🫀 Interná medicína · 14

Nádory pažeráka a žalúdka

Definícia

• Zhubné nádory pažeráka sú prevažne dlaždicobunkový karcinóm (proximálne dve tretiny) a adenokarcinóm (distálna tretina). Zhubné nádory žalúdka sú v 95 % adenokarcinómy; menej časté sú napr. lokalizované lymfómy, gastrointestinálne stromálne tumory (GIST) a leiomyosarkómy.

Etiológia a patogenéza

• Karcinóm pažeráka: rizikové faktory dlaždicobunkového karcinómu sú napr. fajčenie, alkohol a strava chudobná na ovocie a zeleninu; adenokarcinómu napr. Barrettov pažerák, fajčenie, vysoký BMI a GERD.
• Ďalšie rizikové faktory karcinómu pažeráka sú napr. achalázia, infekcia HPV, poleptanie lúhom, skleroterapia, pažerákové membrány pri Plummerovom-Vinsonovom syndróme a ožiarenie pažeráka.
• Karcinóm žalúdka má multifaktoriálnu etiológiu s významnou úlohou H. pylori; riziko zvyšujú aj napr. perniciózna anémia a chronická atrofická gastritída (intestinálny typ) alebo polypy žalúdka.
• Genetické faktory, napr. hereditárny difúzny karcinóm žalúdka (autozómovo dominantná mutácia CDH1 s vysokou penetranciou), familiárna adenomatózna polypóza, Lynchov syndróm, juvenilná polypóza, Peutzov-Jeghersov syndróm.

Klinický obraz

• Karcinóm pažeráka: včasné štádium býva asymptomatické; progresívna dysfágia – najprv tuhá strava, potom kašovitá, nakoniec tekutiny a sliny.
• Karcinóm pažeráka: úbytok hmotnosti je takmer univerzálny (aj pri zachovanej chuti do jedla); útlak n. laryngeus recurrens môže spôsobiť chrapot.
• Karcinóm žalúdka: počiatočné príznaky sú nešpecifické, často dyspepsia pripomínajúca peptický vred; neskôr napr. skorá sýtosť, dysfágia (nádor kardie), úbytok hmotnosti.
• Metastatický karcinóm žalúdka – napr. Virchowova uzlina (ľavá supraklavikulárna), uzlík sestry Mary Josephovej (periumbilikálne), Irishova uzlina (ľavá axila), Krukenbergov tumor (ovárium).

Diagnostika

• Pri podozrení na karcinóm pažeráka endoskopia s cytológiou a biopsiou; bárnatá pasáž môže ukázať obštrukciu, ale na histologickú diagnózu je potrebná endoskopia.
• Staging karcinómu pažeráka: CT hrudníka, brucha a panvy a celotelové PET-CT; ak nie sú metastázy, endosonografia (hĺbka invázie, regionálne uzliny).
• Pri podozrení na karcinóm žalúdka endoskopia s viacerými biopsiami a kefkovou cytológiou; CT hrudníka a brucha, pri negatívnom CT endosonografia; CEA pred operáciou a po nej.
• Histológia adenokarcinómu žalúdka podľa Laurena: intestinálny typ (tvorba žliazok, častejší) a difúzny typ (chýbajú medzibunkové adhézne molekuly, spravidla bez tvorby žliazok).

Liečba

• Karcinóm pažeráka: v štádiu 0 a včasnom štádiu I (T1a) je často možná endoskopická resekcia.
• Karcinóm žalúdka štádia I: liečbou voľby je resekcia s regionálnou lymfadenektómiou; endoskopická mukózna resekcia u vybraných pacientov v štádiu IA; perioperačná chemoterapia alebo pooperačná chemorádioterapia pri T1 N1 a T2 N0.
• Karcinóm žalúdka štádia II–III: resekcia po posúdení multidisciplinárnym tímom; pre vysoké riziko recidívy sa má okrem operácie zvážiť perioperačná alebo pooperačná liečba.
• Metastatické/inoperabilné ochorenie: paliatívna liečba – pri karcinóme žalúdka systémová liečba (pri metastatickom adenokarcinóme zvážiť vyšetrenie HER2, dMMR/MSI a PD-L1); pri dysfágii z karcinómu pažeráka je odporúčanou metódou samoexpandovateľný kovový stent.

Komplikácie a prognóza

• Karcinóm pažeráka: fistula medzi pažerákom a tracheobronchiálnym stromom môže spôsobiť pľúcny absces a pneumóniu.
• Karcinóm pažeráka metastázuje zvyčajne do pľúc a pečene.
• Karcinóm žalúdka: obštrukcia pyloru – paliatívna gastroenteroanastomóza, len ak môže zlepšiť kvalitu života.
• Karcinóm žalúdka: masívna hematemeza alebo meléna sú nezvyčajné, skrytá strata krvi však môže viesť k anémii.

Kľúčové pojmy

karcinóm pažeráka	carcinoma oesophagi
karcinóm žalúdka	carcinoma ventriculi
dlaždicobunkový karcinóm	carcinoma planocellulare
adenokarcinóm	adenocarcinoma
Barrettov pažerák
dysfágia	dysphagia
gastrektómia	gastrectomia

📎 Zdroje:

Esophageal Cancer - MSD Manual Professional Edition (úvod – lokalizácia)The most common malignant tumor in the proximal two-thirds of the esophagus is squamous cell carcinoma; adenocarcinoma is the most common in the distal one-third.
Stomach Cancer - MSD Manual Professional Edition (úvod – typy nádorov)Gastric adenocarcinoma accounts for 95% of malignant tumors of the stomach; less common are localized gastric lymphomas, gastrointestinal stromal tumors, and leiomyosarcomas.
Esophageal Cancer - StatPearls - NCBI Bookshelf (Epidemiology – rizikové faktory)Risk factors for esophageal squamous cell carcinoma include smoking, alcohol consumption, and a diet low in fruits and vegetables. In contrast, esophageal adenocarcinoma high-risk factors include Barrett esophagus, smoking, high body mass index, and gastroesophageal reflux disease.
Esophageal Cancer - MSD Manual Professional Edition (úvod – ďalšie rizikové faktory)Other risk factors include achalasia, human papillomavirus infection, lye or other caustic substance ingestion (resulting in stricture), sclerotherapy, esophageal webs due to Plummer-Vinson syndrome, and irradiation of the esophagus.
Stomach Cancer - MSD Manual Professional Edition (úvod – etiológia)Etiology of stomach cancer is multifactorial, but Helicobacter pylori plays a significant role.
Gastric Cancer - StatPearls - NCBI Bookshelf (Etiology – host factors)Pernicious anemia and chronic atrophic gastritis increase the risk of intestinal-type gastric cancer up to 6-fold.
Gastric Cancer - StatPearls - NCBI Bookshelf (Etiology – ďalšie stavy)Other conditions associated with an increased risk include benign gastric ulcers, hypertrophic gastropathy, and gastric polyps.
Stomach Cancer - MSD Manual Professional Edition (Etiology – CDH1)Hereditary diffuse gastric cancer is associated with a mutation in the cadherin 1 gene (CDH1) and has no precursor lesion. This mutation is an autosomal dominant trait with high penetrance.
Stomach Cancer - MSD Manual Professional Edition (Etiology – iné syndrómy)Other genetic syndromes that predispose to stomach cancer include familial adenomatous polyposis, Lynch syndrome, juvenile polyposis syndrome, and Peutz-Jeghers syndrome.
Esophageal Cancer - MSD Manual Professional Edition (Symptoms and Signs – dysfágia)Early-stage esophageal cancer tends to be asymptomatic. When the lumen of the esophagus becomes progressively constricted, dysphagia commonly occurs. The patient first has difficulty swallowing solid food, then semisolid food, and finally liquids and saliva
Esophageal Cancer - MSD Manual Professional Edition (Symptoms and Signs – úbytok hmotnosti, chrapot)Weight loss, even when the patient maintains a good appetite, is almost universal. Compression of the recurrent laryngeal nerve may lead to vocal cord paralysis and hoarseness.
Stomach Cancer - MSD Manual Professional Edition (Symptoms and Signs – počiatočné príznaky)Initial symptoms of stomach cancer are nonspecific, often consisting of dyspepsia suggestive of peptic ulcer.
Stomach Cancer - MSD Manual Professional Edition (Symptoms and Signs – neskoré príznaky)Later, early satiety (fullness after ingesting a small amount of food) may occur if the cancer obstructs the pyloric region or if the stomach becomes nondistensible secondary to linitis plastica.
Stomach Cancer - MSD Manual Professional Edition (Symptoms and Signs – neskoré príznaky – dysfágia, hmotnosť)Dysphagia may result if cancer in the cardiac region of the stomach obstructs the esophageal outlet. Loss of weight or strength, usually resulting from dietary restriction, is common.
Gastric Cancer - StatPearls - NCBI Bookshelf (History and Physical – eponymné metastázy)Metastatic gastric cancer can present with several distinctive signs, including the Virchow node (ie, left supraclavicular adenopathy), Sister Mary Joseph node (ie, periumbilical nodule), and Irish node (ie, left axillary node).
Gastric Cancer - StatPearls - NCBI Bookshelf (History and Physical – Krukenbergov tumor)Direct metastasis to the peritoneum may manifest as a Krukenberg tumor (ovarian mass)
Esophageal Cancer - MSD Manual Professional Edition (Diagnosis – endoskopia)Patients suspected of having esophageal cancer should have endoscopy with cytology and biopsy. Although barium radiograph may show an obstructive lesion, endoscopy is required for biopsy and tissue diagnosis.
Esophageal Cancer - MSD Manual Professional Edition (Diagnosis – staging)Patients in whom esophageal cancer is identified require CT of the chest, abdomen, and pelvis as well as whole-body positron emission tomography (PET)-CT to determine extent of tumor spread.
Esophageal Cancer - MSD Manual Professional Edition (Diagnosis – endosonografia)If cross-sectional imaging results are negative for metastasis, endoscopic ultrasound should be done to determine the depth of the tumor in the esophageal wall and regional lymph node involvement.
Stomach Cancer - MSD Manual Professional Edition (Diagnosis – endoskopia)Patients suspected of having stomach cancer should have endoscopy with multiple biopsies and brush cytology.
Stomach Cancer - MSD Manual Professional Edition (Diagnosis – staging)Patients in whom cancer is identified require CT of the chest and abdomen to determine extent of tumor spread. If CT is negative for metastasis, endoscopic ultrasound should be done to determine the depth of the tumor and regional lymph node involvement.
Stomach Cancer - MSD Manual Professional Edition (Diagnosis – CEA)The carcinoembryonic antigen (CEA) level should be measured before and after surgery.
Gastric Cancer - StatPearls - NCBI Bookshelf (Histopathology – Lauren)The most common variant is the intestinal type, characterized by gland formation and similar in appearance to other intestinal adenocarcinomas. The less common diffuse-type gastric cancer lacks intercellular adhesion molecules and does not typically have gland formation.
Esophageal Cancer - MSD Manual Professional Edition (Treatment – endoskopická resekcia)Patients with stage 0 and early stage I (T1a) tumors are often amenable to endoscopic resection.
Gastric Cancer Treatment (PDQ®)–Health Professional Version - NCI (Treatment of Stage I – resekcia)Surgical resection including regional lymphadenectomy is the treatment of choice for patients with stage I gastric cancer.
Gastric Cancer Treatment (PDQ®)–Health Professional Version - NCI (Treatment Options for Stage I – EMR a perioperačná liečba)Endoscopic mucosal resection (EMR) for select patients with stage IA gastric cancer. Postoperative chemoradiation therapy or perioperative chemotherapy for patients with node-positive (T1 N1) and muscle-invasive (T2 N0) disease.
Gastric Cancer Treatment (PDQ®)–Health Professional Version - NCI (Treatment Options for Stages II and III)Surgical resection (after discussion with a multidisciplinary team regarding the role of perioperative and adjuvant therapy)
Gastric Cancer Treatment (PDQ®)–Health Professional Version - NCI (Stages II and III – perioperačná liečba)Because of the high risk of locoregional and distant recurrence, perioperative and postoperative therapy should be considered in addition to surgery.
Gastric Cancer Treatment (PDQ®)–Health Professional Version - NCI (Stage IV, Inoperable, and Recurrent)Treatment options for stage IV, inoperable, and recurrent gastric cancer, including patients with medically or surgically unresectable disease, include a combination of cytotoxic therapies, targeted therapies, immunotherapies, and palliative locoregional therapies.
Gastric Cancer Treatment (PDQ®)–Health Professional Version - NCI (Stage IV – biomarkery)Patients with metastatic gastric adenocarcinoma should consider undergoing testing for HER2 amplification, defective mismatch repair (dMMR) (immunohistochemistry [IHC] staining), or microsatellite instability (MSI)
Gastric Cancer Treatment (PDQ®)–Health Professional Version - NCI (Stage IV – biomarkery – PD-L1)along with programmed death ligand 1 (PD-L1) combined positive score
Esophageal Cancer Treatment (PDQ®)–Health Professional Version - NCI (Treatment Option Overview – paliácia dysfágie)Self-expandable metal stent positioning is the recommended method for palliation of dysphagia from esophageal cancer.
Esophageal Cancer - MSD Manual Professional Edition (Symptoms and Signs – fistula)Fistulas between the esophagus and tracheobronchial tree may cause lung abscess and pneumonia.
Esophageal Cancer - MSD Manual Professional Edition (Symptoms and Signs – metastázy)The tumor usually metastasizes to lung and liver
Stomach Cancer - MSD Manual Professional Edition (Treatment – paliatívna chirurgia)Palliative surgery typically consists of a gastroenterostomy to bypass a pyloric obstruction and should be done only if the patient’s quality of life can be improved.
Stomach Cancer - MSD Manual Professional Edition (Symptoms and Signs – krvácanie)Massive hematemesis or melena is uncommon, but secondary anemia may follow occult blood loss.

Precvičiť tému (6)

Kartičky

Vymenujte rizikové faktory dlaždicobunkového karcinómu a adenokarcinómu pažeráka.

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.

Vymenujte eponymné znaky metastatického karcinómu žalúdka.

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.

Opíšte diagnostický postup pri podozrení na karcinóm žalúdka.

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.