I-Adenocarcinoma yesisu

nguJason Wasserman MD PhD FRCPC
December 21, 2023

I-Adenocarcinoma yesisu, eyaziwa nangokuthi umdlavuza wesisu, iwuhlobo lomdlavuza oqala emangqamuzaneni amboze ingaphakathi lesisu. Iwuhlobo oluvame kakhulu lomdlavuza wesisu, olubalelwa ku-90% kuya ku-95% wawo wonke umdlavuza wesisu. I isibikezelo I-adenocarcinoma yesisu iyahluka kakhulu ngokuya ngebanga le-histological, isigaba ngesikhathi sokuxilongwa, kanye nokusabalala kwamangqamuzana omdlavuza ama-lymph node.

Lesi sihloko sizokusiza ukuthi uqonde ukuxilongwa kwakho kanye nombiko we-pathology we-adenocarcinoma yesisu.

Isisu

Isisu siyisitho esinemisipha, esingenalutho emgudwini wamathumbu wabantu nezilwane eziningi. Idlala indima ebalulekile ohlelweni lokugaya ukudla ngokucubungula ukudla okugwinyisiwe, ukuhlephule kube uhlobo oluwuketshezi oluncane olubizwa ngokuthi i-chyme, bese kancane kancane likukhiphele emathunjini amancane.

Isisu sihlukaniswe izigaba ezine eziyinhloko, ngasinye sinemisebenzi ethile:

• I-Cardia: Lesi yisigaba sokuqala lapho ukudla kungena khona esiswini kusuka emthonjeni. Iqukethe izindlala ezikhiqiza amafinyila, avikela ulwelwesi lwesisu kujusi wesisu one-asidi.
• I-Fundus: Itholakala ngaphezu kwe-cardia, i-fundus igcina ukudla okungagayekile kanye namagesi akhishwa ekugayweni kwamakhemikhali kokudla. Idlala indima encane enqubweni yokugaya.
• Umzimba (i-corpus): Ingxenye enkulu kunazo zonke kanye nengxenye eyinhloko yokugaya yesisu, ikhophasi ikhiqiza i-asidi kanye nama-enzyme okugaya ukuze ahlukanise ukudla ngamakhemikhali kube uhlobo oluwuketshezi oluwuketshezi, i-chyme.
• I-Pylorus: Ingxenye yokugcina yesisu esebenza njenge-valve yokulawula ukuphuma kokuqukethwe kwesisu emathunjini amancane. Iqukethe i-pyloric sphincter, evula ukuvumela i-chyme ukuthi idlule emathunjini amancane futhi ivale ukuvimbela ukugeleza emuva.

I-antrum iyindawo evame kakhulu ye-adenocarcinoma ehlaselayo yesisu. Le ndawo isengozini yokungenwa yi-adenocarcinoma ngenxa yokuchayeka kwayo ezintweni ezahlukahlukene ezingaba nomthelela ekukhuleni komdlavuza, njengokuthi Helicobacter pylori ukutheleleka, ukuvuvukala okungapheli, izici zokudla, nokuba khona kwe-bile acids.

Yini ebangela i-adenocarcinoma esiswini?

Izici zemvelo ezihlobene ne-adenocarcinoma esiswini zifaka Helicobacter pylori ukutheleleka, Igciwane le-Epstein-Barr (EBV) ukutheleleka, ukubhema ugwayi, nezici zokudla. Ukuguqulwa kofuzo okubandakanya izakhi zofuzo ze-CDH1 noma i-APC nazo zihlotshaniswa nengozi eyengeziwe yokuthuthukisa i-adenocarcinoma yesisu.

Yiziphi izimpawu ze-adenocarcinoma yesisu?

Izimpawu ze-adenocarcinoma yesisu zingase zihlanganise ubunzima bokugwinya, ukuncipha, ubuhlungu besisu, isicanucanu, ukuhlanza, nokuzizwa usuthi ngemva kokudla ukudla okuncane. Kodwa-ke, izigaba zokuqala zalesi sifo zivame ukuveza izimpawu ezimbalwa noma zingabibikho nhlobo, okwenza kube inselele ukusibona kusenesikhathi.

Yini okufanele uyibheke embikweni wakho we-pathology we-adenocarcinoma yesisu:

Ibanga le-Histology

I-adenocarcinoma ehlaselayo yesisu ihlukaniswe ngamabanga amathathu - ihlukaniswe kahle, ihlukanisiwe ngokusesilinganisweni, futhi ihlukaniswe kabi. Ibanga lisekelwe kumaphesenti amaseli wesimila akha izakhiwo eziyindilinga ezibizwa acorns. Isimila esingakhi noma yiziphi izindlala sibizwa nge-unifferentiated. Ibanga libalulekile ngoba izimila ezingahlukanisiwe kahle nezingahlukanisiwe zivame ukuziphatha ngendlela enolaka; isibonelo, lezi zimila kungenzeka zisabalale ama-lymph node nezinye izitho zomzimba.

• Ihluke Kahle: Ngaphezu kwama-95% wesimila ahlanganisa izindlala. Odokotela bezifo baphinde bachaze lezi zimila njengebanga loku-1.
• Ihlukaniswe ngokumaphakathi: ama-50 kuye kwangama-95% wesimila ahlanganisa izindlala. Odokotela bezifo baphinde bachaze lezi zimila njengebanga lesi-2.
• Ihlukaniswe kabi: Ngaphansi kwama-50% wesimila ahlanganisa izindlala. Odokotela bezifo baphinde bachaze lezi zimila njengebanga lesi-3.
• Okungahlukanisiwe: Zimbalwa kakhulu izindlala ezibonakala noma yikuphi esimila.

Uhlobo lokusabalalisa i-adenocarcinoma yesisu

I-Diffuse-type adenocarcinoma yesisu iwuhlobo oluthile lwe-histologic olubonakala ngamaseli omdlavuza asakazeka kakhulu kulo lonke ulwelwesi lwesisu ngaphandle kokwenza inqwaba ehlukile. Lokhu kuhlukaniswa kuyingxenye yesistimu yokuhlukanisa i-Lauren, ehlukanisa i-adenocarcinoma yesisu ibe yizinhlobo zamathumbu nezihlakazekile. Elinye igama le-diffuse type adenocarcinoma i-adenocarcinoma engahlangani kahle.

Umdlavuza wesisu wohlobo olusabalele ubonakala ngokusatshalaliswa okusabalele kwamaseli omdlavuza odongeni lwesisu, ngokuvamile okuhlanganisa amaseli endandatho yesiginesha, ezaziwa ngokubukeka kwazo okuhlukile ngenxa ye-vacuole enkulu esusa i-nucleus yeseli. Lolu hlobo oluncane aluhlotshaniswa kancane nezici zemvelo futhi ngaphezulu luhambisana nokuthambekela kofuzo, okungenzeka kuthinte iziguli ezisencane nokubonisa iphethini yomndeni.

I-Diffuse-type adenocarcinoma yesisu ibeka izinselelo ezinkulu mayelana nokuxilongwa nokwelashwa. Ngenxa yemvelo yayo esabalele kanye nokuntuleka kwesimila esichazwe kahle, kungaba nzima ukusibona kusenesikhathi. Ngokuvamile kubhekwa njengobudlova kunohlobo lwamathumbu, nokuthambekela kwe-metastasis yakuqala kanye nokusabela okungekuhle ekwelapheni ngamakhemikhali okungokwesiko. Ngakho-ke, ukubikezelwa komdlavuza wesisu osabalele kuvame ukuba kubi kakhulu, kugcizelela ukubaluleka kokuhlonza lolu hlobo oluncane kusenesikhathi ukuze kulungiselelwe amasu okwelapha aphumelela kakhulu.

Uhlobo olungahlangene kahle lwe-adenocarcinoma yesisu

I-adenocarcinoma yesisu engahlangani kahle iwuhlobo oluthile lwe-histologic olubonakala ngamaseli omdlavuza angabambeleli ndawonye noma akhe izimila eziqinile, esikhundleni salokho asakazeke ngokusabalale kulo lonke ulwelwesi lwesisu nodonga. Lesi sici senza umdlavuza kube nzima ukuwubona futhi uwuhlonze kusenesikhathi njengoba ukuntuleka kwesisindo esichaziwe kusho ukuthi ungase ungabonakali kalula nge-imaging noma i-endoscopy. Elinye igama lohlobo olungahlangene kahle lwe-adenocarcinoma i-diffuse-type adenocarcinoma.

Uhlobo olungahlangene kahle lwe-adenocarcinoma lubonakala ngokusatshalaliswa okuhlakazekile kwamangqamuzana omdlavuza odongeni lwesisu, ngokuvamile okuhlanganisa amaseli endandatho yesiginesha. Lawa maseli aziwa ngokubukeka kwawo okuhlukile ngenxa ye-vacuole enkulu esusa i-nucleus yeseli.

Ukuhlonza uhlobo oluncane lwe-discohesive olungalungile kubalulekile ekuhleleni ukwelashwa kanye nokubikezela. Ngenxa yokuthi la mangqamuzana omdlavuza asakazeka kakhulu futhi awanakho ukuxhumana phakathi kwama-intercellular, angangena ajule odongeni lwesisu futhi i-metastasis kwezinye izitho ngaphambi kwezinhlobo zomdlavuza ezihlangene. Lokhu kuziphatha kunomthelela esimweni sokwelashwa esiyinselele futhi ngokuvamile kubonisa ukubikezela okubi kakhulu. Ukuqaphela lolu hlobo oluncane kuvumela odokotela ukuba bacabangele izindlela zokwelapha ezinolaka nezihambisanayo, bevuma izinselele eziyingqayizivele ekulawuleni lolu hlobo lomdlavuza wesisu.

Amaseli endandatho yesiginesha

Amaseli endandatho yesiginesha ngokuvamile zitholakala ku-adenocarcinoma yesisu ehlakazekile noma engahlangani kahle. Lawa maseli aqukethe ama-vacuoles amakhulu e-mucin aphusha i-nucleus endaweni ezungezile, enikeza iseli ukubonakala okufana nendandatho. Lesi sici sibalulekile ngoba i-signet ring cell carcinoma yaziwa ngokuziphatha kwayo okunolaka nokuthambekela kokusabalala ngokusabalele odongeni lwesisu nangale kwalokho, uma kuqhathaniswa nezinye izinhlobo zomdlavuza wesisu. Amaseli endandatho yesiginali avame ukubonakala ohlotsheni olungahlangani kahle lwe-adenocarcinoma kanye nohlobo lwe-diffuse-type adenocarcinoma yesisu.

Ukuhlonza amaseli endandatho yesiginesha kubalulekile ngezizathu ezimbalwa. Okokuqala, kuvame ukuphakamisa ukubikezela okubi kakhulu ngenxa yesimo esinolaka somdlavuza kanye nekhono lawo lokusabalala ngokushesha. Okwesibili, lokhu okutholakele kungaba nomthelela ezinqumweni zokwelashwa, njengoba umdlavuza onamaseli endandatho yesiginesha ungase uphendule ngendlela ehlukile ku-chemotherapy nezinye izindlela zokwelapha kunezinye izinhlobo zomdlavuza wesisu.

Ukujula kokuhlasela kanye nesigaba se-pathologic (pT)

Ku-pathology, "sokuhlasela” ibhekisela enqubweni lapho amangqamuzana omdlavuza asakazeka khona esuka endaweni yokuqala yesimila aye ezicutshini noma ezithweni ezizungezile. Ikakhulukazi, esimweni se-adenocarcinoma, eqala esiswini mucous (ulwelwesi olungaphakathi), ukuhlasela kusho ukuthi amangqamuzana omdlavuza adlulele kwezinye izingqimba zesisu noma ezithweni ezingaphandle kwesisu. Udokotela wezifo angabona kuphela ukuhlasela ngokuhlola isimila ngesibonakhulu.

Phakathi nalokhu kuhlolwa kwe-microscopic, udokotela wezifo unquma ukuthi amangqamuzana omdlavuza adlulele kangakanani ngaphesheya kwe-mucosa ezicubu eziseduze, ezaziwa ngokujula noma izinga lokuhlasela. Ukubaluleka kokuhlonza ukujula kokuhlasela kusekukwazini kwawo ukubikezela ulaka lomdlavuza: amathumba angena ajule odongeni lwesisu athambekele ekubeni ama-metastasize kwezinye izingxenye zomzimba, okuhlanganisa. ama-lymph node, isibindi, noma amaphaphu. Ngaphezu kwalokho, ukujula kokuhlasela kusiza ekusunguleni isigaba se-tumor's pathological (pT), esibalulekile ekunqumeni isu lokwelapha elifaneleka kakhulu.

Imibiko eminingi ye-pathology ye-adenocarcinoma ehlaselayo yesisu izochaza ukujula noma izinga lokuhlasela ngale ndlela elandelayo:

• I-Intramuscosal: Isimila sibizwa ngokuthi i-intramucosal uma amangqamuzana omdlavuza engakasakazeki ngaphandle kwe-mucosa. I-mucosa ihlanganisa i-lamina propria noma i-muscularis mucosa.
• I-Submucosal: I-Submucosal isho ukuthi amangqamuzana omdlavuza asedlule i-muscularis mucosa futhi angena ku-submucosa.
• I-Muscularis propria: I-muscularis propria yinqwaba yemisipha ephakathi nesisu. Leli zinga lokuhlasela ngokuvamile lingabonakala kuphela ngemva kokuba isimila sesisusiwe.
• Izicubu ezithambile ze-subserosal: Amaseli omdlavuza kuzicubu ezithambile ezingaphansi kwe-subserosal aseduze nendawo engaphandle yesisu.
• I-Serous: Amaseli omdlavuza adlula i-serose ngaphandle kwesisu. Ukusuka lapha, amangqamuzana omdlavuza angasakazekela ezithweni eziseduze ezifana nobende, amanyikwe, amathumbu amancane, ikholoni, indlala ye-adrenal, noma izinso.

I-pathologist yakho izosebenzisa ukujula kokuhlasela ukunquma isigaba se-pathologic tumor (pT) kanje:

• T1a: Amaseli omdlavuza atholakala kuphela ku-mucosa. Lokhu kubizwa nangokuthi i-intramucosal adenocarcinoma.
• I-T1b: Amaseli omdlavuza asabalale ku-submucosa.
• I-T2: Amaseli omdlavuza asabalale ku-muscularis propria.
• I-T3: Amangqamuzana omdlavuza asendaweni ethambile ye-subserosal ngezansi nje kwendawo engaphandle yesisu.
• T4a: Amaseli omdlavuza adlule ku-serose futhi angaphandle kwesisu.
• I-T4b: Amangqamuzana omdlavuza asabalale ezithweni eziseduze nesisu

HER2

Amaseli kuwo wonke umzimba akhiqiza HER2 amaprotheni, asebenza njenge-switch ukuze akhuthaze ukukhula kwamangqamuzana nokuhlukana. Kodwa-ke, lapho amangqamuzana omdlavuza ekhiqiza ngokweqile i-HER2, akhula futhi ahlukane ngokushesha kakhulu kunamaseli avamile. Cishe isimila esisodwa kwezinhlanu zesisu sikhiqiza ngokweqile i-HER2. Ngakho-ke, udokotela wakho wezifo uzohlola amangqamuzana akho omdlavuza ukuthi kukhona yini i-HER2.

I-Immunohistochemistry (IHC) ukuhlolwa okuvame ukusetshenziswa kakhulu ukuthola i-HER2 kumaseli omdlavuza. Enye indlela ibizwa ngokuthi I-fluorescence in situ hybridization (INHLANZI). Amanye amalebhu azokwenza ukuhlolwa kwe-FISH kuphela ngemva kokuba ukuhlolwa kwe-IHC kukhiphe umphumela olinganayo.

Uma isimila sakho sihlolwe kusetshenziswa i-immunohistochemistry, umbiko wakho uzohlukanisa imiphumela njenge:

- Negative (0 noma 1) - Ibonisa ukuthi amangqamuzana omdlavuza awakhiqizi ngokweqile i-HER2.
- Equivocal (2) - Iphakamisa ukuthi amaseli omdlavuza angase akhiqize ngokweqile i-HER2.
- Okuhle (3) - Iqinisekisa ukuthi amangqamuzana omdlavuza akhiqiza ngokweqile i-HER2.

Iziguli ezine-HER2-positive tumors zingase zifanelekele ukwelashwa okuthile. Xoxa nodokotela wakho ngezindlela zokwelapha ongakhetha kuzo.

Amaprotheni okulungisa okungafani (MMR)

Ukulungiswa kokungafani (MMR) kuwuhlelo olubalulekile ngaphakathi kwawo wonke amaseli avamile, anempilo alungisa amaphutha e-DNA. Lolu hlelo luncike kumaprotheni ahlukene, ikakhulukazi i-MSH2, i-MSH6, i-MLH1, ne-PMS2.

Lawa maprotheni amane, i-MSH2, MSH6, MLH1, ne-PMS2, abhanqa (i-MSH2 ne-MSH6 ne-MLH1 ne-PMS2) ukuze kulungiswe i-DNA eyonakele. Uma iphrotheni ingekho, umbhangqwana wawo awukwazi ukulungisa i-DNA ngokuphumelelayo, okwandisa ingozi yomdlavuza.

Izazi ze-pathology zenza izivivinyo zokulungisa ukungafani kumasampula wesimila ukuze zihlole ukuthi awekho yini lawa maprotheni, inqubo enemininingwane emibikweni ye-pathology. Indlela eyinhloko yalokhu kuhlola iwukuba i-immunohistochemistry, ekhomba ukuthi amangqamuzana e-tumor akhiqiza yini amaprotheni amane okulungisa ukungafani.

Uma iphrotheni ingekho, umbiko we-pathology uzoyiphawula ngokuthi “ilahlekile” noma “intula.” Ngokuvamile, lapho iphrotheni eyodwa ingekho, umbhangqwana wawo nawo uyalahleka. Uma iphrotheni ivezwa ngokujwayelekile, umbiko we-pathology uzoyiphawula ngokuthi “iphelele”.

Nge-adenocarcinoma yesisu, ukungabikho kwephrotheni eyodwa noma amaningi okulungisa ukungafani kuvame ukubonisa ukubikezelwa okungcono futhi kukhombisa ukusabela okuphezulu okungaba khona kuma-immune checkpoint inhibitors, uhlobo lokwelashwa komdlavuza.

Ukuhlasela kwe-Perineural

Izazi zezifo zisebenzisa igama elithi “perineural invasion” ukuchaza isimo lapho amangqamuzana omdlavuza enamathela noma ehlasela inzwa. "Ukuhlasela kwe-Intraneural" yigama elihlobene elisho ngokuqondile amangqamuzana omdlavuza atholakala ngaphakathi kwenzwa. Imizwa, efana nezintambo ezinde, iqukethe amaqembu amaseli aziwa ngokuthi ama-neurons. Lezi zinzwa, ezikhona kuwo wonke umzimba, zidlulisela ulwazi olufana nezinga lokushisa, ukucindezela, nobuhlungu phakathi komzimba nobuchopho. Ukuba khona kokuhlasela kwe-perineural kubalulekile ngoba kuvumela amangqamuzana omdlavuza ukuthi ahambe eduze kwenzwa aye ezithweni eziseduze nezicubu, okuphakamisa ingozi yokuphindaphinda kwesimila ngemva kokuhlinzwa.

Ukuhlasela kwe-lymphovascular

Ukuhlasela kwe-lymphovascular kwenzeka lapho amangqamuzana omdlavuza ehlasela isitsha segazi noma isitsha se-lymphatic. Imithambo yegazi, amashubhu azacile athwala igazi kuwo wonke umzimba, ahluke emithanjeni ye-lymphatic, ethwala uketshezi olubizwa ngokuthi i-lymph esikhundleni segazi. Le mikhumbi ye-lymphatic ixhuma ezithweni zokuzivikela ezincane ezaziwa ngokuthi ama-lymph node, zihlakazeke umzimba wonke. Ukuhlasela kwe-lymphovascular kubalulekile ngoba kwenza amangqamuzana omdlavuza asakazekele kwezinye izingxenye zomzimba, kuhlanganise nama-lymph nodes noma isibindi, ngegazi noma imithambo ye-lymphatic.

Ama-lymph nodes

Izitho zokuzivikela ezincane, ezaziwa ngokuthi ama-lymph nodes, zitholakala kuwo wonke umzimba. Amangqamuzana omdlavuza angahamba esuka esimila aye kulawa ma-lymph nodes ngokusebenzisa imikhumbi emincane ye-lymphatic. Ngenxa yalesi sizathu, odokotela bavame ukususa futhi bahlole ngama-lymph nodes ukuze babheke amangqamuzana omdlavuza. Le nqubo, lapho amangqamuzana omdlavuza esuka esimilanjeni aye kwenye ingxenye yomzimba njenge-lymph node, ibizwa ngokuthi i-metastasis.

Amangqamuzana omdlavuza ngokuvamile aqala ukuthuthela kuma-lymph nodes eduze nethumba, nakuba ama-lymph nodes akude nawo angase athinteke. Ngakho-ke, odokotela abahlinzayo ngokuvamile basusa ama-lymph nodes aseduze nesimila kuqala. Angase asuse ama-lymph nodes kude nethumba uma ekhulisiwe futhi kunokusola okunamandla ukuthi aqukethe amaseli omdlavuza.

Izazi zezifo zizohlola noma yimaphi ama-lymph nodes asusiwe ngaphansi kwesibonakhulu, futhi okutholakele kuzochazwa kabanzi embikweni wakho. Umphumela “omuhle” ukhombisa ukuba khona kwamaseli omdlavuza ku-lymph node, kanti umphumela “omubi” usho ukuthi awekho amaseli omdlavuza atholakele. Uma umbiko uthola amaseli omdlavuza ku-lymph node, ungase futhi ucacise usayizi weqoqo elikhulu kunawo wonke lalawa maseli, elivame ukubizwa ngokuthi “i-focus” noma “idiphozithi.” Isandiso se-Extranodal kwenzeka lapho amangqamuzana e-tumor engena ku-capsule yangaphandle ye-lymph node futhi esakazeka esicutshini esiseduze.

Ukuhlola ama-lymph nodes kubalulekile ngenxa yezizathu ezimbili. Okokuqala, kusiza ukunquma isigaba se-pathologic nodal (pN). Okwesibili, ukuthola amangqamuzana omdlavuza ku-lymph node kuphakamisa ingozi eyengeziwe yokuthola amangqamuzana omdlavuza kwezinye izingxenye zomzimba kamuva. Lolu lwazi luqondisa udokotela wakho ekunqumeni ukuthi udinga ukwelashwa okwengeziwe, okufana ne-chemotherapy, i-radiation therapy, noma i-immunotherapy.

Amanqamu

Ku-pathology, umkhawulo uwunqenqema lwezicubu ezikhishwa ngesikhathi sokuhlinzwa kwesimila. Isimo semajini embikweni we-pathology sibalulekile njengoba sibonisa ukuthi isimila sisusiwe sonke noma uma ezinye zishiywe ngemuva. Lolu lwazi lusiza ekunqumeni isidingo sokwelashwa okwengeziwe.

Ama-pathologists ngokuvamile ahlola ama-margins ngokulandela inqubo yokuhlinzwa njenge- ukuziqhenya or ukukhishwa kabusha, okuhloswe ngayo ukususa sonke isimila. Amajikijolo awavami ukucutshungulwa ngemva kwe-a i-biopsy, esusa ingxenye kuphela yesimila. Inani lamamajini abikiwe kanye nosayizi wawo—ukuthi singakanani izicubu ezivamile phakathi kwesimila nonqenqema olusikiwe—ziyahlukahluka ngokuya ngohlobo lwethishu nendawo yesimila.

Izazi ze-pathologists zihlola ama-margins ukuze zihlole ukuthi ama-tumor cells akhona yini emaphethelweni ezicubu. Umkhawulo omuhle, lapho kutholakala khona ama-tumor cells, uphakamisa ukuthi omunye umdlavuza ungase uhlale emzimbeni. Ngokuphambene, imajini engalungile, engenawo amaseli e-tumor emaphethelweni, iphakamisa ukuthi isimila sisuswe ngokuphelele. Eminye imibiko iphinda ilinganise ibanga phakathi kwamaseli wesimila aseduze kanye nemajini, noma ngabe wonke amamajini anegethivu.

Mayelana nalesi sihloko

Odokotela babhale lesi sihloko ukuze bakusize ufunde futhi uqonde umbiko wakho we-pathology. Xhumana nathi uma unemibuzo mayelana nalesi sihloko noma umbiko wakho we-pathology. Ukuze uthole isingeniso esiphelele sombiko wakho we-pathology, funda lesi sihloko.

Ezinye izinsiza eziwusizo

I-atlas ye-pathology