Where the cancer is confined to the oesophagus on the staging tests outlined above, the chance of cure is there and the choice is between radical surgery and radiotherapy (often nowadays combined with chemotherapy). The problem is that, despite the staging suggesting that the growth is confined to the oesophagus, there is nevertheless a high chance that in fact disease has spread outside the oesophagus, as witnessed by the fact that only 15% of these ostensibly localised disease patients will be alive in five years.
In younger and fitter patients with disease in the mid or lower third of the oesophagus, there is a case for radical surgery – a radical oesophagectomy. The operation is a large one and has a finite morbidity and mortality associated with it; given these facts and the overall poor prognosis for the disease overall, careful thought must be given to subjecting any patient to this procedure.
The operation is carried out through the chest and abdomen and the stomach is mobilised and pulled up to link to the upper oesophagus above the resected segment. The post-operative complications include cardiopulmonary failure (i.e heart failure and pneumonia) and leakage at the site of anastomosis (the joint of the upper segment of oesophagus with that of the stomach). The procedure is even more risky for patients with upper third growths, with a mortality of the operation not less than 10%.
The alternative to surgery is radical radiotherapy and this option has been implemented for many years. The patient attends a Radiotherapy department every week day for some six weeks or so and lies on a couch each day as a high energy x-ray beam is shone from several directions to ‘catch’ the oesophageal cancer and its immediate surrounds in the cross-fire of all the beams and hence in the high dose region of the therapy.
There is no doubt that the disease responds to such therapy but the cure rate is low (overall less than 10%) due to distant metastatic disease developing in the months ahead rather than local recurrence (although may this occur also). The patient develops side effects towards the end of radiotherapy, in particular worse dysphagia (due to radiotherapy induced inflammation of the oesophagus); occasionally other complications occur including, most seriously but thankfully rarely, the development of a hole (fistula) through the oesophagus tumour. The leakage of oesophageal content into the chest in these circumstances is very serious.
In recent years it has been shown that the combination of chemotherapy together with radiotherapy may improve the responses and may additionally have an effect on any microscopic disease that has escaped (the likelihood being high to explain the overall poor survival results in this disease).
For younger and fitter patients the doctor may recommend a course of combined chemotherapy and radiotherapy.
There are still clinical trials ongoing trying to truly discern the place of simultaneous chemotherapy and radiotherapy in this disease, particularly as the combined treatment is more unpleasant for the patient. However, at this time chemo-radiotherapy protocols look the most promising hope for the future in terms of sterilising the oesophageal cancer itself and sterilising cells that have moved outside the immediate vicinity of the oesophagus.
For older patients and those who are more infirm, then radiotherapy alone is still the therapy recommended.
Where the disease is locally extensive and the problem is one of inability to swallow (dysphagia), then curative therapy is not possible and the therapy options are directed towards easing the patients main problem. This can be achieved in several ways. First, a course of the external beam radiotherapy such as just described can be delivered and the dysphagia relieved. Secondly, a source of sealed radio-isotope can be lowered down the oesophagus via a bougie until it sits in the oesophagus at the level of he cancer and the emissions treat the cancer which surrounds it.
An advantage of this technique is that it treats the immediate cancer with a very high dose of radiation due to the dosimetric advantages of brachytherapy, whilst the dose to the rest of the surrounding structures is minimised due to the fall-off of dose according to the inverse square law (see brachytherapy section of cervical cancer therapy in the gynaecological cancer section).
In the current era a microselectron machine is used for this type of therapy. Thirdly laser debulking of oesophageal growths has been performed successfully in this situation and the cancers are vaporised under direct vision down an oesophagoscope to re-establish the lumen. Lastly, and perhaps most simply of all, the oesophagoscopist may dilate the strictured oesophagus and place a stent in the oesophagus to ensure a patent channel for food. A stent is a ramrodded tube, which stays in situ to ensure a passage down the oesophagus for food. If placement of a stent is not possible due the extent of a growth that has consumed the oesophagus, then the whole oesophagus may be by-passed by placing a feeding tube through the skin of the upper abdominal wall into the stomach (a percutaneous gastrostomy feeding tube - PEG), although the advantages of such a tube in a patient with an evil outlook must be individually decided in all cases.
