Upper GI and Esophageal Cancer
Cancers of the esophagus, stomach, gastro-esophageal junction
Questions About Upper GI or Esophageal Cancer?
We’re here to help. Contact Vanessa Boral, MSN, RN at 203 276-2273 (Press 2).
The Bennett Cancer Center offers state-of-the art diagnosis and treatment for cancers of the esophagus, stomach and the gastro-esophageal junction. We offer the services of a Nurse Navigator who meets all patients early in their care and provides a familiar face and voice. Furthermore, since GI cancers tend to run in certain families, we also offer the services of a genetic counselor.
Signs of Upper GI Cancer
The presenting signs or symptoms of most of these potentially malignant tumors are usually non-specific. Patients can experience weight loss, swallowing difficulties, acid reflux, upper abdominal or back pain, discomfort, feeling full after meals, nausea, vomiting, decreased energy, occasionally blood in the stool. These signs or symptoms can trigger an exam by a primary care physician or an emergency room. Occasionally these lesions are found incidentally on studies performed for other complaints (heart burn) or endoscopic work up for acid reflux or history of Barrett’s esophagus.
Work-up and Clinical Staging
Patients at Stamford Health have access to advanced imaging technology including barium swallow, thin cut CT scans and state of the art PET scan. To diagnose and better stage suspicious gastro-esophageal lesions our center uses upper GI endoscopy and other advanced endoscopic procedures, like endoscopic ultrasound or endoscopic mucosal resection. We also use diagnostic thoracoscopy and laparoscopy selectively. Wait time for these imaging and diagnostic studies are short, usually measured in a few days.
After collecting enough information about the patient and the condition, complex patients are presented in our multidisciplinary tumor board. The presentation is done in front of a large group of clinicians, all specializing in the treatment of gastro-intestinal and gastro-esophageal malignancies. Our well trained participants in these conferences include medical oncologists, radiation oncologists, surgical oncologists, dietitian, radiologist, pathologist, interventional radiologist, genetic counselor, and a gastrointestinal (GI) oncology nurse navigator.
During this presentation each case is carefully and individually reviewed focusing on presenting symptoms, exam findings, radiographic studies, endoscopic studies, pathology slides, laboratory findings and tumor markers. We occasionally decide to obtain additional studies to help clarify diagnostic dilemmas. At the end of each presentation our multidisciplinary team agrees on the next best step in further work-up or management.
Major Gastro-esophageal Cancers Our Medical/Radiation /Surgical Oncologists Treat
- Esophageal cancer
- Gastric cancer
- Gastro-esophageal cancer
- Small bowel cancer
- Carcinoid tumors of the upper GI tract (primary and metastatic)
- Gastro-intestinal tumors of the upper GI tract (GIST)
Treatment Options for Gastro-esophageal/Upper GI Cancers
Once a diagnosis is obtained, or confirmed, treatment depends on the type and stage of your gastro-esophageal/upper GI cancer. Options usually include endoscopic procedures like Endoscopic Mucosal Resection, laparoscopic or open surgery, chemotherapy, radiation therapy or a combination of these treatment modalities together.
Early Stage Esophageal Tumors
Accurate staging of any tumor is paramount. Especially true for esophageal conditions like high grade dysplasia in Barret’s or intramucosal carcinoma, as early stage tumors can sometimes be treated endoscopically (EMR). Endoscopic resection can also be used to determine the exact T stage of the tumor. Once the exact T stage is determined, a decision is made about further treatment. Surgery is a possibility.
Treatment of More Advanced Stage Esophageal Cancer
If a tumor penetrates into the esophageal wall deeper (T2 and above) or there is evidence or strong suspicion of regional nodal involvement, preoperative treatment with a chemotherapy, radiation, or most commonly a combination of both is usually indicated. This is also called neoadjuvant treatment of locally advanced esophageal cancer. A five to 6 week treatment course is followed by additional imaging studies as part of what we call restaging. If we find no new sites of disease during restaging we offer surgery.
Upfront treatment of certain larger tumors or locally advanced malignancies frequently results in downstaging of the tumor. Downstaging can convert inoperable tumors to operable tumors, or more extensive operations to less extensive surgeries.
A landmark study from Europe published in the New England Journal of Medicine in 2012 found that patients treated with neoadjuvant therapy and surgery had a near doubling in overall survival compared to the surgery alone arm in the setting of locally advanced esophageal cancer.
Treatment of Gastro-esophageal (GE) Cancer
Gastro-esophageal tumors are located at the gastero-esophageal junction. This is a very common location for distal esophageal cancers or proximal gastric cancers. These malignancies can behave more like gastric cancer or more like esophageal carcinoma. Distinguishing between the two entities can be difficult. We use radiographic , endoscopic and pathologic clues. Depending on the stage, these tumors may or may not require preoperative treatment. Locally advanced GE cancers can be treated similar to gastric cancers (usually preoperative chemotherapy) or similar to esophageal cancers (usually preoperative chemo-radiation). Similarly, these tumors may require a proximal/total gastrectomy versus a formal esophagectomy, depending on how high the proximal extension of the tumor is in the esophagus. This is part of the intraoperative decision making and we rely heavily on intraoperative endoscopy, performed in the operating room after the patient goes to sleep.
Treatment of More Advanced Stage Gastric Cancer
For the most accurate staging we prefer to perform and an EUS for all gastric cancers. This information helps us determine if a tumor should be considered locally advanced. Other signs of locally advanced tumors are enlarged lymph nodes on various imaging studies potentially harboring regional metastasis. Once a locally advanced gastric cancer is identified, most patients will receive neoadjuvant therapy, likely using systemic chemotherapy sometimes combined with radiation. Selected patients may undergo diagnostic laparoscopy prior to a final treatment plan being rendered. We strongly believe in the importance of peritoneal washings for all patients diagnosed with gastric cancer.
Major procedures our thoracic surgeons/surgical oncologists perform for the treatment of gastro-esophageal/upper GI malignancies:
- Esophagectomy (laparoscopic and open)
- Transhiatal esophagectomy
- Ivor-Lewis esophagectomy
- Selective abdominal lymphadenectomy for upper GI malignancies
- Partial gastrectomy (laparoscopic and open)
- Distal gastrectomy (laparoscopic and open)
- Proximal gastrectomy (laparoscopic and open)
- Total gastrectomy
- Small bowel resection
- Feeding tube insertion