notes by dr Claudio Italiano
If you read this page because you have problems with swallowing or chest or burning pain, go to your doctor immediately and talk about it.
The writer has had to follow patients with cancer of the esophagus, implementing palliative maneuvers to allow them to feed themselves. In fact, the doctor must clearly discern if the surgical risk is superior to the benefits intended for the patient. In short, we must ask, according to science and conscience, what is the right way to intervene, that is, if the surgery and the therapeutic follow-up can guarantee a lasting life or not, given that it is already an excellent result survive for 5 years. For this reason, anyone with problems of dysphagia or burning in the chest, or feeling of bolus must go immediately and confidently to his doctor to resolve as soon as possible and definitively his case.
The patient with cancer of the esophagus is referred to the doctor because he has one of the following signs:
- retrosternal pain radiating behind the shoulders, simulating an angina pectoris;
- burning in the retrosternal region
- feeling of difficulty in swallowing (cf. dysphagia), like a bolus that stops
- odinophagia, ie sensation of retrosternal pain after swallowing
- regurgitation of food, sensation of acid in the mouth, especially if I lie down;
- dry, irritating cough at night, as I may unconsciously regurgitate during sleep and the regurgitated material migrates into the airways.
I am reminded of the case of a lady who was visibly losing weight and ate less and less, treated for chronic bronchitis (pneumonia ab ingestis, with hindsight), because the food went wrong, due to the esophageal injury that prevented a adequate power supply. A palliation with prosthesis represented for her the solution of her problem, so much so that she wanted to resume eating her much-desired pescestocco alla Messina! To our great disappointment. But how can such a wish be denied to a patient?
Key symptoms
The patient who has pain and does not swallow may have a lesion of the
esophagus, often of a heteroplastic nature, that is a tumor, but also a
simple motor alteration, or at best a reflux oesophagitis or an
ulceration or a Barrett disease, but in this case, it is similar to a
precancerous lesion, ie it is a half cancer or, in any case, a lesion to be
treated and followed because it may over time be associated with a tumor of the
esophagus.
esophageal neoplasms classification |
||
Epithelial | Not epithelial | |
Adenoma |
B
E N I G N I |
Leiomyoma |
Squamous carcinoma Adenocarcinoma adenosquamous Adenoid cystic Undifferentiated |
M A L I G N A N T |
leiomyosarcoma |
To learn more about this topic, compare: >>
- Esofago di Barrett; quello strano dolore al petto - Palliation of esophagogastric neoplasms
Endoscopy: esophageal vegetative tumor |
Endoscopic classification of esophageal carcinoma | |
Early I The superficial and protrudent type II a flat surface type: high II b flat surface type: flat |
II c flat
surface type: depressed
|
Advanced
protrudent type Localized ulcerated type |
Ulcerated
infiltrating type Widespread infiltrating type |
Among the most frequent benign tumors we mention leiomyoma
which alone accounts for 70% of benign neoplasms and is located at the lower
third of the esophagus, consisting of smooth muscle fibrocellulas and muscularis
mucosae.
The endoscopic aspect is that of a wall of the esophagus that allows the passage
of the endoscope. The papilloma and the angioma are lesions that are completely
random and in the case of the latter there may be multiple angiomatosis. But
let's get to the malignant tumors. In fact, before thinking of benign lesions,
once all the other noxas that cause dysphagia are excluded, having carried out
an esophagogastroduodenoscopy or at least a "baritiated esophagus", ie an x-ray
examination of the esophagus with contrast medium, it is advisable to make a
diagnosis immediately a neoplastic lesion, because if precious time passes, it
will be impossible to carry out a radical treatment of the lesion or you can
only carry out a palliation of the possible tumor lesion (see The palliation of
cancer of the esophagus: the prosthesis). The malignant neoplasia of the most
frequent esophagus, we said, is squamous carcinoma and adenocarcinoma, which
make up 60-70% and 20-30%, respectively. Squamous carcinoma can present
different degrees of differentiation and sometimes it can manifest as early
squamous cell carcinoma with initial development limited to the mucosa and
submucosa. Adenocarcinoma is the neoplasm most associated with Barrett's
esophagus, this strange lesion of the last tract of the esophagus, recognizable
by the orange appearance of the metaplastic mucosa, is extruded in the esophagus,
by acid insult continued over time, for example in the conditions of
gastroesophageal reflux. Therefore, the patient who addresses the doctor must be
carefully investigated and said to have an epigastric and retrosternal burning.
The ecoendoscopic investigation is of considerable help in the preoperative
staging of esophageal carcinomas, as it allows an accurate evaluation of the
infiltration degree of the esophageal wall and adjacent structures, with an
accuracy of 89% and in particular allows the study of peri-oesophageal lymph
nodes
Old TNM staging system of carcinoma always useful
T1: Limited mucosal and submucosal neoplasm
T2: Neoplasm that infiltrates the muscular tunic
T3: Neoplasm affecting the adventitia habit
T4: Neoplasm that infiltrates adjacent structures (trachea, lax and fatty
connective tissue, aorta and heart)
No: Negative lymph nodes, not affected
N1: Regional lymph nodes involved
M0: No metastasis
M1: Remote metastasis
M1 liymph: Neoplasm with involvement of distant lymph nodes: celiac lymph nodes,
perigastric lymph nodes, cervical and supraclavicular lymph nodes
That being the case, let's say immediately that staging is the basis for
decisions to be taken to intervene and treat the patient with cancer of the
esophagus. In fact, the factors that are considered are:
- Is the wall of the esophagus infiltrated and are the nearby structures taken,
ie the tumor has encroached on the mediastinum?
- The lymph nodes are affected by the process, so the tumor has spread?
- Are there distant metastases, ie, have the tumor cells taken to other organs
with blood, lymphatic and / or contiguity?
At this point the doctor traces the first sums and a prognostic judgment,
regarding the patient's 5-year survival, based on the following criteria:
If submucosa is invaded but not other tissues then 5-year survival is in 46% of
patients, unless complications.
If even the muscular tunic has been invaded and, therefore, the tumor has
trespassed, the 5-year survival falls to 30%;
If even the adventitia is taken, then it drops to 22%
If the neighboring organs are infiltrated, 7%
If there are distant metastases, it is still reduced to 3%.
If, in the opinion of the endoscopist, the radiologist, the echoso- scopist and
the oncologist, the lesion is liable to surgery, then he can think of making a
resection of the neoplastic esophagus which is followed by a non-simple
reconstruction of the alimentary pathway which, in general, it is obtained by
tracing an intestinal loop of the jejunum in mediastinum, biting it from the
pharynx. Other times, on the other hand, it is preferable to simply use laser,
to palliate lesions or prostheses, which allow to recanalize or, at worst, the
patient can be fed by enteral or parenteral nutrition. In recent years,
chemotherapy is providing increasingly satisfactory results, even if it remains
a palliative therapy or used as a support for subsequent surgical therapy.
see on topic: >>
Barrett, la diagnosi
Salivazione Disfagia esofagea, cause