[216] CHAPTER XXVII—MALIGNANT DISEASE OF THE ESOPHAGUS
Cancer of the esophagus is a more prevalent disease than is commonly thought. In the male it usually develops during the fourth and fifth decades of life. There is in some cases the history of years of more or less habitual consumption of strong alcoholic liquors. In the female the condition often occurs at an earlier age than in the male, and tends to run a more protracted course, preceeded in some cases by years of precancerous dysphagia.
Squamous-celled epithelioma is the most frequent type of neoplasm. In the lower third of the esophagus, cylindric cell carcinoma may be found associated with a like lesion in the stomach. Sarcoma of the esophagus is relatively rare (Bibliography 1, p. 449).
The sites of the lesion are those of physiologic narrowing of the esophagus. The middle third is most frequently involved; and the lower third, near the cardia, comes next in frequency. Cancer of the lower third of the esophagus preponderates in men, while cancer of the upper orifice is, curiously, more prevalent in women. The lesion is usually single, but multiple lesions, resulting from implantation metastases have been observed (Bibliography 1, p. 391). Bronchoesophageal fistula from extension is not uncommon.
Symptoms.—Malignant disease of the esophagus is rarely seen early, because of the absence, or mildness, of the symptoms. Dysphagia, the one common symptom of all esophageal disease, is often ignored by the patient until it becomes so marked as to prevent the taking of solid food; therefore, the onset may have the similitude of abruptness. Any well masticated solid food can be swallowed through a lumen 5 millimeters in diameter. The inability to maintain the nutrition is evidenced by loss of weight and the rapid development of cachexia. When the stenosis becomes so severe that the fluid intake is limited, rapid decline occurs from water starvation. Pain is usually a late symptom of the disease. It may be of an aching character and referred to the vertebral region or to the neck; or it may only accompany the act of swallowing. Blood-streaked, regurgitated material, and the presence of odor, are late manifestations of ulceration and secondary infection. In some cases, constant oozing of blood from the ulcerated area adds greatly to the cachexia. If the recurrent laryngeal nerves are involved, unilateral or bilateral paralysis of the larynx may complicate the symptoms by cough, dyspnea, aphonia, and possibly septic pneumonia.
Diagnosis.—It has been estimated that 70 per cent of stenoses of the esophagus in adults are malignant in nature. This should stimulate the early and careful investigation of every case of dysphagia. When all cases of persistent dysphagia, however slight, are endoscopically studied, precancerous lesions may be discovered and treated, and the limited malignancy of the early stages may be afforded surgical treatment while yet there is hope of complete removal. Luetic and tuberculous ulceration of the esophagus are to be eliminated by suitable tests, supplemented in rare instances by biopsy. Aneurysm of the aorta must in all cases of dysphagia be excluded, for the dilated aorta may be the sole cause of the condition, and its presence contraindicates esophagoscopy because of the liability of rupture. Foreign body is to be excluded by history and roentgenographic study. Spasmodic stenosis of the esophagus may or may not have a malignant origin. Esophagoscopy and removal of a specimen for biopsy renders the diagnosis certain. It is to be especially remembered, however, that it is very unwise to bite through normal mucosa for the purpose of taking a specimen from a periesophageal growth. Fungations and polypoid protuberances afford safe opportunities for the removal of specimens of tissue.
The esophagoscopic appearances of malignant disease, varying with
the stage and site of origin of the growth, may present as follows:—
1. Submucosal infiltration covered by perfectly normal membrane,
usually associated with more or less bulging of the esophageal wall,
and very often with hardness and infiltration.
2. Leucoplakia.
3. Ulceration projecting but little above the surface at the edges.
4. Rounded nodular masses grouped in mulberry-like form, either dark
or light red in color.
5. Polypoid masses.
6. Cauliflower fungations.
In considering the esophagoscopic appearances of cancer, it is necessary to remember that after ulceration has set in, the cancerous process may have engrafted upon it, and upon its neighborhood, the results of inflammation due to the mixed infections. Cancer invading the wall from without may for a long time be covered with perfectly normal mucous membrane. The significant signs at this early stage are: 1. Absence of one or more of the normal radial creases between the folds. 2. Asymmetry of the inspiratory enlargement of lumen. 3. Sensation of hardness of the wall on palpation with the tube. 4. The involved wall will not readily be made to wrinkle when pushed upon with the tube mouth.
In all the later forms of lesions the two characteristics are (a) the readiness with which oozing of blood occurs; and (b) the sense of rigidity, or fixation, of the involved area as palpated with the esophagoscope, in contrast to the normally supple esophageal wall. Esophageal dilatation above a malignant lesion is rarely great, because the stenosis is seldom severely obstructive until late in the course of the disease.
Treatment.—The present 100 per cent mortality in cancer of the esophagus will be lowered and a certain percentage of surgical cures will be obtained when patients with esophageal symptoms are given the benefit of early esophagoscopic study. The relief or circumvention of the dysphagia requires early measures to prevent food and water starvation. Bouginage of a malignant esophagus to increase temporarily the size of the stenosed lumen is of questionable advisability, and is attended with the great risk of perforating the weakened esophageal wall.
Esophageal intubation may serve for a time to delay gastrostomy but it cannot supplant it, nor obviate the necessity for its ultimate performance. The Charters-Symonds or Guisez esophageal intubation tube is readily inserted after drawing the larynx forward with the laryngoscope. The tube must be changed every week or two for cleaning, and duplicate tubes must be ready for immediate reinsertion. Eventually, a smaller, and then a still smaller tube are needed, until finally none can be introduced; though in some cases the tube can be kept in the soft mass of fungations until the patient has died of hemorrhage, exhaustion, complications or intercurrent disease.
Gastrostomy is always indicated as the disease progresses, and it should be done before nutrition is greatly impaired. Surgeons often hesitate thus to "operate on an inoperable case;" but it must be remembered that no one should be allowed to die of hunger and thirst. The operation should be done before inanition has made serious inroads. As in the case of tracheotomy, we always preach doing it early, and always do it late. If postponed too long, water starvation may proceed so far that the patient will not recover, because the water-starved tissues will not take up water put in the stomach.
Radiotherapy.—Radium and the therapeutic roentgenray are today our only effective means of retarding the progress of esophageal malignant neoplasms. No permanent cures have been reported, but marked temporary improvement in the swallowing function and prolongation of life have been repeatedly observed. The combination of radium treatment applied within the esophageal lumen and the therapeutic roentgenray through the chest wall, has retarded the progress of some cases.
The dosage of radium or the therapeutic ray must be determined by the radiologist for the particular individual case; its method of application should be decided by consultation of the radiologist and the endoscopist. Two fundamental points are to be considered, however. The radium capsule, if applied within the esophagus, should be so screened that the soft, irritating, beta rays, and the secondary rays, are both filtered out to prevent sloughing of the esophageal mucosa. The dose should be large enough to have a lethal effect upon the cancer cells at the periphery of the growth as well as in the center. If the dose be insufficient, development of the cells at the outside of the growth is stimulated rather than inhibited. It is essential that the radium capsule be accurately placed in the center of the malignant strictured area and this can be done only by visual control through the esophagoscope (Fig. 95)
Drs. Henry K. Pancoast, George E. Pfahler and William S. Newcomet have obtained very satisfactory palliative effects from the use of radium in esophageal cancer.