Neoplasm of Esophagus

Overview of Neoplasm of Esophagus

Esophageal cancer occurs when cells in the esophagus develop changes (mutations) in their DNA.

The changes make cells grow and divide out of control.

The accumulating abnormal cells form a tumor in the esophagus that can grow to invade nearby structures and spread to other parts of the body.[5]

Spread of carcinoma

1. Direct-

• The lesion may fill the lumen and infiltrate the wall of esophagus. It may also spread to the adjoining structures such as the trachea, left bronchus, aorta or pericardium.
• Involvement of the recurrent laryngeal nerves causes aspiration problems.

2. Lymphatic–

• Depending on the site involved, cervical, mediastinal or coeliac nodes may be involved.
• Cervical and thoracic lesions also spread to supraclavicular nodes.
• “Skip lesions” may also occur due to spread through the submucosal lymphatics.

3. Blood borne-

• Metastases may develop in the liver, lungs, bone and brain.[1]

Causes of Neoplasm of Esophagus

• Smoking and alcohol consumption are high-risk factors and so are some particular dietary habits.
• High incidence is associated with tobacco chewing and smoking.
• About 5% of esophageal cancers arise in the pre-existing pathological lesions, such as benign strictures, hiatus hernia, cardiac achalasia and diverticula.
• Plummer–Vinson syndrome is another predisposing factor.

Classification of Neoplasm of Esophagus

1. Benign neoplasms:

• Benign neoplasms are rare compared to malignant ones. Leiomyoma is the most common and accounts for two thirds of all the benign neoplasms.
• It arises from the smooth muscle and grows in the wall of esophagus.
• Dysphagia is produced when tumor exceeds the diameter of 5 cm. Barium swallow shows an ovoid filling defect.
• Endoscopy reveals a submucosal swelling. Biopsy should not be taken.
• Treatment is enucleation of the tumor by thoracotomy. Mucosal polyps, lipomas, fibromas and hemangiomas are other benign tumors.
• They are often pedunculated and present in the esophageal lumen. Endoscopic removal is avoided because of the danger of esophageal perforation. Treatment is surgical excision by esophagostomy.

2. Carcinoma esophagus

• Incidence of esophageal carcinoma is high in China, Japan, USSR and South Africa.
• In India, it constitutes 3.6% of all body cancers in the rich and 9.13% of those in those people who have less income.[1]

Pathophysiology of Neoplasm of Esophagus

Squamous cell carcinoma is the most common (93%). Adenocarcinoma (3%) is also seen, but in the lower esophagus, and may be an upward extension of the gastric carcinoma.

Other types are rare..

Clinical Features

The clinical presentation of esophageal neoplasms (both benign and malignant) is often insidious and nonspecific, leading to delayed diagnosis. The most common symptoms include:

• Dysphagia (difficulty swallowing): This is the hallmark of esophageal neoplasms and is often the first symptom. It typically starts with difficulty swallowing solids and progresses to liquids as the tumor grows and obstructs the esophagus.
• Odynophagia (painful swallowing): This can occur as the tumor invades the esophageal wall or surrounding structures.
• Weight loss: This is due to a combination of dysphagia, odynophagia, and the metabolic demands of the tumor.
• Regurgitation: This can occur as the tumor obstructs the esophagus, preventing the passage of food and liquids.
• Heartburn and indigestion: These can be caused by acid reflux due to the tumor disrupting the normal function of the lower esophageal sphincter.
• Hoarseness: This can occur if the tumor invades the recurrent laryngeal nerve, which controls the vocal cords.
• Coughing: This can be caused by aspiration of food or liquids due to the tumor obstructing the esophagus.

In advanced cases, patients may also present with:

• Bleeding: This can occur as the tumor erodes into blood vessels.
• Anemia: This can be caused by chronic blood loss or by the tumor interfering with the absorption of nutrients.
• Malnutrition: This can be caused by dysphagia, odynophagia, and the metabolic demands of the tumor.
• Metastasis: This occurs when the tumor spreads to other organs, such as the liver, lungs, or bones.[9]

Please note that this is a simplified overview of the clinical features of esophageal neoplasms. The presentation can vary depending on the type and location of the tumor, as well as the individual patient’s overall health and comorbidities. A thorough medical evaluation, including imaging studies and biopsies, is necessary to confirm the diagnosis and guide treatment decisions.

Sign & Symptoms of Neoplasm of Esophagus

1. Early symptoms. They include substernal discomfort and preference for soft or liquid food.
2. Progressive dysphagia and emaciation. Dysphagia first to solids and then to liquids. Patient loses weight and becomes emaciated.
3. Pain. Usually signifies extension of tumor beyond the walls of esophagus. It is referred to the back.
4. Aspiration problem. Spread of cancer may cause laryngeal paralysis or fistulae formation leading to cough, hoarseness of voice, aspiration pneumonia and mediastinitis.[1]

Diagnosis of Neoplasm of Esophagus

1. Barium swallow-

• It shows narrow and irregular esophageal lumen, without proximal dilatation of the esophagus.

2. Esophagoscopy-

• Useful to see the site of involvement, extent of the lesion and to take biopsy. Flexible fiberoptic oesophagoscope obviates the need for general anesthesia and gives a magnified view.

3. Bronchoscopy-

• It helps to exclude extension of growth into the trachea and bronchi.

4. CT scan-

• It is useful to assess the extent of disease and nodal metastases [1]

Differential Diagnosis

1. Benign Tumors:

   • Leiomyoma (most common)
   • Polyps (Inflammatory fibroid polyp, hamartoma, etc.)
   • GIST (Gastrointestinal stromal tumor)
   • Granular cell tumor

2. Malignant Tumors:

   • Squamous Cell Carcinoma (most common worldwide)
   • Adenocarcinoma (most common in Western countries)
   • Small Cell Carcinoma
   • Lymphoma
   • Melanoma

3. Non-Neoplastic Conditions:

   • Achalasia
   • Esophageal Stricture (Peptic, radiation-induced, etc.)
   • Esophageal Web (Plummer-Vinson syndrome)
   • Esophageal Ring (Schatzki ring)
   • Infectious Esophagitis (Candida, Herpes simplex virus, Cytomegalovirus)
   • Eosinophilic Esophagitis
   • Barrett’s Esophagus (premalignant condition)

Clinical Approach:

A thorough history and physical examination, along with appropriate diagnostic tests (endoscopy with biopsy, barium swallow, CT scan, endoscopic ultrasound), are essential to accurately diagnose esophageal neoplasms and differentiate them from other conditions. Early diagnosis and prompt treatment are crucial for improving outcomes in patients with esophageal cancer.[8]

Treatment of Neoplasm of Esophagus

Surgery of upper two-thirds of esophagus is difficult due to great vessels and involvement of mediastinal nodes.

Radiotherapy is the treatment of choice.

Surgery is the preferred method of treatment for cancer of lower one-third.

The affected segment, with a wide margin of esophagus proximally and the fundus of stomach distally, can excise with primary reconstruction of the food channel.

Disease of esophagus in advanced lesions, only palliation is possible. An alternative food channel can provide by:

1. A by-pass operation.
2. Esophageal intubation with Celestin or Mousse au barb in or a similar tube.
3. Permanent gastrostomy or a feeding jejunotomy.
4. Laser surgery: esophageal growth is burnt with Nd: YAG laser to provide a food channel. Chemotherapy use only as a palliative measure in the locally advanced or disseminated disease.

Preventive Measures:

• Avoid Tobacco and Alcohol: Quitting smoking and limiting alcohol intake can significantly reduce your risk.
• Manage GERD: If you have GERD, work with your doctor to manage it effectively. This may involve lifestyle changes, medications, or surgery.  
• Maintain a Healthy Weight: If you are Higher Weight, losing weight can help reduce your risk.
• Eat a Healthy Diet: A diet rich in fruits and vegetables may help protect against esophageal cancer. Focus on cruciferous vegetables like broccoli, cauliflower, and cabbage.[10]

Important Note: This information is not intended as a substitute for professional medical advice. Always consult with your doctor for personalized recommendations on esophageal cancer prevention.

Homeopathic Treatment of Neoplasm of Esophagus

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?.

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improved with homeopathic medicines.

Homeopathic Medicines for Neoplasm of Esophagus:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy.

Homoeopathic Approach:

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines are selected after a full individualizing examination and case-analysis, which includes the medical history of the patient, physical and mental constitution, family history, presenting symptoms, underlying pathology, possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) is also often taken into account for the treatment of chronic conditions. A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’.

The disease diagnosis is important but in homeopathy, the cause of disease is not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness are also looked for.

Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition. The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology is not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can be greatly improved with homeopathic medicines.

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications are also taken into account for selecting a remedy.

Medicines

Acetic Acid

• Scirrhous of pylorus; additionally cancer of stomach, ulcerative gnawing at one spot in stomach, with agony and depression, preventing sleep.
• Moreover, Intense and constant thirst.
• Severe burning pain in stomach also abdomen.
• Vomiting after every meal of yellow, either yeast-like matter, or blood.
• Besides this, Pale, waxen skin.
• Lastly; Tongue pale and flabby; marked debility; copious pale urine.

Arsenic Album

• Basically; Cancer of stomach, with burning pain and excessive thirst, desire for acids.
• Aggravation specifically from cold drinks and cold diet, on the other hand amelioration from hot drinks.
• In detail, Vomiting of all he takes; terrible sensation of weakness and exhaustion with anxiety in region of stomach.
• Uterine cancer with burning pain in uterine region also shooting, stinging pains in upper part of abdomen.
• Thirst and dryness of mouth and throat, worse by motion.
• All in all; Acrid, corroding, burning discharges, often very offensive, light or dark-colored.[3]

Bismuth

• Cancer of stomach with burning, stinging, crampy pains.
• Stomach hangs down to the crest of the ilium; hard lumps between navel and edges of lower ribs, side.
• Vomits only at intervals of days when food has filled the stomach, then vomits large quantities of food during the whole day; vomits all fluids.

Causticum

• Patient cannot bear the pressure of the clothes on the stomach.
• The lightest food or even the smallest quantity causes a violent lancinating pain in the stomach.
• Scirrhous of the lips, with itching and soreness, which when ulcerated has a violent burning pain; pus bloody, or greenish, or corroding, or thin, watery and yellow.

Hydrastis Canadensis

• Cancers hard, adherent, skin mottled, puckered, cutting pain like knives also even after ulcerations sets in, where it may regulate faulty nutrition.
• Epithelioma, cancer to rectum, cancer of stomach vomits everything except water with milk; additionally pain in pit of stomach, emaciation.

Lachesis

• Cancer of stomach, the pit very sensitive to touch, with a gnawing pressure, better by eating, but coming on again in a few hours, and the more violent the emptier the stomach.
• Cancer of breast with lancinating pains and a constant painful feeling of weakness and lameness in left shoulder and arm;[3]

Mezereum

• Cancer of stomach with burning, corroding pains.
• Great emaciation; the muscles of the face are tensely drawn, like strings; additionally internal surface of the gastric mucous membrane feels raw, with sensation as if food remained for a long undigested in the stomach.
• Constant vomiting of chocolate-coloured masses, with great burning in throat.
• Hematemesis; violent retching, accompanied with the agony of death.
• Sleepiness and exhaustion; hard lumps in epigastrium region; hypochondriasis; constipation.

Spigelia

• Cancer of Esophagus, pylorus or rectum, narrowing the lumen of the canal, with constant severe and pressing pains, pressing through to the back and shooting down into the thighs.
• Cancer of uterus, with pressure and pain in the whole pelvic region and shooting down the limbs.
• Burning heat in vagina, with sense of fulness and pressure, worse standing and dislike to move.[3]

Diet & Regimen of Neoplasm of Esophagus

• Eat foods high in calories and protein.
• These include whole, full-fat dairy products, nut products, and meats. For example milkshakes, smoothies with protein powder, peanut butter, beans, eggs, cheese, and yogurt.
• If swallowing is still hard, soften your foods with gravies or sauces. Chop up meat into small pieces. For example scrambled eggs, pasta, custard, pudding, and soups and stews made with ground meat.
• Furthermore; If you’ve had surgery, your stomach may be smaller.
• You may fill up quickly. It may help to eat smaller meals more often. You should also avoid drinking fluids before meals. And keep lots of snacks on hand for between meals.
• You may need to sip fluids while you’re eating. This can help make swallowing easier. It can also help food pass through your esophagus.
• Besides this, Highly acidic or spicy foods, foods with sharp pointed edges, or extremely hot or cold foods.
• Fluids may be irritating, especially during certain types of treatments.
• Overall; Use caution with foods like tough cuts of meat, doughy bread, alcohol, citrus juices or sauces, also piping hot beverages.[4]

Do’s & Don’ts

Esophageal cancer (neoplasm of the esophagus) is a serious condition, but there are steps you can take to reduce your risk and improve your chances of early detection if it does occur.

Do’s:

• Maintain a Healthy Diet: Eat plenty of fruits, vegetables, and whole grains. These foods are rich in antioxidants and fiber, which may help protect against esophageal cancer.
• Limit Alcohol Consumption: If you drink alcohol, do so in moderation. Heavy alcohol use is a major risk factor for esophageal cancer.
• Quit Smoking: Smoking is a leading cause of esophageal cancer. Quitting smoking can significantly reduce your risk.
• Manage GERD: If you have gastroesophageal reflux disease (GERD), work with your doctor to manage it effectively. Chronic GERD can increase your risk of developing esophageal cancer.
• Get Regular Checkups: If you have any risk factors for esophageal cancer, talk to your doctor about getting regular screenings. Early detection can greatly improve your chances of successful treatment.

Don’ts:

• Don’t Smoke: As mentioned earlier, smoking is a major risk factor for esophageal cancer. Avoid smoking or using tobacco products.
• Avoid Drink Excessively: Heavy alcohol use is also a major risk factor. If you drink alcohol, do so in moderation.
• Don’t Ignore Symptoms: If you experience any symptoms of esophageal cancer, such as difficulty swallowing, pain when swallowing, or unintentional weight loss, see your doctor right away. Early detection is crucial for successful treatment.
• Don’t Eat a Diet High in Processed Foods: Processed foods are often high in fat, sugar, and salt, and low in nutrients. A diet high in processed foods may increase your risk of esophageal cancer.

Remember, these are general recommendations. It’s important to talk to your doctor for personalized advice based on your individual risk factors and medical history.

References use for Article Neoplasm of Esophagus

1. Diseases_of_Ear_Nose_and_Throat_6Edition
2. https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=34&ContentID=17970-1
3.  Homoeopathic Therapeutics by Lilienthal
4. https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=34&ContentID=17970-1#:~:text=Eat%20foods%20high%20in%20calori
5. https://www.google.com/search?q=overview+of+neoplssm+of+esophagus&rlz=1C1CHBF_enIN990IN990&oq=overview+of+neoplssm+of+es
6. Consensus Document for Management of Esophageal Cancer – Indian Council of Medical Research (ICMR) (2014).
7. Epidemiological Review: Esophagus Squamous Cell Carcinoma in India – Thieme Connect (2022).
8. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 11th Edition,  Mark Feldman, Lawrence S. Friedman, Lawrence J. Brandt, 2021,  Elsevier Saunders.
9. Robbins & Cotran Pathologic Basis of Disease (10th Edition), Vinay Kumar, Abul K. Abbas, Jon C. Aster,  2021, Elsevier.
10. Esophageal Cancer: Prevention, Diagnosis and Therapy Edited by Nabil F. Saba and Bassel F. El-Rayes, published in 2019 by Springer.