Introduction
The pathology of early esophageal cancer can be substantially divided into insidious type, erosive type, plaque type, and papillary type. The medium-advanced stage is divided into medullary type, fungating type, ulcerative type, and constrictive type. According to the histological features of esophageal cancer, it can be divided into esophageal squamous cell carcinoma, adenocarcinoma, adenoacanthoma, small cell undifferentiated carcinoma, and sarcoma, of which squamous cell carcinoma accounts for more than 90%. Because the esophagus has no serosal layer, the cancer can easily spread to adjacent organs, such as trachea, bronchus, lung, pleura, pericardium, aorta, and so on, through the loose external coat of the esophagus after penetrating the muscular layer. In addition, metastasis of esophageal cancer is also accessible to peripheral lymph nodes and remote regions through lymph node metastasis, blood-borne metastasis, and other ways.
Esophageal cancer is occult in onset and is asymptomatic in the early stage. Some patients have esophageal foreign body sensation, or food passes slowly or the patient has a choking feeling. Also, it can be expressed as retrosternal burning, prickly, or referred pain when swallowing. Patients with advanced esophageal cancer often go to the hospital due to acataposis, dysphagia, or inability to eat and often experience vomiting, upper abdominal pain, weight loss, and other symptoms.
Treatments
1.Surgery
Because early esophageal lesions are small with shallow infiltration, surgery combined with integrative treatment means can often achieve a cure. For middle and lower part esophageal cancer, surgical resection is preferred when combined with chemotherapy, radiotherapy, and other symptomatic and supportive treatments. Endoscopic dissection or partial surgical removal can be applied for precancerous lesions or early cancer recognized by gastroscopy. Surgical treatment in combination with radiotherapy or chemotherapy is recommended when cancer cells have deep infiltration in the esophageal wall. For patients with esophageal cancer of stages I, II, and III (T3N1M0 and partial T4N1M0) and recurrent esophageal cancer after radiotherapy but not distant metastasis, surgery treatment can be conducted for patients who are able to tolerate surgery in general. Because the late lesion is difficult to be resected, and to relieve symptoms such as feeding problems, cytoreductive, bypass, or gastrostomy surgery can be carried out. Clinical data show that the operation can achieve radical resection purpose for early- and mid-stage carcinoma. For patients with advanced esophageal cancer who cannot eat, or for patients with esophageal stenosis or esophageal fistula, endoscopic stenting can be used to relieve esophageal obstruction. Complete esophageal resection should be combined with routine regional lymph node dissection.
2.Radiotherapy
Indications for esophageal cancer radiotherapy are wide. Except for esophageal fistula formed by esophageal perforation; distant metastasis; apparent cachexia; and severe heart, lung, and liver diseases, radiotherapy can be carried out. Radiotherapy includes radical radiotherapy and palliative radiotherapy. Because the trauma of cervical and upper thoracic esophageal cancer surgery is major with a high incidence of complications while radiotherapy damage is small and efficacy is greater than surgery, radiotherapy should be preferred. If the patient’s general condition is acceptable, the patient can comfortably eat a semiliquid or liquid diet.
Thoracic esophageal cancer is without supraclavicular lymph node metastasis and distant metastasis; without trachea invasion, esophageal perforation, and signs of bleeding; with lesion lengths less than 7 to 8 cm; and without medical contraindications; with the aforementioned conditions, radical radiotherapy can be carried out. Other patients may have palliative radiotherapy aimed at alleviating esophageal obstruction, improving feeding difficulty, reducing pain, improving quality of life, and prolonging survival time. If the patient cannot tolerate surgery, or the tumor is judged to be unresectable, and if the symptom of dysphagia is mild, radiotherapy can be carefully selected. If the dysphagia symptom is obvious and seriously affects eating, laser treatment should be used, especially when the stenosis is in the middle or lower esophagus, which is caused by the pedunculated tumor projecting within the lumen of the esophagus. If the annular stenosis is in the thoracic esophagus, foreign researchers recommend probe dilatation plus built-in tube surgery. At the same time, conduct adjuvant radiotherapy (external exposure and brachytherapy).
3.Chemotherapy
As a systemic treatment, chemotherapy is an important part of the integrative treatments of esophageal cancer. Esophageal cancer chemotherapy is divided into palliative chemotherapy, neoadjuvant chemotherapy (preoperative), and adjuvant chemotherapy (postoperative). Esophageal cancer chemotherapy mostly uses a cisplatin and 5-fluorouracil combination chemotherapy program. While esophageal cancer palliative chemotherapy has been using a cisplatin and 5-fluorouracil combination program, in the past 5 years, there have been studies to explore the efficacy of a new generation of chemotherapy drugs for esophageal cancer treatment, mainly focusing on palliative chemotherapy in advanced esophageal cancer. These commonly used drugs include capecitabine, TS-1, taxanes, vinorelbine, camptothecin, nedaplatin, and carboplatin.
4.Hyperthermia
Hyperthermia can directly kill residual cancer cells; promote cancer cell apoptosis; regulate the body to produce tumor necrosis factor (TNF), interleukin (IL)-2, and other immune factors; enhance the anticancer effect itself; enhance sensitivity to chemotherapy; inhibit primary or metastatic lesions from continuous proliferation; and prevent metastasis. The combination of whole-body hyperthermia with chemotherapy is recommended for the early stage, in which it can modulate the immune function and enhance the ability of anticancer effect. If it is difficult for the patient to tolerate whole-body hyperthermia, whole-body medium- low temperature hyperthermia can be given. For medium-advanced patients with KPSs of 80 points or above, whole-body hyperthermia can be given. Patients without abnormal cardiopulmonary function can consider having high temperature hyperthermia. If it is not suitable for the patient to have whole-body hyperthermia, local deep hyperthermia could be offered once every other day.
5.Chelation Detoxification Therapy
Chelation detoxification therapy can not only effectively remove toxins from the body and improve immune function but also reduce the side effects of chemotherapy and enhance chemosensitivity. Simultaneous use of chelation detoxification with hyperthermia can have a synergistic effect. Application of chelation detoxification can have the inhibitory effect of reducing cancer recurrence and metastasis, repair the damage of various tissues and organs, and improve cell function.
6.Medical Ozone Therapy
It can stimulate improvement to the immune system itself, directly kill the early cancer cells present in the blood or lymph, and reduce the side effects of chemotherapy. It can also promote the healing of surgical wounds.
7.Traditional Chinese Medicine
For the syndrome of liver stagnation and phlegm coagulation, a modified Xuefu Zhuyu Decoction is given. For the syndrome of blood stasis and sputum block, Xuanfu Daizhe Decoction plus modified Sini Powder are given. For the syndrome of yin deficiency and internal heat, Yiguan Decoction plus modified Yangwei Decoction are given. For the syndrome of deficiency of qi and declination of yang, Danggui Buxue Decoction plus modified Ginseng Guizhi Decoction are given. Chinese formulated products commonly used are Pingxiao Capsule, Huachansu Injection, Yadanzi Emulsion, Antike, Zengshengping Tablet, Tongdao Powder, and so on.
8. Acupuncture
8.1 Early esophageal cancer
The syndrome is mainly qi stagnation and coagulated phlegm. The therapeutic principle should focus on soothing the liver and regulating the circulation of qi, as well as removing phlegm and resolving mass.
8.2 Medium-advanced esophageal cancer
The syndrome is mainly phlegm and blood stasis, or deficiency of both qi and yin. The therapeutic principle should be to supplement qi and nourish yin, reverse adverse flow of qi, control nausea and vomiting, and relieve chest stiffness to regulate qi.
9.Medicated Diet, Nutrition, and so on
Medicated diet is mainly for the early stage. Enteral or total parenteral nutrition can be considered to be given according to the nutritional status of patients when surgery, whole-body hyperthermia, and chemotherapy are conducted, to prevent malnutrition and establish a therapeutic sensitizing effect.
For patients in the medium and advanced stages who often have difficulty eating, intravenous infusion of high nutrition should be carried out in combination with other integrative treatments to prolong survival time and improve quality of life. For patients with gastrointestinal obstruction, total parenteral nutrition should be given for support. For esophageal cancer patients in the medium-advanced stage, the therapy should be the same as that for early esophageal cancer and be in combination with qigong, music therapy, psychotherapy, and so on to calm heart, regulate breathing, and calm the nerves for relieving pain.
10.Others
For patients in the early stage, we recommend them to actively practice qigong, tai chi, and so on and use TCM to regulate emotions. Guide patients to have peace of mind and to overcome panic and desperation, so that they can face the disease with a positive, optimistic, and open-minded attitude. Also, combine music therapy and sound wave therapy to alleviate psychological pressure. Because esophageal cancer at the medium-advanced stage has more complications that could seriously affect the patient’s quality of life, such as dysphagia due to gastrointestinal obstruction and irritating cough caused by cancer compression, central antibechic can also be applied to alleviate these complications and minimize the suffering of patients. Note that if esophageal stent implantation has been implemented, local hyperthermia cannot be reused after the installation of the esophageal stent.
Typical Case
49 year old male patient complained of repeated upper abdominal pain with vomiting which began two years ago. CT scan showed suspected lower esophageal malignancy. Endoscopy revealed neoplasm in lower esophagus, and pathological results showed moderately differentiated squamous cell carcinoma. Radical resection of the esophageal cancer was conducted under general anesthesia. Pathological examination revealed esophageal squamous cell carcinoma; infiltration of muscle to the serosa layer; no cancer invasion in the upper and lower cut ends, and no lymph node metastasis. One and a half year post surgery, patient presented weight loss of about 10 kg within 2 months, hoarseness, poor appetite, and occasional vomiting. Physical examination: body weight loss, weight 49 kg, moderate anemia, no superficial lymph node enlargement, and normal heart and lung auscultation. Abdomen was flat without tenderness. Liver and spleen were not palpable. Petechiae could be seen on the left side of the abdomen and waist. The KPS was 70.
Diagnosis: Recurrence after resection of esophageal cancer.
Integrative treatment prescription: patient faced recurrence after resection of esophageal cancer. His general condition was poor and KPS was 70 with nausea, vomiting, and significant weight loss, likely from the esophageal stricture contributing to difficulty feeding after tumor recurrence and the tumor growth caused severe malnutrition. On admission, patient was immediately given nutritional support i.e., total parenteral nutrition and medicated nutritional supplements. TCM was also given to regulate the functions of spleen and stomach. For cancer treatment, local hyperthermia of the chest was given once every other day. Hyperthermia was conducted simultaneously with chelation and detoxification therapy. Intravenous medical ozone saline treatment was carried out once every other day, alternated with hyperthermia, chelation and detoxification therapy. The patient’s symptoms of nausea and vomiting disappeared after 1 week. TCM decoction adjusted. Patient still had weak voice, pale tongue with thin white fur and thready and weak pulse. The differentiation of symptoms and signs was deficiency of Qi and blood. TCM decoction for supporting healthy energy was in conjunction with the above treatments one dose per day, with a total of 90 doses. Dosage was increased for chelation and detoxification therapy three times a week for 6 consecutive weeks. Intravenous medical ozone saline injection was used for 2 consecutive weeks. After 2 weeks, the patient’s mental condition was improved and his weight had increased to 52 kg; his symptom of anemia relieved. At that time, intravenous medical ozone saline was adjusted to EBOO for 18 times of treatment, and the hyperthermia was changed to the combination of whole body medium-high temperature hyperthermia and local hyperthermia. The whole body hyperthermia was conducted once every 2 weeks for a total of 4 times. Local hyperthermia was conducted 3 times a week and once every other day for a total of 27 times. Chelation and detoxification therapy was conducted simultaneously with hyperthermia. Patient continued to practice medical Qigong every day after admission. When his strength restored, he practiced tai chi every morning. He felt relaxed, his mental state improved gradually along with the increase of confidence in treatment. After 3 months of treatment, endoscopy revealed that the anastomotic mild swelling and erosive lesions were significantly reduced. After discharge, the patient continued to receive local hyperthermia, EBOO, chelation detoxification, TCM, acupuncture, systemic biofeedback therapy, medicated conditioning, and other nontoxic integrative treatments as an outpatient, once a week.
Treatment outcome: After 3 months of integrative treatments dominated by hyperthermia, the patient’s nausea, vomiting, anorexia, weight loss, anemia and other symptoms were markedly improved. A clear distinction between the primary and the secondary treatment was drawn. The treatment prescription focused on rectifying malnutrition and relieving symptoms, followed with regulating whole-body constitution, strengthening immunity and eliminating pathogen. All the treatments achieved the same goal. The patient’s mind-set was significantly better, weight had increased by 9 kg, diet was normal, sleep improved, anemia was corrected, and KPS was 100. Patient continued to comply with integrative treatment 1 week per month in order to consolidate the effect, to prevent recurrence and metastasis, and to improve immunity. Patient continued with TCM, the practice of medical Qigong and moderate exercise. He was prescribed herbal cuisine to boost nutrition, to strengthen immunity, and to prevent recurrence or metastasis.
