I. Epidemiology
Esophageal cancer is one of the more common malignant tumors in human beings, which seriously threatens people’s life and health, and it is estimated that about 200,000 people die from esophageal cancer worldwide every year. The incidence rate of esophageal cancer has obvious geographical characteristics, and even between two adjacent regions, there are obvious differences in its incidence rate. From a worldwide perspective, the high incidence areas are distributed in Iran, South Africa, Rhodesia and China, while the average incidence rates in Europe, America, Oceania and Israel in Asia are very low, mostly below 5/100,000. In China, esophageal cancer accounts for the first place of various malignant tumors in 9 provinces, three provinces in North China, Sichuan Province and Guangdong Province have a high incidence center which is significantly higher than the surrounding areas, such as the main concentration of esophageal cancer in North China is in the junction area of the southern section of Taihang Mountains, whose incidence rate is over 130/100,000. It is the main cause of death for both men and women in the region. In other counties not far from Taihang Mountains, the mortality rate of esophageal cancer drops to less than 2/100,000. The highest incidence in Guangdong is in Nan’ao Island. In Sichuan, it was mainly concentrated in Yanting, Langzhong and the border area of three counties in the southwest of Sichuan. In addition, Shandong, Jiangsu, Fujian, Anhui, Hubei, Shaanxi and Xinjiang provinces also have relatively concentrated high incidence areas of esophageal cancer, and more than 20 counties and cities have been identified with an average annual mortality rate of esophageal cancer exceeding 100/100,000.
Pathology and typing
1. Histological features: esophageal cancer occurs in the basal cells of esophageal mucosal epithelium, and most of them are squamous epithelial carcinoma (95%), while adenocarcinoma originated from esophagus is rare and mostly located at the end of esophagus. Adenocarcinoma of the cardia is mostly adenocarcinoma, but it can also extend into the esophagus.
2.Clinico-pathological classification
Early stage general pathological typing.
Occult type: Esophageal mucosa is only mildly congested or rough, which is not easily recognized by naked eye and can only be diagnosed by exfoliative cytology and tissue section.
Cicatricial type: There is very shallow cicatricial on the mucosal surface with different shapes and sizes, and the boundary is clearly demarcated, like a map. The cancer tissue is poorly differentiated, with in situ cancer and early invasion each accounting for half, and it develops later than the first type.
Plaque type: the surface mucosa is slightly elevated, uneven in height, folds disappeared, resembling annual lichen planus, lesions of different sizes, more advanced than the former type, about 1/3 of in situ carcinoma and 2/3 of early invasive carcinoma.
Papillary type: The tumor forms obvious hard nodes, some are like nipples, some are like polyps with short tips, protruding into the lumen, and the cancer cells are better differentiated, most of them are early invasive carcinoma, which is the most advanced type of early carcinoma.
Middle and late stage general pathological typing: According to the X-ray examination and the general pathology, esophageal cancer is divided into the following types.
Medullary type: It is the most common type, accounting for about 60%. The tumor often involves the whole layer of esophagus and grows around the lumen to the inside and outside of the lumen, forming a large and irregular tubular mass.
Myxomatous type: It accounts for about 15%, the tumor grows toward the mucosal surface and forms a flat mass, involving part of the circumference of the esophagus, and protrudes into the lumen like a myxomatous mushroom with clear borders.
Ulcerated type: about 15% of the cases, the tumor forms a depressed ulcer and erodes part of the esophageal wall, which usually does not produce serious blockage of the lumen.
Narrowing type: About 10% of the cases, the cancer forms a circular or short tubular stricture with dilatation of the esophagus above the stricture.
Intraluminal type: less common, accounting for about 3%, the cancer is polyp-like and protrudes into the lumen of esophagus, with the tip attached to the wall of esophagus, with erosion and ulcer on the surface, and can invade the muscle layer.
3.The general pathological classification of cardia cancer: anatomically, cardia belongs to the structure of stomach, but when malignant tumor occurs, its diagnosis and treatment have a lot in common with esophageal cancer, so cardia cancer is also included in the description of esophageal cancer. The general pathological typology of cardia cancer is divided into the following categories.
Cauliflower type: The tumor mainly grows into the lumen, forming a mass like “cauliflower”.
Diffuse infiltration type: The tumor infiltrates widely and can involve the esophagus and most of the stomach, with thickening of the stomach wall and mucosal erosion.
Ulcerated type: The tumor is a large ulcer and often penetrates into the adjacent organs.
Mixed type: Most of them are advanced lesions and cannot be classified as above.
Early and late manifestations
Early manifestations
1.Choking sensation of swallowing food, often caused by eating solid food, after the first occurrence of choking sensation, it will disappear on its own without treatment, and reappear in a few days or months.
2.Posterior sternal pain, which often occurs after swallowing food and is aggravated when eating rough and hot food or irritating food.
3.Slow passage of food and a feeling of retention.
4.Burning-like stinging pain under the sternum, varying in severity, mostly occurring when swallowing food and relieving or disappearing after eating.
5.Dryness and tightness of the pharynx, poor swallowing of food, and slight pain.
6.Distention and discomfort behind the sternum.
Middle and late stage symptoms
1.Difficulty in swallowing: Progressive difficulty in swallowing is the main symptom of esophageal cancer. Initially, there is a feeling of choking when eating solid food, and then it gradually worsens progressively, and even liquid diet cannot be swallowed. The severity of dysphagia is not only related to the stage of disease, but also related to the type of tumor. The obstructive symptoms appear early and severe in constricted type, and later in ulcerated type and intracavitary type.
2. Pain and vomiting: It is seen in cases of severe dysphagia, where the newly eaten food is vomited with saliva in the form of mucus. Pain is also a common symptom, mostly located in the posterior sternum and interscapular region, which is intermittent in the early stage.
3.Patients with cardia cancer may have blood in stool and anemia.
4.Weight loss and cachexia: due to long-term swallowing difficulties, causing nutritional disorders, weight loss is obvious and emaciation is obvious. The appearance of cachexia is a manifestation of advanced stage of tumor.
5.Symptoms of adjacent organs involvement: tumor invasion of adjacent organs may cause corresponding symptoms.
Physical signs
Early stage patients have no obvious physical signs. In advanced cases, there may be enlarged supraclavicular lymph nodes, emaciation and malignant fluid. Patients with advanced pancreatic cancer mostly have epigastric pressure pain or mass.
Diagnosis
1.Medical history
2.X-ray barium esophagogram: It is the main method to diagnose middle and late stage esophageal cancer. It can show interruption of esophageal mucosal striae, disorder, different degrees of lumen narrowing, filling defect, niche shadow, restricted dilation and stiffness of the canal wall. Early lesions may have no positive findings.
3.Esophageal mesh cytology examination: the positive rate of esophageal mesh cytology examination is 90%, this method is easy to operate and less painful, especially useful in cancer prevention and screening.
4.Fiber esophagoscopy: This is a reliable method to diagnose esophageal cancer, but because early esophageal cancer is located in the small mucosal layer, endoscopy is easy to miss it, if toluidine blue or iodine solution is injected into the lumen of esophagus during examination, it can help to detect early cancer. During fiberoptic esophagoscopy, intra-luminal mucus smear and biopsy can be done at the same time.
Differential diagnosis
1.Benign esophageal tumor
2.Spasm of cardia
3.Esophageal scar stenosis
Surgical treatment
Surgery is the first choice of esophageal cancer treatment. For those who meet the following conditions, active surgical treatment is appropriate.
Indications.
1.Patients with good general condition and basically normal functions of heart, brain, lung, liver and kidney, who are estimated to be able to tolerate surgery.
2.No distant metastasis.
3.The local lesion can be removed.
Surgical methods
1.Esophageal cancer: partial esophagectomy, esophagogastric anastomosis or reconstruction of esophagus with intestinal tube.
2.cardia cancer: partial resection of stomach and esophagus, esophagogastric anastomosis.
Non-radical surgery: for cases that cannot be resected surgically, the lumen can be intubated, esophagogastric fundoplication, or gastrostomy.