Esophageal Cancer~HOW IT’S DIAGNOSED & STAGED~Info 4 “rjollie” & Others Who Need 2 Know

Dear “rjollie” –

 You’re a brave sister to dig this deeply into the intricacies of how Esophageal Cancer is diagnosed and staged.  This info is taken from an American Cancer “pdf” file.  No believe it or not, I’m not going to put the entire 59 page document here…at one time. J

It would appear that some medical doctors want your brother to start chemo right away.  But you’re concerned about how thorough the workup has been, since the cancer has not been staged.  I don’t blame you for wondering.  I’m wondering if every test has been completed.  Who ordered the test?  Does your brother have a copy of the results?  Has it been explained to him?  Just to say you have Esophageal Cancer leaves a lot of unanswered questions.

 Yes, chemo ordered is based on the stage of the cancer.  You are correct that treatment prescribed will be according to the “stage” of the cancer.  Rarely will a person present with the very first stage of this cancer which would be “in situ” meaning it is only located in its infancy and has not spread beyond the point of origin.  In those cases, surgery has been performed to remove it without prior chemo treatments, but that is rare.  Most EC is in the later stages, and all too often is not found until it has progressed to the Stage IV category.  In that stage, the cancer will have metastasized (spread) in or near another major organ already.  Now generally surgery is limited to Stages III and below.  If the cancer has spread to another major organ, palliative treatments are given that will include chemo and/or radiation. 

 When your brother goes for his consultation with Dr. Swanson, he should have been given a written report from this group of doctors at EMMC, as well as the findings of the Gastroenterologist, if he isn’t part of the EMMC team.  If tests have been omitted, I am certain that this new surgeon will order them.  I would think that since the EMMC team knew this cancer was not something they were equipped to handle, that they would have already made that appointment for your brother sooner.  Doctors can always get a consult scheduled more quickly than if the patient calls to make the request.  What doctor is going to be administering the chemo that begins on May 23^rd?  Your questions need answers.  Believe me, we never really understood half of what was happening until it was all over, although we asked questions.  The amount of info you need to know to have confidence going in is “mind boggling.”  It’s all so new and it’s all so confusing, and all so uncertain as to how things will turn out.  It is really an “anxiety-filled experience” when you are muddling through it all.  And that’s just about how all the “newbies” feel going in. 

 And yes, chemo regimens will differ.  It will differ according to the patient’s medical condition and if he has any other prior medical problems.   

 And I don’t know why one oncologist will order one combination of chemo/radiation therapy while another will use another combination of chemo components plus radiation.  Have they told your brother what drugs he will be taking? 

 There is usually an interim CT scan in the middle of a regimen to be certain that the drugs are effective.  If there is no response, the oncologist may want to change the formula.  My husband’s combo of CARBOPLATIN & 5-FU worked wonderfully and completely eliminated all the tumors. 

 However, we had already been told that even if the drugs eliminated the cancer, that the surgery would still be necessary.  We didn’t understand it then, but we do now.  Sometimes a scan does not pick up all the cancer in one’s body, and at the time of surgery MORE cancer is found.  That’s why at least 22 or 23 lymph nodes should be tested for residual cancer during the time of surgery.    I read an article recently that indicated that the higher the number of lymph nodes tested by a pathologist during surgery that contained no residual cancer, the longer the period of survival after surgery. 

 My husband had a complete workup prior to his first chemo session.  By the time we met with the oncologist, William had been thoroughly staged.  I’ve said before, we were so “uninformed” about this cancer, that we even thought, “we will just skip the chemo bit and get this thing cut out!”  My how far we’ve come since then.  Our thoracic surgeon who was scheduled to perform the surgery kept on insisting that we visit the Oncologist.  Now actually I don’t think he would have ever performed the Ivor Lewis (OPEN) surgery on my husband without neo-adjuvant (pre-op) chemo/radiation.  He knew how invasive Stage T3N1M0 was, but we didn’t.  The only word that stuck in our mind was ESOPHAGEAL CANCER!  But we were so clueless, we thought it was possible.  Now in hindsight, we know how disastrous it would have been for us, if William had actually skipped the pre-op treatments.  Chemo circulates throughout the entire body in search of cancerous cells, but it also kills good cells as well.  And believe me, one can think they’re never going to make it through the chemo regimen, much less be strong enough to undergo surgery.  Fortunately for us, when we learned there was a laparoscopic Esophagectomy that was far less invasive than the OPEN surgery we were scheduled to have here locally, we immediately called Dr. Luketich and went to the University of Pittsburgh Medical Center for a SECOND opinion.  William was considered a “good candidate” for the MIE, and so that is the surgery we had.  We couldn’t be happier.

 Usually the only time surgery is performed without pre-op chemo is if the doctors think it is in the “very earliest of stages (in situ) meaning the cancer was confined to its place of origin.”  The “TNM” classification is used to accurately define the stage of Esophageal Cancer.   The letter “T” stands for tumor—the letter “N” stands for nodes—the “M” stands for Metastasis (spread).  My husband’s stage was “T3N1M0”.  That meant that in the “T3” stage, cancer had invaded all 4 walls.  The “N1” meant that cancer was also found in 1 or 2 lymph nodes right next to the Esophagus.  The “M0” meant that the cancer had not spread near or in another major organ. 

 Briefly, without going into detail for each stage, the stages are:

 ·       Stage 0: This refers to cancer that is "in situ," meaning that cancerous cells are confined to their site of origin. This type of cancer has not spread and is not invading other tissues.

 ·       Stage I – Stage III: These higher stages of cancer correspond to larger tumors and/or greater extent of disease. Cancers in these stages may have spread beyond the site of origin to invade regional lymph nodes, tissues, or organs.

 Stage IV: This type of cancer has spread to distant lymph nodes, tissues, or organs in the body far away from the site of origin.

 Having a medi-port put in now is okay.  That’s the best way to go.    However, if a complete series of tests have NOT been done, they should have been.  For instance, my husband had a series of 25 radiation treatments.    Prior to his radiation, they “marked up his stomach with “blue crosses” so they would know exactly where to radiate.  The doctors should know the exact location of your brother’s cancer in the Esophagus. 

 Furthermore, what is the diagnosis?  Is it “Adenocarcinoma @ the GE junction?  Or is it “Squamous Cell Carcinoma”?   Doctors are not supposed to keep their patients “in the dark.”

 Does your brother know what has been done “for him” or should I say “to him?”

Has he been tested for an overactive cancer gene that spreads wildly?  We call it cell proliferation in the extreme.  It is a HER2 test.  If your brother has this overactive gene, then he needs to be treated with a drug called HERCEPTIN, in addition to any chemo regimen.  It is an approved drug for gastric cancer patients and is paid for by insurance.  This is given at intervals during the chemo sessions.  So it is very important to know if he has this over-active “onco gene”.

 It is obvious by the information about EMMC that they are incapable of treating your brother properly.  Thankfully, they have said he needs to be in a major cancer specialty hospital, where Esophageal Cancer is a “routine” surgery.  Higher volume hospitals are best.  I saw in their website that no specialists had recommended EMMC as a place to go for major surgery.

  The types of chemo drugs can differ for Esophageal Cancer.  My husband had Carboplatin and 5-FU.  It was given by medi-port.  He had a “fannie pack” which he wore for 96 straight hours.

 I have posted this previously, but I will put it here again for your records.  This was my husband’s treatment schedule.

 MY HUSBAND’S TREATMENT SCHEDULE:

Week 1 ~ (02-10-03) Chemo 96-hr. continual infusion of Carboplatin/5-FU

 Weeks 2, 3, and 4 ~ (02-17-03) 5-day-a-week radiation treatment. 

 Week 5  ~ Combination radiation plus SECOND chemo continuous 96-hr. infusion

 Week 6 ~ (03-17-03) Final week of radiation.

 Repeat PET Scan on 04-28-03 ~ results - COMPLETE ERADICATION OF TUMOR  in Esophagus and the 2 affected lymph nodes

 Ivor Lewis Minimally Invasive Esophagectomy, (MIE) May 17, 2003 by Dr. James D. Luketich @ UPMC

 I haven’t seen the word “Squamous Cell Carcinoma” mentioned so you assume your brother’s cancer is “Adenocarcinoma at the GE Junction.”  What were the questionable places in his lung and stomach?  How were they checked out?  I don’t expect you to know the answers, but these are questions that deserve answers.  And I hope someone is writing all these things down.  Times & dates become important when a medical history is requested by another physician.  

You are wondering how thoroughly your brother was tested, since no one has given him a Stage.  I am wondering that as well.  Just how thoroughly has he been tested?  My husband was put through a myriad of tests prior to beginning his chemo/regimen.  At this point, I think a “check list” of all the types of tests and biopsies used to determine the “Stage” for EC would be helpful.  So I have copied excerpts of the “pdf” portion that detail the different tests that are used to find exactly where the tumor is located, and its level of penetration. 

So “rjollie”, I hope I’ve not taken you too far “into the weeds” in trying to help.  I’m no expert but I’ve graduated from Kindergarten (the point at which all newbies usually are in the beginning) and am a bit farther along in my understanding of Esophageal Cancer, as well as Peritoneal Carcinomatosis and Ovarian Cancer, Stage IV. 

May God guide you and your brother as you travel this road together.  You are carrying a heavy load taking care of your mother.   May He give you the inner strength and the physical strength to carry on. 

Loretta

(Wife of William) EC Stage T3N1M0 diagnosed in 2002—MIE surgery by Dr. James D. Luketich @ UPMC May 17, 2003—husband still blessed to be entering his 14^th year of remission.

 So I will start here since you need to know what tests are conducted to determine the presence of Esophageal Cancer.  This info is taken from this ACS “PDF” file which is about 59 pages long.  Anyone who opens this file, will have a wealth of information.  But for purposes of the preliminary tests to diagnose Esophageal Cancer, I will post only those “portions” of this voluminous file. 

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

HOW IS CANCER OF THE ESOPHAGUS DIAGNOSED?

 “Esophagus cancers are usually found because of signs or symptoms a person is having. If esophagus cancer is suspected, exams and tests will be needed to confirm the diagnosis. If cancer is found, further tests will be done to help determine the extent (stage) of the cancer.

 MEDICAL HISTORY AND PHYSICAL EXAM

 If you have symptoms that might be caused by esophageal cancer, the doctor will ask about your medical history to check for possible risk factors and to learn more about your symptoms. Your doctor will also examine you to look for possible signs of esophageal cancer and other health problems. He or she will probably pay special attention to your neck and chest areas. If the results of the exam are abnormal, your doctor probably will order tests to help find the problem.

 You may also be referred to a gastroenterologist (a doctor specializing in digestive system diseases) for further tests and treatment…

  Squamous cell carcinoma - The esophagus is normally lined with squamous cells. Cancer starting in these cells is called squamous cell carcinoma. This type of cancer can occur anywhere along the esophagus. Once, squamous cell carcinoma was by far the more common type of esophageal cancer in the United States. This has changed over time, and now it makes up less than half of esophageal cancers in this country.

 Cancers that start in gland cells are called adenocarcinomas. This type of cell is not normally part of the inner lining of the esophagus. Before an adenocarcinoma can develop, gland cells must replace an area of squamous cells, which is what happens in Barrett’s esophagus.

 This occurs mainly in the lower esophagus, which is where most adenocarcinomas start. Adenocarcinomas that start at the area where the esophagus joins the stomach (the GE junction, which includes about the first 2 inches of the stomach called the cardia), tend to behave like cancers in the esophagus (and are treated like them, as well), so they are grouped with esophagus cancers…

 IMAGING TESTS

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. Imaging tests might be done for a number of reasons both before and after a diagnosis of esophageal cancer, including: • To help find a suspicious area that might be cancer • To learn if and how far cancer has spread • To help determine if the treatment has been effective • To look for possible signs of cancer coming back after treatment…

 BARIUM SWALLOW

 In this test, a thick, chalky liquid called barium is swallowed to coat the walls of the esophagus. X-rays of the esophagus are then taken, which the barium outlines clearly. This test can be done by itself, or as a part of a series of x-rays that includes the stomach and part of the intestine, called an upper gastrointestinal (GI) series. A barium swallow test can show any abnormal areas in the normally smooth surface of the inner lining of the esophagus…

 This is often the first test done to see what is causing a problem with swallowing. Even small, early cancers can often be seen using this test. Early cancers can look like small round bumps or flat, raised areas (called plaques), while advanced cancers look like large irregular areas and cause a narrowing of the width of the esophagus. This test can also be used to diagnose one of the more serious complications of esophageal cancer called a tracheo-esophageal fistula.

 This occurs when the tumor destroys the tissue between the esophagus and the trachea (windpipe) and creates a hole connecting them. Anything that is swallowed can then pass from the esophagus into the windpipe and lungs. This can lead to frequent coughing, gagging, or even pneumonia. This problem can be helped with surgery or an endoscopy procedure. A barium swallow only shows the shape of the inner lining of the esophagus, so it can’t be used to determine how far a cancer may have spread outside of the esophagus…

 COMPUTED TOMOGRAPHY (CT OR CAT) SCAN

 The CT scan uses x-rays to produce detailed cross-sectional images of your body. CT scans are not usually used to diagnose esophageal cancer, but they can help show where it is in the esophagus and if it has spread to nearby organs and lymph nodes (bean-sized collections of immune cells to which cancers often spread first) or to distant parts of the body. The CT scan can help to determine whether surgery is a good treatment option…

 Before the test, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the esophagus and intestines so that certain areas are not mistaken for tumors…

 CT-GUIDED NEEDLE BIOPSY:

 CT scans can also be used to guide a biopsy needle precisely into a suspected area of cancer spread. For this procedure, you remain on the CT scanning table while the doctor advances a biopsy needle through the skin and toward the tumor. CT scans are repeated until the needle is within the mass. A needle biopsy sample is then removed to be looked at under a microscope…

 MAGNETIC RESONANCE IMAGING (MRI) SCAN

 Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body… MRI scans are very helpful in looking at the brain and spinal cord, but they are not often needed to assess spread of esophageal cancer…

 POSITRON EMISSION TOMOGRAPHY (PET) SCAN

  For a PET scan, a form of radioactive sugar (known as fluorodeoxyglucose or FDG) is injected into the blood. The amount of radioactivity used is very low and will pass out of the body over the next day or so. Cancer cells in the body are growing rapidly, so they absorb large amounts of the radioactive sugar. After about an hour, you will be moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not finely detailed like a CT or MRI scan, but it provides helpful information about your whole body. This type of scan may be used to look for possible areas of cancer spread if nothing is found on other imaging tests… Special machines can do both a PET and CT scan at the same time (PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET scan with the more detailed appearance of that area on the CT scan…

 ENDOSCOPY

 An endoscope is a flexible, narrow tube with a tiny video camera and light on the end that is used to look inside the body. Tests that use endoscopes can help diagnose esophageal cancer or determine the extent of its spread.

 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). For details about grading, see “How is cancer of the esophagus staged?” It can often take a few days to get the results of a biopsy.

 HER2 TESTING

 If esophageal cancer is found but is too advanced for surgery, your biopsy samples may be tested for the HER2 gene or protein. Some people with esophageal cancer have too much of the HER2 protein on the surface of their cancer cells, which helps the cells grow. A drug that targets the HER2 protein, known as trastuzumab (Herceptin®), may help treat these cancers when used along with chemotherapy.

 Only cancers that have too much of the HER2 gene or protein are likely to be affected by this drug, which is why doctors may test tumor samples for it. (See “Targeted therapy for cancer of the esophagus” for more information on this treatment.)

 OTHER TESTS

  When looking for signs of esophageal cancer, a doctor may order a blood test called a
complete blood count (CBC) to look for anemia (a low red blood cell count, which could be caused by internal bleeding).

 A stool sample may be checked to see if it contains occult (unseen) blood. If esophageal cancer is found, the doctor may order other tests, especially if surgery might be an option. For instance, blood tests can be done to make sure your liver and kidneys are working normally.

 Tests may also be done to check your lung function, since some people might have lung problems (such as pneumonia) after surgery. If surgery is planned or you are going to get medicines that could affect your heart, you may also have an electrocardiogram (EKG) and echocardiogram (ultrasound of the heart) to make sure your heart is working well.

_________________________End of  ACS "pdf" portion on How Esophageal Cancer is staged.____________________