Oesophageal tumours are a very serious condition originating from the inner oesophageal layer, the treatment of which is extremely difficult, but can be highly successful in that it can lead to a complete recovery.
Treatment consists of various sequences of chemotherapy, irradiation, and surgery. Typically, the process principally comprises of concurrent chemo- and radiation therapies, which is then followed by a surgical procedure.
Over 500 people are diagnosed with oesophageal tumours in the Czech Republic each year. It is most frequently diagnosed in patients between 50 and 70 years of age. The risk factors include smoking, the consumption of hard liquor, alcoholism, and low-residue unbalanced diet. Oesophageal tumour symptoms manifest early on, and include difficulties swallowing, painful swallowing, rapid weight loss, vomiting, bleeding and/or the vomiting of partly digested blood, persistent chest pain.
Oesophageal malignancies are treated with different methods (technically “modalities”), the choice and sequence of which has fixed regularities. The treatment is always determined after a thorough medical consultation between the surgeons and oncologists.
Tumours are treated by surgery, resection, either initially (in case of small initial findings), or following the preparatory phase featuring irradiation or chemotherapy (in progressed tumours). The resection is a very complex and complicated procedure, which will be described in greater detail by the surgeon. The choice between irradiation and chemotherapy is made on the basis of tumour location. (Chemotherapy is preferred in tumours originating in the passage between the oesophagus and the stomach.)
In tumours originating in the cervical section of the oesophagus, it is impossible to perform surgeries.
Chemotherapy in oesophageal tumours is predominantly applied concurrently with irradiation. The goal of this type of chemotherapy treatment is to make the tumour more sensitive to irradiation. This type of chemotherapy is applied in lower doses and using a decreased concurrent number of substances – two at the most. It is therefore well-tolerated by the patients. Chemotherapy as an independent form of treatment is used in tumours originating in the passage between the oesophagus and the stomach.
Pancreatic tumours occur mainly in the gland’s duct system. They rarely occur in the endocrine portion of the pancreas (which produces a number of hormones, e.g. insulin, among others). Those that do, however, are called “PNETs,” have a better prognosis, and their treatment entails special rules and procedures.
Pancreatic cancer is a very serious disease that is typically quite severe. It has a strong tendency to produce further lesions – metastases – especially in the liver and the peritoneum. The treatment of pancreatic tumours is very difficult and often unsuccessful.
Over 2,000 people are diagnosed with pancreatic cancer in the Czech Republic each year. The incidence increases in people over the age of 50. Risk factors for the development of pancreatic cancer are not clearly defined. They certainly include smoking, alcoholism, and recurring inflammations of the pancreas (pancreatitis). The disease lacks early symptoms. It is usually diagnosed at an advanced stage. The very first symptom is often yellowing (“jaundice,” not to be confused with “infectious hepatitis,” i.e. a viral inflammation of the liver). Other symptoms include intense pain in the upper part of the abdomen, loss of appetite (with a particular aversion to meat) and significant weight loss. The symptoms of advanced stage include persistent nausea and recurrent vomiting.
Pancreatic malignancies are treated with different methods (technically “modalities”), the choice and sequence of which has fixed regularities. In the treatment of pancreatic tumours, surgery – pancreatic resection (full or partial), including the resection of the duodenum – as well as surgery of the small intestine are of paramount importance. If it is not possible (for any reason), the disease is treated principally by chemotherapy, which can be followed by radiation (radiotherapy). The irradiation makes sense solely in the context of chemotherapy, i.e. in relation to chemotherapy. Successful resection is followed by postoperative chemotherapy, also supplemented by irradiation. Special rules apply to postoperative irradiation.
For pancreatic tumours, radical surgical treatment always comes first, if feasible. In other words, if the surgeon is able to perform radical surgery, it is best to do so as soon as possible. (Options are determined by the extent of pancreatic involvement and the health of the patient. Radical surgery means complete removal of a certain part of the organ). If a radical procedure is not possible, they may perform surgery to bring the patient relief, depending on the situation (e.g. interconnection of the stomach and small intestine, which relieves gastrointestinal issues).
Primary liver tumours (i.e., not the secondary lesions of other tumours in the liver) are quite a rare type of disease in Europe. The treatment process is therefore unique and special. In this case, liver transplantation represents the most effective treatment method. Less effective treatments include partial liver resection, radiotherapy, chemotherapy administered via the hepatic artery, and many specific methods, e.g., RF heating of tumorous lesions, and biological therapy.
Approximately 400 people suffer from primary liver tumours in the Czech Republic annually; the statistics, however, are not exact in this area. Infectious hepatitis, cirrhosis, and alcoholism are unequivocally considered as the risk factors. The primary liver tumour symptoms usually appear at advanced stages of the illness. Early signs and symptoms are often missing – therefore, the illness is often diagnosed as advanced. The symptoms include undefined aches in the upper right part of the abdomen, undefined indigestion complications, jaundice (only as a symptom, not hepatitis proper), or deteriorated blood coagulation.
Primary liver tumours, that is not the secondary lesions of other tumours (metastases), are treated with different methods than other tumours. The most effective treatment is liver transplantation. Less effective treatments include partial liver resection, radiotherapy, chemotherapy administered via the hepatic artery, and many specific methods, e.g., RF heating of tumorous lesions, and biological therapy.
· The surgical methods are the most effective. Only when the surgeon definitely rejects transplantation or resection other treatment modalities can be indicated. (Naturally, in conditions of well progressed illness, e.g., with multiple metastases, the position is already clear so to speak and it is not necessary to burden the top-ranking facilities with non-essential consultation requests.)
Radiotherapy of primary liver tumours is a relatively new method which has thus far not been used frequently. This follows from the fact that it has thus far not been feasible to apply prevalent radiation methods using photon (gamma) radiation for liver tumour radiation in effective and at the same time safe doses.
Only with the advent of advanced radiotherapy methods, for instance, proton radiotherapy, has it become possible to radiate a primary liver tumour with high efficiency. A tumorous lesion designated by the surgeon as unsuitable for resection or transplantation and that does not affect any tissues outside the liver is subjected to radiation. The lesion also must not be larger than half of the liver itself.
Effective primary liver tumour chemotherapy has so far not been developed. Only a special type of chemotherapy called “TACE”, administered directly into the liver artery, has shown any efficiency. Some primary liver tumours can be treated with direct intervention, usually via a needle inserted into the tumour under CT supervision – generally called “ablation methods”. These include RFA (radiofrequency ablation), PEI (percutaneous ethanol injection), IRE (irreversible electroporation), etc. For advanced findings, targeted biologic therapy is used in the form of tablets.
Anal tumours are a highly specific type of condition originating in the sphincter area, or even in the area of the transition between the sphincter and the skin. Currently, radiotherapy in anal tumours treatment is predominantly preferred over a surgical procedure, which requires the establishment of a permanent (lifelong) colostomy.
Radiotherapy alone is sufficient to completely cure about 90% of patients, and it is a very difficult and high-risk treatment. Treatment using proton radiotherapy is less difficult.
170 to 190 people are diagnosed with anal tumours in the Czech Republic each year. The incidence increases after 40 years of age. Anal tumour risk factors include HPV infection (vaccination available), smoking, and unusual sexual practices. Although the anal tumour symptoms are early, they are often mistakenly diagnosed as mere haemorrhoids. The main symptom is bleeding, as well as undefined pain in the sphincter, painful defecation, or sometimes finding of enlarged inguinal lymph-nodes.
The treatment of anal tumours is governed by specific rules. The choice of therapeutic modalities is completely different from tumours of the adjacent anatomical site – rectum. Therefore, it is necessary to clearly (and of course correctly) determine the diagnosis: tumour of the anus vs. tumour of the rectum.
The treatment process is always chosen in consultation with the patient who has the choice between a surgical procedure and irradiation. Irradiation is always complemented with concurrent chemotherapy. Radiotherapy is very complicated and demanding, accompanied by a number of adverse effects not only in the areas of the sphincter skin and epithelium and surroundings, but also those adverse effects manifesting themselves in the blood count. For this reason, proton radiotherapy techniques have been developed to limit the adverse effects, typically allowing for the application of irradiation without needing to perform a temporary (relief) colostomy.
Surgical treatment of anal tumours has not been primarily used since the 1980s. This is because a distinct radiation effect has been discovered leading to a high proportion of affected patients (depending on the disease stage between 80% and 95%) to a complete cure without surgery.
Nonetheless, the surgical procedure is still available as a standard procedure as an alternative modality to radiation treatment. It consists in the complete removal of the sphincter, i.e. it requires the introduction of permanent colostomy.
Currently, the main indications for surgery (rescue treatment) are situations where the disease either recurs or has not been completely cured by radiation (the risk is 5–15%, depending on the stage of the disease).
The realm of surgical treatment also includes the question of a temporary colostomy for the period of radiotherapy application, facilitating better tolerance in post-radiation skin and epithelium response.
Radiotherapy is considered to be the primary treatment modality in anal tumours, unless the patient decides to undergo surgery. Radiotherapy in anal tumours is an extremely complicated form of treatment. Standard application of chemotherapy concurrently with irradiation forms its integral part. It is accompanied by an array of adverse effects to the skin, epithelia, urogenital system, and the blood count as well.
This is why proton radiotherapy is used, which has a more favourable dose distribution than conventional photon radiotherapy and enables a reduction (but not elimination, of course) of adverse effects.
In most cases, proton radiotherapy can be used without the establishment of a temporary opening in the large intestine, known as colostomy. The anticancer efficacy of both proton and photon radiotherapy is identical.
It is indicated in cases of large tumorous masses prior to radiotherapy with the goal of reducing the size of the radiated mass. It is also indicated for relapses in the form of distant metastases (local relapse can be resolved with “life-saving” surgery).
