Oesophagus Cancer

Oesophagus Cancer

Oesophagus Cancer
Cancer of​ the​ oesophagus is​ one of​ the​ cancers of​ the​ digestive tract of​ the​ most serious prognosis. Incidence and​ death rates are higher for​ populations other than the​ white race 5years long survival rate in​ the​ United States in​ years 1992 1999 equalled 15% for​ the​ white race and​ 9%for others. as​ far as​ the​ incidence rate is​ concerned, the​ cancer is​ classified on the​ 13th position among men and​ on the​ 29th position among women. as​ far as​ the​ death rate is​ concerned, it​ is​ classified on the​ 12th and​ 25th positions respectively.
The following regions are characterized by the​ highest incidence rate north Iran, southern republics of​ the​ former USSR and​ the​ north of​ China over 100 for​ 100,000 Asian belt of​ cancer of​ the​ oesophagus. Medium incidence rate Sri Lanka, India, South Africa, France, Switzerland 1050 for​ 100,000; low Europe, Japan, Great Britain, Canada under 10 for​ 100,000.
Increasing tendency for​ adenocarcinoma before 1980, it​ constituted about 15%, nowadays its about 3537% in​ the​ USA and​ in​ Europe. the​ incidence rate of​ cancer of​ the​ cardia area is​ also increasing.
Tobacco use increases the​ risk of​ adenocarcinoma, no connection with the​ occurrence of​ squamous carcinoma. ​alcohol​ abuse increases the​ risk of​ squamous carcinoma. Joint effects of​ tobacco and​ highproof spirits use increase the​ risk of​ cancer of​ the​ oesophagus about 100 times. Obesity increases the​ risk of​ the​ incidence about 2 times. Diet poor in​ fruit increases the​ risk of​ squamous carcinoma about 2 times. Lack of​ carotene, selenium, E vitamin, scarcity of​ hot meals and​ consumption of​ spoiled fruit have influence on the​ incidence of​ adenocarcinoma and​ squamous carcinoma.
Culturally inclined dietary habits increase the​ risk of​ incidence in​ Asia, south Africa, south America and​ the​ Middle East; in​ Europe and​ in​ the​ USA these are tobacco use and​ ​alcohol​ abuse.
Additional risk factors Tylosis Plantaris, Plummer syndrome / Vinson and​ Patterson / Kelly, Achalasia, Preexisting presence of​ caustic substances, Preexisting cancers of​ respiratory and​ digestive tract, Barretts oesophagus Infections of​ Helicobacter Pyroli and​ Human Papilloma Virus.
Symptoms Dysphagia, often preceded by discomfort of​ swallowing lasting several months, and​ loss of​ weight are the​ first symptoms in​ 90% of​ patients. Difficulties with swallowing may not be perceptible even if​ the​ narrowing of​ the​ oesophagus reaches 66%. There are 4 degrees of​ dysphagia I ​ grade ability to​ swallow solids, II grade ability to​ swallow ground food III grade ability to​ swallow liquids only IV grade aphagia
The following symptoms appear frequently bringing up food, stomachaches and​ pneumonia. in​ more advanced cases bloodstained vomit, blood spitting because of​ tracheoesphageal fistula, retrosternal aches infiltration of​ mediastinum structures, hoarseness, and​ cough invasion of​ tracheal lymph nodes and​ infiltration of​ recurrent laryngeal nerve.
Natural course of​ the​ illness
Phase I ​ initial is​ reversible thanks to​ prevention methods. it​ may last up to​ 30 years, it​ is​ characterized by a​ low or​ advanced metaplasia of​ epithelium cells, then it​ results in​ dysplasia, hyperchromasia and​ dyscariosis of​ nuclei. Phase II results in​ carcinoma in​ situ preinvasion cancer. it​ is​ clinically asymptomatic and​ may last for​ a​ long time. Afterwards, cancer permeates basement membrane and​ assumes an infiltrative character. in​ clinical terms, it​ is​ the​ first degree of​ advanced cancer. Phase III II and​ III grade of​ advanced cancer. Clinical symptoms increasing dysphagia, narrowing of​ the​ inside diameter of​ the​ oesophagus visible in​ radiological examination. Phase II clinical no metastases to​ regional lymph nodes, III metastases are present. Phase IV IV degree of​ advanced cancer. Terminal phase, it​ lasts for​ a​ short time, remote metastases are possible, often a​ nonoperational cancer.
TNM classification Size of​ tumour TX primary tumour cannot be assessed T0 no evidence of​ the​ primary tumour Tis carcinoma in​ situ T1 tumour affects lamina propria of​ the​ mucosa or​ submucosa T2 tumour affects muscularis propria T3 tumour affects tunica adventitia T4 tumour infiltrates adjacent structures Lymph nodes NX regional lymph nodes cannot be assessed N0 regional lymph nodes are not affected N1 regional lymph nodes are affected Remote metastases M0 absent M1 remote metastases are present including visceral nodes
Classification of​ the​ American Joint Committee on Cancer Abbreviations mentioned above are used in​ the​ description 0 grade Tis, N0, M0; I ​ grade T1, N0, M0; IIA grade T2, N0, M0 or​ T3, N0, M0; IIBgrade T1, N1, M0 or​ T2, N1, M0; III grade T3, N1, M0 or​ T4, any N, M0; IV grade any T, any N, and​ M1.
Diagnostically basic tests Thorough subjective test with medical history. Radiological examination of​ the​ oesophagus with contrast medium, together with stomach and​ duodenum tests narrowing or​ change of​ the​ oesophageal axis may signify the​ presence of​ a​ tumour and​ it​ estimates the​ usefulness of​ the​ stomach to​ be joined. Double contrast use is​ advisable in​ order to​ reveal smaller changes that are invisible during tests with single contrast use.
Diagnostically additional tests Aspirational biopsy of​ palpable cervical nodes in​ order to​ exclude metastases beyond the​ chest. Oesophagoscopy with a​ sample taken to​ histopathological tests estimates the​ cancer macroscopally it​ can be assigned to​ one of​ the​ following groups convex, ulcerating, superficial, egzofitic and​ mixed and​ microscopally, it​ is​ localized precisely against the​ physiological narrowing of​ the​ oesophagus, and​ regarding the​ distance from the​ upper incisors; one should pay attention to​ changes in​ the​ area of​ the​ pharyngeal muscle connection of​ squamous and​ column epithelinum and​ diaphragm hiatus, presence or​ absence of​ satellite changes such as​ erosions, Barretts oesophagus or​ esophagitis. in​ the​ case of​ unambiguous test results, toluidine blue or​ Lugols iodine should be used. Bronchoscopy should always be conducted if​ there is​ a​ possibility of​ resection of​ upper or​ middle part of​ the​ oesophagus in​ order to​ exclude tracheas and​ bronchial tree infiltration. CT of​ the​ chest and​ the​ upper abdomen in​ order to​ localize metastatic changes. Esophageal ultrasonography EUS as​ a​ confirmation of​ the​ afflicting of​ mediastinal lymph nodes. MRI its precision is​ comparable to​ CT. PET with 18F fluorodeoxyglucose FDG according to​ initial tests detects the​ tumour and​ presence of​ the​ regional metastases with a​ greater precision than CT, it​ certainly works better in​ the​ detection of​ the​ presence of​ remote metastases. PET with 11Cmethacholine detects with greater precision presence of​ small metastatic foci in​ the​ mediastinal area; according to​ some tests, best results are achieved by PET together with combined use of​ FGD and​ 11Cmethacholine.
Preoperative tests Test of​ cardiovascular system function ECG, in​ some justified cases echocardiography, exercise test, arteriography of​ carotid artery, Dopplers USG of​ carotid arteries. Test of​ respiratory system function spirometrical and​ gasometrical tests; assessment of​ vital lung capacity, onesecond tense tidal volume, Tiffeneautest. Kidneys and​ liver function test determination of​ urea level, creatinine, creatinine clearance, level of​ sodium, potassium, chloride and​ calcium ions, level of​ transaminases GOT, GPT, bilirubin, alkaline phosphatase, hepatic tests. Determination of​ the​ complete albumin level and​ albumin found in​ plasma. Assessment of​ the​ degree of​ undernourishment and​ dehydration assessment of​ the​ thickness of​ a​ skin fold, Determination of​ the​ general state of​ a​ patient scales of​ Karnofsky and​ WHO.
Qualification to​ operation General state according to​ Karnofskys scale at​ least 80, according to​ WHO not more than 1. Normal functioning of​ bone marrow RBC 3. 5 mln/1ml, PLT 100thous/1ml. Normal functioning of​ kidneys indicator/gauge of​ creatinine clearance >50l l/min. No remote metastases M0. Treatment
Surgery usually consists in​ a​ removal of​ the​ tumour together with a​ part or​ the​ whole of​ the​ oesophagus and​ surrounding lymph nodes and​ tissues. Then, the​ remaining part of​ the​ oesophagus is​ joined to​ the​ stomach in​ the​ cervical area in​ order to​ preserve swallowing ability. Sometimes, endoprostheses are used, however, usually only of​ stomach or​ intestine . An additional joint of​ the​ stomach directly to​ the​ intestine may be carried out in​ order to​ facilitate passage of​ food from the​ stomach to​ the​ intestine. it​ should be remembered that this type of​ surgery depends mainly on the​ general state of​ a​ patient and​ the​ stage of​ cancer development.
Main methods used in​ surgery are presented below
Transhiatal esophagectomy m. Orringer. 1. Upper part of​ abdomen and​ lower part of​ neck are opened, no direct invasion in​ the​ chest. 2. Oesophagus is​ dissected with care from mediastinal structures and​ then removed. 3. Subsequently, stomach is​ connected with the​ cervical part of​ the​ oesophagus endtoend esophagogastrostomy carried in​ the​ site of​ anterior mediastinum. Transmediastinal esophagectomy m. Akiyama. 1. Chest is​ opened on the​ left and​ right side more often on the​ right side, with the​ tumour in​ the​ upper and​ middle part of​ the​ oesophagus, and​ taking into consideration the​ aortic arch; more often on the​ left if​ the​ tumour is​ localized in​ the​ joint of​ the​ oesophagus and​ the​ stomach. 2. Incision in​ the​ sixth left intercostal area exposes anterior mediastinum. 3. Semicircular incision of​ the​ diaphragm, 1 inch from the​ costal arch, exposes upper part of​ abdomen. 4. Oesophagus is​ removed with perioesophageal nodes and​ nodes of​ lesser curvature of​ the​ stomach 5. Substitute is​ made mainly from stomach a​ with incision made on the​ right side, laparotomy is​ additionally performed in​ order to​ prepare stomach and​ to​ place in​ the​ site in​ the​ anterior mediastinum or​ in​ the​ retrosternal area, b with incision made on the​ left side, stomach is​ pulled under the​ aortic arch and​ joined to​ cervical stump of​ the​ oesophagus. Esophagectomy en bloc. 1. it​ consists in​ excision of​ the​ tumour with a​ wide margin including surrounding structures in​ the​ background together with pleura and​ with pericardium in​ front. 2. Lymphatic vessels placed between the​ oesophagus, aorta and​ thoracic duct are excised en bloc. 3. Anterior mediastinum excision guarantees complete removal of​ nodes from the​ split of​ trachea to​ oesophageal hiatus. 4. Hepatic, visceral, left gastric nodes and​ nodes of​ lesser curvature of​ the​ stomach, parahiatal and​ retroperitoneal, which reduces the​ number of​ local post operational metastases to​ less than 10%. Esophagectomy en bloc with tripolar lymphadenectomy it​ consists in​ additional excision of​ cervical nodes.
Radiotherapy treatment consists in​ the​ use of​ highly energetic rays in​ order to​ destroy cancerous cells. Radiotherapy may be provided from an external or​ an internal source brachytherapy, it​ consists in​ introduction of​ a​ pipe with radiating material into the​ inside diameter of​ the​ oesophagus. Radiotherapy may only be used together with chemotherapy, as​ an alternative treatment method, if​ the​ stage of​ cancer or​ other factors do not allow to​ carry out a​ surgery. it​ can be used either alone or​ together with chemotherapy, before surgery is​ performed. in​ palliative treatment, radiotherapy also plays an important role.
Pharmaceutical treatment consists in​ anticancerous medicines use, usually administered intravenously affecting cancerous cells by circulation around/ in​ the​ body. it​ can be used together with radiotherapy, as​ an alternative way of​ treatment to​ surgery and​ preoperatively.
In the​ phase of​ controlled clinical tests, other ways of​ treatment are possible, such as​ laser therapy or​ photodynamic therapy PDT.
Palliative treatment
Over 70% of​ the​ diagnosed patients cannot be qualified for​ surgical treatment because of​ the​ extensiveness of​ cancerous changes. Palliative treatment is​ intended to​ improve the​ general state of​ a​ patient, decrease ailment and​ difficulties swallowing. the​ following methods are applied Palliative resection Evasive connections creation of​ a​ bridge evading a​ narrowing or​ a​ closure of​ the​ inside diameter of​ the​ oesophagus. Oesophageal prostheses. Gastric and​ intestinal fistula, including microfistula of​ small intestine enabling feeding directly to​ the​ inside diameter of​ the​ intestine. Mechanical widening of​ the​ narrowing. Selfwidening Stents mass. Laser therapy a​ surgery consisting in​ introducing a​ fiberscope with a​ laser light into the​ oesophagus, with breaks lasting several days, which enables exfoliation of​ cells and​ widening of​ the​ inside diameter of​ the​ oesophagus. the​ most popular laser Nd Yag laser.

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