I. Diagnostic points
(I) Clinical manifestations
1.Early esophageal cancer
Choking sensation of swallowing food, discomfort or stuffiness behind the sternum, foreign body sensation in the esophagus, dryness and tightness in the throat, slow passage of food and stagnant feeling.
2.Middle and late stage esophageal cancer
The most common typical symptoms are progressive dysphagia, obstruction, pain, hemorrhage, hoarseness, weight loss and anorexia.
3.End-stage symptoms and complications
(1) Cachexia, dehydration and failure.
(2) Tumor infiltration symptoms: tumor infiltration penetrates the esophagus and invades the mediastinum, trachea, bronchus, hilum, pericardium and large blood vessels, causing mediastinitis, pneumonia, lung abscess, tracheoesophageal fistula, lethal hemorrhage, etc.
(3) Corresponding symptoms caused by extensive systemic metastasis: such as jaundice, ascites, tracheal compression causing dyspnea, vocal cord paralysis, coma, etc.
(ii) Laboratory tests: CA199 CEA SCC
(C) Imaging diagnosis
1.X-ray examination
(1) Early stage esophageal cancer: thickened esophageal mucosal folds, interrupted tortuosity, mucosal destruction and/or niche shadow.
(2) Middle and late stage esophageal cancer: barium meal of esophagus shows mucosal filling defect in the lumen of esophagus, varying degrees of stiffness in the wall of the tube, restricted dilatation or even stenosis. The normal esophagus at the upper end of the lesion has different degrees of dilatation.
2.CT/MRI examination: CT scan shows that the thickness of normal esophageal wall is usually 3~5 mm. when there is tumor in the esophagus, the wall becomes circular or irregularly thickened.
3.Esophagoscopy, ultrasound endoscopy.
(D) Pathological diagnosis
Squamous cell carcinoma, adenocarcinoma, undifferentiated carcinoma, etc.
(V) Others: cytology
II. Diagnosis
(I) TNM staging criteria.
T: primary tumor
Tx: primary tumor cannot be determined
T0: no evidence of primary tumor
Tis: carcinoma in situ
T1: Tumor invades only the intramucosal layer and submucosal layer
T2: Tumor invaded the muscular layer
T3: Tumor invaded outer membrane
T4: Tumor invaded adjacent organs
N：Regional lymph nodes
Nx: Regional lymph nodes cannot be measured
N0: No regional lymph node metastasis
N1：Regional lymph node metastasis
M：Distant metastasis
Mx: distant metastasis cannot be measured
M0: No distant metastasis
M1: distant metastasis
Esophageal cancer of the upper thoracic segment
M1a: cervical lymph node metastasis
M1b: Other distant metastases
Mid-thoracic esophageal cancer
M1a: not applied
M1b: non-regional lymph nodes or other lymph nodes
Subthoracic esophageal cancer
M1a: lymph nodes adjacent to the abdominal aorta
M1b: other distant metastases
Note: Definition of regional lymph nodes in esophageal cancer: cervical segmental esophageal cancer: cervical lymph nodes including supraclavicular lymph nodes, thoracic segmental esophageal cancer: mediastinal lymph nodes and perigastric lymph nodes, excluding para-aortic abdominal lymph nodes.
(II) Clinical staging
Stage 0: TisN0M0
Stage I: T1N0M0
Stage IIa: T2N0M0 T3N0M0
Stage IIb: T1N1M0 T2N1M0
Stage III: T3N1M0 T4 any NM0
Phase IV: any T any NM1
Stage IVa: any T any NM1
Stage IVb: any T any NM1b
(C) Pathological classification
1.Pathological classification.
Early stage esophageal carcinoma are: occult type, cachectic type, plaque type, papillary type; middle and late stage typing are medullary type, umbrella type, ulcerated type, narrowing type and intraluminal type.
2.Pathological types.
Squamous cell carcinoma accounts for 68.5% to 90.6% of the cases (most of the Chinese are of this type), adenocarcinoma accounts for 61% to 30.2% (in recent years, there is an increase of this type in foreign Caucasians), undifferentiated carcinoma accounts for 1.4% to 1.5%, and others for 1.7%.
III. Treatment
(I) Treatment principles
Esophageal cancer is still mainly treated by surgical resection and radiotherapy. Stage I patients should be surgically resected, and stage II and III patients should be surgically resected, and they can also be treated with radiotherapy or chemotherapy or chemotherapy and radiotherapy at the same time, and then strive for surgical treatment or postoperative chemotherapy or radiotherapy to improve the resection rate and long-term efficacy. Chemotherapy and radiotherapy are mainly used for stage IV patients to prolong survival and improve quality of life.
(II) Treatment methods
1.Surgical treatment
(1) Indications.
Early stage esophageal cancer (stage 0 and I) patients should actively strive for surgical treatment if their condition allows. stage II cases, i.e. middle and upper esophageal cancer, with lesions below 5cm and upper segment below 3cm are suitable for surgical treatment. stage III cases, i.e. middle and upper esophageal cancer, with lesions above 5cm and without obvious distant metastases, should adopt the comprehensive treatment of preoperative radiation and surgical resection if conditions allow, and lower segment esophageal cancer, even though it is below 6 or 7cm, can be considered for surgery. Although the lower segment esophageal cancer is 6 or 7 cm, surgical treatment can also be considered.
For recurrence after radiotherapy, surgery should also be pursued if the lesion is not large in scope, without distant metastasis and in good circumstance.
Esophageal cancer with high obstruction and no obvious distant metastasis should be actively treated by surgery.
(2) Contraindications.
X-ray imaging and other imaging examinations invade adjacent important organs. Those who have distant metastasis. Those with severe cardiopulmonary insufficiency who cannot afford surgery. Those who have a high degree of cachexia.
2.Radiotherapy
(1) External radiation therapy
①Radical radiation therapy alone
Indications.
The patient’s general condition is above moderate; the lesion length does not exceed 8cm is appropriate; there is no perforation or sinus fistula formation, no precursor of perforation or severe pain in the chest and back; semi-liquid or general diet is possible; no supraclavicular and abdominal lymph node metastasis, no vocal cord paralysis, no distant metastasis; first treatment (only refers to radiation therapy); strive for cytological or pathological diagnostic basis (especially superficial cancer).
Contraindications.
Tube perforation (esophagotracheal fistula or possible esophageal aortic fistula) or complete esophageal obstruction; cachexia; those with obvious symptoms and multiple distant metastases; those with heavy medical entrapment.
②Palliative radiotherapy
Indications: Except for patients with systemic failure or severe cardiovascular disease, all patients can receive palliative radiotherapy.
Contraindications: existing esophageal perforation; cachexia; severe cardiovascular disease.
③ Design of irradiation field
Methods include: isocentric irradiation (one anterior and two posterior oblique fields and two anterior oblique fields are commonly used); non-isocentric anterior-posterior countertransparent field + oblique field irradiation.
The width and length of the irradiation field: tumor diameter ≤5.0cm, tumor-centered or symmetrical infiltrating tumor centered on the esophageal lumen, 90% of the isodose curve wraps the whole tumor and the spinal cord and lung receive low dose and uniform dose distribution.
When the tumor diameter is ≥5.0 cm, and/or the tumor is asymmetrically infiltrated in front and behind and/or there are lymph node metastases in the mediastinum, non-isocentric front-to-back field irradiation should be used, and then CT scan of the lesion area should be performed after TD36~40Gy, and the irradiation technique of split field should be used according to the tumor shrinkage. In this way, the dose distribution in the tumor is not as uniform as isocentric irradiation, and the spinal cord receives the same dose as the tumor, but it can ensure that no tumor is missed and the lung receives less. In order not to miss the tumor, the TPS optimization technique can be used.
The field size is set according to the actual extent of tumor invasion. In most cases, the length of the field is 3~5 cm at the upper and lower end of the tumor.
Upper esophageal cancer.
Mostly, two anterior oblique fields are used for isocentric irradiation, and the second anterior field is 4.5~5.0 cm wide with a rack angle of 50~60o and a 30° wedge-shaped plate. When the tumor is large or there are enlarged lymph nodes, the above irradiation field cannot cover the whole tumor, the combined mediastinal + supraclavicular irradiation field should be used, and the anterior and posterior pair of fields should be irradiated to TD36Gy, then CT scan of the lesion area should be performed, and the irradiation technique of split field should be used according to the tumor shrinkage.
Irradiation dose: radical dose is 60~70Gy/6-7w, palliative dose is 50Gy/5w.
④Pre-operative radiotherapy
Preoperative radiotherapy range
Most of the literature at home and abroad reports that the scope of radiotherapy is mostly 5cm above and below the lesion or the whole mediastinal lymph node drainage area. Preoperative radiotherapy for cervical and upper segment esophageal cancer is recommended to include both supraclavicular region and middle and upper mediastinum, because supraclavicular lymph node metastasis is found to be as high as 46.3% during lymph node dissection in three fields. Radiation therapy for lower esophageal cancer includes subsegmental, i.e., left paracranial lymph nodes of the stomach. The width of the irradiation field is 6~6.5 cm, and the anterior and posterior pairs are irradiated.
Radiotherapy dose: TD40Gy is recommended for preoperative radiotherapy of middle and lower esophageal cancer, while the dose of radiotherapy for cervical or upper esophageal cancer can reach TD50Gy.
⑤ Postoperative radiotherapy
Post-radical surgery prophylactic radiotherapy irradiation scope: including tumor bed, anastomosis and regional lymph node drainage area.
Radiation dose: about 50-60Gy.
Radiation therapy after palliative surgery.
Mostly using anterior-posterior pair penetrating vertical irradiation field and/or oblique field irradiation. The dose of radiation therapy is TD60Gy/6w, and the dose of small field for individual residual sites is increased to TD70Gy/7w. The irradiation range is mainly based on the possible residual tumor sites as shown in the preoperative CT or the metal markers shown by the surgeon after surgery, and secondly, the general condition of the patient and the number of positive postoperative lymph node metastases should be appropriately expanded to the lymphatic drainage area with a high proportion of metastases.
(2) Intracavitary radiation therapy
Indications
Intracavitary irradiation alone: for postoperative anastomotic recurrence or residual cancer; for local recurrence after radiotherapy; for severe obstruction and difficulty in eating, for palliative intracavitary irradiation to relieve symptoms.
Intracavitary irradiation combined with extracorporeal irradiation: additional intracavitary irradiation for local residual lesions when sufficient amount of extracorporeal irradiation is given; local recurrence after external irradiation, medium or small dose extracorporeal irradiation combined with intracavitary irradiation; postoperative anastomotic recurrence or residual cancer, planned extracorporeal combined with intracavitary irradiation; cervical esophageal cancer, extracorporeal irradiation combined with intracavitary irradiation for those who have difficulty avoiding the spinal cord.
Contraindications.
Patients with malignant fluid; patients with severe cardiovascular disease; patients with ulcer perforation on X-ray; patients with severe chest and back pain and hypopharyngeal pain;
3.Chemotherapy
Examples of commonly used combination chemotherapy regimens are as follows.
(1) PF
(2) PMF
(3) PP
4.Other treatments: intracavitary laser therapy or electrochemical therapy, intracavitary stent placement, supportive therapy.
(IV) Follow-up
1.Follow-up time: every four months in the first year; every six months in the second year, for a total of two years; and annually thereafter.
2, follow-up content: blood cell count, biochemical examination; X-ray or CT of the chest, barium swallow of the esophagus; esophageal endoscopy; abdominal ultrasound or CT, etc.
3.Observation of treatment response: improvement of symptoms and signs, and the occurrence of any complications.