Most of our patients with esophageal cancer are already in the middle to late stages when they seek medical attention, and surgical treatment alone is not effective and needs to be combined with preoperative neoadjuvant therapy or postoperative adjuvant therapy to achieve better outcomes. However, there are some patients who are diagnosed at an early stage and can not only get surgical resection, but also have the possibility to use minimally invasive techniques that are less harmful to the body.
Below, let’s take a look at the surgical treatment process for early-stage thoracic esophageal cancer in the context of a real-life case.
First visit
Mr. Wu (pseudonym), 54 years old, suddenly felt choking in his food for more than 1 month. He came to the hospital with a gastroscopic examination suggesting a lamellar mucosal erosion, about 2*3 cm, in the esophagus 35-38 cm from the incisor. pathological biopsy showed a moderately differentiated squamous carcinoma.
To clarify the staging, Mr. Wu underwent additional chest enhancement CT, ultrasound gastroscopy, PET-CT, and barium meal. The final diagnosis was: mid-thoracic esophageal cancer, clinical stage I with local lymph node metastasis and no distant metastasis.
Communicating treatment plan
The diagnosis was clear, and the physician had an in-depth communication with him and his family before treatment began.
The doctor said:
Esophageal cancer is still relatively fast moving, with a natural course of only a few months, and treatment needs to be a race to the bottom. The main treatment is currently surgery. As long as the physical condition is tolerable and the tumor is resectable, surgical treatment should be actively sought. In particular, surgery is recommended by several global guidelines for patients with early-stage esophageal cancer.
Because your tumor is early staged and the lesion is in the thoracic segment, you are a candidate for lumpectomy with a three-incision procedure for esophageal cancer. This is a minimally invasive procedure that requires only a few very small incisions to complete a series of surgical operations with the help of a thoracoscope, with rapid physical recovery and few side effects after surgery.
After careful consideration, Mr. Wu and his family agreed to minimally invasive surgical treatment as soon as possible.
Pre-surgery preparation
Three days before the surgery, Wu began fasting and providing energy through oral enteral nutrition powders.
The night before the surgery, his doctor prescribed medications to promote the emptying of the intestinal contents.
Four hours before the surgery, Mr. Wu took 40 ml of olive oil orally to fill the thoracic ducts to avoid intraoperative damage and reduce the risk of “celiac disease” complications.
Post-operative monitoring and recovery
Mr. Wu successfully underwent a minimally invasive resection for esophageal cancer. Through a few “keyhole” sized incisions, the tumor was completely removed with the help of a lumpectomy, and the lymph nodes in the chest and abdomen were cleared. The specimen was sent to the pathology department, and the final diagnosis showed a “clean” resection with minimal risk of lymph node metastasis, resulting in a “radical” treatment.
On the first day after surgery, Mr. Wu was encouraged to get out of bed as soon as possible with the help of a chaperone to reduce the risk of thrombosis, and to strengthen his respiratory function by actively coughing and coughing up sputum to help reduce lung infections.
Mr. Wu and his family asked their doctor about when they could resume normal eating.
The doctor said:
After surgery, you will not be able to eat normally yet. We will give you a low-rate enteral nutrition infusion through a gastric tube first; along with an intravenous infusion of parenteral nutrition to replenish the energy your body needs. During the process of pumping the nutrition solution, the medical staff will closely observe whether there is any abdominal pain, bloating, nausea, vomiting, diarrhea and other discomfort, as well as monitor the blood sugar level. As the gastrointestinal tract gradually recovers, the doctor gradually increases the pumping rate of enteral nutrition fluid up to 80 ml/h, which can meet the energy needs of an average adult.
It is important to follow the surgeon’s advice as to when you can resume a normal diet.
- Eating can be started as early as the 7th postoperative day, starting with soft, smooth solid foods, such as bananas and solid yogurt, which can prevent aspiration;
- After 1 week, gradually start to eat semi-liquid food, such as rice porridge, noodles, etc., without liquid food and water for the time being;
- After 2~3 weeks of gradual adaptation of swallowing function, start to drink water slowly with low head, paying attention to avoid choking and coughing. After proficiency, normal diet can be resumed.
Post-operative follow-up
Mr. Wu recovered well and was discharged from the hospital soon. Three months after surgery he came to the hospital for follow-up chest enhancement CT, barium meal, neck and abdominal ultrasound as prescribed by the doctor, and no significant signs of recurrence were seen. The doctor told him to come back in six months to review his tumor, considering its early stage.
A 9-month postoperative review still showed no signs of recurrence. Mr. Wu is now in good health and resuming a normal life.
Summary
This case gives us several insights:
1. When esophageal cancer occurs early, surgery can usually achieve radical results. However, the symptoms of early esophageal cancer are often not obvious. After eating, there may be a feeling of obstruction and choking, burning, pinching or pulling and rubbing pain behind the sternum, etc. These manifestations are easily confused with other diseases. The most typical symptom of middle and late stage esophageal cancer is progressive dysphagia. If you find the above symptoms, you should go to hospital for gastroscopy in time. If you have a family history of esophageal cancer, regular gastroscopy is recommended after the age of 40. If esophageal cancer is detected, please do not be overly afraid, but cooperate with your doctor for scientific and effective treatment.
2. If gastroscopy suspects esophageal cancer, you will need to remove the diseased tissue for pathologic biopsy. You will also need to have the following tests to clarify the diagnosis and tumor stage.
- Barium meal of the upper gastrointestinal tract: to observe the location of the tumor in the chest cavity and the degree of obstruction.
- Enhanced CT of the chest: to clarify the size, location, and relationship of the tumor to surrounding tissue structures, as well as the mediastinal lymph node metastasis.
- Ultrasound gastroscopy: it can clarify the depth of tumor infiltration and the presence of periesophageal lymph node metastasis.
- PET-CT: To assess the presence of distant metastases or other tumorigenic lesions by scanning all tissues and organs of the body.
3. Early-stage esophageal cancer is usually amenable to direct surgery. If it is intermediate or advanced, preoperative neoadjuvant therapy (including chemotherapy alone, synchronous or sequential radiotherapy) should be performed. Some patients are prone to chemotherapy intolerance after suffering major surgical blows. Having 1 to 3 cycles of neoadjuvant chemotherapy before surgery allows your doctor to observe how well you tolerate it and how well your tumor responds to chemotherapy drugs, and to make choices about further treatment.
During the neoadjuvant phase, whether you have difficulty eating or not, we recommend a nutritional tube (often called a “gastric tube”) to prevent possible malnutrition or nutritional imbalance through the infusion of enteral nutrient solution. During treatment, you will also need to monitor your weight closely to avoid being too heavy or too light.
4. For one month after discharge from the hospital, you will need weekly follow-up visits with your bedside doctor. Your doctor will assess your general condition and make timely adjustments to your nutritional support program.
Post-operatively, you will need to follow your doctor’s orders for follow-up exams, approximately as often as needed:
every 3 months for 2 years after surgery;
2 to 5 years after surgery, every 6 months;
After 5 years of surgery, annually.
The exact review schedule may vary depending on the results of the review, and should be determined by your supervising physician’s request.
Disclaimer:
Tumor disease and treatment options are extremely complex, and treatment should be fully individualized, and this case does not represent a treatment decision for a “similar patient. Please seek professional advice from a competent physician regarding your specific treatment plan.