Esophageal cancer

　　1. Etiology

　　As with other tumors, the cause is unknown and may be related to dietary factors, environmental factors, genetic factors, and Helicobacter pylori infection. There are also precancerous changes such as chronic atrophic gastritis, gastric ulcer, gastric polyps, metaplasia of gastric mucosal epithelial cells, and dysplasia of gastric mucosal epithelial cells. Currently, the etiology of esophageal cancer is still poorly understood. In addition, the incidence of esophageal cancer is on the rise year by year in some Asian, North American, and European countries. Therefore, it is necessary to conduct comprehensive multidisciplinary research on esophageal cancer to improve its early diagnosis and treatment level and the 5-year survival rate of patients after surgery.

　　The etiology of gastric cardia cancer is complex. It is generally believed that living environment and diet are two main carcinogenic factors for various cancers of the upper gastrointestinal tract, and they may also be related to gastroesophageal reflux and esophageal hiatus hernia. In the histogenesis of gastric cancer, gastric ulcers, gastric polyps (adenomas), and chronic atrophic gastritis were all considered as precancerous lesions of gastric cancer in the past. Recent research has found that the chance of malignancy in the above conditions is very small. As a special type of gastric cancer, gastric cardia cancer has little relationship with the histogenesis of the above lesions. Currently, it is more believed that gastric cardia cancer originates from the cervical stem cells of the gastric cardia gland with multi-directional differentiation potential, which can form adenocarcinoma with characteristics of gastric or glandular epithelium. Light microscopy, electron microscopy, and histochemical studies have found that gastric cardia cancer is a mixed type, which strongly supports this view. Atypical hyperplasia is a precancerous lesion of gastric cardia cancer and is also a key pathological process common to the above conditions related to the onset of gastric cardia cancer, such as ulcers, polyps, and atrophic gastritis. It is only possible to become malignant when they undergo changes in atypical hyperplasia, among which the colon-type has a majority of atypical hyperplasia characteristics.

　　Schottenfeld (1984) conducted a study on the epidemiology of esophageal cancer in North America and Europe and found that drinking and smoking are important risk factors for esophageal squamous cell carcinoma, but their role in the pathogenesis of esophageal adenocarcinoma and gastric cardia cancer is not clear.

　　2. Pathogenesis

　　1. Gross typing

　　(1) Advanced stage: The classification of gastrointestinal tumors generally follows the Borrman classification, with the basic classification being fungiform, ulcer type I, ulcer type II, and infiltrative type. Chinese authors have classified gastric cardia cancer into four types based on this.

　　① Elevated type: The tumor is a clear margin elevated mass in the cavity, presenting as cauliflower, nodular mass, or polypoid, with possible superficial ulcers.

　　② Limited ulcerative type: The tumor is a deep ulcer with elevated marginal tissue resembling a dam, and the cut surface is clearly demarcated from normal tissue.

　　③ Infiltrative ulcerative type: The edges of the ulcer are unclear, and the cut surface is not clearly demarcated from the surrounding tissue.

　　④ Infiltrative type: The tumor grows infiltratively within the gastric cardia wall, the affected area thickens uniformly, and there is no boundary with the surrounding tissue. The surrounding mucosa often presents with radial contraction.

　　The gross typing is related to the histological type, with type 1 and 2 mainly composed of well-differentiated adenocarcinoma and mucinous adenocarcinoma. The infiltrative ulcerative type has a higher proportion of poorly differentiated adenocarcinoma and mucinous adenocarcinoma. The infiltrative type is mostly poorly differentiated diffuse-type adenocarcinoma or mucinous adenocarcinoma. The prognosis of surgical treatment is the best for the elevated type, followed by the limited ulcerative type, then the infiltrative ulcerative type, and the worst for the infiltrative type.

　　The histological types of gastric cardia adenocarcinoma mainly include two types: adenocarcinoma and mucinous adenocarcinoma with obvious mucus secretion. These two types are further divided into three subtypes according to the degree of differentiation: well-differentiated, poorly differentiated, and diffuse. The degree of differentiation is closely related to the prognosis of surgery. In addition to adenocarcinoma and mucinous adenocarcinoma, gastric cardia cancer also has some rare histological types, such as adenosquamous carcinoma, undifferentiated carcinoma, carcinoid ( argentaffin cell carcinoma), and carcinosarcoma, etc.

　　(2) Early stage: The gross morphology of early gastric cardia cancer is similar to that of early cancer in other parts of the stomach and the esophagus. It can be simply divided into three types,

　　① Concave type: The mucosa of the tumor area is irregularly slightly concave, and a few are shallow ulcers, with unclear boundaries with the surrounding normal mucosa. The differentiation is often poor under the microscope.

　　② Umbilicated type: The mucosa of the cancerous area thickens and roughens, slightly elevated, and some are manifested as plaques, nodules, or polypoid, with most being well-differentiated adenocarcinoma.

　　③ Latent type: The mucosal color of the lesion is slightly deeper, the texture is slightly rough, and there are no obvious changes in gross morphology. Diagnosis is made only after histological examination, which is the earliest morphology among the three types.

　　2. The law of spread and metastasis of cardia cancer

　　(1) Direct infiltration and extension to other parts of the stomach below the esophagus, the diaphragmatic hiatus, the left lobe of the liver, the gastrohepatic ligament, the tail of the pancreas, the hilum of the spleen, the spleen, and other retroperitoneal structures.

　　(2) Lymphatic metastasis: There are rich lymphatic networks within the wall of the cardia, especially submucosa and subserosa, which communicate with the esophageal lymphatic network and gather into extramural lymphatic vessels, draining upwards to the mediastinum and downwards to the celiac plexus, finally entering the thoracic duct. Some authors propose that there are three lymphatic drainage systems of the cardia:

　　① Ascending trunk: ascending along the esophageal wall to the mediastinum.

　　② Right trunk: from the lesser curvature of the stomach along the left gastric vessel and cardia-esophageal branch to the para-celiac artery.

　　③ Left trunk: along the posterior wall along the great curve to the superior margin of the pancreas and retroperitoneum.

　　It can be further divided into the great curve branch, posterior gastric branch, and diaphragmatic branch. Lymph nodes are present along the systems. The original first station is the para-cardia (left and right), para-cardia of the lower esophagus, and paragastric lymph nodes of the lesser curvature of the stomach. The second station includes the left gastric vascular, splenic vascular, and omental lymph nodes. The distant ones include the celiac artery, para-renal aorta, portal area, mediastinum, and supraclavicular lymph nodes.

　　(3) Hematogenous metastasis:

　　① Passing through the portal vein into the liver, and then through the inferior vena cava into the systemic circulation.

　　② Directly entering the systemic circulation through the interorgan venous route. The former is the most common route of metastasis.

　　(4) Implantation: Cancer cells can fall off and implant in places such as the peritoneal omentum, and can be accompanied by hemorrhagic ascites.

　　3. Clinical-pathological staging of cardia cancer

　　The gastric cancer TNM staging method revised by the International Union Against Cancer (UICC) in 1987 is as follows:

　　T indicates the primary tumor: Tis indicates in situ carcinoma within the epidermis, not yet invading the basement membrane. T1 indicates invasion of the basement membrane or submucosa, T2 indicates invasion of the muscularis and subserosa, T3 indicates penetration of the serosa (visceral peritoneum) without reaching adjacent structures, and T4 indicates invasion of adjacent structures (such as spleen, transverse colon, liver, diaphragm, pancreas, abdominal wall, adrenal glands, kidneys, small intestine, and retroperitoneum).

　　N indicates regional lymph nodes, N0 indicates no regional lymph node metastasis. In the 1997 revised edition, it is changed to PN0, which requires examination of more than 15 negative regional lymph nodes. N1 indicates 1-6 metastases in regional lymph nodes, N2 indicates 7-15 metastases in regional lymph nodes, and N3 indicates more than 15 metastases in regional lymph nodes.

　　In staging, IIIB is T3N2/M0, T4N2M0 is canceled, and stage IV is divided into three categories: ① T4N1-3M0; ② T1-3N3M0; ③ Any T and any N and M1.

　　M indicates distant metastasis, M0 indicates no distant metastasis, and M1 indicates distant metastasis. The site of metastasis can also be indicated, such as PUL for lung, OSS for bone, HEP for liver, BRA for brain, PER for peritoneum, and so on.

　　4. Pathological factors affecting the prognosis of cardia cancer

　　The tumor volume, infiltration depth, macroscopic typing, histological type, lymph node metastasis, and vascular lymphatic tumor thrombus all have varying degrees of impact on the prognosis, with infiltration depth, histological type, and lymph node metastasis being closely related. When the lesion is localized to the mucosa or submucosa in the early stage, the 5-year survival rate after resection can reach more than 90%. Well-differentiated cancer has a good prognosis, while poorly differentiated cancer has a poor prognosis.

　　In recent years, pathological morphological changes reflecting the body's immune status and other defensive responses have been paid attention to by people. It has been found that:

　　(1) The immunological response of lymph nodes adjacent to the tumor and in the drainage area, such as follicular hyperplasia or lymphoid hyperplasia, has a better prognosis than no change or exhaustion type. The prognosis of patients with lymphocytic response or fibrous encapsulation around the tumor is better than those without response or encapsulation.

　　(2) The immunological response of lymph nodes adjacent to the tumor and in the drainage area is the most basic factor determining the prognosis. The 5-year and 10-year survival rates of grade I adenocarcinoma in well-differentiated cancer are 56.5% and 40% respectively. If grade I adenocarcinoma coexists with three positive indicators of peritumoral lymphocytic response, peritumoral fibrous encapsulation, and lymph node immunological response, the 5-year survival rate reaches 100% (52/52).

　　Mostly, they are complications and compressive symptoms of esophageal cancer. If the tumor invades adjacent organs, esophageal tracheal fistula, mediastinal abscess, pneumonia, lung abscess, and aortic perforation with massive hemorrhage may occur. When the metastatic lymph nodes compress the trachea, it can cause dyspnea; when it compresses the recurrent laryngeal nerve, it can cause hoarseness; when it compresses the phrenic nerve, it can cause diaphragmatic paradoxical movement. The initial symptoms of cardia cancer patients may include upper gastrointestinal bleeding, manifested as hematemesis or melena. Severe bleeding can be accompanied by severe anemia, weakness, or shock. In advanced cases, hypoalbuminemia, dehydration, and weight loss may occur.

　　1. Due to the anatomical characteristics of the esophagus, it is like the mouth of a river into the sea, where the esophagus is the river and the stomach cavity far from the cardia is the sea. As the cardia passage becomes wider, it is not as easy to cause obstruction as the esophagus does after cancer. The initial volume of cancer in the cardia area is small and not easy to cause obstruction. If there is difficulty in swallowing, the tumor must have progressed significantly. Therefore, early-stage cardia cancer patients lack clear characteristic symptoms. The symptoms of cardia cancer include discomfort in the upper abdomen, mild postprandial fullness, indigestion, or hidden pain in the epigastrium, which are easy to be confused with symptoms of peptic ulcer disease and do not attract the attention of patients. It is not until the difficulty in swallowing worsens that patients seek medical attention. Another initial symptom of cardia cancer is upper gastrointestinal bleeding, manifested as hematemesis or melena. Severe bleeding can be accompanied by weakness or shock, or it can manifest as severe anemia. The incidence of this condition is about 5% of patients. Due to the lack of symptoms of dysphagia, patients are prone to be misdiagnosed as bleeding from peptic ulcer disease and undergo surgery by abdominal surgeons. It is precisely because most of these cases are emergency surgeries, with insufficient preparation in all aspects, that the incidence of surgical complications and mortality are relatively high, and the efficacy is poor. In advanced cases, in addition to difficulty in swallowing, there can also be persistent hidden pain in the upper abdomen and lower back, indicating that the tumor has involved retroperitoneal tissues such as the pancreas, which is a contraindication for surgery.

　　Early gastric cardia cancer patients have no positive signs, while patients in the middle and late stages may have signs of anemia, hypoalbuminemia, weight loss, dehydration, or hypoalbuminemic edema. If there is a mass in the abdomen, liver enlargement, ascites, pelvic mass (digital rectal examination), they are not suitable for surgical treatment.

　　The first significant epidemiological characteristic of gastric cardia cancer is its inconsistency with gastric distant site tumors. In areas with a high incidence of gastric cardia cancer, the incidence of distant site tumors in the stomach is very low. Epidemiological and population studies suggest that the triggering factors, pathological characteristics, and clinical features of gastric cardia cancer are significantly different from those of distant site tumors in the stomach. Helicobacter pylori infection is closely related to the occurrence of distant site tumors in the stomach, while drinking and smoking are important factors in the occurrence of gastric cardia cancer. It needs to be emphasized that since the 1980s, the incidence of distant site tumors in the stomach has shown a significant downward trend in many countries around the world, especially in the United States, Japan, China, and some European countries. However, the incidence of gastric cardia cancer and primary adenocarcinoma of the esophagus has shown a significant upward trend, especially in white Americans and some European countries, where the incidence has increased nearly 6 times in the past 30 years, making it the fastest-growing type of malignant tumor among all malignant tumors. Although the cause is still unclear, these phenomena suggest that gastric cardia cancer is different from distant site tumors in the stomach and should be treated as an independent disease. It is obvious that gastric cardia cancer has significant epidemiological characteristics similar to esophageal cancer, suggesting that they may have common pathogenic factors. However, the current understanding of the etiological characteristics of gastric cardia cancer is very limited.

　　One, X-ray barium meal examination

　　It is the main means of diagnosing gastric cardia cancer.

　　1, Early stage

　　Early manifestations include subtle mucosal changes, small ulcerative indentation shadows, and not very obvious but constant filling defects. In early cases, endoscopic examination, brushing cytology, and biopsy pathology must be performed to make a diagnosis.

　　2, Advanced stage

　　In advanced cases, the X-ray findings are clear, including soft tissue shadows, mucosal destruction, ulcers, indentation shadows, filling defects, twisted and narrowed cardia passage, invasion of the lower esophagus, and infiltration of the gastric fundus, both sides of the stomach body, with stiff gastric wall and reduced gastric volume.

　　Two, gastroscopy

　　Visible tumor or erosion at the cardia, with脆hard texture and prone to bleeding. In severe cases, the lumen may be twisted and narrowed, making it difficult to enter the scope. Biopsy can be performed multiple times during the examination for pathological examination.

　　Three, abdominal CT

　　It is possible to understand the relationship between the tumor and the surrounding organs. Compared to the CT findings of the esophagus, the positive findings of gastric cardia cancer are often not very certain. CT is helpful in detecting liver metastasis and determining whether it invades the pancreas and peritoneal lymph nodes, which is beneficial for preoperative evaluation of gastric cardia cancer.

　　Fourth, diagnosis by cytology

　　The positive rate of cardiac cancer is lower than that of esophageal cancer, which is caused by the conical anatomical characteristics of the cardia, making it difficult for the ball to contact the tumor. After using a larger ball, the diagnostic rate has been improved.

　　Firstly, Gastric cancer therapeutic recipes

　　1, Sugar cane and ginger drink: sugar cane and ginger in appropriate amounts. Squeeze half a cup of sugar cane juice, mix with one spoon of ginger juice, and simmer to make it. Take twice a week, after simmering, it has the effect of harmonizing the middle and invigorating the stomach, and is suitable for the early stage of gastric cancer.

　　2, Brown sugar stewed tofu: 100 grams of tofu, 60 grams of brown sugar, 1 bowl of clear water. Dissolve the brown sugar in water, add tofu, and boil for 10 minutes. Take regularly, it has the effect of harmonizing the stomach and stopping bleeding; it can be chosen for hematemesis.

　　3, Tangerine peel and red date drink: one piece of tangerine peel, 3 red dates. Remove the kernel from the red dates and boil with the tangerine peel to make a decoction. Take once a day, this therapeutic recipe can promote qi, invigorate the spleen, relieve nausea and vomiting, and is suitable for虚寒vomiting.

　　4, Radish seed porridge: 30 grams of radish seed, and an appropriate amount of glutinous rice. First, roast the radish seed, then cook it with glutinous rice into porridge. Take once a day, for breakfast, this prescription can eliminate food accumulation and relieve abdominal distension, and can be chosen for obvious abdominal distension.

　　5, Tangerine peel pork rice porridge: 9 grams of tangerine peel, 12 grams of cuttlefish bone, 50 grams of lean pork, and an appropriate amount of glutinous rice. Cook the tangerine peel, fish bone, and rice into porridge, remove the tangerine peel and cuttlefish bone after boiling, add slices of lean pork and boil again, add a little salt for seasoning and eat. Take twice a day, in the morning and evening, this therapeutic porridge can relieve nausea and vomiting, invigorate the spleen and harmonize the qi, and is the first choice for abdominal distension.

　　6, Lettuce and jujube cake: 250 grams of lettuce, 250 grams of jujube, 500 grams of flour. Cut the lettuce into pieces, cook the jujube and remove the kernel, mix it with flour to make a cake. Serve as a snack, invigorating the spleen and stomach, drying dampness and promoting diuresis; it can be chosen for loose stools or diarrhea.

　　Secondly, what is good for gastric cancer patients to eat

　　1, It is recommended to eat more foods that can enhance immunity and have anti-gastric cancer effects, such as yam, mung beans, Job's tears, water chestnut, chrysanthemum flower, mushroom, sunflower seeds, kiwi fruit, fig, apple, sardine, honey, quail egg, milk, pork liver, sandworm, monkey head fungus, abalone, needlefish, sea cucumber, oyster, squid, shark, tiger fish, yellowfish bladder, sea horse, and turtle.

　　2, It is recommended to eat more high-nutrient foods to prevent malnutrition, such as black-bone chicken, pigeon, quail, beef, pork, rabbit meat, eggs, duck, soy sauce, tofu, silver carp, grass carp, flatfish, mola mola, crucian carp, eel, bream, mudfish, shrimp, conpoy, pork liver, and sturgeon.

　　3, Nausea and vomiting are recommended to eat water shield, pomelo, orange, loquat, millet, walnut, rose, starfruit, fig, ginger, lotus root, pear, winter vegetable, mango, plum, and lotus seed.

　　4, Anemia is recommended to eat conpoy, turtle, shark, shark fin, malan tou, chrysanthemum flower, monkey head fungus, honey, qicai, banana, olive, plum, black fungus, sheep's blood, broad bean skin, sesame, persimmon cake, dregs of tofu, and snail.

　　5, Diarrhea is recommended to eat shark, mung beans, pear, myrtle, taro, chestnut, pomegranate, lotus seed, euryale, and white osmanthus flower.

　　6, Abdominal pain is recommended to eat kumquats, cabbage, flounder, cuttlefish, frogfish, sandworm, sea cucumber, squid, wansui, and lotus flower bud.

　　7. Foods to prevent and treat the side effects of chemotherapy: kiwi, asparagus, longan, walnut, crucian carp, shrimp, crab, goat's blood, goose's blood, jellyfish, grass carp, mullet, mushroom, black fungus, quail, Job's tears, mud clam, mung bean, chive, apple, luffa, walnut, turtle, turtle, prune, apricot cake, fig.

　　Thirdly, what foods should gastric cancer patients avoid

　　1. Avoid moldy or rotten foods.

　　2. Avoid high-salt diets.

　　3. Avoid over-stimulating foods, such as chili and Sichuan pepper.

　　4. Abstain from smoking and drinking.

　　5. Patients after surgery should avoid milk, sugar, and high-carbohydrate diets to prevent倾倒综合征.

　　6. Eat less or no smoked or over-salted foods and vegetables.

　　7. Avoid spicy and pungent foods, such as coriander, cumin, pepper, chili, scallion, wasabi, garlic, etc.

　　8. Rich and greasy foods that produce phlegm: such as fatty meat, fatty chicken, fatty duck, various sweets (high in sugar content), butter, cheese, etc.

　　6. In traditional Chinese medicine, 'hair' refers to items such as lamb, fish without scales, pork head meat, animal internal organs, shrimp and crab, etc., as well as roosters, dog meat, silkworm eggs, etc.

　　10. Avoid smoking and drinking, as smoking and drinking can only make the disease progress faster, with hundreds of harms and no benefits. Winter is a good season for nourishing and protecting the stomach. For those with gastritis, along with irregular diet, stomach cancer may be getting closer to you. Japanese medical experts have conducted many years of research on dietary status in people aged 30-40, and 38.4% of those with stomach cancer have irregular dinner times.

　　Surgical treatment of esophageal cancer is the first choice, the purpose of surgical treatment is: 1. To remove the tumor and prevent or alleviate the stricture and obstruction of the esophagus, and prolong the life of the patient; 2. To ensure as much as possible that there is no cancer tissue left at the esophagus and stomach margins after the primary tumor is removed, reducing the recurrence rate; 3. To thoroughly clean the suspected drainage areas or local lymph nodes. Studies have shown that in esophageal cancer surgery, the resection of the lower esophagus and the length of the resection are one of the important links affecting the surgical outcome. The surgical margin distance from the upper and lower margins of the tumor reaching or exceeding 5cm, and more extensive cleaning of the lymph nodes in the tumor drainage area, can improve the 5-year survival rate of the patients.