cáncer de esófago

Introduction to Esophageal Neoplasia

Opening Remarks

• Buenas tardes a todos, la doctora inicia la sesión y verifica que se le escuche correctamente.

• Se disculpa por la demora y comienza a compartir su pantalla para presentar el tema.

Overview of Esophageal Cancer

Prevalence and Screening

• El cáncer de esófago no es el más frecuente en el tracto digestivo; el cáncer gástrico y colorrectal son más comunes.

• Las estrategias de tamizaje están enfocadas principalmente en estos tipos de neoplasias, aunque las endoscopias pueden detectar lesiones esofágicas iniciales.

Anatomy of the Esophagus

• El esófago tiene tres porciones: cervical, torácica y abdominal, cubiertas por capas histológicas como mucosa y muscular.

• La falta de una capa serosa facilita la diseminación del cáncer a órganos contiguos en etapas tempranas.

Endoscopic Evaluation

Normal Mucosal Appearance

• Durante una endoscopía, se observa una mucosa normal con un lumen conservado; esto es crucial para identificar alteraciones iniciales.

• La unión entre epitelio columnar y escamoso (línea Z) se encuentra aproximadamente a 40 cm de la arcada dentaria, siendo un punto anatómico importante para evaluar riesgos de reflujo.

Advanced Diagnostic Techniques

• Se utilizan métodos avanzados en endoscopía como tinciones y magnificación para detectar alteraciones microvasculares que podrían indicar procesos neoplásicos incipientes.

Epidemiology and Risk Factors

Incidence and Demographics

• El cáncer de esófago representa entre el 5% al 7% de los tumores digestivos; hay mayor incidencia en varones y ciertas etnias específicas.

• Solo alrededor del 25% de los casos diagnosticados son potencialmente resecables con intención curativa; muchos pacientes presentan estadios avanzados sin posibilidad curativa.

Lifestyle and Genetic Factors

• Los factores de riesgo incluyen tanto modificables (estilos de vida insalubres) como no modificables (edad, género, carga genética).

• Hábitos nocivos como consumo de tabaco y alcohol, así como dietas poco saludables son relevantes para el desarrollo del cáncer esofágico.

Esophageal Disorders and Cancer Risk Factors

Calasia as a Recognized Risk Factor

• Calasia is identified as a significant risk factor for esophageal disorders, often discussed in the context of motor disorders of the esophagus.

• The radiological image associated with calasia shows a "pencil tip" or "golden peak" appearance, indicating typical findings related to this condition.

Caustic Injuries and Esophagitis

• Ingestion of caustic substances can lead to caustic esophagitis, resulting in mucosal damage characterized by necrosis from either coagulation or liquefactive processes.

• Conditions like tilosis (hyperkeratosis palmoplantar) and Plummer-Vinson syndrome are also noted as contributing factors to esophageal cancer risk.

Impact of Previous Cancers and Treatments

• Patients with a history of cancers treated with radiation therapy in the thoracic or cervical regions may have an increased risk for developing esophageal neoplasia.

Adenocarcinoma and Reflux Disease

• Adenocarcinoma is particularly relevant for patients with long-standing gastroesophageal reflux disease (GERD), which can cause chronic injury to the esophagus.

• Erosive reflux seen during endoscopy can lead to cellular differentiation changes, termed metaplasia, specifically Barrett's esophagus.

Understanding Barrett's Esophagus

• Barrett's esophagus is recognized as a precancerous condition linked to chronic GERD; it occurs primarily in the distal third of the esophagus.

• Obesity is highlighted as a contributing factor due to its association with increased reflux episodes.

Progression Towards Cancer

• The progression from initial cellular alterations through growth and differentiation underscores the importance of early detection via screening methods.

• Early-stage cancers may be localized and resectable if diagnosed promptly; however, advanced stages can infiltrate surrounding tissues and lymphatic systems.

Monitoring Dysplasia Levels

• Differentiating between types of Barrett's esophagus—those without dysplasia versus those with varying degrees—is crucial for assessing cancer risk.

• Increased dysplasia correlates with higher cancer risks, necessitating stricter surveillance protocols for affected patients.

Histopathological Confirmation

• Endoscopic examinations reveal characteristic features such as salmon-colored mucosa indicative of Barrett’s. Biopsies are essential for histopathological confirmation by expert pathologists.

• If initial pathology results are inconclusive despite strong clinical suspicion, seeking a second opinion from another expert pathologist may be warranted.

Esophageal Pathology and Management

Key Concepts in Esophageal Pathology

• The presence of goblet cells (caliciform cells) indicates metaplasia, where squamous epithelium is replaced by columnar epithelium in the esophagus.

• Pathologists must determine if dysplasia is present; absence of dysplasia suggests a pure Barrett's esophagus, which is a risk factor for adenocarcinoma.

• If dysplasia is detected, treatment options include ablative therapy to remove dysplastic lesions, with follow-up endoscopies recommended every 3 to 5 years.

Treatment Approaches Based on Dysplasia Severity

• Low-grade dysplasia may require close monitoring with endoscopy every 6 to 12 months or ablative treatment if available.

• High-grade dysplasia necessitates ablative therapy or surgical intervention due to increased cancer risk.

Neoplasia Dissemination and Symptoms

• Neoplasia can spread locally to adjacent organs such as the heart, trachea, bronchi, and lungs or through hematogenous routes to distant sites.

• Tumor growth can lead to symptoms like dysphagia (difficulty swallowing), especially when tumors obstruct the esophageal lumen.

Clinical Presentation and Diagnosis

• Symptoms may include ulcerations leading to gastrointestinal bleeding (hematemesis or melena), weight loss, odynophagia (painful swallowing), and potential hoarseness from nerve infiltration.

• Endoscopy with biopsy remains the gold standard for diagnosing esophageal cancer; imaging studies like esophagograms assist but are not definitive.

Diagnostic Imaging Techniques

• Additional diagnostic tools include tomography for assessing lymph node involvement and distant metastasis after histopathological confirmation of cancer.

• Endoscopic ultrasound combines endoscopy with ultrasound technology for detailed evaluation of tumor invasion depth and surrounding structures.

Histological Layers and Cancer Staging

Understanding Mucosal Invasion

• The degree of mucosal invasion is critical; more extensive involvement reduces the chances for curative surgical or endoscopic resection.

• If cancer is localized to the lamina propria, it may be amenable to minimally invasive endoscopic resection, offering a potential cure.

Early Detection Strategies

• Screening at certain ages can help identify asymptomatic lesions early, often found incidentally during other procedures.

• Cancer infiltration progresses through stages: from high-grade dysplasia to intramucosal cancer, then deeper layers including lymph nodes and distant metastasis.

Tumor Classification and Resection Options

• The TMM classification aids in staging: T indicates tumor size, N indicates lymph node involvement, and M indicates metastasis presence. Understanding this is crucial for esophageal tumors.

• Cancers classified as T1A (infiltrating mucosa) are suitable for minimally invasive endoscopic resection; T1B or higher may require surgical intervention if no metastasis exists.

Treatment Approaches Based on Staging

• For cancers in situ and T1A, the first treatment option is endoscopic mucosal resection; if unavailable, esophagectomy becomes necessary. For advanced tumors (T1B+), palliative care options like stenting may be considered instead of curative treatments.

Endoscopic Techniques and Surgical Considerations

• Endoscopic therapies include ablation techniques for Barrett's dysplasia and mucosectomies; these require specialized training due to their complexity. Surgical options are available when trained personnel and facilities are accessible.

• Advanced cases with significant esophageal obstruction might necessitate placing stents or using feeding tubes to maintain patient quality of life despite limited prognosis.

Clinical Decision-Making in Cancer Diagnosis and Treatment

Clinical Judgment and Suspicion of Cancer

• The clinical judgment is crucial when suspecting cancer, as normal results may not rule out malignancy. A clinician's suspicion can lead to further investigation despite negative pathology results.

• If there is a strong clinical suspicion of cancer, options include additional biopsies or close monitoring through follow-up procedures like endoscopy.

Staging and Diagnostic Procedures

• Staging begins with imaging techniques such as tomography to check for distant metastasis; the presence of metastasis indicates advanced disease.

• In cases without distant metastasis, localized staging is performed using endoscopic ultrasound to determine tumor characteristics (T classification).

Evaluating Tumor Characteristics

• Assessing lymphovascular invasion is critical; if absent, it suggests a more favorable T classification (pure T).

• For tumors classified as T1 or TIS, endoscopic resection may be considered if appropriate resources and expertise are available.

Treatment Options Based on Tumor Size and Invasion

• For tumors larger than 2 cm with mucosal invasion (T1B or T2), surgical options should be evaluated first as they represent the best treatment approach.

• Multidisciplinary management involving gastroenterologists, oncological surgeons, and clinical oncologists is essential for effective cancer treatment planning.