Esophageal cancer

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  • 1. Dr. Yannko González DomínguezCirugía general y del aparato digestivo Hospital La Paz
  • 2. www.isdecongress2008.com Epidemiology /Outcomes of EsophagealCancer.Molecular Biology and CarcinogenesisAdvances in Diagnostics Multimodal Treatment of EsophagealCancer.Cancer of the EG Junction.Barretts Esophagus.Clinical challenges in reflux disease. New GERD Therapies .Esophageal Reconstruction.
  • 3.  IT is estimated that 16,470 men and women(12,970 men and 3,500 women) will be diagnosed with and 14,280 men and women will die of cancer of the esophagus in 2008. Probabilidad de desarrollar cáncer 0,50 % ( 0,36% H y 0,08% M) 1 de cada 198 personas ( serán diagnosticadas de cáncer de esófago durante su vida) http://seer.cancer.gov/crs/1975_2005/results_single/sect.
  • 4. Sexta. Causa de muerte por cáncer Epidermoide : más frecuente a nivel mundial EE.UU incremento del 70 % adenocarcinoma. Supervivencia a 5 años 15,8 % Townsend.sabiston textbook of surgery.18 th ed.2007
  • 5. Incidencia Alta Media Baja540 x 100 mil Kazakhastan160x 100 mil China, Japón, Francia, Mongolia Brasil, Bermudas. África (Zimbabue, Kenia), Sudáfrica ( Transkei)20 x 100 mil Estados Unidos, resto de Europa1,5 x 100 mil Norte áfrica, América central, Asia occidental, Polinesia Townsend.sabiston textbook of surgery.18 th ed.2007
  • 6. Criterios Epidermoide AdenocarcinomaEdad 50-70 años >40 añosSexo H-M 3:1 H-M 15:1Raza Afroamericanos Varones blancosLocalización más 1/3 medio e inferior 1/3 inferiorfrecuenteFactores de riesgo Alcohol, tabaco, déficit Obesidad, vitaminas y minerales ERGE A,C,E,B12,acido fólico,, Hernia hiato riboflavina, Zn, Mb Ingesta de cáusticos. Bebidas calientesEnfermedades Achalasia Esófago de barrets.pre malignas Epidermoide Cabeza y cuello. Tylosis Plummer Vinson VPH Divertículos esofágicos. Enf. Celiaca.Abordaje quirúrgico Trans-torácico Trans- hiatalQuimioterapia- Menos sensible Responde mejor 25-30%RadioterapiaÍndice resecabilidad Menor MayorPronóstico Peor Mejor
  • 7. Supresores P 53, Es una condición p21,p16,p14 adquirida Apoptosis Bcl2,Bcl XL , BaX , Tylosis: 40 % epidermoide Oncogenes Bad, BaK Achalasia: 16 veces epidermoidee –caderina, ciclina D1 Plummer Vinson: epidermoide Barrets:40 veces adenocarcinoma 1-Origin of adenocarcinoma in barretts esophagus:p53 and ki67 expression and histopathologic background. december 10,2004 2-Molecular aspects of esophageal squamos cell carcinoma carcinogenesis.december,2003
  • 8. LA. Feagins.RF Souza. Molecular targets for treatment of barretts esophagus.disease of the esophagus .(2005)18,75-86
  • 9. D. Vallbohmer. H-J lenz. Predictive and prognostic molecular markers in outcome of esophageal cancer.Disease of the esophagus(2006).19,425-432
  • 10. •Risk assesment: •Cardiovascular funtion •Pulmonary funtion •Nutritional status Patient •Accurate staging: selection •CT •EUS •EUS+FNA •PET SCAN •MIS Optimal management of Surgical • TTE,THE,VSE,EBE,MIE,MIRE esophageal cancer approach And extent • Three field vs two field of resection • Lymph node dissection • CHEMOTHERAPYHigh hospital volume Multimodality • RADIOTHERAPY • ADYUVANT ANDSurgeons experience treatment • NEO ADJUVANT • PALLIATIVE MESURES.Arjun pennathur, MD. Resection for esophageal cancer: Strategies for optimal management.Ann thorac surg 2008;85:S751-6 .
  • 11. Técnicas diagnósticas. Evaluación.Esofagograma: Todo paciente con disfagia/ Apple Core.Endoscopia. 1. Localización de lesión+ Biopsia. 2. Naturaleza ( friable, firme, poliploide) 3. Extensión proximal y distal 4. Relación con músculo cricofaríngeo, unión GE, cardias. 5. Distensibilidad del estomago.TAC c-t-a.  Tamaño tumoral.  Engrosamiento pared esófago y estomago.T s 57%  Nódulos 3 field(cervical, mediastino, celiaco)N s 74%  Metástasis a distancia (hígado, pulmón, etc.)M s 83%  T 4 (infiltración estructuras adyacentes)PET- TAC i. Evaluar tumor primario.N s 72 % ii. Nódulos linfáticos.M s 88% iii. Metástasis a distancia.RMN T 4 (infiltración estructuras adyacentes)T y N s 74% Vascular y nerviosaEco endoscopia +/- BAAF  Tamaño tumoral. Invasión de la pared esofágica.T s 85-90% Grado de compromiso luminal.N s 70-90% Nódulos linfáticos 3 mm y toma de biopsia.N+B >90% (para traqueales, sub carinales, para esofágicos, celiacos)MISM Broncoscopia.( tos, evidencia de cáncer cervical, localización( minimally invasive supracarinal, descartar fistulas traqueo esofágicas, invasión tumoralsurgical modalities) de la tráquea) Laparoscopia. (Biopsia/Nódulos celiacos, peri hepáticos, gástricos)  Mediastinoscopia.(biopsia ganglionar, no accesible por otras vías) Toracoscopia. ( Nódulos , metástasis, afectación estructuras adyacentes).
  • 12. Radioterapia Adyuvante: 6000-6400 Gy (180-200 Gy) 5 veces x semana. Radioterapia neo adyuvante: 4500 Gy En combinación con quimioterapia. 50-50,4 Gy Quimioterapia Quimio neo adyuvante: cisplatino+5 fluoracilo 4 ciclos 1 x semana Quimio adyuvante: cisplatino+5 fluoracilo 8 ciclos 1 x semanaSimon law. John Wong. Current managment of esophageal cancer . journal of gastrointestinal surgery 2005 vol 9 N 2.
  • 13.  Radiotherapy before surgery for cancer of the esophagus does not seem to improve patients chances of survival. (five randomised trials and 1147 patients) Meta-analysis. Cochrane database of systematic reviews 2008 issue 2/ first published on line: 19 october 2005. When a non operative approach is selected then concomitant RTCT is superior to RT alone for patients with localized esophageal cancer but with significant toxicities. Meta-analysis. Cochrane database of systematic reviews 2008 issue 1 / first published on line: 25 january 2006. Preoperative chemotherapy plus surgery may offer a survival advantage compared to surgery alone for resectable thoracic esophageal cancer but the evidence is inconclusive. ( eleven randomised trials and 2019 patients) Meta-analysis. Cochrane database of systematic reviews 2008 issue 2/ first published on line: 19 julio 2006. The most recent meta-analysis ,combinig neoadjuvant chemotherapy and surgery, and the largest RCT of 804 patients, demostrated and absolute survival advantage of around 7-9 % at two years wihich just reached statistical significance. Benefit was less clear for squamos cell carcinoma than adenocarcinoma. ( eight randomised trials and 804 patients) Gesbki V : a meta-analysis. Lancet Oncol 2007;8:226-234.
  • 14.  Esofagectomía trans- torácica.(TTE) Esofagectomía trans- hiatal.(THE) Vagal sparing.(VSE) Esofagectomía en bloque.(EBE) Esofagectomía mínimamente invasiva.(MIE) Esofagectomía robótica.
  • 15. Comparación de las diferentes técnicas de resección esofágicas EBE TTE THE VSE MIEIncisión Cuello Tórax Cuello Cuello Cuello Tórax Abdomen Abdomen Abdomen Tórax Abdomen abdomenAnastomosis Cuello Tórax Cuello Cuello CuelloLinfadenectomía Radical Torácica Mediastínica NO Torácica y Torácica abdominal baja y abdominal abdominal abdominalPiloroplastia SI SI SI NO SIPreservación de NO NO NO SI NOnervios vagos Esofagectomía trans- torácica.(TTE) Esofagectomía trans- hiatal.(THE) Vagal sparing.(VSE) Esofagectomía en bloque.(EBE) Esofagectomía mínimamente invasiva.(MIE) Townsend.sabiston textbook of surgery.18 th ed.2007
  • 16. M S Kent, M Schuchert. Minimally invasive esophaguectomy: State of the art. Disease of the esophagus(2006) 19;137-145.
  • 17. 500 esofaguectomias.Luketich J, Alvelo-Rivera M, Buenaventura P et al.Minimally invasive esophagectomy: outcomes in 222 patients.Ann Surg 2003; 238: 486–95 .Mortalidad :1,4 %Fistulas anastomoticas:11,7 % The University of Pittsburgh MedicalParalisis cuerdas vocales: 3,6 % Center (UPMC) LA.Supervivencia 5 años: 36% Palanivelu C, Prakash A, Rangaswamy S et al. Minimally invasive esophagectomy: Thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position. An experience of 130 patients. J Am Coll Surg in press . Mortalidad:1,5 %. Fistulas de anastomosis: 3 % Morbilidad: 11% India. Coimbatore.
  • 18. Dr. Horgan Santiago . 2003.Realizó la primera esofagectomía robótica.Tiempo quirúrgico total 246 min (consola 52 min)Sangrado 50 ml.Dr. Kerstine. 2004.Realizó la primera esofagectomía trans-torácica ytrans-abdominal robótica Thornton Hospital. California, San Diego.Tiempo quirúrgico total 11 horas (consola 4 hrs y 20 min).Sangrado 900 ml Pctes T Qx Ganglios Estancia Tiempo abdominal y hospitalaria cervical Austria 4 173 12 14 días Vía abierta 2005 min Países 21 180 20 18 días Vía abierta bajos min 2006 Thomas J. Watson, MD. Robotic esophaguectomy: Is it an advance and what is the future.Ann thorac surg 2008;85:S757-9.
  • 19.  Mayores.  Menores1. TEP 1. Derrame pleural2. IAM 2. Neumonía3. Mediastinitis 3. Infección de Hxqx4. SDRA 4. Alteraciones hidro-5. Shock electrolitícas6. Quilo-tórax7. Fuga anastomosis
  • 20.  Los bio-marcadores genéticos: Útiles para:1. predecir respuesta a terapias neo-adyuvantes.2. Necesidad de terapia adyuvantes.3. Riesgo de recurrencia local.4. Supervivencia.5. Desarrollo de nuevas terapias especificas. Las técnicas mínimamente invasivas presentan menores tasas de morbi-mortalidad.
  • 21. 1. SJ Arnold. Preoperative radiotherapy for esophageal carcinoma. Cochrane database of systematic reviews 2008. issue 2.2. R Wong, R Malthanner. Combined chemotherapy and radiotherapy ( without surgery) compared with radiotherapy alone in localizad carcinoma of the esophagus. cochrane database of sytematic reviews 2008. issue 1.3. RA malthaner, S Collins. Preoperative chemotherapy for resectable thoracic esophageal cancer. Cochrane database of systematic reviews 2008. issue 2.4. Shahzad G.Raja. Does neoadjuvant chemotherapy improve survival in patients with thoracic oesophageal cancer ? Interact Cardio Vasc Thorac Surg 2007; 6:661-6645. R A Malthaner . Neoadjuvant or adjuvant therapy for resectable esophageal cancer: a systematic review and meta-analysis. BMC Medicine 2004,2.35.6. Simon law. John Wong. Current managment of esophageal cancer . Review article. 2005 the thoracic Society for surgery of the alimentary tract.7. Patricio burdiles. Displasia de alto grado en esofago de barret: parte I. fundamentos para el clinico. Rev chilena de cirugia Vol 59- N 2 abril 2007 :150-155.8. Patricio burdiles. Displasia de alto grado en esofago de barret: parte II. Alternativas de tratamiento. Rev chilena de cirugia Vol 59- N 3 junio 2007 :233-243.9. Darcido Matenhauer LEHRBACH. Molecular aspects of esophageal squamos cell carcinoma carcinogenesis. Review article. Arq gastroeterol . V 40 n 4 out/dez. 2003.10. Sergio Szachnowicz. Origin of adenocarcinoma in barrets esophagus: p53 and Ki 67 expression and histopathologic background.original reserch. Clinics 60(2):103-112,2005.
  • 22. 11. Arjun pennathur, MD. Resection for esophageal cancer: Strategies for optimal management.Ann thorac surg 2008;85:S751-6.12. Gu Y, Swisher SG, Ajani JA, et al: The number of lymph nodes with metastasis predicts survival in patients with esophageal cancer or esophagogastric junction adenocarcinoma who receive preoperative chemoradiotherapy. Cancer 2006; 106:1017-1025.13. W-T-Fang, W-T. Chen. Selective three field lymphadenectomy for thoracic esophageal squamos carcinoma. Disease of the esophagus. Original article (2007) 20.206-211.14. Thomas J. Watson, MD. Robotic esophaguectomy: Is it an advance and what is the future.Ann thorac surg 2008;85:S757-9.15. M S Kent, M Schuchert. Minimally invasive esophaguectomy: State of the art. Disease of the esophagus(2006) 19;137-145.16. Elbert Y. Kuo, MD, MPH. Impact of hospital volume on clinical and economic outcomes for esophaguectomy. Original article.Ann thorac surg 2001;72:1118-24.17. I Braguetto,A. Csendes,G. Open transthoracic or transhiatal esophaguetomy in terms of morbidity, mortality and survival. Surg endoc (2006) 20: 1681-1686.18. D vallbomer, H-J lenz. Predictive and prognostic molecular markers in outcome of esophageal cancer. Review article. Disease of hte esophagus (2006) 19,425-432.19. RE Sampliner. Managing Barretts esophagus: What is new in 2005 ?. Review article. Disease of the esophagus(2005)18; 17-20.20. Burkhard HA von Rahden, Hubert J Stein, j Rudiger siewert. Surgical management of esophagogastric juntion tumors. Review article. World gastroenterol 2006 november 7;12(41):6608-6613.