If esophageal cancer is detected early, it can usually be treated endoscopically to obtain a radical cure. This is known as “surgery without incisions. It is similar to gastroscopy in that the diseased tissue can be removed or inactivated directly in the body without opening the chest or abdomen. It is comparable to surgery and has a less invasive and faster recovery rate of over 95%.
Minimally invasive endoscopic treatment can be divided into two categories: endoscopic resection and non-resectional treatment.
In principle, endoscopic resection is appropriate for early-stage esophageal cancer without lymph node metastasis, or with very low lymph node metastasis rate. If one is too old or in poor health to tolerate endoscopic resection, or is unwilling to undergo endoscopic resection, then endoscopic non-resectional treatment is an option.
In this article, we will use a case to show how doctors determine whether endoscopic resection can be performed and how the treatment plan is developed when faced with a patient with early-stage esophageal cancer.
Mr. Ren, 68 years old, had occasional acid reflux and heartburn symptoms for the past 6 months. The tumor marker reports all showed normal. The company’s main goal is to provide the best possible service to its customers.
Diagnostic process
During the gastroscopy, the doctor found a patch of mucosal erosion in the middle part of Mr. Ren’s esophagus that was red in color and about 1 cm in diameter, with no other abnormal mucosal elevations or ulcers.
The doctor took a sample of this erosion area and sent it to the pathology department for biopsy, and the report suggested early-stage esophageal cancer (carcinoma in situ).
The doctor explained to Mr. Ren that the gastroscopy and biopsy pathology had confirmed the diagnosis of esophageal cancer. From the gastroscopy, the initial judgment is that it is a relatively early stage of cancer. But whether it is early or not, and whether there are lymph node metastases, further relevant staging tests need to be perfected. These tests include: ultrasound gastroscopy to determine the depth of invasion of esophageal cancer; enhanced CT of the chest to determine whether there are lymph node metastases; and other whole-body tests, such as PET-CT, to determine whether there are metastases to other organs.
If the tumor is confined to this area of mucosal erosion in the esophagus and has not grown to other parts of the body, then it can be cured with surgery.
Mr. Ren then had all the tests that his doctor prescribed for him. The tumor was only invading the superficial layer of the esophageal wall (the mucosal layer), and no tumor was seen in the deeper structures; no lymph node metastases were found in the chest enhancement CT; and no distant metastases were found in other systemic tests.
Therefore, the doctor confirmed that Mr. Ren’s esophageal cancer was in the early stage. According to current guidelines, if the esophageal cancer is located in the mucosal layer of the esophagus, the risk of lymph node metastasis is extremely low and can be treated with endoscopic resection.
Treatment options
In light of Mr. Ren’s condition, he has the option of either surgical or endoscopic resection. So, which is a little better?
His doctor explained to Mr. Ren that surgical treatment for esophageal cancer includes both surgical and endoscopic resection, or “open surgery” and “minimally invasive surgery,” as they say. The endoscopic resection has a shorter operating time and shorter hospital stay than the open surgery (surgical open-heart or thoracoscopic surgery), faster post-operative recovery, and higher quality of life in the future.
Of course, endoscopic resection is not perfect. It can only remove the primary esophageal focus, but not the mediastinal lymph nodes located outside the esophageal lumen, so it is only suitable for early-stage esophageal cancer that is located in the mucosal or submucosal layer and has no or very low metastasis to the lymph nodes.
Mr. Ren’s esophageal cancer was located in the mucosal layer, and imaging also ruled out lymph node and other organ metastases. Accordingly, he was advised by his doctor, to undergo endoscopic resection.
Mr. Ren’s doubts
After listening to the doctor’s analysis, Mr. Ren raised several concerns:
“First, when I had the gastroscopy, I felt nauseous and wanted to vomit when I entered the scope, but it was tolerable. Will endoscopic resection be more painful than regular gastroscopy? And how was the esophageal cancer removed? Does it cost much?”
The doctor said:
- The endoscopic resection is done under anesthesia, and you won’t have any pain.
- The endoscopic resection is like cutting the rind of a watermelon. Through a microscopic injection needle, saline is first injected under the mucosal layer to form a cushion of water that lifts the mucosal layer; then through a microscopic electric knife, all of the mucosal layer and most of the submucosal tissue where the lesion is located is peeled off intact along the cushion of water.
- After endoscopic excision, the wounds heal completely at an average of 1 to 2 months.
- The cost of endoscopic treatment varies depending on the condition and the presence or absence of comorbidities. Overall, it is less expensive than surgical procedures.
“Second, can endoscopic resection completely cure esophageal cancer?”
The doctor said:
After complete removal of the cancer by endoscopy, the excised specimen is sent intact to the pathology department for a thorough and careful examination by a pathologist and a final pathological diagnosis.
- If the pathology confirms that the cancer is within the mucosal layer and the lesion is clean (the medical term for “clean margins”), then you are considered to have had a complete resection.
- If the pathology report shows no other risk factors for lymph node metastasis (e.g., vascular thrombosis, poor differentiation, etc.), then you do not need additional treatment.
- If the pathology diagnosis is “submucosal invasive carcinoma,” that means the cancer has spread beyond the mucosa. At this point, the physician will need to develop a subsequent treatment plan depending on the depth of the submucosal infiltrate. The submucosal layer can be subdivided into upper, middle, and lower layers, and the deeper the cancer infiltration, the higher the rate of lymph node metastasis.
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“Third, I’ve heard that surgical removal is an irritation to the tumor, will it cause the tumor to spread faster? How long will I live after the endoscopic resection?”
The doctor said:
There is no scientific basis for the claim that “surgery stimulates the spread of tumors,” so don’t believe it. Neither surgery nor endoscopic surgery stimulates tumor growth, and it is unlikely to cause cancer cells to spread.
If you are diagnosed with early-stage esophageal cancer and have a radical resection, the probability of living beyond 5 years (i.e., 5-year survival rate) is more than 95%; and the probability of metastasis or recurrence after 5 years becomes very small, which means a cure is achieved.
Pre-treatment evaluation
After listening to the doctor’s explanation, Mr. Ren’s doubts were completely dispelled and he began pre-treatment preparations.
First, the doctor asked him if he had ever had any other diseases, such as hypertension, diabetes, or heart disease; if he had taken any long-term oral anticoagulants, such as aspirin; if he smoked or drank alcohol in general; and what his current physical condition was, how much he could usually walk and how many floors he could climb.
The doctor explained that these questions were all designed to assess the risk of surgery and anesthesia:
- If you have underlying conditions such as high blood pressure, diabetes, or heart disease, you need to undergo medical treatment first and wait for your condition to stabilize before you can undergo surgery.
- If long-term oral anticoagulants are taken, they need to be stopped for at least 1 week before surgery.
- For those who smoke, strict abstinence from smoking for 2 weeks is required before surgery.
Fortunately, Mr. Ren had good habits, did not smoke and drank alcohol occasionally; had hypertension but was on long-term oral antihypertensive medication and his blood pressure was well controlled; had no other underlying disease and was not on long-term oral anticoagulants. Therefore, Mr. Ren was quickly hospitalized.
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Treatment procedure
The day before the procedure
The endoscopic surgeon and anesthesiologist spoke with Mr. Ren separately and asked him to sign the informed consent form.
The endoscopist mainly explained the risks of the procedure: endoscopic resection is a minimally invasive treatment, there will be no incisions on the surface of your body, and you will suffer very little trauma.
But the removal of the lesion requires the use of an endoscopic electric knife. Therefore, endoscopic resection is not 100% safe.
There are 3 main categories of risks associated with endoscopic resection: bleeding, perforation, and stenosis. However, in general, the incidence of complications in each category is relatively low and can usually be managed by the surgeon immediately during the procedure. Therefore, you do not need to be overly concerned.
The anesthesiologist performs a preoperative anesthesia evaluation, which includes a review of past medical history and any possible post-anesthesia adverse effects (e.g., nausea, vomiting, dizziness, pain, etc.). In addition, the physician will explain anesthesia-related precautions and discuss the postoperative administration of analgesic medications, such as epidural, intravenous indwelling analgesic pump, etc.
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Surgery completed successfully
On the day of the surgery, Mr. Ren successfully received anesthesia. The endoscopist resected the lesion intact endoscopically, removing approximately 2.5 cm of esophageal mucosa.
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After the surgery, doctors resuscitated Mr. Ren and closely monitored his vital signs until he became conscious. On the first day after surgery, he began eating a liquid diet and did not feel any discomfort during the process. Doctors judged that Mr. Ren was recovering well and approved his discharge on the second day after surgery.
Pathology results
The cut-down sample was sent to the pathology department the same day. The final report showed that Mr. Ren had a highly differentiated squamous carcinoma of the esophagus, located in the mucosal layer, and that the lesion was all cut clean.
The doctor told him that highly differentiated cancer indicates a relatively low level of malignancy, and that it was excised so thoroughly that the risk of lymph node metastasis is extremely low and no further surgery or radiotherapy is needed.
Mr. Ren was pleased with the treatment and felt lucky to be faced with the pathology results. Because the cancer did not invade too deeply, he just needs regular follow-ups.
After discharge from the hospital
Mr. Ren followed his doctor’s orders and has been taking medications to suppress acid secretion and protect the gastric mucosa since his discharge, and has recovered well without complications such as delayed bleeding or perforation.
A month later, he returned on time for a follow-up gastroscopy, which showed that the surgical wound was completely healed and that he could resume a normal diet.
Regular review
Now, a year has passed since the surgery. Mr. Ren has been strictly following his doctor’s instructions, returning for gastroscopy reviews every three months and a chest CT review at six months and one year after surgery, with no recurrence or metastasis.
His life has not changed much as a result of the endoscopic procedure. His doubts about cancer recurrence or metastasis disappeared with the results of regular postoperative reviews.
When he was first diagnosed with esophageal cancer a year ago, Mr. Ren felt like a “God-forsaken child. The company’s main goal is to provide the best possible service to its customers. The company’s main business is to provide a wide range of products and services to its customers.
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.