This is an automatically translated article.
Esophageal cancer metastasis to bone is rare but prognosis is poor. Many studies have been conducted to identify independent risk factors for predicting the development of metastatic esophageal cancer, but the results are ambiguous. Meanwhile, the treatment of esophageal cancer with bone metastases by combining radiation therapy with chemotherapy can only improve the prognosis of patients from 1 to 8 months.
1. Introduction to esophageal cancer
Histologically, most esophageal cancers are divided into squamous cell carcinoma and adenocarcinoma. Regardless of the type, esophageal cancer is generally the 5th most common gastrointestinal cancer and the 6th most common cancer worldwide. The region with the highest risk, known as the "oesophageal cancer belt," includes regions of northern Iran, southern Russia, Central Asian countries, and northern China, where the cancer Scales account for 90% of all cases. Within this risk area, esophageal cancer is the 4th most common cause of cancer. A history of smoking, alcohol consumption, and a diet low in fruits and vegetables account for nearly 90% of esophageal squamous cell carcinoma cases. In developing countries, risk factors for esophageal squamous cell carcinoma include poor nutritional status and high temperature beverages. Human papillomavirus (HPV) infection is also associated with an increased incidence of squamous cell carcinoma of the upper esophagus.
Meanwhile, most esophageal adenocarcinomas arise from Barrett's metaplasia, of which 80% are attributed to smoking history, high body mass index, reflux disease gastroesophageal reflux disease (GERD) and a diet low in fruits and vegetables. Drinking alcohol is not associated with adenocarcinoma. Barrett's esophagus has been associated with epidermal growth factor polymorphisms, Helicobacter pylori infection, and other conditions that increase exposure to esophageal acid, including Zollinger-Ellison syndrome, scleroderma, and scleroderma. , medications, or procedures that relax the lower esophageal sphincter.
2. Symptoms of Esophageal Cancer
The most common clinical presentation of both esophageal adenocarcinoma and squamous cell carcinoma is progressive solid food dysphagia due to progressive in situ cancer causing obstruction and dysphagia in the patient. liquid manifests itself in the severe stage. At this point, significant weight loss is the result of dysphagia, which may be indicative of an advanced disease that leaves many patients so debilitating at the time of diagnosis.
In addition, the person may also have vague symptoms that appear before, such as discomfort or burning in the back of the throat. Symptoms of bleeding, melena, and anemia may be present at the initial differential diagnosis as gastrointestinal bleeding. Vomiting can also occur, but rarely causes aspiration pneumonia. Some patients with metastatic esophageal cancer that invades the tracheal wall causing gastric leakage may present clinically with laryngeal nerve palsy, cough, and/or obstructive pneumonia.
3. How to diagnose and treat esophageal cancer
A clinical examination focusing on the supraclavicular and axillary lymph nodes is fundamental when approaching a patient with choking with suspected esophageal cancer. Clinicians may choose to begin with a barium swallow chest x-ray in patients with suspicious findings. However, as upper gastrointestinal endoscopy is now quite common, in combination with minimally invasive biopsy should be performed to confirm the diagnosis.
Computed tomography of the thorax and abdomen should be performed to assess the extent of the primary esophageal tumor and to look for possible metastases of the esophageal cancer. However, computed tomography is not suitable for discriminating tumor depth, lymph node sensitivity is poor, and sometimes small metastases are not detected, especially in the peritoneum or esophageal cancer. bone metastasis.
Endoscopic ultrasonography has become the standard for site segmentation, with up to 90% accuracy in assessing tumor depth and metastasis to mediastinal lymph nodes. In addition, this technique also allows fine-needle aspiration biopsies of suspicious lymph nodes (more than 1cm) to confirm the presence of metastatic esophageal cancer. One limitation of endoscopic ultrasound is that it cannot cut across the tumor if it is small in size.
To evaluate for metastatic esophageal cancer, positron emission tomography (PET/CT) CT has become an important part of the diagnostic process. Adenocarcinoma often metastasizes to intra-abdominal sites, while squamous cell carcinoma usually metastasizes within the thorax. At this time, PET allows to detect how far esophageal cancer has spread and avoids patients from unnecessary aggressive local treatments.
When the preoperative diagnosis is correct, the guidelines for choosing the most appropriate treatment for a person with esophageal cancer will be. In these cases, the general recommendations for the treatment of esophageal cancer are as follows:
Endoscopic resection for superficial, limited mucosal disease; Direct surgical resection combined with lymph node dissection for lesions penetrating the submucosa with negative lymph nodes; Adjuvant chemoradiotherapy for resectable and invasive lesions of the muscle stroma with positive lymph nodes; Palliative systemic therapy for unresectable disease or locally advanced metastatic esophageal cancer.
4. Overview of esophageal cancer metastasis to bone
Despite advances in diagnosis and treatment in recent decades, esophageal cancer remains a highly fatal malignancy with a poor prognosis. Approximately half of patients with esophageal cancer have distant metastases at the time of initial diagnosis, and more than one-third develop distant metastases after surgery or radiation therapy. Although chemotherapy is the standard treatment for patients with esophageal cancer with distant organ metastasis, the prognosis is poor with an overall 5-year survival of less than 5%. Most distant metastases of esophageal cancer involve distant lymph nodes, liver, and lungs.
Bone is a more frequent site of metastasis from breast, prostate and lung cancer than esophageal cancer. Regardless of the malignancy, when bone metastases are present, this is a poor prognostic sign. In particular, esophageal cancer metastasizes to bone, because malignant cells often metastasize to the skeletal system late in the course of the disease, patients with esophageal cancer with bone metastases are relatively uncommon. Several studies have reported rates of metastasis to bone ranging from 5.2-7.7% in patients with all stages of esophageal cancer and 15.3–23.6% in patients with esophageal cancer. distant metastasis. However, the incidence and prevalence of esophageal cancer with bone metastases is increasing because a large part of the population is elderly.
The main independent risk factors for esophageal cancer with bone metastases that were studied were male, middle esophagus, brain metastases, and no lung and liver metastases. Compared with patients with other metastatic sites such as liver, brain, lung, esophageal cancer patients with bone metastases have a worse prognosis. This group of patients should be treated in a multimodal manner, using modalities such as radiation therapy, surgery and chemotherapy, hormone therapy, and bone-modifying agents to prolong survival. In addition, in addition to local effects, esophageal cancer metastases to bone frequently cause independent bone-related events, such as pathological fractures, spinal cord compression, and hypercalcemia , may require radiation therapy or surgery, and significantly reduce physical function and quality of life.
In summary, esophageal cancer is a deadly malignancy with a very low survival rate, even with treatment. Furthermore, in the metastatic sites of esophageal cancer, esophageal cancer with bone metastases is rare and further impairs the prognosis. The early detection of the disease and the identification of independent risk factors for the development of esophageal cancer metastasized to the bone, multimodal combination in early treatment can hopefully prolong survival. for the patient.
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