OESOPHAGEAL CANCER

( By JASCAP )

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Symptoms & diagnosis

Symptoms of oesophageal cancer

Difficulty in swallowing (dysphagia) is the most common symptom of oesophageal cancer. Usually, there is a feeling that food is sticking on its way down to the stomach, although liquids may be swallowed easily at first.

There may also be some weight loss, and possibly some pain or discomfort behind the breastbone or in the back. There may be indigestion or a cough.

These symptoms can be caused by many things other than cancer, but you should always tell your doctor, particularly if they do not go away after a couple of weeks.

How oesophageal cancer is diagnosed

Your GP will examine you, and will arrange for you to go to hospital for tests and to see a specialist. At the hospital the specialist will ask you about your general health and any previous medical problems before examining you. You may have blood tests and a chest x- ray taken to check your general health. The following tests are commonly used to diagnose cancer of the oesophagus:

Upper gastrointestinal endoscopy (oesophagoscopy)

This procedure enables the doctor to look directly at the oesophagus through a thin flexible tube called an endoscope. The endoscope has a tiny camera and a light on the end. If necessary, the doctor can take a small sample of the cells (a biopsy) to be examined under a microscope. This can usually confirm whether or not there is a cancer.

You can usually have an endoscopy as an outpatient, but occasionally an overnight stay in hospital is needed. Once you are lying on your side on the couch you may be given a sedative, usually injected into a vein in your arm, to make you feel sleepy and reduce any discomfort during the test.

Alternatively, a local anaesthetic may be sprayed on to the back of your throat before the doctor passes an endoscope down into your oesophagus. Sometimes both an injection and the spray are used. The doctor then looks through the endoscope and examines the inside of the oesophagus.

Endoscopy can be uncomfortable but should not be painful. After a few hours, the effect of the sedative will wear off and you will be able to go home. You should not drive for several hours after the test and if possible you should arrange for someone to travel home with you.

If you have had the local anaesthetic spray to the back of your throat you may need to stay in the hospital until the anaesthetic has worn off. This usually takes about four hours and you should not try to swallow anything during this time. Some people have a sore throat afterwards; this is normal and should disappear after a couple of days. If it doesn‟t, let your doctor at the hospital know. You should also tell your doctor if you have any chest pain.

Occasionally, the doctor may want to carry out treatment such as stretching (dilatation) of the oesophagus at the same time as an endoscopy. This can help you to swallow food more easily.

Barium swallow

A liquid barium solution is swallowed, which shows up on x-ray. Using an x-ray machine, the doctor can watch the barium as it flows down the oesophagus towards your stomach. At the same time x-ray pictures are taken of your oesophagus. A barium swallow takes about 15 minutes and should not be painful.

Further tests for oesophageal cancer

If the tests show that you have cancer of the oesophagus, your doctor may want to carry out further tests. These help the doctor to see the extent (or stage) of the cancer and decide on the best type of treatment. You will probably have a chest x-ray (if one has not already been done) and other tests, which may include any of the following:

CT scan

A CT (computerised tomography) scan takes a series of x-rays which build up a three- dimensional picture of the inside of the body. The scan is painless but takes from 10 to 30 minutes. CT scans use a small amount of radiation, which will be very unlikely to harm you and will not harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan.

You may be given a drink or injection of a dye which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand. You will probably be able to go home as soon as the scan is over.

Endoscopic ultrasound (EUS)

The involves the same procedure as the upper gastrointestinal endoscopy, but a tiny ultrasound probe is connected to the end of the endoscope tube and passed along the oesophagus.

Ultrasound uses sound waves to build up a picture of the area. It allows the doctors to get a deeper view of the wall of the oesophagus and surrounding areas. This may give them a clearer idea of the size and depth of the tumour. It also allows them to see whether lymph nodes nearby are enlarged, and possibly, whether this enlargement is due to cancer or simply an inflammation caused by infection.

Laparoscopy

This test involves a small operation done under a general anaesthetic and will mean a short stay in hospital. It allows the doctor to look at the upper part of the abdomen (tummy) from the inside. This is to see whether the cancer has spread into the abdomen.

The doctor makes a small cut (about 2cm) in the skin and muscle near the tummy button (navel) and carefully inserts a thin, flexible fibre-optic tube (laparoscope) into your abdomen. The doctor can then examine the area and may take samples of tissue (biopsies) to be examined under the microscope. Whether or not a laparoscopy is needed depends on the position of the tumour within the oesophagus.

PET scan

Positron emission tomography scans (PET scans) can be used to find whether the cancer has spread beyond the oesophagus, or to examine any lumps that remain after treatment to see whether they are scar tissue or whether cancer cells are still present.

A PET scan uses low-dose radioactive glucose (a type of sugar) to measure the activity of cells in different parts of the body. A very small amount of a mildly radioactive substance is injected into a vein, usually in your arm. A scan is then taken a couple of hours later. Areas of cancer are usually more active than surrounding tissue and show up on the scan.

PET scans are a new type of scan and you may have to travel to a specialist centre to have one. They are not always necessary but you can discuss with your doctor whether one would be useful in your case.

Waiting for your test results

It will probably take from one to two weeks for the results of your tests to be ready, and a follow-up appointment should be arranged for you before you go home. This waiting period will be an anxious time for you and it may help to talk things over with the hospital's specialist nurse, a close friend, a relative.

Staging of oesophageal cancer

The stage of a cancer is a term used to describe its size and whether it has spread beyond its original site. Knowing the extent of the cancer helps the doctors to decide on the most appropriate treatment.

A commonly used staging system for cancer of the oesophagus is described below:

Stage 0 or carcinoma in situ (CIS) This is a very early stage of oesophageal cancer. There are cancer cells in the lining of the oesophagus, but they are contained entirely within the lining. Oesophageal cancer is not often diagnosed this early, as there are usually no symptoms at this stage.

Stage 1 The cancer is found only in the surface layers of the lining of the oesophagus or in a small part of the oesophagus. It has not spread to nearby tissues, lymph nodes or other organs.

Stage 2 This means that the cancer has either grown into the muscle layer of the oesophageal wall or spread to nearby lymph nodes, but has not spread to any other organs. If the cancer has not spread to nearby lymph nodes, it is stage 2A. If the cancer has spread to nearby lymph nodes, it is stage 2B.

Stage 3 The cancer has grown through the wall of the oesophagus. It may also have spread to nearby lymph nodes and other body tissues close to the oesophagus, but there is no spread to other parts of the body.

Stage 4 The cancer has spread to lymph nodes and other parts of the body, such as the liver, lungs or stomach and is known as secondary or metastatic cancer.

TNM staging

Your doctors may also describe your cancer using the TNM staging system.

  • T describes the size of the tumour. There are five different stages ranging from T0T4.
  • N describes whether the cancer has spread to the lymph nodes. There are four stages depending upon the number of lymph nodes that are involved, ranging from N0N3.
  • M describes whether the cancer has spread to another part of the body, such as the liver or the lungs (secondary or metastatic cancer). There are two stages: M0 is where there are no metastases; M1 is where there are metastases.

The TNM staging system is more complex, and it can give more precise information about the stage of your tumour.

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