None — BACKGROUND: According to the National Cancer Institute, esophageal or throat cancer, is a cancer that forms in tissues lining the esophagus, the muscular tube through which food passes from the throat to the stomach. There are two types of esophagus cancer: one that begins in flat cells lining the esophagus and the other that begins in cells that make and release mucus and other fluids.
Symptoms can be as common as heartburn, but most symptoms include difficulty swallowing, losing weight without trying, chest pains and fatigue. It's not clear what causes esophageal cancer. It occurs when cells in your esophagus develop errors in their DNA. The errors make cells grow and divide out of control. It's estimated that more than 16,000 Americans will be diagnosed with esophagus cancer in 2010 and that there will be more than 14,000 deaths as a result of this. What treatments you receive for esophageal cancer are based on the type of cells involved in your cancer, your cancer's stage, your overall health, and your own preferences for treatment. The most common forms of treatment include surgery, chemotherapy and radiation.
NEW ENDOSCOPIC TREATMENT: Researchers at Mayo Clinic are taking a less-invasive approach to stop the cancer before it spreads. This approach is called Endoscopic Mucosal Resection. According to Mayoclinic.com, EMR is a procedure to remove cancerous or other abnormal tissues from the digestive tract. A long, narrow tube equipped with a light, video camera and other instruments is passed down the throat to reach an abnormality in the esophagus, stomach or upper part of the small intestine. If cancer is present, EMR can help determine if the cancer has invaded tissues beneath the digestive tract lining. Studies showed that the new, less-invasive treatment was just as effective as removing the esophagus for early-staged cancers. Patients who undergo full removal spend days in the hospital and face lifelong eating restrictions, while the new procedure is an outpatient procedure. Patients can eat full meals two days later. Typically, a follow-up exam is performed three months after your procedure to be sure the lesion was removed. Depending on what is found, your doctor will decide when further examinations are necessary.
IN-DEPTH INTERVIEW WITH MICHAEL WALLACE, M.D
Michael Wallace, M.D., from the Mayo Clinic in Jacksonville, tells us about a new and less invasive procedure to help fight throat cancer.
How common is esophageal cancer and who gets them?
Dr. Wallace: There are two types of esophageal cancer. There is one that is associated with a condition called Barrett's esophagus, and this is the one that's the most common in the United States. It typically develops in people, who have longstanding acid reflux or heartburn, and it's more common in obese patients and in white males, but everyone can get esophagus cancer. The other form of esophageal cancer is called squamous cell, and it's less common in the United States. It's much more common in developing countries, particularly in China and in Africa and is mostly caused by alcohol and tobacco abuse.
Is traditional treatment for esophagus cancer pretty invasive?
Dr. Wallace: The most important thing that determines how we treat esophageal cancer is the stage. So if someone comes in with a late stage cancer, treatment options are pretty limited and they include chemotherapy, radiation and surgery. What we're really seeing a major advance in now is treatment of early esophageal cancer. Traditionally the only option was surgery, to have your esophagus literally removed and then to reconnect your upper esophagus to your stomach, and that's been the treatment of choice for decades now. What we're really seeing change dramatically now are minimally invasive options for treating these cancers, even options that don't require surgery.
What is "Shaving away"? How do you do it?
Dr. Wallace: The important part of this new procedure is the fact that these cancers are limited to the first layer of the esophagus. The esophagus actually has four layers. If you imagine layers of a cake, this is just on the icing of the cake. Traditionally we removed all four layers surgically. Now we have a technique called endoscopic mucosal resection, which literally shaves off that first layer and a little bit of the second layer just to be sure, and removes all of that cancer if it's limited to that first layer. What we do with this technique is, first of all, we need to separate those layers and so we use a variety of techniques to separate the deeper layers from the surface layers. Literally we can suction these surface cancers into a special resection device, called a cap, and then shave it off. One of the advantages is you actually remove the tissue and the pathologist can examine it and tell you exactly what you have and if it's a complete resection. And yet, it preserves the esophagus. You still keep all of your normal body parts.
What does it mean for these patients?
Dr. Wallace: It's a really dramatic difference. A patient who has surgical removal of their esophagus literally has to have their stomach pulled up into their chest to replace where their esophagus used to be, and as you can imagine, those patients get a lot of heartburn because all that acid is up in their chest now. They also have more difficulty eating and swallowing, their stomach is smaller. Now with this procedure, they really maintain pretty normal swallowing function. Within a month or two after the procedure their esophagus returns to a normal, healthy state and they can eat normally. They really don't know much of a difference in terms of what symptoms they would have before or after the procedure.
Are you looking at a new way to do a biopsy?
Dr. Wallace: There are a couple of really important new developments in early diagnosis, and this is true for virtually any kind of cancer. If you can detect it really early, treatment options are much better. We're seeing two really new developments in early diagnosis. One is a special type of a high definition endoscope. Just like our televisions have all gone high-def, endoscopy, which is the examination of the esophagus through a flexible tube has also gone high-def. We also now have some special optical devices that allow us to see these cancers much better and much earlier. For example, there's a device called a narrow band imaging, which is a special type of a blue light that highlights the cancer, the cancer is much easier to see, and before we really could only see in a low definition endoscope and take biopsies really at random. Now we can actually see exactly where the cancer is and target both biopsies and treatment to those areas. The other really important new development is a technology we call virtual biopsy. Normally we take a biopsy and we send it off to the pathology department and they look under a microscope to tell us if it's cancer or not. That's been the way we've done things for four or five decades now. Now we have an instrument that is basically a miniaturized microscope. Companies have made this microscope so small that we can put it inside the esophagus and look at the tissue as a pathologist does, but without removal. What this allows us to do is really examine the esophagus, get a pathologic diagnosis, but in a real time. So when we're there, we can look at it, we can look at the cells, we can look at the tiny blood vessels, and if it's abnormal, we can immediately do treatment as opposed to taking the biopsy and bringing the patient back for another procedure at a later date.
In your trial, how do the outcomes compare?
Dr. Wallace: We've just finished a very large clinical trial with multiple centers around the world looking at this virtual biopsy technology and we compared it to what we call the gold standard pathologist. The accuracy looks really almost as good as the pathologist themselves with tissue removed and examined under a regular microscope. So we're building confidence now that we can examine the esophagus, do a microscopic, almost pathological examination without having to remove tissue and do it just as accurately as a pathologist would.
Is the shaving procedure as effective in terms of long term viability of the patient as it would be to remove their whole esophagus?
Dr. Wallace: That's a very important question because whenever you have a minimally invasive technique, often you deal with a tradeoff, it's less invasive, but it's not quite as effective. This trial that was just recently published out of the Mayo Clinic looked directly at people who got the minimally invasive treatment as well as the more invasive surgical treatment. They followed them for five years, so a good amount of follow-up. What they showed is that the patients who have the minimally invasive treatment did just as well. They had just as high a cure rate as the patients who got the surgical procedure. There was one caveat, which is about 10% of patients did have a local recurrence of the cancer during that five year follow-up, but all of those patients, they were able to detect that occurrence and treat it for cure at that time as opposed to the surgical side where they had a lot of the usual issues with surgery. About 4% of the patients did not survive the surgery and at least 10 to 20% of patients have significant complications of the surgery that require long term hospitalization and other issues.
What's the Barrett's esophagus condition?
Dr. Wallace: It's characterized by a pink or salmon colored tissue in the lower esophagus. A slight bump of tissue represents the very earliest stage of cancer, what we call a stage 1 or T1 cancer that's just developed in the first surface layer. This is what we can now remove through a technique called endoscopic mucosal resection.
What is the endoscopic mucosal resection technique?
Dr. Wallace: We use a special high definition endoscope called a narrow band imaging high definition endoscope. The blue light really allows us to see very, very clearly this early cancer in the lower part of the screen. It really highlights. We use a virtual biopsy instrument, a very small microscope. It's less than 3 millimeters in size, just the size of a spaghetti noodle. We now have that microscope inside the esophagus and we can see the individual cells and we can see where the cancer cells are located. We can also look at the normal area. It really allows us to target our treatment to the areas that harbor the cancer and leave the other healthy tissues alone.
How does the treatment work?
Dr. Wallace: We use what's called an endoscopic mucosal resection device. We've got a little plastic cap or plastic tube on the end of the endoscope in little black bands that are like small rubber bands. What we do is we use suction on the surface layer, that icing on the esophagus, we suction that up into the cap. We place a little band around the base of the cancer, and then we use a special cutting instrument called a snare to resect that cancer. After we've removed the entire cancer, we send that off to that pathology department to make sure that we have a complete removal. We actually will remove not only the cancer that we see, but a little bit of margin around it just to make sure that we have a completely safe removal. The final result will allows us to see if we resected the entire cancer.
How does a traditional biopsy work?
Dr. Wallace: We use a small biopsy instrument. It's a pinching device that we put through the endoscope. We put it up against the tissue and we simply pinch off a small amount of tissue.
What kind of symptoms do patients have?
Dr. Wallace: These patients typically have very few symptoms. If any, it's just heartburn. The key issue is that by the time you develop symptoms, it's often too late. So people who have chronic heartburn, chronic acid reflux symptoms, that's when you want to come in and see your doctor and get an examination, not waiting until food is getting stuck.
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