Tokushukai Medical Group

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Digestive System Surgery: Cancer of Esophagus

Morbidity and death rate is high in middle to high aged male.

Esophagus is the 40 to 45cm long digestive tract which connect throat and stomach.Esophagus consists with mucosal, layer of muscle, and enveloping membrane from inside of tract. Cancer of Esophagus is a cancer developed from this mucosal.

Predictive morbidity number for male is 19,500, and for female is 3,300, and they are taking 4% and 1% proportion accordingly in predictive statistics for cancer in 2016. And male death number is 9,300, and women is 1,900, then they are taking 4% and 1% accordingly (The National Cancer Research Center, Cancer Information Service; ganjoho.jp). For both morbidity and death rate, male, 50 years old or elder, is relatively high percentage.

And, death rate is in decreasing tendency, for male from 2000, for female from 1970, but morbidity is a little increasing tendency for both male and female. (Cancer, statistical white paper 2012, Shinohara New Publishing Co.)

Developing location of cancer of esophagus is mostly at midthoracic esophagus, then lower thoracic, upper thoracic, thoracic esophagus, and cervical esophagus follows in order.

Cancer of Esophagus Handling Standard 11th version (Kinbara Publishing Co.)
  • Ce Cervical esophagus
    Ce Upper thoracic esophagus
    Mt Midthoracic esophagus
    Lt Lower thoracic esophagus
    Ae Abdominal esophagus

“Esophagus Cancer Handling Standard ‘Kinbara Publishing Co.” is used to classify Esophagus Cancer. Among Japanese, epidermoid cancer takes 90% of entire cancer of esophagus. In the rest of them, there are scarcity tumor like glandular cancer, adenosquamous cancer, neuroendocrine tumor.

Alcoholic drink and smoking is the risk factor.

It is said that alcoholic drink and smoking is the risk factor for developing epidermoid cancer which is common among Japanese. It is also reported that alcoholic drink and cigarette smoking affect in synergistic manner to increase the risk of cancer development. As for the relation of alcoholic drinking and cancer development, it is reported also that the functional difference of aldehyde dehydrogenation enzyme, which breaks acetaldehyde as alcoholic metabolite down, affects to the relation. For the glandular cancer which is common cancer among westerner, reflux esophagitis or barrette esophagus, and obesity is the risk factor. (New England Journal of Medicine 2003)

In advancing stage, it has a feeling which get food stuck in throat.

They say that the early stage symptom of esophagus cancer is arctation, difficulty in swallowing, chest pain, and/or sense of chest discomfort. But there are many cases with no symptom. Especially, nearly 60% of early stage of esophagus cancer in submucosal layer are no symptom.

In advance stage, patient has a feeling of food stuck due to arctation of esophagus caused by cancer, one has lost weight due to less meal volume caused by the difficulty of swallowing. In case when chest pain, back pain, coughing, blood in the sputum, or phlegmy voice are observed, there is a possibility that disease may advance greatly.

Diagnose invasion depth or disease stage of the primary focus.

As the exam, invasion depth (how deep cancer invades in) diagnosis of primary focus (part of esophagus where cancer is originally developed), diagnosis of lymphatic node metastasis, diagnosis of distal metastasis, are conducted then disease stage (progress level) is determined.

Upper Alimentary Canal Endoscopic Exam
This is so called Gastric Camera. It can look from laryngeal pharynx as entrance to duodenum at the end of stomach. 90% of early stage esophagus cancer is found at endoscopic exam. In case something is found as abnormal, biological exam (pick up tissues and exam) is available. To verify pathological abnormality, not only performing endoscopic exam, but also dye-spraying endoscopy exam which spray dye and narrow band imaging (NBI) can be conducted.
  • Endoscopic remark of esophagus cancer
  • Biopsy: Pick up tissue for cancer test
  • Spraying Iodine: spraying iodine to check cancer invaded area
  • NBI: Narrow band Imaging exam
  • Ultrasonic Endoscope Exam: Ultrasonic endoscope exam may be combined to check invasion depth diagnosis.
Magnetic Resonance Imaging
This will take image picture using strong magnetic field. This may be conducted to check infiltration to the surrounding of cancer.
Positron Tomography - CT
FDG-PET, among PET, which images the change of glyco-metabolism in the body composition, is used to diagnose cancer. And recently, PET-CT, which can view synthesized image with conducting CT at the same time, is used in many cases. This is used when checking distal metastasis which is difficult to determine by normal CT scan.
Esophagography
The exams with swallowing Barium and taking Roentgen image. Gathering from the shadow of barium, position, size and depth of cancer is presumed.
CT (Computer Laminographic)
The test viewing the cross-section image of human body with using radioactivity. In case of esophagus cancer, this is used to check, infiltration to the surrounding area, with or without lymphatic node metastasis, with or without distal metastasis (metastasis to lung, liver, or bone).

Endoscopic or surgical Treatment corresponding to disease stage.

Esophagus Cancer Diagnosis / Treatment Guideline” (Kinbara Publishing Company) is published by Japan Esophageal Society.

And, the part of “Esophagus Cancer Diagnosis / Treatment Guideline” is uploaded as cancer diagnosis guideline in the homepage of Japan Society of Clinical Oncology (http://www.jsco-cpg.jp/)

0 stage Esophagus Cancer
Cancer which stays in mucosal is corresponded to this cancer. Endoscopic treatment is applied. In case cancer stays at mucosal epithelia which is the top layer of mucosal, or at lamina propria of the mucous membrane which is one layer down from mucosal epithelia or below, possibility of lymphatic node metastasis is low. In this case, endoscopic cut off will complete the treatment. But in case cancer invades to muscular layer of mucosa, the lowest layer of mucosal, there is a possibility of lymphatic node recurrence or metastasis to other organs, so that additional treatment needs to be considered based on patients age and entire body status.
Photo of Endoscopic Submucosal Decollement
I stage Esophagus Cancer
It corresponds to the cancer which infiltrate to submucosal level. Possibility of lymphatic node metastasis is high so that treatment selection is either surgical operation or chemoradiation therapy. And, in case cancer metastasis invades to submucosal level as the result of endoscopic cut off operation is conducted, it is recommended to conduct surgical operation or chemoradiation therapy newly again.
II to III Stage Esophagus Cancer
Permanent cut off is applied after 2 cycle of FP treatment (5- fluorouracil + cisplatin) as preoperative chemotherapy. This is based on; the result of clinical trial (JCOG9204 Trial), listed in Journal of Clinical Oncology 2003, in which 242 persons attended from 17 facilities including National Cancer Center and University Hospitals, and clinical trial (JCOG9907 Trial) in which 330 persons attended from 12 facilities. In the former trial, applying postoperative anticancer drug treatment shows prevent more recurrence in comparison to surgical operation only treatment. And in the latter trial, it describes that in comparison of preoperative anticancer drug treatment with postoperative one, preoperative anticancer drug treatment shows the improvement on survival rate.
Preoperative chemotherapy is done with the combination of two drugs, cisplatin and 5- fluorouracil. Surgery is take place after two of this treatment in 3 weeks interval.
FP (cisplatin + 5-FU) treatment
Week 1 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Cisplatin 5- fluorouracil    
Week 2
Week 3
It is recommended to perform standard surgical treatment, esophagectomy and lymph node dissection. Esophagus is the organ which continues from cervical region to abdominal region, so that surgical area is also getting wide. Firstly, open the chest part and cut esophagus out to the top of stomach, to replace esophagus, gastric tube is formed by stomach. Pulling up such gastric tube to cervical region and anastomose with esophagus at cervical region. For the people having a cancer or stomach already cut off before, cannot use gastric tube, if this is the case, large intestine is used for regeneration.
In case of cancer of cervical esophagus, regenerate with using small intestine. As for the area where newly replaced esophagus is generated, there are; post mediastinal route where regenerate esophagus through the original pathway (post mediastinal), retrosternal route where regenerate esophagus through the back of breast bone, or presternal route where regenerate esophagus through the front side (under the skin) of breast bone. Generally, post mediastinal route or retrosternal route is used. Surgery may take 6 to 10 hours. That is a very big surgery. Recently, there is a case where surgery is made by trivial trauma using laparoscopy and thoracoscopy. In case when determined as non-resistant for surgery or do not wish to have surgery, then definitive chemoradiation therapy is considered.
IVa Stage Esophagus Cancer
This correspond to cancers which infiltrate to surrounding area and develops metastasis at distanced lymph node. In case possible cut off is expected with preoperative chemotherapy, permanent cut off operation is performed after 2 cycle of FP treatment (5-fluorouracil + cisplatin) as preoperative chemotherapy same as II to III stage.
In case curative ablation is difficult, in case patient is found as non-resistant for the surgery, or in case patient do not want to have surgery, definitive chemoradiation therapy is then considered.
Definitive chemoradiation therapy is performed in accordance with the concurrent chemotherapy and radiation combination therapy second phase trial (JCOG9516) which is listed in Japanese Journal of Clinical Oncology 2004, and third phase trail (RTOG9405/INT0123 trial) which is listed in Journal of Clinical Oncology 2002. Same as chemotherapy, cisplatin and 5-fluorouracil are used. Radiation therapy takes 6 weeks, and chemotherapy takes place on 1st week and 5th week.
FP-R Therapy (based on JCOG trial)
Week 1 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Cisplatin 5- fluorouracil      
Week 2
Week 3
Week 4
Week 5 Day 29 Day 30 Day 31 Day 32 Day 33 Day 34 Day 35
Cisplatin 5- fluorouracil      
Week 6

* △ mark means Radiation Therapy

In case when chemotherapy is difficult, esophagus stent indwelling for the alleviation of symptoms, or gastrostomy for alimentation is considered.
IVb Stage Esophagus Cancer
This corresponds to the cancer which develops distanced metastasis in liver or lung. Since most of the case cure is hardly expected, chemotherapy /chemoradiation therapy as life-prolonging therapy is conducted. For those who has no treatment history, FP therapy is used. For those who has therapy history, paclitaxel and docetaxel are use. Esophagus stent indwelling for the alleviation of symptoms, or gastrostomy for alimentation is considered.

5 years survival rate is about 10% at stage IV.

5 years survival rate for each disease stage (relative survival rate with death other than cancer is amended) is reported as 83.7% at Stage I, 48.8% at Stage II, 26.4% at Stage III, and 11.2% at Stage IV. (Survival Rate Joint Research 2003 – 2007, by Japan Association of Clinical Cancer Centers affiliated facilities).

Lower the risk with β-Carotene or Vitamin C.

There are no abortive measures effective. Risk decreasing factors, such as fruit, non-starch vegetables, β carotene or vitamin C contained in foods are listed as possibility, (World Cancer Research Foundation & USA Cancer Research Association 2007), but because of the difficulty in making accurate understanding of the amount of intake, and in the first-place meals’ effect on carcinogenesis is not so much, so that it is difficult to clarify how much effect is given. Therefore, it is not yet reached to prevent the development of esophagus by up taking these.  

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