Mom with esophageal cancer

 Dear Sharon:

 Glad you wrote here.  Age 72 is not too old to have an Esophagectomy.  Surgery will depend on what stage she is.  The first thing I would do is have a SECOND OPINION. 

 So what—so the surgeon doesn’t want to do surgery “because of her age” or because her cancer has metastasized to the lung—which is it?   The determination as to possibility of surgery would be contingent upon (1) whether or not the cancer has spread to another major organ.  So it should be determined whether or not the place on her lung is a malignant tumor or scar tissue.  If it is shown to be cancerous, then she would be treated palliatively with chemo and/or radiation as a rule.  If proper testing has taken place, the surgeon should already know whether it is simply scar tissue, or whether it is a malignancy.

 Secondly, what type of training has the “surgeon” had?  Are you at a major cancer hospital that performs Esophagectomies on a regular basis?  You need to be. 

 I would find out if your mom’s insurance pays for a second opinion.  If it does, and she hasn’t had one, that would be my first advice.

 We know many people over 72 that have had Esophagectomies.  My husband goes to a support group here and most everyone is over 72.  They are recovering from surgery, or anticipating surgery after completion of their pre-op chemo/radiation treatments.  Clinical trials have shown that “tri-modal” treatments provide the most success.  (That being chemo/radiation/surgery.)

 Did you know that there is more than one kind of an Esophagectomy?  We had a 2^nd opinion because there was no surgeon in our town trained to perform the newest and best totally laparoscopic procedure.  My husband is a survivor of Esophageal Cancer, Stage III, and (T3N1M0).  Dr. James D. Luketich at the University of Pittsburgh Medical Center performed an Ivor Lewis Minimally Invasive Esophagectomy (MIE).  My husband had pre-op chemo of Carboplatin and 5-FU plus 25 radiation treatments.  Then he had a successful MIE surgery.  He only had 7 Band-Aid cuts.  The surgery is totally laparoscopic.  I suggest that you consult Dr. Luketich’s office if possible.  Dr. Luketich did NOT require a referral from another doctor.  We simply called and made an appointment ourselves!

 Please don’t give up on your mom simply because of one surgeon’s advice.  I am curious as to who the surgeon is.  Can you share his name?  You can do some research on him over the web and see what kind of training he has, how many esophagectomies he performs yearly, and whether he is trained in the latest laparoscopic procedure known as the MIE.  It may be that he is not capable of performing the latest surgery.  Dr. Luketich pioneered this surgery in the mid-90s.  It is not new, it’s now been around about 20 years, and has been proven to have the quickest recovery with less morbidity than other more invasive types.    You really haven’t been too specific about the testing that your mother has had done, nor the kind of chemo she has had. 

 Lastly, if the correct diagnosis is Stage III, chemo and radiation is not sufficient for a cure.  When my husband and I talked with our surgeon and oncologist at the very first, we were told that chemo/radiation should be done first.  And then, even if, the PET/CT scan at the end of the treatments, indicated the cancer had been wiped out, surgery would STILL BE NECESSARY.  Often there is still more cancer that only shows up during the surgery itself.  Then at least 22 lymph nodes will be removed for pathological analysis during the time of surgery. They will be tested to see if any cancer is in any of them.  Thank God no residual cancer was found after the surgery.

 Surgery is necessary even after treatments for a late stage diagnosis.  (Stage III is late stage.)  Now if your mom was frail and had other medical problems that would indicate that she couldn’t survive surgery, then that’s another matter.  But if age is the only reason this surgeon doesn’t want to perform surgery—your mom needs a “new” surgeon.

 Would I be wrong if I found that this surgeon is an older person that only knows how to perform the oldest Ivor Lewis Esophagectomy that was first introduced in the 1940s?  Most surgeons in training today are learning how to perform the totally laparoscopic Esophagectomy.  He would have to have some other reason for refusing surgery for your mom other than merely being 72.  It may be that he only knows how to perform the Ivor Lewis that consists of two massive incisions and takes much longer to recuperate.  He certainly knows how “invasive” that surgery is.

 My husband was 65 when diagnosed.  He is now 79.  He is now in his 14^th year of survival with no recurrence to date.  So please fill us in a bit more.  If you want to talk to my husband and me personally, send me your phone number by private message, and we will glad to call you and talk as long as you wish, and answer as many questions as we can. 

 This surgery is not a “piece of cake”—it is major surgery.  But we know many people that are 72 that have been diagnosed and had surgery and are survivors.  There will be others here who will answer you I would imagine that are probably 72 and have had surgery.  I know for a fact that we had one fella here a long time ago by the name of Randy.  Randy was between 75 and 80 when Dr. Luketich performed a successful Minimally Invasive Esophagectomy on him. 

 Hope this helps.

 Loretta Marshall, (Wife of William) who had a Minimally Invasive Esophagectomy in 2003 by Dr. James D. Luketich at UPMC

 P.S.  In the last few days, this site has been revamped, and it was supposed to be an improvement.  But quite the contrary, I am accustomed to providing many informative and reputable medical sites that will give good information.  But as of now, I have reported this problem of not being able to send along web links.  I hope they “fix” it rapidly because I cannot begin to provide you with all the information you need to make informed decisions.  Now the only thing I can think of is this.  If you want to send me a private e-mail address, I can forward via regular e-mail all the links that you need to know about.  

 Hello again Sharon:

 First let me ask, do you have obligations back in Michigan that would keep you from staying very long in California?  If you need to go home, is there a close relative or dear friend that could be with your mom.  This is not something that she should face alone.  You don’t have to answer me as to who that might be.  However, no one should be alone once they have been diagnosed with Esophageal Cancer. 

 I would suggest you check out Mom’s policy and see how many places they would allow your mother to go for a Second Opinion.  From there we could try to figure out the best from that group.  There is a great Thoracic surgeon on the West Coast.  His name is Dr. Ninh Nguyen.  He worked with Dr. Luketich in the 90s when the Minimally Invasive Esophagectomy was in its infancy.  He works with UC-Irvine.  However, I don’t know if Kaiser would allow your mom to go there, and if Dr. Nguyen accept Kaiser.  HMOs can be “stingy” with their $ if you ask me.  So Kaiser will be “calling the shots” so to speak as to where she can go.  Once they give the okay for a second opinion, which a great many companies do, then different surgeons could be checked out, as to their level of expertise.  I’ve often called a surgeon’s office when trying to find a good doctor, and asked about their training, and if they perform the MIE or not. 

 I've spent quite a bit of time going over a "pdf" file that is over 50 pages.  Fortunately, I see that the web link problem has been corrected, so hooray for that.  I've highlighted lots of info, but this one article will tell you everything you need to know about Esophageal Cancer.  And I'm going to see if I can condense the information even more from what I have scanned.  You will certainly have to print it out.  Will send that separately but that will be later.  There’s a 3-hour time difference between Virginia and California, and I usually “turn into a pumpkin” at midnight, and it is now past that hour here.

 Mom needs someone to accompany her to all doctor's visits and treatments.  And if surgery is deemed a possibility, usually surgery is scheduled within 3 to 4 weeks following completion of last chemo/radiation treatments.  Chemo has a residual effect of 3 weeks so doctors like to schedule the last PET/CT scan 3 weeks out to see the maximum effect of the treatments.   After that surgery, if it is possible, as soon after as possible.  At this point, evidently doctors haven’t given your mom a “clear path” as to what is they’re intending to do beyond chemo and radiation.  It would appear only “palliative” measures by what you tell me.  It is extremely important that you see if you can get Mom a SECOND opinion.  That way, you will know for certain if surgery is actually possible or not.  By reading this “pdf”, you can compare what SHOULD HAVE BEEN done and what this medical group has actually done.  It explains biopsies, how and why they are done.  I will put portions of this report here, so you can judge for yourself if all the tests that could have been done have been done.  Obviously an upper endoscopy has been done, but biopsies could have been done. The purpose of a second opinion is to confirm and/or give additional information as to the condition of the patient and what treatment regimen they would recommend. 

 So below are some excerpts that will explain a bit more.  And may I say that it is essential that the patient “take charge” of their own cancer, and insist on knowing what the doctors intend to do and why, or why not.  I hope Mom is capable of “tackling” this cancer head on and dealing with it from a positive perspective.  That is why also that it’s best for someone to accompany her on all trips to the doctor.  Hopefully, she is keeping a journal of what doctors she has seen, and what their findings were.  This is a long road Sharon.  I’ll be back in touch soon. For now I’m going to “retire”.

 Loretta

 This is an excellent pdf file on CANCER OF THE ESOPHAGUS.

 http://www.cancer.org/acs/groups/cid/documents/webcontent/003098-pdf.pdf

 “…Upper endoscopy.   This is an important test for diagnosing esophageal cancer. During an upper endoscopy, you are sedated (made sleepy) and then the doctor passes the endoscope down the throat and into the esophagus and stomach. The camera is connected to a monitor, which lets the doctor see any abnormal areas in the wall of the esophagus clearly. The doctor can use special instruments through the scope to remove (biopsy) samples from any abnormal areas. These samples are sent to the lab so that a doctor can look at them under a microscope to see if they contain cancer. If the esophageal cancer is blocking the opening (called the lumen) of the esophagus, certain instruments can be used to help enlarge the opening to help food and liquid pass. Upper endoscopy can give the doctor important information about the size and spread of the tumor, which can be used to help determine if the tumor can be removed with surgery.

 Endoscopic ultrasound  - This test is usually done at the same time as the upper endoscopy, although it is actually a type of imaging test. Ultrasound tests use sound waves to take pictures of parts of the body. For an endoscopic ultrasound, a probe that gives off sound waves is at the end of an endoscope, which is passed down the throat and into the esophagus. This allows the probe to get very close to tumors in the esophagus or nearby. The probe sends out sound waves, and the echoes are picked up by the probe. A computer turns the pattern of sound waves into a black-and-white image showing how deeply the tumor has grown into the esophagus. It can detect small abnormal changes very well. This test is very useful in determining the size of an esophageal cancer and how far it has grown into nearby areas. It can also help show if nearby lymph nodes might be affected by the cancer. If enlarged lymph nodes are seen in the chest on the ultrasound, the doctor can pass a thin, hollow needle through the endoscope to get BIOPSY SAMPLES of them. This helps the doctor decide if the tumor can be removed with surgery.

 Bronchoscopy.   This exam may be done for cancer in the upper part of the esophagus to see if it has spread to the windpipe (trachea) or the tubes leading from the windpipe into the lungs (bronchi). For this test, a lighted, flexible fiber-optic tube (bronchoscope) is passed through your mouth or nose and down into the windpipe and bronchi. The mouth and throat are sprayed first with a numbing medicine. You may also be given medicine through an intravenous (IV) line to make you feel relaxed. If abnormal areas are seen, small instruments can be passed down the bronchoscope to take BIOPSY samples.

 Thoracoscopy and laparoscopy These exams let the doctor see lymph nodes and other organs near the esophagus inside the chest (by thoracoscopy) or the abdomen (by laparoscopy) through a hollow lighted tube. These procedures are done in an operating room while you are under general anesthesia (in a deep sleep). A small cut (incision) is made in the side of the chest wall (for thoracoscopy) or the abdomen (for laparoscopy). Sometimes more than one cut is made. The doctor then inserts a thin, lighted tube with a small video camera on the end through the incision to view the space around the esophagus. The surgeon can pass thin instruments into the space to remove lymph node and BIOPSY samples to see if the cancer has spread. This information is often important in deciding whether or not a person is likely to benefit from surgery.

 Lab testing of biopsy samples An area seen on endoscopy or on an imaging test may look like cancer, but the only way to know for sure is to do a biopsy. For a biopsy, the doctor removes small pieces of tissue from an abnormal area. This is most often done during an endoscopy exam. A doctor called a pathologist then looks at the tissue under a microscope to see if it contains cancer cells. If there is cancer, the pathologist will determine the type (adenocarcinoma or squamous cell) and the grade of the cancer (how abnormal the patterns of cells look under the microscope).

______End of excerpts - these are only some of the tests used to determine extent of cancer & treatment recommended____