cancerul de esofag
DESCRIPTION
CANCERUL DE ESOFAG. CONSIDERATII GENERALE. ETIOLOGIE. alcool si tutun prezenta de nitrosamine in mancare si apa contaminarea mancarii cu fungi malnutritia deficienta cronica de fier deficienta cronica de vitamine. Stari precanceroase. acalasia- incidenta de 7 ori mai mare - PowerPoint PPT PresentationTRANSCRIPT
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CANCERUL DEESOFAG
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CONSIDERATII GENERALE
ROMANIA
- locul 4 in tumorile maligne ale tubului digestiv
- raportul barbati:femei 4:1
- incidenta maxima intre 50 si 65 ani
SUA
- incidenta 20 la 100000
- la negri carcinomul scuamos este de 5 ori mai frecvent decat celelalte forme
-la albi 1 din 3 cazuri= adenocarcinom
Alte regiuni-Iran,South Africa, Incidence
incidenta de 5 ori mai mare
-Kazahstan – Guriev incidenta de 20 ori mai mare
-Iran, China femei/barbati 1/1
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ETIOLOGIE
• alcool si tutun
• prezenta de nitrosamine in mancare si apa
• contaminarea mancarii cu fungi
• malnutritia
• deficienta cronica de fier
• deficienta cronica de vitamine
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Stari precanceroase
• acalasia- incidenta de 7 ori mai mare
• esofagita coroziva
• esofagul Barrett
• reflux esofagian
• sindromul Plummer Winson
• factori virali
• malformatii congenitale
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INCIDENCE
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• Carcinom scuamos
• Adenocarcinom
Forme rare
• Chistadenocarcinom
• Carcinom cu celule mici
• Sarcom
• Melanom malign
Anatomopatologie
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• Ulcerativ
• Infiltrativ
• Superficial
Forme anatomo-patologice
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Piesa de exereza
cardia
tumora
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Aspect microscopic
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Cai de diseminare1.Invazie directa, de vecinatate: -extramural -intramural: proximal si distal2.Invazie pe cale limfatica: -ggl. cervicali -ggl. mediastinali -ggl. trunchi celiac3.Invazie hematogena: -plamani, oase, ficat, suprarenale
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Semne cliniceA. Simptome si semne - sindrom esofagian:• Disfagie progresiva: alimente solide, lichide• Regurgitatii• Sialoree• Pierdere in greutate• Astenie• Dureri retrosternale la deglutitie• Tuse la deglutitie = fistula esotraheala, bronsica• Disfonia = invazia n. recurenti
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Explorari imagistice
• Radiologia: tranzit baritat, Rx toracic
• Esofagoscopie si bronhoscopie
• Ex. Bioptic si citologic
• ECO:ficat, rinichi, suprarenale, adenopatie
• ECO transluminal
• Tomografie computerizata
• Rezonanta magnetica
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Examen baritat
Extensia tumorii in ax
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Imagine endoscopica
Carcinom scuamos
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Imagine endoscopica
Adenocarcinom
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Imagine endoscopica
Carcinom infiltrativ
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Imagine endoscopica
Carcinom vegetant, obstructiv cu retentie de corpi straini (medicamente)
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Ecografie transluminala
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Tomografie computerizata
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Semne principale de diagnostic:
• Disfagie progresiva initiala pentru solide
• Pierdere progresiva in greutate
• Examene radiologice
• Endoscopie cu biopsie si citologie
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Stadializare TNMT (tumora)
T0 = nu se evidentiaza tumora (in situ)T1 = tumora invadeaza mucoasa, posibil submucoasa, fara muscularaT2 = tumora invadeaza muscularaT3 = tumora depasesta musculara
N (adenopatia)N0 = fara metastaze ggl.N1 = metastaza ggl. regionalaN2 = metastaza ggl. regionala multiplaN3 = metastaza ggl. la distanta (trunchi celiac,
laterocervical)M (metastaza)
M0 = fara metastaza la distantaM1 = cu metastaza la distanta (cale hematogena)
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Stadializare postoperatorie
Stadiu I T0-1 N0 M0
Stadiul II T2 N0 M0
Stadiul III T3 N0 M0orice T, orice N, M0
Stadiul IV orice T, orice N, M1
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Diagnostic diferential• Tumori benigne• Alte afectiuni ale esofagului:
- acalazia
- reflux gastroesofagian
- diverticuli esofagieni
- hernia hiatala
-stenoze esofagiene benigne• Compresiuni extrinseci (tumori mediastinale, etc.)
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Evolutie, complicatii
• Sangerare (HDS)
• Invazia structurilor mediastinale
• Fistule: esotraheala, esobronsica, vasculara
• Pneumonie de aspiratie - abces pulmonar
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Complicatii - fistula esobronsica
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Tratament
• Chirurgical: » - curativ » - paleativ
• Radioterapie
• Chimioterapie
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Criterii de nerezecabilitate
• Invazie traheobronsica, aortica (bronhoscopie, tomografie)
• Criterii radiologice (lungimea tumorii in ax peste 5 cm)
• Fistula esobronsica, invazia nervilor recurenti (raguseala)
• Metastaze la distanta
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Radioterapie
• Carcinomul scuamos este radiosensibil
• Radioterapie + chirurgie (stadiul III)
• Chimioterapie (stadiul IV)
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Operatii curative (radicale)
Esogastrectomie polara superioara cu anastomoza esogastrica termino-terminala intratoracica
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Operatii curative
Esogastrectomie totala cu splenectomie
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Operatii paleative
Esogastroanastomoza
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Operatii paleative
Esogastroanastomoza termino-laterala
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Reconstructie esofagiana cu intestin subtire
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Reconstructie esofagiana cu colon
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Esofagoplastie cu colon (variante)
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Esofagoplastie cu tub gastric
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Reconstructie cu tub gastric
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Reconstructie cu tub gastric
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Operatii paleative
• Dilatare esofagiana transtumorala
• Gastrostoma sau jejunostoma
• Protezare esofagiana transtumorala
• Rezectii paleative
• Operatii de ocolire (by pass) a obstacolului tumoral
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Protezare transtumorala
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Gastrostoma cu sonda Petzer
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Anastomoza esogastrica termino- laterala fara indepartarea tumorii
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Rata de supravietuire