Of Dysphagia and sophageal tumors

Dr Arvind Kohli
Dysphagia is the medical term for the symptom     of difficulty in swallowing. It may be a sensation that suggests difficulty in the passage of solids     or liquids from the mouth to the stomach a lack of pharyngeal sensation, or various other inadequacies of the swallowing mechanism.
Dysphagia is distinguished from other symptoms including odynophagia, which is defined as painful swallowing. There are numerous causes of dysphagia, however noteworthy are Benign Esophageal strictures Achalasia Cardia Esophageal divertculum Webs and rings and Esophageal cancer.
Esophageal cancer is cancer that occurs in the esophagus- a long, hollow tube that runs from throat to stomach. The Esophagus helps move the food from the back of throat to stomach to be digested. Esophageal cancer usually begins in the cells that line the inside of the esophagus. Esophageal cancer can occur anywhere along the esophagus. More men than women get esophageal cancer. Esophageal cancer is the sixth most common cause of cancer deaths worldwide. Incidence rates vary within different geographic locations. Esophageal cancer is a disease in which malignant (cancer) cells form in the tissues of the esophagus. The most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma begins in flat cells lining the esophagus.
Adenocarcinoma begins in cells that make and release mucus and other fluids. Smoking and heavy alcohol use increase the risk of esophageal squamous cell carcinoma. Gastroesophageal reflux disease and Barrett esophagus may increase the risk of esophageal adenocarcinoma.
Risk factors
Men are up to 5 times more likely than women to be diagnosed with esophageal cancer. Important risk factors in developing countries include the following: Nutritional deficiencies related to lack of fresh fruit and vegetables, drinking hot  beverages, a range of chewing betel nut and smoking habits and HPV infection increase the incidence of Esophageal Cancer (squamous cell cancer of the esophagus ) Barrett’s esophagus is an acquired condition characterized by precancerous cells that replace the normal cellular lining of the lowest portion of the esophagus. The condition occurs as a complication of chronic reflux of gastric contents (GERD) into the lower esophagus. Further ingestion of corrosive substances forms corrosive strictures which has increased incidence of Esophageal cancer.
Symptoms and signs : Sometimes, people with esophageal cancer do not have any of the symptoms, and the cause of a symptom may be another medical condition that is not cancer. However important symptoms are : Difficulty and pain with swallowing, particularly when eating meat, bread, or raw vegetables. As the tumor grows, it can block the pathway to the stomach. Even liquid may be painful to swallow. Patient can experience pressure or burning in the chest, Indigestion or heartburn, Vomiting Frequent choking on food : Unexplained weight loss : Coughing or hoarseness Pain behind the breastbone or in the throat.
Management of Esophageal Cancer
This disease is best managed by a different types of doctors who often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team
Surgery is mainstay of treatment since it restores the vital feeling of eating. It involves the removal of the tumor and some surrounding healthy tissue during an operation. The most common surgery to treat esophageal cancer is called an esophagectomy, where the diseased esophagus is removed and then connects the remaining healthy part of the stomach after converting it into a longtube to esophagus in neck so that the patient can swallow normally. Part of the intestine may sometimes be used to make the connection. The surgeon also removes lymph nodes around the esophagus.
Surgery for palliative care
In addition to surgery to treat the disease, surgery may be used to help patients eat and relieve symptoms caused by the cancer. This is called palliative surgery. By Putting in a percufaneous gastrostomy or jejunostomy, also called a feeding tube, so that a person can receive nutrition directly into the stomach or intestine. This may be done before chemotherapy and radiation therapy is given to make sure that the patient can eat enough food to maintain his or her weight and strength during treatment. Or create a bypass, or new pathway, to the stomach if a tumor blocks the esophagus but cannot be removed with surgery; this procedure is rarely used.
Endoscopic therapy  : Endoscopy helps immensely in management of esopageal cancer in form of dilation. This procedure expands the esophagus. It may have to be repeated if the tumor grows, stent placement is another procedure which uses an endoscopy to insert a stent in the esophagus. An esophageal stent is a metal, mesh device that is expanded to keep the esophagus open.
Photodynamic therapy :  A palliative or supportive care option used to make swallowing easier, especially for people who cannot or choose not to have surgery, radiation therapy, or chemotherapy. In photodynamic therapy, a light-sensitive substance is injected into the tumor and stays longer in cancer cells than in healthy cells. A light is then aimed at the tumor, destroying the cancer cells. Although photodynamic therapy may relieve swallowing problems for a short period of time, it does  not cure esophageal cancer.
Cryotherapy :  This is a type of palliative treatment that uses an endoscope with a probe attached that can freeze and remove tumor tissue. It can be used to reduce the size of a  tumor to help a patient swallow better.
Radiation therapy : Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. When radiation treatment is given directly inside the body, it is called internal radiation therapy or brachytherapy. For esophageal cancer, this involves temporarily inserting a radioactive wire into the esophagus using an endoscope. Side effects from radiation therapy may include fatigue, mild skin reactions, soreness in the throat and esophagus, difficulty or pain with swallowing, upset stomach, nausea, and loose bowel movements.
Chemotherapy : Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an IV tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.
Targeted therapy : Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.
Metastatic esophageal cancer : If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. For metastatic esophageal cancer, palliative or supportive care is very important to help relieve symptoms and side effects. The goal of treatment is usually to lengthen a person’s life, while easing symptoms such as pain and Dysphagia Treatment plan may include Palliative Surgery to restore eating chemotherapy, as well as radiation therapy to help relieve pain or discomfort. Further esophageal stent, laser therapy, photodynamic therapy, or cryotherapy may help keep the esophagusopen.
Watching for recurrence :  One goal of follow-up care is to check for a recurrence. Cancer recurs because small areas of cancer cells may remain undetected in the body. Over time, these cells may increase in number until they show up on test results or cause signs or symptoms. If the esophageal cancer is in remission, follow-up care may include CT scans and upper endoscopies.
(The author is CTV Surgeon SSH Jamu)