Author: Heather Bolan, MA, CCC-SLP Edited by: Ainsley Martin, MS, CCC-SLP
Esophageal cancer and the SLP. It may be odd to think about managing this population since we so often refer to GI for esophageal dysphagia and focus on the oropharynx. Do we have a place in managing these cases? And if so, to what extent?
Esophageal carcinoma is considered one of the most difficult malignancies to cure (3) accounting for more than 90% of esophageal cancers (15). Radiation and chemotherapy alone may be sufficient to treat early stage cervical esophageal cancers; however, surgical intervention or esophageal resection (ER) is typically required with larger tumors and positive lymph node involvement.
ER remains the standard treatment for resectable esophageal carcinoma and for some benign esophageal conditions (13). There are two primary approaches for ER:
Esophagectomy- the stomach is pulled up and attached to the remaining esophagus. This approach is often performed when the tumor extends into the thoracic inlet (opening at the top of the thoracic cavity).
Gastric pull-up- if the tumor originates in a location higher than the distal esophagus the majority of the esophagus will have to be removed and the upper portion of the esophagus that remains will be attached to the stomach.
Esophagectomy has been found to be associated with higher morbidity, as well as a relatively longer hospital stays and prolonged delays to recovery of baseline activity level in comparison to other thoracic surgical procedures (11). According to the National Cancer Institute, the five year survival rate for localized esophageal cancer is 38% with a drop to 20% for cancers involving the esophagus and associated lymph nodes/adjacent tissues (16). The impact of surgical complications on survival rates and quality of life cannot be overlooked by healthcare professionals.
So, what does any of this have to do with SLP?
Respiratory complications after ER are the most common cause of postoperative death after esophagectomy, with aspiration pneumonia representing the primary complication leading to early death in ER patients (12).
Post esophagectomy pneumonia partially occurs because of swallowing dysfunction and silent tracheobroncial aspiration, which has been found to occur in a noteworthy amount of patients in the early postoperative period (11).
Postoperative quality of swallowing has been reported as variable (5) and can take up to 12 months to recover interdigestive motor activity of the gastric tube (6). Yet, there are minimal reports evaluating the quality of the swallow post management secondary to the reduced number of long-term survivors (4).
A number of studies have found an increased pharyngeal phase abnormality after esophagectomy (7), decreased upper esophageal sphincter diameter and reduced hyoid excursion association in altered swallowing and aspiration in the early postoperative period (8), and a functional etiology of swallowing impairments may be caused by hypertensive peristalsis in the cervical esophagus (9).
So now that you know the rationale for SLP involvement, let's get into what you need to know when it comes to esophageal cancer and how it can impact the oropharyngeal swallow mechanism.
Esophageal Anatomy
As medical SLPs we can identify important anatomical structures involved in the oropharyngeal cavity- but how about the esophagus?
The esophagus has three anatomical segments: cervical, thoracic, and abdominal (25).
Cervical Segment: Begins at the cricopharyngeus and terminates at the suprasternal notch.
Thoracic Segment: Extends from the suprasternal notch to the diaphragm.
Abdominal Segment: Runs from the diaphragm to the fundus of the stomach.
The esophagus is a 23 to 25 cm tube measured from the upper esophageal sphincter to the lower esophageal sphincter and consists of four layers (mucosa, submucosa, muscularis propria, and adventitia) in the esophageal wall. It is innervated by the vagus nerve, which initiates peristalsis of the esophagus as well as stimulates glandular contraction.
Mucosa: The inner lining of the esophagus consisting of three layers; the epithelium, lamina propria, and muscularis mucosa.
Submucosa: made of connective tissue, blood vessels, and glands that help lubricate the esophagus and helps food pass down easily.
Muscularis propria: Make-up varies based on the vertical level. This thick layer of muscle is responsible for the coordination of food from the cervical esophagus to the stomach. Upper ⅓ striated muscle Lower ⅓ smooth muscle Middle ⅓ combination of both
Adventitia: The outermost layer made of connective tissue that merges with the connective tissues of other surrounding structures.
Types of Esophageal Cancer
Squamous Cell Carcinoma:
Often caused by chronic irritation and inflammation of the squamous epithelium from heavy alcohol consumption in combination with smoking (15).
This type of esophageal cancer has decreased as cigarette consumption in the US has decreased (17).
Adenocarcinoma:
Caused by glandular cells of internal organs (15).
Prevalence continues to increase secondary to the rise in obesity (15).
The theory is there is an increase in intraabdominal pressure and gastroesophageal reflux (GERD) with obesity, with intraabdominal adiposity correlating with prevalence of adenocarcinoma (18).
Approximately 75% are found in the distal esophagus (17).
Patients with GERD are 8 times more likely to acquire adenocarcinoma (15).
Barrett’s esophagus can lead to Barrett’s adenocarcinoma (17).
Staging:
Esophageal cancer staging systems for squamous cell carcinoma and adenocarcinoma can be complex, depending on the severity and stage group (i.e. all categories combined). As the numbers behind the letters increase, the more advanced the cancer.
Extent (size) of the tumor (T)
Spread to any of the nearby lymph nodes (N)
The spread metastasized to distant sites (M)
As treatment of esophageal cancer can vary, different staging systems are utilized for each situation.
Pathological/surgical staging: The most commonly used system, determining the pathology when surgery is done first.
Clinical staging: When surgery is not an option or will be done after other treatments, staging is determined based on biopsy, imaging tests, and physical examination
Postneoadjuvant stage: When surgery is completed after chemotherapy or radiation, a separate stage will be done after surgery.
Classification Based on Location:
When cells turn cancerous in the epithelium, it leads to squamous cell carcinoma. In the distal part of the esophagus this leads to adenocarcinoma (most common form of esophageal cancer). If the cancer cells spread past the lamina propria, the extent is rated as a T1 or greater.
Once cancer reaches this level of the adventita, it is considered a T3 cancer. At this stage and extent, cancer cells can metastasize outside of the esophagus.
Typical Intervention for Esophageal Cancer
Cervical Esophageal Cancer (2):
Radiation and chemotherapy alone may be sufficient to treat early stage cervical esophageal cancers.
Surgical intervention of esophageal resection (ER) is typically required with larger tumors and positive lymph nodes.
When the tumor is located near the larynx or cricopharyngeus, chemoradiation is typically performed before ER
Thoracic Esophageal Cancer (2):
When the tumor extends into the thoracic inlet, an esophagectomy is performed for end-stage esophageal disease.
An esophagectomy is where the stomach is pulled up and attached to the remaining esophagus.
If the tumor originates in a higher location of the distal esophagus the majority of the esophagus will have to be removed (this is called a gastric pull-up).
Open Surgical Approach:
Transthoracic esophagectomy (TTE):
Approximately 56.6% of patients who underwent TTE developed early complications, with higher incidences of respiratory infections (24). The population that may benefit the most from TTE are those who are more medically stable with a limited number of lymph node involvement.
Utilized for cancers of the distal esophagus
Performed by combining the abdominal endoscopic approach with an open right thoracotomy, thereby performing the anastomosis within the thoracic cavity (22). Advantages: Superior outcomes due to direct visualization and exposure of the thoracic esophagus. Disadvantages: Very invasive procedure which may lead to increased chance of cardiopulmonary compromise, pneumothorax, tracheoesophageal injury, and recurrent laryngeal nerve (RLN) damage.
Minimally Invasive Approach:
Laparoscopic Transhiatal Esophagectomy (LTE):
Approximately 59.3% of patients who underwent LTE developed early complications with a higher incidence of vocal cord paralysis (24). Higher risk surgical patients with more morbidities may benefit from LTE vs TTE.
Allows for resection of the distal esophagus through the diaphragmatic hiatus (22). Advantages: Avoids the thoracotomy approach which is speculated to lead to a decrease in pain and pulmonary complications. Disadvantages: Less optimal visualization during the procedure which could lead to less favorable oncological outcomes. Increased chance of RLN damage, strictures, and anastomotic leak. Higher incidences of regurgitation and need for GERD medications (23).
Total Minimally Invasive Esophagectomy (MIE):
Approximately 38.2% of individuals who underwent MIE developed early complications (24). Aspiration rates have not decreased with MIE secondary to vocal cord paralysis secondary from RLN injury (20). With this approach morbidity rates were significantly reduced when compared to TTE and LTE.
Performed by deflating the right lung in prone position while the esophagus is mobilized for resection of pathological lymph nodes as surgically appropriate. Advantages: In theory limits intraoperative complications with opening surgical openings of the chest and abdomen. Disadvantages: Very complex with extensive training requirements (23).
Esophageal Cancer and The Oropharyngeal Swallow
It’s important for the medical SLP to understand typical symptoms of esophageal cancer, as we may be the first medical professional this patient was referred to. Some common complaints or symptoms that should raise a red flag are;
Complaints of dysphagia
Unexplained weight loss
Vomiting/regurgitation of meals
Pain (odynophagia) with dry/rough foods
Hoarse voice (secondary to proximity of the recurrent laryngeal nerve to the vagus)
Dyspnea
Did you know patients with esophageal cancer have an abnormal swallow both preoperatively and postoperatively (1)? Martin and colleagues in 2001 looked at VFSS results of esophageal carcinoma patients and found at minimum mild impairments in the oropharyngeal swallow that varied in severity prior to ER (14).
It is hypothesized that oropharyngeal dysphagia from esophageal carcinoma stems from alterations in feedback modulation of the oropharyngeal motor sequences, thereby causing swallowing impairments (15). Carcinoma-related changes to the esophagus from reflux modulating the upper esophageal sphincter (UES) and pharyngeal function can alter the reflexes of the pharyngoesophageal mechanism (14). Tumor growth in the esophagus may also impact the oropharyngeal swallow (14).
Typical oral phase deficits:
Reduced bolus formation
Premature posterior spillage
Oral residue
Typical pharyngeal phase deficits:
Delayed swallow initiation
Decreased pharyngeal constriction
Reduced laryngeal elevation
Penetration/aspiration
Pharyngeal residue.
Post esophagectomy oropharyngeal dysphagia is believed to be caused by surgical damage of the innervation to the pharyngeal plexus and other nerves mediating the swallow (4). A number of studies have found at least a mild impairment in the oropharyngeal swallow mechanism post-ER, with an increase in frequency of aspiration in comparison to pre-ER (10, 14, 19).
Symptoms of dysphagia post ER may include;
Globus sensation in 60% of patients (15).
Coughing during/after meals
Xerostomia (i.e. dry mouth)
Expectoration of saliva
Avoidance of specific foods
While baseline oral dysphagia has been found to remain unchanged or improved post ER, at least one new pharyngeal phase impairment was found in 80% of patients post ER (15).
One smaller study of eight ER patients reported a decreased UES diameter and reduced hyoid excursion were associated with altered swallowing and aspiration events in the early postoperative stage (8).
There have been some encouraging findings suggesting that hyoid excursion post esophagectomy may be recovered by rehabilitation (4). However, reduced laryngeal movement post esophagectomy may represent a long-term deficit (10).
Temporary or permanent Recurrent Laryngeal Nerve (RLN) damage during ER can occur, impacting the nerve innervation to the vocal folds secondary to the proximity of cervical and thoracic peripheral nerves exposed to the resection of the trauma (2). This damage can result in dysphagia, vocal fold immobility, and impaired airway protection increasing the chance of aspiration/acquiring aspiration pneumonia (20). Recovery rates for RLN damage vary from a few days to 12 months (2). It is also important for us to consider the protracted duration of NPO status post surgery which could potentially lead to disuse atrophy for our older, more medically complex patients (2).
Mechanical problems may also lead to increased risk of aspiration (2);
Anastomotic leak (a leak caused from a surgical joint)
Can be an early complication
Identified by Esophagram days post surgical intervention. It is NOT ideal to utilize barium with this population as it can lead to soft tissue damage. Typical management is to utilize water soluble contrast for immediate post op imaging.
Can resolve with conservative management.
Anastomotic stricture
Can occur early or late post op.
Patient must be assessed for no tumor recurrent if stricture is identified later.
Dilation of the stricture can be utilized to reestablish a functional lumen.
Diaphragmatic hernia
Occurs when an opening in the diaphragm allows organs to rise into the chest.
Delayed emptying of conduit
Common symptoms of dysphagia and regurgitation.
Consider this as a possible etiology of patient complaints following esophagectomy.
The SLPs Role in Esophageal Carcinoma Management
The SLP should be considered an imperative part of the team from diagnosis to survival. The SLP may be the first person to make the appropriate referrals secondary to unexplained dysphagia during MBSS (primarily with solids) and is an important member of the interdisciplinary management team if oropharyngeal dysphagia is identified preoperatively.
Involvement in the Preoperative Stage:
Through my hospital organization I am referred all cervical and thoracic esophageal patients for baseline MBSS to determine extent of oropharyngeal dysphagia prior to intervention in order to establish a baseline. It is important for us to establish this baseline as pharyngeal impairments will not improve and may potentially worsen after ER. Knowing our patient’s baseline swallow function gives us a better understanding of what risks may occur for that specific patient post ER.
Radiation induced strictures may be prevented or limited if oral intake continues during radiation. Tumors that are more proximal may be more likely to result in meaningful radiation doses in the pharynx, leading to common deficits in patients with hypopharyngeal primary tumors.
Patients with a high proximal tumor in the cervical esophagus are seen and treated by the SLP in a similar fashion to those patients with hypopharyngeal tumors.
Intervention will be very similar to hypopharyngeal cancers, with prophylactic exercises and management. If you have the ability in your setting to see the radiation oncology treatment plans, it can help you get a sense as to where the doses are highest and which at risk structures are getting radiation doses. It is also important to consider your patient's baseline swallowing functions. Many esophageal cancer patients have obstructive lesions and therefore don't eat, leading to disuse atrophy of the oropharyngeal swallow musculature. For these patients it is particularly important to keep them swallowing, even if the pharynx is not receiving a high dose. The biggest question to ask yourself when planning your intervention with this population is: are you fighting against atrophy or fibrosis? Answering this question will lead you to understanding what treatment plan your patient needs.
Involvement in the Postoperative Stage:
A comprehensive postoperative swallowing evaluation should be utilized for patients following ER secondary to the high risk of pharyngeal dysphagia and aspiration. Initiation of a bedside swallowing evaluation in order to detect any signs and symptoms of dysphagia/aspiration bedside. Although we cannot tell bedside if a patient is at risk of aspiration, this clinical information will allow us to develop a protocol for testing any hypotheses during instrumentation.
No clinical signs/symptoms bedside should lead the clinician to proceed with imaging utilizing the MBSS/VFSS to evaluate for any dysphagia, extent of airway protection, and efficacy of compensatory strategies.
Clinical signs/symptoms bedside should lead the clinician to recommend NPO with aggressive oral care with continued reevaluation for improvement in swallow function. An imaging study would be the next logical step.
Any concerns for postoperative laryngeal/pharyngeal motor impairments should be deferred to an otolaryngologist.
Initiation of Oral Intake:
The University of Michigan has developed a post-esophagectomy protocol for initiation of PO (21).
Post-op day three: removal of NG with small trials of clear liquid
Post-op day four: patient allowed clear liquids as tolerated with no fluid restrictions
Post-op day five: Full liquid diet initiated
Post-op day six: A puréed or soft diet is initiated
Post-op day seven: Assessment utilizing a barium swallow to determine anastomotic integrity is completed.
It is also our job to help our patients adjust to their “new normal” swallowing function post ER. Secondary to the upward mobilization of the gastric conduit leading into the thoracic cavity, these patients will require adjustments in their eating habits. Typical recommendations made by the SLP for this population include;
Small portions
Six to eight meals a day (secondary to the limited capacity of their stomachs)
Limit fluid consumption during meals to avoid early satiety
Overtime adaptations will allow larger amounts during meals
Esophageal cancer has been associated with high levels of morbidity and mortality, with aspiration pneumonia representing the primary complication leading to early death in ER patients. Symptoms of esophageal cancer can present similarly to those seen with oropharyngeal cancer and have a high likelihood of some type of baseline oropharyngeal dysphagia prior and following surgical management. It's time for the medical SLP to start reconsidering our role in management of this population and push to be an important player in the management of esophageal cancer.
References
Berry, M. F., Atkins, B. Z., Tong, B. C., Harpole, D. H., D'Amico, T. A., & Onaitis, M. W. (2010). A comprehensive evaluation for aspiration after esophagectomy reduces the incidence of postoperative pneumonia. The Journal of Thoracic and Cardiovascular Surgery, 140(6), 1266–1271.
Starmer, H. (2019, April). Esophageal Cancer: Implications for Communication/Swallowing. Lecture presented at ASHA Cancer Care 2019 Online.
Kato H, Fukuchi M, Miyazaki T, Nakajima M, Kimura H, Faried A, Sohda M, Fukai Y, Masuda N, Manda R, Ojima H, Tsukada K and Kuwano H: Classification of recurrent esophageal cancer after radical esophagectomy with two- or three-field lymphadenectomy. Anticancer Res 25: 3461-3467, 2005.
Kato, H., Miyazaki, T., Kimura, H., Inose, T., Tanaka, N., Sakai, M., . . . Kuwano, H. (2008). Videofluoroscopic Evaluation in Oropharyngeal Swallowing after Radical Esophagectomy for Esophageal Cancer. Nihon Kikan Shokudoka Gakkai Kaiho, 59(2), 212-212. doi:10.2468/jbes.59.212
Nakabayashi T, Mochiki E, Garcia M, Haha N, Kate H, Suzuki T, Asao T and Kuwano H (2002). Gastropyloric motor activity and the effects of erythromycin given orally after esophagectomy. Am J Surg, 183: 317-323
Kirby J D (1999). Quality of life after oesophagectomy: the patients’ perspective. Dis Esophagus 12: 168-171.
Martin RE, Letsos P, Taves DH, Inculet RI, Johnston H and Preiksaitis HG (2001). Oropharyngeal dysphagia in esophageal cancer before and after transhiatal esophagectomy. Dysphagia 16: 23-31.
Easterling CS, Bousamra M 2nd, Lang IM, Kern MK, Nitschke T, Bardan E and Shaker R (2000). Pharyngeal dysphagia in postesophagectomy patients: correlation with deglutitive biomechanics. Ann Thorac Surg 69: 989-992.
Koh P, Turnbull G, Attila E, LeBrun P and Cason AG (2004). Functional assessment of the cervical esophagus after gastric transposition and cervical esophagogastrostomy. Eur J Cardiothorac Surg 25: 480-485.
Heitmiller RF and Jones B (1991). Transient diminished airway protection after transhiatal esophagectomy. Am J Surg 162: 442-446.
Berry M., Zane B., Tong B.C., Harpole D.H., D’Amico T.A., Onaitis M.W. (2010). A comprehensive evaluation for aspiration after esophagectomy reduced the incidence of postoperative pneumonia. Journal of Thoracic and Cardiovascular Surgery 140: 1266-1271.
Atkins B.Z., Shah A.S., Hutcheson K.A., Mangum J.H., Pappas T.N., Harpole D.H. Jr., et al. (2004). Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 78: 1170-1176.
Luketich J.D., Alvelo-Rivera M., Buenaventura P.O., Christie N.A., McCaughan J.S., Litle V.R., Schauer P.R., Close J.M., Fernando H.C. (2003). Minimally invasive esophagectomy: Outcomes in 222 patients. Ann Surg 238: 486-495.
Martin RE, Letsos P, Taves DG, et al. (2001). Oropharyngeal dysphagia in esophageal cancer before and after transhiatal esophagectomy. Dysphagia; 16: 23-31.
Evangelista LM & Coyle JC. (2016). Considerations in dysphagia management following esophagectomy. Perspective in ASHA Special Interest Groups. 1(13): 169-176.
National Cancer Institute. (2016, November 18). Esophageal cancer-health professional version. Retrieved from https://www.cancer.gov/types/esophageal/hp
Enzinger, P. C., & Mayer, R. J. (2003) Esophageal cancer. The New England Journal of Medicine, 349(23), 2241–2252.
Lagergren, J., & Lagergren, P. (2013) Recent developments in esophageal carcinoma. CA: A Cancer Journal for Clinicians, 63, 232–148.
Hambraeus GM, Ekberg O, Fletcher R (1987) Pharyngeal dysfunction after total and subtotal esophagectomy. Acta Radiologica 28 : 409.
Atkins, B. Z., Fortes, D. L., & Watkins, K. T. (2007). Analysis of respiratory complications after minimally invasive esophagectomy: Preliminary observation of persistent aspiration risk. Dysphagia, 22, 49–54.
Cooke, D. T., Lin, G. C., Lau, C. L., Zhang, L., Si, M. S., Lee, J., . . . Orringer, M. B. (2009). Analysis of cervical esophagogastric anastomotic leaks after transhiatal esophagectomy: risk factors, presentation, and detection. Annals of Thoracic Surgery, 88,177–185.
Barreto, J. C., & Posner, M. C. (2010) Transhiatal versus transthoracic esophagectomy for esophageal cancer. World Journal of Gastroenterology, 16(30), 3804–3810.
Smithers, B. M., Gotley, D. C., Martin, I., & Thomas, J. M. (2007). Comparison of the outcomes between open and minimally invasive esophagectomy. Annals of Surgery, 245(2), 232–240.
Braghetto, I., Csendes, A., Cardemil, G., Burdiles, P., Korn, O., & Valladares, H. (2006). Open transthoracic or transhiatal esophagectomy versus minimally invasive esophagectomy in terms of morbidity, mortality and survival. Surgical Endoscopy, 20, 1681–1686.
Chaudhry SR, Bordoni B. Anatomy, Thorax, Esophagus. [Updated 2019 Apr 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482513/