Gullet cancer
Description:
Cancer - the most often found gullet disease. 70-90% of all diseases of a gullet fall to its share. In structure of incidence of malignant new growths of the person cancer of a gullet takes the 9-10th place. Gullet cancer meets at men more often, women are ill it 2-3 times less often.
Distinguish 3 forms of cancer of gullet:
* ulcer (saucer-shaped, crateriform) - grows ekzofitno in a gullet gleam preferential on length;
* nodal (fungoid, papillomatous) - has a cauliflower appearance, obturirut a gullet gleam, at disintegration can remind ulcer cancer;
* infiltriruyushchiya (the scirrhus stenosing) - develops in a submucosal layer, tsirkulyarno covers a gullet, it is shown in the form of whitish dense mucous against the background of which there can be ulcerations; the stenosing circular growth prevails over growth on length of body.
For the correct assessment of prevalence of process, the choice of a method of treatment and reliable assessment of the long-term results of treatment use classification of cancer of gullet by stages.
* The I stage - the small tumor affecting a mucous membrane and a submucosa of a wall of a gullet without germination of its muscular coat. There is no narrowing of a gleam of a gullet. There are no metastasises.
* The II stage - a tumor strikes also a muscular coat of a gullet, but does not go beyond a wall of body. There is a narrowing of a gleam of a gullet. Single metastasises in regional lymph nodes are found.
* The III stage - a tumor sprouts all layers of a wall of a gullet, pass periesophagal cellulose or a serous cover. There is no germination in the next bodies. Esophageal stenosis. Multiple metastasises in regional lymph nodes.
* The IV stage - a tumor sprouts all layers of a wall of a gullet, periesophagal cellulose, extends to adjacent bodies. There can be esophageal and tracheal or esophageal and bronchial fistula, multiple metastasises in the regional and remote lymph nodes (classification is accepted by the Ministry of Health of the USSR v1956g.).
Gullet Cancer symptoms:
It is necessary to refer the progressing deterioration in the general condition of patients, a loss of appetite, increase of the general weakness, decrease in working capacity, loss of body weight to precursory symptoms of cancer of gullet. Accruing gradually, gradually, these phenomena a long time remain unnoticed patients.
The first, but, unfortunately, not an early symptom of cancer of gullet is the dysphagy - disturbance of swallowing of food. This symptom is observed more than at 75% of patients with cancer of a gullet. Approximately at 2% of patients the delay of passing of food on a gullet occurs imperceptibly. Or rather, patients do not fix on it attention, though refuse reception of rough and dry food. Patients swallow food which reception causes plentiful salivation (fried meat, sausage, herring) better, and worse — black bread, boiled potatoes, boiled meat. In the beginning the careful chewing of food and a zapivaniye its water possible to remove the burdensome phenomena of a dysphagy that allows patients to eat without restrictions. In these cases the dysphagy has periodic character and is observed only in cases of hasty meal of a proglatyvaniye of the big, badly chewed pieces. In process of progressing of a disease the dysphagy becomes a constant.
At some patients with the first symptom of a disease plentiful hypersalivation is. Usually it appears at sharp degrees of an esophageal stenosis. On A. I. Savitsky's classification the dysphagy can distinguish 4 degrees of its expressiveness:
* The I degree - difficulty of passing of firm food on a gullet (bread, meat);
* The II degree - the difficulties arising at reception of kashitseobrazny and semi-fluid food (porridge, puree);
* The III degree - difficulties when swallowing liquids;
* The IV degree - full impassability of a gullet.
Approximately in 17-20% of cases the disease is shown by pain behind a breast or in epigastriß area, in spin. Patients note a dull, nagging pain behind a breast more often, is more rare - the feeling of a prelum or compression in heart extending up to a neck. Pain can arise at the time of swallowing and disappear after a while after the gullet is exempted from food. Less often pain has constant character and amplifies when passing food on a gullet. Pain at cancer of a gullet can be felt at irritation of nerve terminations in изъязвившейся and the breaking-up tumor as the passing food masses. In such cases patients feel how the food lump, passing through a certain place of a gullet, "scratches", "burns" it. Pain can arise at the strengthened spastic reductions of a gullet directed to pushing through of a food lump through the narrowed site of a gullet and also at germination of a tumor in the fabrics and bodies surrounding a gullet with squeezing of vessels and nerves of a mediastinum. In that case it is not connected with the act of swallowing and has constant character.
It is important to note that patients with cancer of a gullet it is often inexact characterize the level of a delay of food and level of developing of pain. About 5% of patients before development of a resistant dysphagy note only uncertain character unpleasant feelings behind a breast not only when swallowing food, and out of that. All this complicates clinical interpretation of the first symptoms of cancer of gullet.
By consideration of clinical displays of widespread cancer of gullet it is necessary to pay special attention to the general condition of the patient. As a rule, at patients with cancer of a gullet deficit of body weight is noted. Loss of body weight is connected first of all with limited receipt in an organism of the patient of food, but not with toxic influence of widespread tumoral process. Especially considerable loss of body weight is observed at extreme degrees of a dysphagy when the patient loses an opportunity to accept even liquid owing to what his general state sharply worsens from organism dehydration. therefore at cancer of a gullet it is necessary to distinguish the general serious condition of the patient which arose owing to intoxication at far come tumoral process (cancer intoxication and a cachexia) and a nutritional dystrophy and dehydration of an organism.
Smell from a mouth, unpleasant taste in a mouth, a coated tongue, nausea, vomiting - all these signs which are usually poorly expressed in early stages of cancer of gullet rather well are shown at common forms of a disease and can be explained not only with the esophageal stenosis, but also disbolism, qualitative inferiority of oxidizing processes strengthened by disintegration of proteins leading to accumulation in an organism of nedookislenny products and excess of lactic acid.
At widespread cancer of a gullet it is possible to observe a voice osiplost that is a consequence of a prelum metastasises or germinations by a tumor of a recurrent nerve. At widespread cancer of a cervical part of a gullet, and also at a tumor of its chest part quite often there is a poperkhivaniye and cough when swallowing liquid food because of dysfunction of the closing device of a throat or formation of esophageal and tracheal, esophageal and bronchial fistula. At such patients symptoms of aspiration pneumonia develop.
Gullet Cancer reasons:
Refer systematic reception of the hot, burning, rough, badly chewed food, consumption of hard alcoholic beverages and smoking to the factors promoting developing of cancer of gullet. These factors cause chronic inflammatory processes which at long existence lead to development of malignant new growths. Here it should be noted the processes involving development of hems, chronic inflammatory changes - postburn strictures, esophagites because of hernia of an esophageal opening of a diaphragm, a "short" gullet, etc. Along with it, cancer of a gullet has also professional character - machine operators are ill more often: tractor operators, drivers, combine operators.
Development of cancer of gullet is promoted also by diverticulums in which chronic inflammatory processes are supported. The big part in development of cancer of gullet is assigned by leukoplakias.
The leukoplakia of a mucous membrane passes into gullet cancer in 48% of cases. Therefore most of researchers consider a leukoplakia an obligate precancer. Communication between cancer of a gullet and a sideropenic syndrome arising owing to decrease in content of iron in plasma (sideropenia) is noted. The sideropenic syndrome (a sideropenic dysphagy, Plummer-Vinson's syndrome) is characterized by a dysphagy, an akhiliya, a chronic glossitis and a cheilitis, an early hair loss and the loss of teeth expressed by hypochromia anemia. In development of cancer of gullet polyps and benign tumors have a certain value. However these diseases in itself meet rather seldom, and at a developed cancer it is not always possible to establish traces of the existing earlier pathological process.
Cancer therapy of a gullet:
The main methods of cancer therapy of a gullet are:
* surgical,
* beam,
* combined (combining beam and surgical components),
* complex (representing a combination surgical, beam and medicinal methods (chemotherapeutic) treatment).
Low sensitivity of a tumor to the existing himiopreparata, palliative and short-term effect of radiation therapy do surgical intervention by a choice method in treatment of patients with cancer of a gullet.
History of broad use of a surgical method of cancer therapy of a gullet contains a little more than 50 years. Use of surgical treatment restrained lack of reliable ways of anesthesia that significantly extended operative measure time, and lack of the fulfilled technique of a plastic stage of surgical treatment. It caused long existence of a two-stage way of operational treatment. Dobromyslov-Toreka's operation (a gullet extirpation with imposing of a cervical ezofagostoma and gastrostomy), the second stage - an esophagoplasty by one of the numerous developed techniques was the first stage. For plastics practically all departments of a digestive tract were used: the small bowel and various departments of thick, were applied various methods of plastics by the whole stomach and gastric rags.
There was a set of ways of an arrangement of a transplant: presternal, retrosternal, in a bed of a remote gullet, and even, nowadays almost not applied, a way of skin plastics.
High postoperative lethality, technical difficulties of intervention, bulky system of multi-stage operations - all these factors divided surgeons into two camps.
Most of surgeons were supporters of radical removal of the struck body or its part at not started forms of a disease and did not object to radiation therapy. Other surgeons and oncologists critically estimated possibilities of surgical cancer therapy of a gullet, especially its high localizations, and gave preference to methods of radiation therapy.
Improvement of the surgical equipment, anesthesiology grant, the choice of optimum medical tactics caused the prevailing role of surgical cancer therapy of a gullet.
Modern principles of surgery of cancer of gullet:
* maximum safety of intervention: right choice of quick access and volume of surgical intervention;
* oncological adequacy: mobilization in "the acute way" by the principle "from a vessel to the struck body", the correct sequence of mobilization of the struck body for the purpose of prevention of intraoperative dissimination, a monoblock limfodissektion;
* high functionality: choice of a rational method of plastics, formation of technically simple anti-reflux anastomosis.
Comparative analysis of efficiency of single-step and multi-stage operations showed advantage of the first on indicators of a postoperative lethality (6,6%), completeness of treatment (98%) and the long-term results (33% of 5-year survival).
When determining the indication to surgical treatment it is necessary to consider that gullet cancer persons at the age of 60 years most often have and are more senior, the having a number of associated diseases, especially cardiovascular and respiratory systems that limits a possibility of use of operations. Besides, gullet cancer rather early leads to disturbance of food and frustration of all types of a metabolism that increases risk of operative measures.
Thus, the choice of an optimum method of treatment for each suffering from cancer gullet is a difficult task. In each case it is necessary to consider strictly a condition of the patient, extent of disturbance of food, prevalence of process, technical capabilities of the operating surgeon, ensuring adequate postoperative leaving.
Now two main ways of operative measures are applied:
* A gullet extirpation with plastics an isoperistaltic gastric rag with an extra pleural anastomosis on a neck in the form of transpleural removal of a gullet or an extra pleural extirpation - transkhiatalny access. The method allows to subject surgical influences all departments of a gullet up to a throat and even with a stomatopharynx resection. Finding of an anastomosis on a neck out of a pleural cavity significantly reduces risk of insolvency of an anastomosis, and it is not fatal. At the same time cases of a cicatricial stenosis of an anastomosis are frequent. It is necessary to emphasize that the traskhiatalny way (without thoracotomy) esophagectomies has limited use at tumors of the big sizes. Unfortunately, most of authors declares dominance of operations at widespread tumoral processes.
* An esophagectomy with a single-step intrapleural esophagoplasty a stomach - operation like Lewis. This way practically excludes an anastomosis stenozirovaniye, provides the best functional results (absence a reflux esophagitis), however upper parts of intrathoracic department of a gullet remain unavailable to a resection (cervical, verkhnegrudny departments).
When performing operation at gullet cancer carrying out a limfodissektion at least in two cavities on zones of lymphogenous innidiation is obligatory, and at an extirpation of a gullet of a limfodissektion also cervical lymph nodes are exposed.
The lethality at such types of operation is in limits of 7-10%. As a transplant in some cases use, except a stomach, thin silt a large intestine.
Toreka-Dobromyslov's operation in cases of a possibility of a single-step stage of plastics (a condition of the patient, technical features of operation) did not lose the value. It is necessary to point to a possibility of performance at unprofitable cancer of chest department of palliative interventions in the form of shunting of a tumoral stenosis by imposing of a bypass anastomosis.
In case of a nerezektabelny tumor the establishment of gastric fistula is possible. Patients with cancer of a gullet with the imposed gastrostomy can be subjected to radiation therapy.
Beam cancer therapy of a gullet remains by the only method of treatment for most of patients to whom operational treatment is contraindicated in view of the accompanying pathology which is available for them (the expressed frustration of cardiovascular, respiratory systems, etc.), at old age of patients, refusal of patients of operation. In some cases beam treatment has initially palliative character (after the laparotomy which is carried out earlier and a gastrostomy).
Use of modern techniques of radiation allows to achieve disappearance of burdensome clinical displays of a disease from 35-40% of patients.
The purpose of radiation is creation in the field of the irradiated body of a therapeutic dose in 60-70gr. At the same time, except the struck body, the area of radiation has to join zones of an arrangement of lymph nodes, a zone of possible innidiation: paraezofagealny lymph nodes, zone of lymph nodes paracardiac, areas of the left gastric artery and celiac trunk, supraclavicular areas. A classical method of radiation are 5 sessions of radiation therapy a week in a single focal dose 1,5-2gr (classical fractionation of a dose). At other options of fractionation of a dose, brought during the day, can change as also single focal doses can change.
Very effective at cancer of a gullet were methods of intracavitary radiation. Intracavitary radiation therapy is carried out on AGATHE WU'S device. At the same time the stylet with a telecobalt is entered into a gleam of a gullet and is established at the level of defeat. Sources of radiation establish 1 cm below and above the defined tumor borders. Optimum it is necessary to consider a tele-irradiation combination with intracavitary.
The combined and complex treatment. The aspiration of oncologists to improve the long-term results of treatment was the cause of development and use of the combined method combining radiation therapy and operation. Use of the combined treatment for patients with localization of a tumor in midthoracic department of a gullet is the most justified.
