食道癌简介课件

食 道 癌 簡 介 奇美醫院 胸腔外科 蘇英傑 食道簡介 食道特色 o長度: 25cm o3層構造 o3個狹窄 o3個走向: 左右左 食道分段 oCervical：環狀軟骨下緣 起至胸骨柄上緣平面， (18cm)。 oUpper third：自胸骨柄 上緣平面至氣管分叉平面 ，(24cm) oMiddle third：自氣管分 叉平面至食管胃交接部全 長的上半(32cm) o Lower third：自氣管分 叉至食管胃交接部全長的 下半，其下界約距上門齒 (40cm) 食道癌簡介 台灣地區食道癌流行病學 o粗發生率:10.92/十萬( 7th in male) o致死率: 10.6/十萬(6th in male) o1350 cases/year 男性為主 快速上昇 Comparison of risk factors Risk factors Squamous cell carcinoma Adenocarcinoma Cigarettes+ Alcohol+- Barretts esophagus-+ GERD-+ Overweight -+ Corrosive injury in esophagus+- Hx of head and neck cancer+- Hx of breast cancer with R/T+ 特殊危險因子 喝酒比不喝酒者得到食道癌之危險比為17.6倍，歸因比率為76%；而抽菸比 不抽菸者的危險比為5.4倍，歸因比率為72%，嚼食檳榔比起不嚼食檳榔的 危險比為1.7倍，未達統計學之意義，但若再細分其嚼食檳榔的行為如嚼食 的檳榔含有老花，其危險比則增加為4.2倍；若吞嚥檳榔汁，也達3.3倍， 具有統計學上之意義 鱗狀上皮癌為主 台灣食道癌特色 oMale predominent o90% Squamous cell carcinoma o1520% coexist with head and neck cancer oHigh association with tobacco and betal nuts oVery poor prognosis 食道癌分期 Current AJCC 2002 staging 注意事項 o食道癌只有 N1 ，沒有 N2 oCeliac and neck LN至少是M1a AJCC Staging - T Stage Clinical T stage determination-1 oEUS(Endoscopic ultrasound) lT stage 準確度高( 80%) l對 After CCRT / Complete tumor obstruction則準確度 降低 Clinical T stage determination-2 oCT scan oBronchoscopy Clinical N stage determination oCT scan: oEUS: oPETS: Clinical M stage determination oCT oBone scan oPETS AJCC Staging and Prognosis Ezinger PC, N Engl J Med 2003; 349:2241-2252 食道癌治療 食道癌的治療 o當確定診斷，及做完癌症分 期檢查後，在選擇治療方式 時必須考慮病人的健康狀態 ，癌症的期別，癌的類型。 vSurgery Chemotherapy Radiation Combination of these techniques ISurgery or Photodynamic therapy IIaSurgery IIb Neoadjuvant CCRT+surgery or CCRT only III Neoadjuvant CCRT+surgery or CCRT only IVChemotherapy or palliative therapy 手術治療 食道癌外科手術目標 o將癌病變區域切除 o周邊淋巴結廓清 o重建食道功能 手術術式選擇原則 癌病變所在區域 癌病變區域與周邊組織之關係 預期替代器官之可用性 有否施行過術前電療與化療 外科醫師之偏好 食道切除之方式 Transhiatal esophagectomy Transthoracic esophagectomy Videothoracoscopic esophagectomy Endoscopic esophagectomy 食道重建之組織選擇 o胃 o大腸 o小腸 oFree Flap o組織皮辦 Reconstruction oThe stomach is the conduit of choice because of ease in mobilization and ample vascular supply Jejunal Free Flap 食道重建之路徑 o皮下路徑 o胸骨後路徑 o後縱膈腔路徑 優點缺點 對呼吸功能影響最 小，即使發生吻合 處滲漏，其影響也 較小 路徑較長，故器官所需 的長度也較長。外觀上 的影響也較大。 發生吻合處滲漏時 ，對mediastinum 及pleural cavity的 影響較小 空間較狹小，易影響血 液循環 路徑短，手術較單 純 吻合處滲漏所產生的併 發症較嚴重 由食道原來的位置 放置重建的器官， 省時而容易施行 如食道癌復發，易再引 起吞嚥困難，使治療更 加複雜化 重建食道接口之位置 o頸部 o胸腔內 食道切除及重建手術 oOne field operation nThoraco-abdomen operation oTwo field operation nIvor-lewis procedure nTranshiatal esophagectomy oThree field operation oEndoscopic operation Thoraco-abdominal Incision oIndication: tumor located at GE junction oOpen the left thoracic and abdominal cavity in one incision oStomach or jejunum pulled up to left chest Ivor-lewis procedure Transhiatal Esophagectomy Three field operation Videothoracoscopic Esophagectomy Endoscopic Esophageal Reconstruction oRegardless of technique, surgeons generally agree on the desirability of a so-called R0 resection (a complete macroscopic and microscopic removal of tumor) ntwo-field lymphadenectomy: mediastinum and superior abdominal compartment nthree-field lymphadenectomy: mediastinum +superior abdominal +bilateral cervical 淋巴結廓清 oPatients with esophageal carcinoma should undergo an esophagectomy with at least a two-field en bloc dissection (level 1 to 2, grade B) oThere is insufficient evidence to make recommendations regarding the role of a three-field dissection. 淋巴結廓清之建議 oMinimally invasive esophagectomy is associated with at least equivalent results in terms of mortality, morbidity, and survival as open esophagectomy (level: 3b to 4, grade C) oPain control and pulmonary function may be better after VATS compared to thoracotomy for esophagectomy (level 3b, grade C) 內視鏡手術與傳統開胸手術比較 胸腔內接口與頸部接口之比較 oAn intrathoracic anastomosis is quicker to perform with lower risk for the development of anastomotic leakage and pulmonary complications (level:2b to 3b, grade B) oMortality due to a cervical anastomotic insufficiency is less lethal (level 3b, grade C) 胸腔內接口與頸部接口之比較 oA cervical anastomosis provides functional advantages concerning the incidence of heart-burn and regurgitation, combined with a lower rate of esophagitis (level 3b, grade C) oA cervical anastomosis allows for a longer esophageal margin from the proximal extent of tumor. However, this does not translate into a lower local recurrence rate (level 2b to 3b, grade B) oThe posterior mediastinal and retrosternal routes are associated with similar rates of immediate postoperative complications (level 1a- to 1b-, grade C) oThe posterior mediastinal and retrosternal routes are associated with similar long-term outcomes in relation to survival and quality of live (level1a to 1b, grade A) 食道重建路徑之建議 非手術治療 o早期食道癌治療 nPhotodynamic therapy nThermal ablation nLaser ablation nEndoscopic mucosal resection o晚期食道癌治療 nNeoadjuvant Chemotherapy nAdjuvant Che