Esophageal cancer, also known as esophageal cancer, is a malignant tumor that occurs in the epithelial tissue of the esophagus.
Causes
Genetic factors: Esophageal cancer has a remarkable phenomenon of family gathering, and it is common to have three or more consecutive generations of affected families in high incidence areas, but esophageal cancer is definitely not genetic, but inseparably related to family eating habits. Nitrosamines: Nitrosamines are strong carcinogenic substances. Studies have shown that residents who consume sauerkraut in high esophageal cancer-prone areas have methylbenzyl nitrosamines, nitrosopyrrolidine and nitrosoguanidine in their gastric juice and urine, which induce esophageal cancer. It was also found that the amount of sauerkraut consumed and the incidence of esophageal cancer were directly proportional. Trace elements and malnutrition: serum molybdenum, hair molybdenum, urine molybdenum and molybdenum in esophageal cancer tissues were lower than normal in the population in the high esophageal cancer incidence area. The lack of molybdenum in water and soil of esophageal cancer high incidence area, and the cancer suppressing effect of molybdenum is confirmed by most scholars. Inadequate intake of animal protein and lack of vitamin A, B2 and C are common features of the diet of residents in high esophageal cancer areas. Damage to esophageal mucous membrane: Long-term preference for hot food and coarse food, drinking strong tea and eating irritating food such as chili pepper can cause damage to esophageal mucous membrane and interstitial changes in esophageal mucous membrane proliferation, which may also be one of the carcinogenic factors. Smoking and drinking strong alcohol have a certain relationship with the development of esophageal cancer. Various kinds of long-term untreated esophagitis may be precancerous lesions of esophageal cancer. Mold carcinogenic factors: the use of moldy food can induce precancerous lesions or squamous epithelial carcinoma in the esophagus and stomach of mice. This kind of mold has synergistic effect with nitrosamines to promote cancer.
1.Pathological morphological typing of early esophageal cancer.
According to its morphology, early esophageal cancer can be divided into cryptic type, erosion type, plaque type and papillary type. Among them, plaque type is the most common, accounting for about 1/2 of early esophageal cancer, and this type of cancer cells are better differentiated. Celiac type accounts for about 1/3, and the differentiation of cancer cells is poor. Cryptogenic lesions are the earliest and are all carcinoma in situ, but they only account for about 1/10 of early esophageal cancer. Papillary type lesions are later, and although the differentiation of cancer cells is generally better, in situ cancer seen in surgery is less common.
2.Pathological morphological typing of middle and late stage esophageal cancer.
It can be divided into medullary type, myxomatous type, ulcerative type, narrowing type, intraluminal type and undetermined type. Among them, medullary type has the highest malignant degree and accounts for more than 1/2 of middle and advanced esophageal cancer. This type of cancer can invade all layers of the esophageal wall and expand inside and outside the lumen. All or most of the circumference of the esophagus and the connective tissue around the esophagus can be involved, and the differentiation of cancer cells varies. The mycelium type accounts for about 1/6 to 1/5 of middle- and late-stage esophageal cancer. The cancer tumor is mostly round or ovoid in shape, and can involve most of the esophageal wall in a mycelium-like protrusion into the lumen of the esophagus. Ulcerated type and narrowed type each account for about 1/10 of middle and advanced esophageal cancer. Ulcerated type has deeper ulcers on the surface, bleeding and metastasis at an earlier stage, and obstruction at a later stage. Constricted type has circular growth and involves the whole esophagus, and the esophageal mucosa is contracted centripetally, so obstruction occurs earlier, while bleeding and metastasis occur later. Intraluminal type is less common, in which the tumor protrudes into the lumen of esophagus, with round or oval elevation, and is connected to the esophageal wall with a tip, and its surface is often eroded or ulcerated. The tumor can invade the muscular layer, but it is shallower than the above-mentioned types. A small number of middle and advanced esophageal cancer cannot be classified as the above mentioned types, which is called undetermined type.
3.Histological typing.
(1) Squamous cell carcinoma: the most common.
(2) Adenocarcinoma: less common, and can be divided into simple adenocarcinoma, adenosquamous carcinoma, mucinous epidermis-like carcinoma and adenoid cystic carcinoma.
(3) Undifferentiated carcinoma: less common, but with high malignancy. Most cancers in the upper and middle esophagus are squamous cell carcinoma, while most cancers in the lower esophagus are adenocarcinoma.
Spread and metastasis
1.Diffusion within the esophageal wall The underlying cells of the epithelium next to esophageal cancer become cancerous or become carcinoma in situ, which is one of the ways of surface diffusion of carcinoma. Cancer cells also often infiltrate along the lymphatic vessels of the lamina propria or submucosa of the esophagus.
2.Direct infiltration into adjacent organs Upper esophageal cancer can invade larynx, trachea and soft tissues of neck, and even invade thyroid gland. Middle segment cancer can invade bronchus and form broncho-esophageal fistula; it can also invade thoracic duct, odd vein, pulmonary hilar and lung tissue, and some of them can invade aorta and form esophage-aortic fistula, which can cause hemorrhage and death. Lower esophageal cancer can often involve the cardia and pericardium. In total, about 1/2 of the neighboring organs of esophagus are directly involved, and the involved organs are lung and pleura, trachea and bronchus, spine, heart and pericardium, aorta, thyroid gland and pharynx in order.
Lymphatic metastasis is more common, accounting for about 2/3 of cases. middle esophageal cancer often metastasizes to paraesophageal or hilar lymph nodes, and also to lymph nodes in the neck, around the culpable portal and the left gastric artery. Lower segment esophageal cancer often metastasizes to the lymph nodes of paraesophagus, cardia, left gastric artery and abdomen, and occasionally to the lymph nodes of the upper mediastinum and neck. The lymphatic metastasis sites are mediastinum, abdomen, trachea and paratrachea, pulmonary hilum and bronchus in order.
4. Hematogenous metastases are mostly seen in patients with advanced disease. The most common metastases are to the liver (about 1/4) and lung (about 1/5), and the other organs are bone, kidney, adrenal gland, pleura, omentum, pancreas, heart, lung, thyroid and brain, in that order.
Clinical manifestations
Esophageal cancer starts insidiously and may be asymptomatic in early stage. Some patients have foreign body sensation in the esophagus, or slow or obstructive choking feeling when passing food. It may also show as burning, pinching or pulling pain behind the sternum when swallowing. Progressive esophageal cancer is often diagnosed with dysphagia, which is progressive in development and even completely unable to eat. It is often accompanied by vomiting, epigastric pain, weight loss and other symptoms.
Late stage of the disease may be accompanied by obvious malnutrition, emaciation and cachexia due to long-term lack of food intake, and complications such as cancer metastasis and compression may occur. Such as hoarseness caused by cancer compression of the recurrent laryngeal nerve, pain caused by bone metastasis; jaundice caused by liver metastasis and other symptoms. If the tumor invades adjacent organs and is complicated by perforation, it may also cause mediastinal abscess and pneumonia. Some patients can occasionally feel a hard abdominal mass in the upper abdomen or touch enlarged lymph nodes on the clavicle.
Common symptoms – early symptoms
1.Esophageal cancer: choking sensation in the throat: the most common, which can disappear or recur on its own and does not affect eating. It often occurs when the patient’s mood fluctuates, so it is easily mistaken for functional symptoms.
2.Post-sternal and subxiphoid pain: more common. When swallowing food, there is pain behind the sternum or subsynovial pain, the nature of which may be burning, pinching or pulling, with the swallowing of rough, burning or irritating food as the most important.
3, food retention infection and foreign body sensation: when swallowing food or drinking water, there is a feeling of slow downward movement of food and retention, as well as a feeling of tightness behind the sternum or food adhering to the esophageal wall, etc., which disappears after eating. Dryness and tightness in the throat: This is especially noticeable when swallowing dry and rough food, and the occurrence of this symptom is often related to the patient’s mood swings.
Symptoms in the middle and late stages
1, dysphagia: progressive dysphagia is the main symptom of most patients at the time of consultation, but it is a more advanced manifestation of the disease.
2.Food reaction: It often appears when dysphagia is aggravated, and the reflux volume is not large, containing food and mucus, but also blood and pus.
3.Other symptoms: When the cancer presses the recurrent laryngeal nerve, it may cause hoarseness; invasion of phrenic nerve may cause eruption or phrenic nerve paralysis; compression of trachea or bronchus may cause shortness of breath and dry cough; erosion of aorta may produce fatal bleeding.
Diagnostic criteria
1.Fiber endoscopy In early esophageal cancer, the detection rate of fiber endoscopy can reach more than 85%.
2.The advantages of esophageal endoscopy are that the depth of lesion infiltration in the esophageal wall can be measured more accurately; the abnormal enlarged lymph nodes outside the wall can be measured; the lesion in the wall part of esophagus can be distinguished more easily.
3.Esophageal exfoliative cytology examination, which is simple, less painful and with low false positive rate, has been proved to be practical and feasible for large area screening in high incidence area of esophageal cancer, and the total positive rate can reach more than 90%, so it is the preferred method for early diagnosis of esophageal cancer.
4.Barium X-ray meal imaging Except for very early esophageal cancer which is not easy to show, experienced radiologists can fully adjust the barium and make the patient swallow it in small bites, and then carefully observe in multiple directions and double air-barium imaging, which can mostly detect the signs of earlier cancer such as thickened esophageal mucosa, tortuous or dashed interruption; or hairy esophageal edge; or small filling defect; or small niche shadow; or limited wall stiffness; or barium retention.
Treatment
Surgical treatment focuses on common postoperative complications and their management.
①Anastomotic fistula: cervical anastomotic fistula does not pose a threat to the patient’s life and can be healed by drainage; intrathoracic anastomotic fistula poses a great threat to the patient and has a high mortality rate; intrathoracic anastomotic fistula mostly occurs 5-10 days after surgery; the patient has respiratory distress and chest pain; there are signs of liquid pneumothorax on X-ray; the contrast agent is seen to flow out of the esophageal cavity on oral iodine; closed chest drainage, fasting, effective antibiotics and supportive treatment; in patients with early fistula, surgical repair can be tried and strengthened by covering with large omentum or intercostal muscle flap.
Pulmonary complications: including pneumonia, pulmonary atelectasis, pulmonary edema and acute respiratory distress syndrome, etc. Pulmonary infection is more common and should be given high priority; postoperatively, patients should be encouraged to cough and sputum, and respiratory management should be strengthened to reduce the occurrence of postoperative pulmonary complications.
(③) Celiac disease: caused by intraoperative thoracic duct injury, mostly occurs 2-10 days after surgery, the patient feels chest tightness, shortness of breath and panic. Once the diagnosis is confirmed, closed chest drainage should be placed and the flow of drainage should be closely observed, and for those with low flow, a low-fat diet can be given to maintain water-electrolyte balance and supplemental nutrition, and some patients can heal. For patients with high celiac flow, the celiac duct should be dissected and ligated in time.
④ Other complications include hemothorax, pneumothorax and chest infection, which should be treated accordingly according to the condition.
Reflux esophagitis: Reflux esophagitis is one of the most common complications after esophageal cancer surgery, mainly manifested as reflux of acidic liquid or food from gastroesophagus to pharynx or oral cavity, and often accompanied by symptoms such as burning sensation or pain behind the sternum and difficulty in swallowing.
Treatment: Patients with esophageal cancer should pay attention to diet after surgery, mostly enter liquid food or semi-liquid food, quit smoking and alcohol, forbid hot, cold, sour and spicy food and other stimulating foods, and keep sitting or semi-recumbent position for 30 minutes after meals, pay attention to gastrointestinal decompression to avoid discomfort caused by high abdominal pressure.
2. Functional thoracic and gastric emptying disorder: After esophageal cancer surgery, gastrointestinal dysfunction often occurs, causing thoracic and gastric emptying disorder resulting in retention of large amount of gastric contents.
Treatment: For functional thoracic and gastric emptying disorder after esophageal cancer surgery, gastrointestinal decompression, inverted gastric tube drainage or gastric fluid reinfusion should be implemented according to specific conditions, and patients should actively improve their nutritional status, nausea and vomiting and other adverse symptoms to promote the recovery of gastrointestinal function.
3.Respiratory tract infection after esophageal cancer surgery: Respiratory tract infection is also a common complication after esophageal cancer surgery, mainly manifested as cough, chest tightness and difficulty in breathing, which should be treated actively to improve the quality of life of postoperative patients.
Treatment: Firstly, the infection should be actively controlled and sputum aspiration or *substance treatment should be given to improve the long-term efficacy.
4.Severe diarrhea after esophageal cancer surgery: Gastrointestinal dysfunction after esophageal cancer resection leads to severe diarrhea, which is clinically believed to be mainly due to severed vagus nerve and increased concentration of gastrin.
Treatment method: actively give antidiarrheal drugs and rehydration at the same time to avoid dehydration.
Radiation therapy
Except for esophageal perforation forming esophageal fistula, distant metastasis, obvious malignant mass, serious heart, lung and liver diseases, radiotherapy is feasible.
Radiation therapy reactions
(1) Esophageal reaction: when the irradiated tumor amount reaches 10-20Gy/1～2 weeks, esophageal mucous membrane edema, which can aggravate the difficulty of swallowing, generally can be left untreated, after the irradiation amount reaches 30～40Gy/3～4 weeks, it can produce subpharyngeal pain and retrosternal pain, which should be treated symptomatically.
(2) Tracheal reaction: cough, mostly dry cough with little sputum.
Complications of radiotherapy
(1) Bleeding: the incidence is about 1%. Special care should be taken in selecting patients with obvious ulcers, especially those with deeper ulcers with burr-like prominence, reducing the dose of each irradiation and prolonging the total treatment time, and frequent X-ray barium meal observation should be performed during radiotherapy.
(2) Perforation: the incidence is about 3%, which can penetrate into the trachea and form esophagotracheal fistula or penetrate into the mediastinum and cause mediastinal inflammation.
(3) Radiation myelopathy: Radiation myelopathy is one of the serious complications of radiation therapy for malignant tumors of the head, neck and chest. The latent period is mostly 1 to 2 years after irradiation.
Late stage treatment
Chinese herbal medicine is the best choice for the treatment of esophageal cancer in late stage. Most of the treatments for esophageal cancer in late stage do not adopt radiotherapy and chemical drug treatment. Surgical treatment for advanced esophageal cancer should be decided by the location of tumor spread and metastasis. The treatment of esophageal cancer in advanced stage is very effective with traditional Chinese medicine. Esophageal cancer in advanced stage is easy to recur and metastasize, and the effect of western medicine treatment is poor. The effect of radiotherapy at this time is not obvious, and the toxic side effects of radiotherapy are so great that it cannot be applied to those who are weak, too old, with impaired heart, liver and kidney function and bone marrow suppression. However, TCM can be used not only in early, middle and late stages of esophageal cancer, but also before and after surgery and after radiotherapy, which obviously improves the treatment effect. It reduces the adverse reactions after radiotherapy, reduces the damage brought by radiotherapy to patients, improves their own immunity and enhances the treatment effect.