Tri-Modality Therapy to Treat Esophageal Cancer

In later stage esophageal cancer (stages 2-3), the cancer has spread deeper into the esophageal wall. Treatment for these cancers may involve trimodality therapy, a combination of chemotherapy, radiation and surgery. It is most common for chemotherapy and radiation to take place before surgery. However, often patients with later stage cancer have difficulty or inability in swallowing food or liquid. When the cancer causes swallowing problems, weight loss, esophageal obstruction or vomiting, a gastroenterologist will use an endoscopic procedure to open up the esophagus. This may involve the placement of a stent to keep the esophagus open. This allows the patient to proceed first with chemotherapy and radiation therapy, which is associated with better long-term survival rates.

When a patient presents with stage 2-3 esophageal cancer at UMGCCC, he or she is evaluated by a multidisciplinary team. This team consists of a medical oncologist, radiation oncologist, and thoracic surgeon. These experts tailor a treatment plan to the patient's individual cancer and other factors such as age, functional status and other health conditions.

Treatment usually begins with chemotherapy and radiation given at the same time in a treatment regimen than usually lasts 5-6 weeks. Four to six weeks of the last dose of radiation, a restaging PET/CT scan is done. If the cancer has not spread, then the patient is a candidate for surgery. Other testing may be required to determine the patient's health (testing of the heart and lungs) to make sure it is safe for the patient to have surgery.

Trimodality therapy not only gives patients a survival advantage, but it sometimes "downstages" the cancer to an earlier stage. This gives patients the best chance to have their cancer completely removed by surgery.

Radiation Therapy for Esophageal Cancer

Traditional photon radiation for esophageal cancer at UMGCCC generally uses intensity modulated radiation therapy (IMRT). IMRT is the most advanced radiation available to destroy cancer cells without damaging normal tissue. Because the esophagus is centrally located in the body, it's important for doctors to minimize the amount of radiation that reaches a patient's heart, lung and spinal cord. Radiation reaching these organs can cause lung inflammation, heart muscle damage, irritation to the sac around the heart, heart attack and coronary artery disease. IMRT is a better approach than other traditional radiation therapies that use X-ray radiation in preventing radiation from reaching these sensitive organs.

image of proton therapy scan However, the radiation oncologists at UMGCCC also have access to proton therapy, the most advanced, precise radiation therapy available. Only available at about 25 centers across the U.S., proton therapy stops the radiation dose at the tumor site so it doesn't reach the healthy tissues behind it. This significantly decreases the amount of radiation that reaches the heart and lungs of esophageal cancer patients. Because it is more precise than traditional radiation therapy, proton therapy has also been associated with fewer complications after a patient has surgery. Read more about proton therapy for esophageal cancer at the Maryland Proton Treatment Center.

Surgical Options for Esophageal Cancer

Surgery for esophageal cancer is available for patients with early stage to locally advanced cancers that have not spread elsewhere in the body. The cancer must be located within the middle to the end of the esophagus near the stomach, and it may also cross over into the top portion of the stomach.

The surgery to remove the part of the esophagus with the cancer is called an esophagectomy. (If a part of the stomach is also removed, the procedure is called an esophagogastrectomy.) About two-thirds of the esophagus will be removed. The surgeon will then create a tube, or "conduit," out of the remaining stomach, and this will take the place of the esophagus in the chest by being reconnected to the remaining portion of the esophagus.

This surgery is done in two parts, the first in the abdomen and the second in the chest. Through the abdomen, the surgeon moves the stomach away from the rest of the organs and creates the conduit. A feeding tube is also placed farther down in the GI tract, in an area of the small intestine called the jejunum. This feeding tube will be used while the patient's anastomosis, or hookup between the remaining esophagus and stomach conduit, is healing.

The surgeon closes the stomach incision and then proceeds with the second part of the surgery. He or she makes an incision in the right chest, and brings the stomach up into the chest behind the lung. The surgeon removes about two-thirds of the esophagus and creates the hookup. The areas around the esophagus are checked to make sure they are free of cancer cells. Also, throughout the entire case, lymph nodes are removed to be examined for any cancer. The presence or not of cancer in these lymph nodes will allow doctors to know what future treatment should involve. The surgeon will place a chest tube around the lung to collect any fluid which may result after the surgery while the patient is healing. He or she will so place a tube into the patient's nose which will pass into stomach conduit to keep it open. This will prevent stomach bloating, which could cause tension on the hookup.

Minimally Invasive vs. Open Surgery Approaches

In some cases, it may be possible for surgeons to perform an esophagectomy in a minimally invasive way. Instead of involving large incisions of several inches each, minimally invasive procedures involve multiple small incisions both in the upper abdomen and on the chest between the ribs on the side. The surgeon uses a camera and video screen to see inside the body and perform the operation. Minimally invasive surgery can result in less postoperative pain and a faster recovery.

In an open esophagectomy, UMGCCC surgeons make an incision in the middle of the abdomen called a laparotomy and an incision between the ribs below the shoulder blade on the side of the back called a thoracotomy. Open procedures take the surgeon less time, which means that patients are under general anesthesia for a shorter period of time. Also, patients who have had prior radiation therapy or surgery may have scarring that requires the surgeon to take an open surgery approach.

To make an appointment with an esophageal cancer expert, please call 410-328-7904.