Esophageal Cancer Treatment

Esophageal cancer is a serious malignant tumor that develops in the esophagus (food pipe) and often presents symptoms at advanced stages. The most common types are squamous cell carcinoma and adenocarcinoma. Early diagnosis is of vital importance and determines the success of treatment.

The question of what the symptoms of esophageal cancer are provides the first clue in diagnosis. Difficulty swallowing, weight loss, chest pain, and chronic cough are the most common findings. In advanced stages, symptoms such as complete obstruction of swallowing, hoarseness, and bloody vomiting may occur.

The question of why esophageal cancer occurs draws attention to risk factors. Tobacco and alcohol use, reflux disease, Barrett’s esophagus, and obesity are the main causes. In addition, genetic predisposition and certain dietary habits also play a role in the development of the disease.

The question of how esophageal cancer is treated includes stage-specific treatment protocols. In early stages, endoscopic removal or surgery is applied, while in advanced stages chemoradiotherapy or targeted treatments are preferred. The treatment process is carried out through cooperation between oncology and surgical teams.

What Is Esophageal Cancer?

Esophageal cancer is a malignant tumor that develops from the cells lining the inner surface of the esophagus. The most common types are squamous cell carcinoma and adenocarcinoma. Smoking, alcohol use, reflux disease, and obesity are important risk factors. It usually presents with difficulty swallowing and weight loss. Diagnosis is made by endoscopy and biopsy. Treatment may include surgery, chemotherapy, and radiotherapy depending on the stage.

What are the symptoms of esophageal cancer and what does the patient feel?

The most insidious aspect of the disease is that it produces almost no symptoms in the early stages. The esophagus has a highly flexible structure; even if a tumor begins to grow inside it, the organ can expand and allow food to pass for a long time. However, when the tumor significantly narrows the diameter of the esophagus, the body begins to give its first serious alarms. The most common reason our patients present to us is difficulty swallowing, medically called “dysphagia.”

This difficulty swallowing does not appear suddenly. Initially, the patient feels a mild sensation of food getting stuck while swallowing solid foods. Most people tolerate this without realizing it; they chew their food more, eat more slowly, or choose softer foods. However, as the disease progresses, these compensatory mechanisms become insufficient. First solid foods such as bread and meat become difficult to swallow, then puréed foods, and in the most advanced stage even water cannot be swallowed. This obstruction naturally leads to serious nutritional deficiency and rapid weight loss.

Other symptoms that may occur as the disease progresses include:

• Difficulty swallowing
• Rapid weight loss
• Chest pain
• Indigestion
• Heartburn
• Persistent hiccups
• Chronic cough
• Hoarseness
• Anemia
• Fatigue

What are the risk factors for this type of cancer?

It is difficult to identify a single culprit in the development of esophageal cancer, but we know very well the factors that significantly increase the risk. The disease mainly originates from two different tissue types, and each has different triggers. The first is “Squamous Cell Carcinoma,” which arises from the flat cells lining the inner surface of the esophagus. This type usually occurs in the upper and middle parts of the esophagus. The second type is “Adenocarcinoma,” which is often seen at the lower end of the esophagus where it meets the stomach.

Lifestyle habits play a major role in the development of squamous cell carcinoma. In particular, tobacco use and alcohol consumption damage the structure of the cells in this region and create a basis for cancer. In addition, certain habits in our dietary culture can also increase the risk. The frequent and rapid consumption of very hot beverages may create a chronic burn effect on the esophageal surface and disrupt normal cell renewal.

Adenocarcinoma, on the other hand, is more related to problems brought by the modern era. Obesity and reflux disease associated with it are the most significant risk factors. Continuous reflux of stomach acid into the esophagus causes the cells there to change shape in order to protect themselves. This change, called “Barrett’s esophagus,” is considered a precancerous condition and requires close monitoring.

In summary, the risk factors include:

• Smoking
• Alcohol consumption
• Obesity
• Reflux disease
• Barrett’s esophagus
• Consumption of hot beverages
• Poor nutrition
• Advanced age
• Male gender

Which methods are used to establish the diagnosis?

When the patient’s symptoms raise suspicion, our most reliable and indispensable tool on the path to diagnosis is endoscopy. By entering the esophagus with a thin, flexible tube with a high-resolution camera at its tip, we directly observe the location, size, and structure of the tumor. Not only do we see it, but we also take small tissue samples (biopsies) from suspicious areas to confirm the diagnosis. The moment cancer cells are detected in the pathology report, we have established the diagnosis.

However, knowing that there is cancer alone is not enough; we must also determine how far the disease has spread, in other words its stage. Because our treatment plan is shaped entirely according to this stage. Is the tumor limited only to the esophagus? Has it penetrated the wall and spread to nearby lymph nodes? More importantly, has it spread to distant organs such as the liver or lungs? To find the answers to these questions, we use advanced imaging technologies such as Computed Tomography (CT) and PET-CT. These examinations provide us with a map of the patient’s body and help us determine whether surgery is possible.

What is the purpose of treatments applied before surgery?

In the past, surgery was planned immediately once the diagnosis was made. However, today our oncological approach has changed. Especially in what we call locally advanced stages, where the tumor has reached a certain size or spread to surrounding lymph nodes, we apply “Neoadjuvant Treatment” protocols before surgery. This means that the patient receives chemotherapy and radiotherapy together before the operation.

There is a very strong rationale behind this approach. Our aim is to make surgical margins safer by shrinking the tumor. Rather than attempting to remove a large tumor, removing a tumor that has been reduced in size with medication and radiation therapy increases the chance of a clean operation without leaving any cancer cells behind, which we call “R0 resection.” In addition, this pre-treatment can eliminate microscopic cancer cells that may be circulating in the body, thereby reducing the risk of recurrence in the future.

Sometimes the response to this treatment is so impressive that we encounter a situation called “Clinical Complete Response,” meaning that the tumor appears to have completely disappeared on imaging methods and endoscopy. In such cases, the decision whether to proceed with surgery is made very carefully by weighing the balance of benefits and risks. However, as a general rule, surgery performed after this pre-treatment in suitable patients offers the highest chance of survival.

How is esophagectomy technically performed?

The cornerstone of curative treatment for esophageal cancer is surgery. This operation is called “esophagectomy.” To speak frankly, esophagectomy is one of the largest and most technically challenging operations performed in the human body. This is because the esophagus is an organ that starts in the neck, passes through the chest cavity, and descends into the abdominal cavity. Therefore, this operation requires the surgeon to work in the abdominal cavity, the chest cavity, and sometimes even the neck region.

The basic principle of the operation is to remove the cancerous part of the esophagus together with the surrounding risky lymph nodes. However, the process does not end there; we must also restore the continuity of the digestive system so the patient can eat again. The method we most commonly use is to shape the stomach into a tube, bring it upward into the chest cavity or neck, and connect it to the remaining healthy end of the esophagus. This new connection point is called an “anastomosis.”

Traditionally, these operations were performed with large incisions using open surgery. However, with advances in technology, “Minimally Invasive Surgery” techniques have come to the forefront. Especially with methods such as VATS (Video-Assisted Thoracic Surgery), laparoscopy, or robotic surgery, it is now possible to perform these major operations through small openings without opening the chest cavity completely.

What are the advantages of minimally invasive methods for the patient?

The greatest advantage of minimally invasive surgery, in other words closed methods, is that they minimize the trauma experienced by the patient. In classical open surgery, the ribs must be spread apart and sometimes even cut in order to open the chest cavity. This causes severe pain after surgery. A patient in pain may be afraid to take deep breaths, cannot cough, and cannot clear mucus. This can lead to collapse of the lungs (atelectasis) and pneumonia.

In contrast, with closed methods the integrity of the chest wall is preserved. Because the procedure is performed with a camera and fine instruments, the patient experiences much less pain after surgery. Less pain means that the patient can breathe more comfortably, cough, and get out of bed earlier even in the hours immediately following surgery. This accelerates the recovery process and shortens the hospital stay. In addition, for the surgeon, being able to see the surgical field much more clearly and magnified thanks to high-resolution cameras provides a great advantage in protecting delicate vessels and nerves.

The benefits of minimally invasive surgery include:

• Less pain
• Early mobilization
• Lower infection risk
• Short hospital stay
• Less blood loss
• Faster recovery
• Cosmetic advantage
• Better breathing

Why is lymph node removal so important?

One of the most important factors determining the quality of a cancer operation is not only removing the tumor but also clearing the pathways through which the tumor may spread. Esophageal cancer has a very strong tendency to spread through the lymphatic channels (metastasis). Therefore, the procedure called “lymphadenectomy,” meaning removal of the lymph nodes around the tumor and along its drainage pathways, is of vital importance.

For surgeons, lymphadenectomy is necessary not only to remove the disease but also to understand the true stage of the disease. The greater the number of lymph nodes removed and the more thoroughly they are examined pathologically, the more accurately we can plan the patient’s future treatment. Scientific studies clearly show that patients in whom an adequate number of lymph nodes are removed have much higher long-term survival rates.

Depending on the type of tumor, the regions from which lymph nodes must be removed may vary. In squamous cell carcinoma, very extensive clearance covering the neck, chest, and abdominal regions may be required, whereas in adenocarcinoma the focus is mainly on the lower chest and abdominal areas. Regardless of the method chosen, the goal is to leave no disease behind, even at the microscopic level.

What complications may develop after surgery?

Although technology and surgical experience have advanced, esophagectomy remains a high-risk operation and some undesirable situations may develop afterward. The most important and most feared complication is “Anastomotic Leakage.” This occurs when the tissues do not heal completely at the point where the gastric tube and the esophagus are stitched together. Such leakage may lead to infection spreading into the chest cavity and requires urgent intervention.

Another frequently encountered problem is lung complications. Because the surgery is performed in the chest cavity and due to the effects of anesthesia, lung collapse, pneumonia, or respiratory failure may develop. Respiratory physiotherapy before and after surgery is very important to minimize these risks. In addition, a condition called “chylothorax,” which is leakage of lymph fluid into the chest cavity, is a rare but serious complication. In this situation caused by damage to the lymphatic channels, the patient’s nutritional balance may deteriorate and sometimes another intervention may be required. Hoarseness may also occur temporarily or permanently because of the proximity of the nerves leading to the vocal cords to the surgical field.

Possible complications include:

• Anastomotic leakage
• Pneumonia
• Respiratory failure
• Wound infection
• Chylothorax
• Cardiac rhythm disorder
• Hoarseness
• Difficulty swallowing

What should patients pay attention to in their diet after surgery?

The postoperative period is the process during which the patient adapts to the new digestive system. The stomach is no longer in its former position or shape; it is now in the chest cavity in the form of a tube. This anatomical change makes it necessary to completely change eating habits. The most important advice we give our patients is to eat “small and frequent meals.” Because the stomach volume is reduced, instead of three large meals per day, 6–8 small meals should be consumed.

Making use of gravity after eating is very important. The patient should never lie down immediately after eating but should sit upright or walk for at least two hours. This facilitates the downward passage of food and prevents reflux. In addition, elevating the head of the bed is a precaution that should be applied lifelong to prevent stomach contents from coming into the mouth during sleep. In the first weeks, nutrition begins with liquid foods, gradually transitions to puréed foods, and then slowly progresses to solid foods. Working together with nutrition specialists during this process is critical to prevent weight loss and accelerate recovery.

Nutritional recommendations include:

• Eat small and frequent meals
• Chew food thoroughly
• Walk after meals
• Sleep with a high pillow
• Avoid carbonated beverages
• Stay away from excessive sweets
• Drink sufficient water
• Follow a protein-rich diet

Are there situations where surgery is not possible?

Unfortunately, not every patient may be a suitable candidate for surgery. One of the most difficult moments for surgeons is telling the patient that surgery is not possible. If the tumor has spread to major vessels such as the aorta, the spine, or the heart and surrounds these structures, surgery may be technically possible but will not benefit the patient and may even cause harm. We call this “unresectable” disease.

Similarly, if the cancer has spread to other parts of the body such as the liver, lungs, or bones (Stage 4), a local operation will not change the overall course of the disease. In such situations, our priority is to improve the patient’s quality of life. With the approach we call “palliative treatment,” we try to suppress the disease with chemotherapy and radiotherapy, reduce pain, and relieve difficulty swallowing. Procedures such as placing a stent in the esophagus or inserting a feeding tube are among our main goals in this stage to ensure adequate nutrition.

How does the long-term follow-up process work?

Treatment of esophageal cancer is not a process that ends with surgery; rather, it is the beginning of a new life. We continue to monitor our patients very closely after the operation. The first two years are the period when the risk of recurrence is highest, so we perform follow-up examinations every 3 to 6 months. During these visits, we track the disease using blood tests, tomography, and if necessary endoscopy.

In the long term, the patient’s quality of life is as important as cancer control. Nutritional status, weight monitoring, swallowing functions, and psychological condition are evaluated continuously. Sometimes strictures may develop in the surgical area and swallowing difficulty may begin again. In such cases, we relieve the patient with endoscopic dilation procedures. With successful surgery and a good follow-up process, most of our patients are able to return to their normal lives and live healthy lives for many years. This process is a long journey based on a relationship of trust between the patient, relatives, and doctor.

What is the role of the thoracic surgery specialist in this process?

The treatment of esophageal cancer is truly a team effort. Oncologists, radiation oncologists, gastroenterologists, nutrition specialists, and surgeons all work together. However, the thoracic surgery specialist is at the center of this multidisciplinary structure and is the captain of the process, especially for patients who are suitable for surgery.

Our responsibility is not limited to performing the surgery. Evaluating whether the patient is suitable for surgery, interpreting the response to neoadjuvant treatment, performing the cleanest possible resection with the most appropriate technique during the operation, and protecting the patient from complications during the critical postoperative recovery period are all part of our duty. Using the innovations of modern medicine, especially minimally invasive techniques, to help our patients overcome this challenging process with minimal harm is our main goal. Every case is a new struggle for us, and every recovering patient is our greatest reward. At this point where knowledge, experience, and technology come together, we continue to work with all our strength to help our patients hold on to life.

Frequently Asked Questions