There are many factors in the development of esophageal cancer. These are listed below:
- Smoking
- Alcohol
- Hot drinks (such as hot tea)
- N-nitroso compounds (pickled vegetables)
- A diet poor in green vegetables and vitamins
- Low socioeconomic conditions
- Fungal toxins and viruses
- History of radiation to the mediastinum
- Corrosive strictures due to chemicals
- Plummer-Vinson Syndrome
- Obesity
- Akalasia
- Reflux
- Barrett's Esophagus
- Celiac Disease
The most common symptom is difficulty in swallowing (dysphagia). Dysphagia initially occurs against solid foods. Later, dysphagia is also observed with liquid foods. A common symptom is weight loss. Weight loss may be due to both dysphagia and tumor-induced catabolism. Symptoms such as painful swallowing (odynophagia), chest pain, regurgitation, hoarseness and bleeding may also be observed.
Various methods are used in the diagnosis and staging of esophageal cancer. The first and most important of these is endoscopy. Advances in endoscopic techniques allow the diagnosis to be made earlier and more safely. The techniques used in diagnosis and staging are listed below:
- Endoscopy + biops
- Bronchoscopy
- Computed tomography
- Endoscopic ultrasonography
- PET-CT
- Magnetic resonance
- Thoracoscopy, laparoscopy
ESOPHAGEAL CANCER SURGERY
The surgical treatment of esophageal cancer (esophageal cancer) is radical removal of the esophagus. This is called radical esophagectomy or radical esophageal resection. This radical surgical treatment is combined with radiotherapy and chemotherapy before and after surgery. In radical surgery, regional lymph nodes are removed along with the esophagus. Currently, these lymph nodes are removed by 2-field or 3-field lymph node dissection.
Historically, esophageal surgery has been considered a difficult and risky surgery in terms of postoperative problems. In addition to the risk to life for patients, problems related to quality of life may also arise. Despite all efforts, the 5-year survival rate after treatment remains at 30%-40%. In recent important scientific studies, radical surgery combined with appropriate neoadjuvant/perioperative treatment has resulted in 5-year survival rates of 45%, 47% and 55%.
There have been significant developments in the fields of endoscopic, laparoscopic and robotic surgery in the treatment of esophageal cancer. In addition, innovations in oncologic treatments are promising.
Esophageal cancer has two main histologic types: adenocarcinoma and squamous cell carcinoma. Lymph node involvement is common in both histologic types. Esophageal cancer can metastasize to abdominal, thoracic and cervical lymph nodes. Since the lymphatic network in the esophageal wall is very rich, lymphatic metastasis can be seen in all directions. Therefore, the width of the lymphadenectomy during surgery is very important. Esophageal cancer surgery usually requires access to two or three body cavities (abdomen, chest, neck).
A multimodal approach is required in the treatment of esophageal cancer. Specialists in surgery, gastroenterology, radiology, pathology, medical oncology and radiation oncology are involved in diagnosis, treatment and follow-up. Although developments in non-surgical treatment methods increase the chances of success, surgical treatment constitutes the center of treatment. Today, there are a wide variety of approaches for surgical treatment. A meticulous evaluation process is required for the selection of these approaches.
ENDOSCOPIC TREATMENTS
Endoscopic techniques are very important in the diagnosis and staging of esophageal cancer. In recent years, endoscopic techniques have been used in early stage esophageal cancers as a result of advances in endoscopic techniques. However, very few esophageal cancers are suitable for endoscopic treatment. The tumor should be smaller than 2 cm and well differentiated. There should be no tumor cells in the lymphatic and blood vessels, and the tumor should be limited to the mucosa (the innermost layer). In these patients, the risk of lymph node metastasis is below 5% and endoscopic treatments are appropriate. Otherwise, surgical treatment should be considered.
Endoscopic treatment includes endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). ESD is usually the recommended method in suitable patients.
OPEN SURGERY
In open surgery, both the abdominal and thoracic parts of the operation are performed through appropriate incisions. In the abdomen, the upper part of the stomach is removed and the stomach is freed and turned into a tube. Regional lymph nodes in the abdomen are also removed. After this part of the operation is completed, the patient is placed on his/her side, the chest is opened and the esophagus is removed together with the regional lymph nodes. In cases where it is not necessary to go all the way to the neck, the stomach is pulled into the chest and the remaining esophagus is anastomosed to the gastric tube. If it is necessary to go up to the neck, the esophagus is completely removed. Lymph dissection is performed by making an incision in the neck area. The stomach is pulled up to the neck and the anastomosis is performed in the neck. With the open method, oncologic surgery can be performed with adequate lymphatic cleansing under direct vision in both the abdominal and thoracic cavity. Complication rates of up to 60% and a mortality risk of 4-5% are reported after surgery.
MINIMALLY INVASIVE SURGERY (Laparoscopic Surgery, Robotic Surgery)
With the widespread use of laparoscopic surgery, minimally invasive surgery has been applied in esophageal cancers as a result of less pain, less hospitalization, earlier initiation of nutrition and better cosmetic results. Laparoscopic surgery for esophageal cancer has gradually increased in the last 10 years. Laparoscopic surgery has reduced postoperative complications, especially pulmonary problems. In addition to advantages such as less pain, earlier recovery, better quality of life, oncologic results have been observed to be very good in the long-term follow-up of patients.
It is also possible to use robot in esophageal cancer surgery. Although it has been reported that lymph node dissection can be performed better and more easily with robotic surgery, the results of laparoscopic and robotic surgery are generally similar.
In the treatment of esophageal cancer, surgery, chemotherapy and radiotherapy should be applied in combination. After a meticulous multidisciplinary evaluation of the patient, it should be decided which treatment method or methods should be used.
