Download - CANCERUL DE ESOFAG
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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