Tumors of the esophagus


 * 1) Benign - most often a leiomyoma.
 * 2) Malignant – squamous cell carcinoma (90%), adenocarcinoma and melanoblastoma (10%).

Benign tumors of the esophagus

 * 1) Intramural (solid or cystic) - leiomyoma, fibroma, lipoma, hemangioma, congenital or retention cysts.
 * 2) Intraluminal (pedunculated or sessile polyps) – adenoma, papilloma, fibrolipoma, myxoma.


 * Mostly no problems, rarely bleeding or dysphagia;
 * Diagnosis endoscopically or X-ray (contrast passage);
 * Indications for removal are clinical difficulties or the impossibility of excluding malignancy - it is performed endoscopically, enucleation of intramural tumors or wedge resection from thoracotomy or thoracoscopically.

Malignant tumors of the esophagus

 * Esophageal cancer is most common between the ages of 50 and 70. per year, more in men, the highest incidence is in China;
 * Risk factors are exogenous (smoking, alcohol, spicy diet, lack of vitamins) and endogenous (precancers - hiatal hernia, Barrett's esophagus, achalasia, Plummer-Vinson syndrome, post-cautery strictures);
 * Five-year survival prognosis is 10%.

Microscopy



 * 90% squamous cell carcinoma;
 * 10% adenocarcinoma (mainly distal esophagus and GE junction underlying Barrett's esophagus); currently, adenocarcinoma predominates.
 * Melanoblastoma.

Macroscopy

 * The tumor can be exophytic (polyp), superficially infiltrating (circular narrowing of the lumen of the esophagus with subsequent longitudinal submucosal spread) or ulcerous;
 * The most common tumors are in the middle thoracic esophagus;
 * Difficult differentiation of tumors of the terminal esophagus from tumors of the cardia (an adenocarcinoma of the esophagus is considered to be one whose volume is more than 80% located in the esophagus) - tumors of this area are divided into:
 * Types:
 * type I – ca in the distal (Barrett's) esophagus;
 * type II – ca cardia;
 * type III – subcardiac (fundus) approx.

TNM classification

 * T1 – mucosa or submucosa;
 * T2 – muscularis externa infiltration;
 * T3 – adventitia infiltration;
 * T4 – moving to the surroundings;
 * N1 – regional nodes (cervical in the cervical section of the esophagus, mediastinal and perigastric in the thoracic section);
 * M1 – distant metastases.

Esophageal cancer spread

 * Continuously - per continuitatem to the surroundings (trachea - fistula with aspirations and bronchopneumonia, mediastinum, lungs, pleural and pericardial cavity);
 * Lymphogenic - mediastinal and paratracheal nodes, subdiaphragmatic gastric nodes;
 * Hematogenously – liver, lung, rarely bone and CNS.

Clinical picture

 * Progressive dysphagia and odynophagia (late symptom);
 * dysphagia initially for solid food (as opposed to achalasia, where the passage of liquids is impaired and solid food passes through);
 * Retrosternal pain, weight loss, anemia, aspiration pneumonia.

Diagnosis

 * Endoscopy with biopsy;
 * CT of the chest and abdomen (tumor extent, distant metastases);
 * EndoUZ (tumor growth into the surrounding area, involvement of nodes);
 * Staging (distant metastases – PET/CT, lung X-ray, liver ultrasound, skeletal scintigraphy);
 * Other – X-ray passage of contrast material through the esophagus, NMR, bronchoscopy (tracheobronchial invasion is a contraindication to esophagectomy);
 * Laboratory examination: tumor markers CEA, SCC.

Surgical and endoscopic
Radical:


 * Stage Tis or T1 tumors can be treated with endoscopic mucosectomy;
 * For more advanced tumors, different types of esophagectomies (for tumors in the GE junction area with different types of gastrectomy – total gastrectomy or just resection of the cardia) with mediastinal and celiac lymphadenectomy and replacement of the esophagus with a tubularized stomach, colon or small intestine, resections can be performed classically from a thoracotomy and laparotomy or only from a cervical approach and laparotomy with transhiatal stripping of the esophagus (for high-risk patients, where thoracotomy can thus be avoided), possibly also using video-assisted thoracoscopy;
 * Contraindications for esophagectomy are distant metastases and tumor growth into the tracheobronchial tree.

Palliative:


 * Dilatation of tumor stenoses:
 * laser recanalization (recurrences occur after it);
 * introduction of stents – coated expandable stent (at the same time the best option);
 * Haring's endoprosthesis (no longer used today, many complications including pressure sores of the esophageal wall);
 * Palliative bypasss – stomach, intestine;
 * Gastrostomy (surgical or endoscopic - PEG).

Radiotherapy

 * Low radiosensitivity (more in squamous cell carcinoma);
 * Neoadjuvant (improvement of operability) and adjuvant (residue removal) are performed, as well as for inoperable tumors;
 * Brachyradiotherapy is also used (palliatively to open stenoses).

Chemotherapy

 * Low sensitivity;
 * The combination of cisplatin and 5-fluorouracil is most often used;
 * It is performed both neoadjuvantly and adjuvantly.

Photodynamic treatment

 * Activated porphyrin is selectively absorbed by tumor tissue, after laser irradiation it forms oxygen radicals causing necrosis of the tumor;
 * Also being tested in Barrett's esophagus.

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