamous cell carcinoma of the esophagus is quite sensitive to radiation. Chemotherapy alone (without radiation therapy) does not bring results. Pre- and postoperative radiation and chemotherapy slightly improve survival compared with surgery alone. Among the cytostatics, the most active are cystatin, fluorouracil, paclitaxel, irinotecan, vinorelbine and gemcitabine. Polychemotherapy is usually carried out followed by surgery or radiation.

Operation. If possible, resection of the esophagus is performed; if this is not possible, esophagectomy is performed. The results are better for tumors of the lower third of the esophagus up to 5 cm in size. Since radical surgery only rarely leads to a cure, palliative resection is sometimes used to eliminate dysphagia. Mortality and risk of complications after extensive thoracotomy for esophageal cancer are still very high. When resecting the esophagus and applying esophagogastroanastomosis, a combined laparotomy and right thoracotomy approach is used; For low-lying tumors, laparotomic access is sufficient. The tumor is removed, if possible, with a large segment of the unchanged esophagus, after which the stomach is moved into the chest and an anastomosis is performed with the esophageal stump. Colon or jejunal esophagoplasty increases the risk of complications. For palliative purposes, a side-to-side esophageal-gastric anastomosis is sometimes performed, bypassing the obstruction area.

Radiation therapy

1. Attempts to treat squamous cell carcinoma of the esophagus with radiation therapy have been unsuccessful. Radiation therapy is used in combination with surgical treatment (before and after surgery), as well as for palliative purposes.
2. Preoperative radiation therapy in the absence of chemotherapy is ineffective.
3. Esophageal adenocarcinoma is poorly sensitive to radiation

Palliative care

1. Bougienage. If surgery and radiation therapy are impossible or there is a relapse after them, they resort to dilatation of the esophagus using Sarari bougies or balloon dilators under endoscopic control. Due to the high risk of perforation, bougienage is carried out slowly and very carefully.
2. Stents. For esophageal obstruction, endoscopic placement of a stent (plastic or metal) helps. The stent also allows the esophagotracheal fistula to be isolated, at least temporarily. The stent may cause a pressure sore of the esophageal wall with ulceration, bleeding, or perforation.
3. laser destruction. In advanced cases of esophageal obstruction, laser destruction of the tumor with a YAG laser is used. The method can also be used to treat early-stage esophageal cancer, but further controlled trials are needed to test its effectiveness.
4. Destruction with ethanol or ethylene glycol under endoscopic control is possible for exophytic tumors. If the lumen of the esophagus is narrowed, bougienage is first performed, and then ethanol is injected around the entire circumference of the esophagus, which further expands the lumen.

Choice of treatment. To date, the optimal tactics for esophageal cancer have not been determined. Ideally, the best solution is to accurately stage the disease according to existing criteria and treat patients whenever possible in carefully designed, authoritative clinical trials. If it is impossible to include a patient in the study, for an operable tumor of the lower third of the esophagus (T1-3N1M0), surgery with pre- and postoperative radiation and chemotherapy can be recommended. If surgery is not possible or if there is esophageal obstruction, the palliative procedures described above are used.

Prevention and Surveillance. For persistent reflux esophagitis, endoscopy with biopsy is advisable to detect columnar cell metaplasia of the epithelium. Regular endoscopy will allow cancer to be detected earlier, which improves the prognosis. There are currently no uniform recommendations regarding columnar cell metaplasia, but most clinics recommend examination every 2 years, and in the presence of mild dysplasia annually. In case of severe dysplasia, the drug should be shown to a second pathologist; When the diagnosis is confirmed, the possibility of resection of the esophagus or photodynamic therapy with destruction of areas of dysplasia is considered. All patients are advised to quit smoking and limit alcohol consumption.

An interdisciplinary approach involving the joint efforts of a surgeon, gastroenterologist, radiation therapist, nutritionist, and chemotherapy is essential for optimal treatment of a patient with esophageal cancer.

Resectable esophageal cancer

For stage I and II esophageal cancer, the method of choice is esophageal resection; for more widespread tumor processes, surgical treatment does not have any advantages over radiation and chemotherapy.

In some centers, extirpation of the esophagus began to be performed using minimally invasive techniques, but these operations have not yet become widespread.

Results obtained in specialized centers indicate lower mortality and lower incidence of complications during surgical treatment.

In patients with stage III tumor process, the 5-year survival rate is only 15-28%. In this category of patients, the possibility of using other approaches and methods of treatment, for example, preoperative chemoradiotherapy, is being studied.

With transdiaphragmatic esophagectomy, the operative mortality rate is 4.5%, and anastomotic suture failure is recorded in 13% of cases.

Despite tumor sensitivity to chemotherapy in advanced esophageal cancer, adjuvant chemotherapy given after surgery does not improve survival. Postoperative radiation therapy increases treatment results only in cases where tumor cells are found at the resection border of the excised part of the esophagus; if regional lymph nodes are affected, it does not affect the outcome of the operation.

Preoperative (neoadjuvant) chemotherapy not only reduces the spread of the tumor process, turning it to an earlier stage, but also suppresses the growth of micrometastases or eliminates them before the release of growth factors caused by surgical trauma occurs.

Drugs that are effective for esophageal cancer include the following:

• fluorouracil;
• cisplatin;
• mitomycin;
• paclitaxel;
• methotrexate.

A study of the role of preoperative radiation therapy in the treatment of esophageal cancer showed that it has essentially no effect on tumor resectability, the extent of locoregional disease, or survival.

Preoperative radiation therapy can be combined with chemotherapy, given simultaneously or sequentially. However, with this treatment, significant damage to normal tissue occurs, esophagitis and pneumonitis often develop, which forces a reduction in the dose of radiation and drugs. In some studies that included only patients with squamous cell carcinoma of the esophagus, there was no significant increase in survival with this treatment strategy.

In phase II clinical trials of chemoradiation therapy for esophageal cancer, 70% of patients achieved complete remission, which casts doubt on the need for surgery after combination therapy.

Unresectable esophageal cancer

In most cases, esophageal cancer is diagnosed when the tumor process has spread so much that it is impossible to resect the esophagus.

Combined chemoradiotherapy for locally advanced cancer is more effective than radiation therapy alone and can, although rarely, be curative.

This circumstance speaks in favor of conducting randomized studies to compare the effectiveness of chemoradiotherapy with modern means and surgical treatment of esophageal cancer at an early stage.

Patients with metastases whose functional activity is assessed as less than 2 points should be treated with chemotherapy. Before chemotherapy is started, it is often necessary to place a stent in the esophagus to improve patency, although if chemotherapy is effective, dysphagia may improve significantly after the first course. Alternative palliative treatment methods that can alleviate local symptoms include irradiation of the tumor with a source introduced into the lumen of the esophagus (brachytherapy), laser coagulation and injection of the tumor with ethyl alcohol.