nguCatherine Forse MD FRCPC kanye noJason Wasserman MD PhD FRCPC
November 27, 2023
I-Adenocarcinoma (eyaziwa nangokuthi i-adenocarcinoma ehlaselayo) uhlobo lomdlavuza wommizo. Iwuhlobo oluvame kakhulu lomdlavuza womminzo emazweni athuthukile futhi uvame kakhulu kwabesilisa kunabesifazane. I-Adenocarcinoma yomphimbo ngokuvamile iqala emangqamuzaneni e-glandula azungeze ingxenye engezansi yomminzo. Ingxenye engezansi yomminzo, eduze kwalapho kuhlangana khona isisu, indawo eyaziwa ngokuthi i-gastroesophageal junction. Lolu hlobo lomdlavuza luvame ukuhlotshaniswa nesimo esibizwa ngokuthi Isisu sikaBarrett lapho evamile ama-squamous cell zomminzo zithathelwa indawo amangqamuzana endlala.
Izimpawu ezivame kakhulu ze-adenocarcinoma yomminzo ubunzima bokugwinya (ikakhulukazi ukudla okuqinile), ubuhlungu besifuba, i-acid reflux eyandayo, nokuncipha kwesisindo.
I-Adenocarcinoma yomphimbo ngokuvamile ivela esimweni esibizwa ngokuthi Isisu sikaBarrett okubangelwa ukuguquguquka kwesikhathi eside kwama-asidi esisu emgodleni (isifo se-acid reflux). Ngenxa yalesi sizathu, i-adenocarcinoma ku-esophagus ivame ukukhula ngemva kweminyaka eminingi ye-acid reflux.
Lapho ingaphakathi lomgudu livezwa i-asidi yesisu isikhathi eside, i- ama-squamous cell ngokuvamile amboze ingaphakathi lomminzo athathelwa indawo amangqamuzana endlala afana namangqamuzana atholakala ngaphakathi emathunjini amancane. Lawa maseli ohlobo lwamathumbu amelana kakhulu nokulimala okuvela kuma-asidi anamandla avela esiswini. Ushintsho ukusuka kumaseli e-squamous ukuya kumaseli ohlobo lwamathumbu kubizwa i-metaplasia yamathumbu.
Isisu sikaBarrett igama odokotela abalisebenzisa ukuchaza i-metaplasia yamathumbu emthonjeni. Iqanjwe ngoDkt. Norman R. Barrett, udokotela ohlinzayo owayesebenza eLondon, eNgilandi ngeminyaka yawo-1950. Abantu abane-Barrett's esophagus iminyaka eminingi bangahlakulela uhlobo lokukhula okungavamile olubizwa ngokuthi umabhebhana lokho kuhlotshaniswa nengozi eyengeziwe yokuthuthukisa i-adenocarcinoma.
Ulwazi olutholakala embikweni wakho we-pathology we-adenocarcinoma kummizo luzoncika enqubweni eyenziwe. Ukuze izinqubo ezincane ezifana a i-biopsy, umbiko wakho ungafaka kuphela ukuxilongwa, i grade (ngokwesibonelo ihlukaniswe kahle), kanye nokujula kwe sokuhlasela (indlela isimila sesisabalale kude kangakanani ukusuka lapho siqala khona endaweni engaphakathi yomminzo). Imiphumela yokuhlolwa okwengeziwe kwe-biomarker noma i-molecular ingase ichazwe. Ngezinqubo ezinkulu njenge- ukuziqhenya or ukukhishwa kabusha kwenziwa ukuze kukhishwe sonke isimila, ulwazi olwengeziwe njengosayizi wesimila kanye nokuhlolwa kwe imishado kungase futhi kuchazwe. Sicela ubheke izigaba ezingezansi ukuze uthole imininingwane eyengeziwe.
Izazi zezifo zisebenzisa igama elihlukaniseki ukuhlukanisa i-adenocarcinoma yomminzo ibe amabanga amathathu - ahlukaniswe kahle, ahlukanisiwe ngokusesilinganisweni, futhi ahlukaniswa kabi. Ibanga lisekelwe ephesentini lesimila esakha izakhiwo eziyindilinga okuthiwa acorns. Isimila esingakhi noma yiziphi izindlala sibizwa nge-unifferentiated. Ibanga libalulekile ngoba izimila ezingahlukanisiwe kahle nezingahlukanisiwe ziziphatha ngendlela enolaka futhi kungenzeka zisabalele kwezinye izingxenye zomzimba njenge ama-lymph node.
I-Adenocarcinoma ye-esophagus ihlukaniswa ngale ndlela elandelayo:
I-muscularis mucosa iyingqimba encane yemisipha ngaphansi nje i-epithelium endaweni engaphakathi yomminzo. I-Adenocarcinoma iqala ku-epithelium kodwa njengoba isimila sikhula, amangqamuzana angasakazekela ku-muscularis mucosa. Izazi ze-pathologists zichaza lokhu njengokuhlasela futhi kubalulekile ngoba izimila ezihlasela i-muscularis mucosa zivame kakhulu i-metastasis (sakaza) ku ama-lymph node. Isimila esihlasela i-muscularis mucosa sibonisa isigaba se-pathologic tumors okungenani se-pT1a.
I-submucosa iyingqimba encane yezicubu ezixhumene ngaphansi kwe-muscularis mucosa. Izimila ezihlasela i-submucosa zihlangana nemithambo yegazi eminingi kanye nemigudu ye-lymphatic. Ngenxa yalokhu, lezi zicubu zisengozini enkulu yokuba zimetastasize (sabalala) kuma-lymph nodes nakwezinye izingxenye zomzimba. Isimila esihlasela i-submucosa sibonisa isigaba se-pathologic tumor okungenani esingu-pT1b.
I-muscularis propria iyingqimba ewugqinsi yomsipha phakathi nodonga lomminzo. Izimila ezihlasela i-muscularis propria ngokuvamile ziba zinkulu impela futhi zivame ukuziphatha ngendlela enolaka uma ziqhathaniswa nezimila ezihilela kuphela i-muscularis mucosa noma i-submucosa. Isimila esihlasela i-muscularis propria sibonisa isigaba se-pathologic tumor okungenani se-pT2.
I-adventitia iyingqimba encane yezicubu endaweni engaphandle yomminzo. Amathumba ahlasela i-adventitia maningi amathuba okuthi asakazeke (sabalala) kuma-lymph nodes nakwezinye izingxenye zomzimba. Izimila ezibandakanya i-adventitia nazo zivame ukusakazeka ngqo ezithweni eziseduze ezifana ne-trachea engenza kube nzima kakhulu ukususa ngokuhlinzwa. Isimila esihlasela i-adventitia sibonisa isigaba sesimila se-pathologic okungenani se-pT3.
Uma sonke isimila sesisusiwe, umbiko wakho cishe uzochaza ukuthi ithumba lalikuphi emmizweni. I-gastroesophageal junction (GEJ) indawo lapho umminzo uhlangana khona nesisu. Izimila ezitholakala ngenhla kwe-GEJ, e-GEJ, noma ngaphansi nje kwe-GEJ zibizwa ngokuthi ama-esophageal tumors. Izimila ezitholakala ngokuphelele ngaphansi kwe-GEJ (ngaphakathi kwesisu) zibizwa ngokuthi ama-gastric tumors. Indawo yesimila ibalulekile ngoba izimila ze-esophageal ne-gastric zivame ukuziphatha ngendlela ehlukile ngokuhamba kwesikhathi futhi izinketho zokwelashwa zihlukile.
I-biomarker ingushintsho lwezakhi zofuzo, amaprotheni, noma amanye amakhemikhali angahlolwa ukuze kubikezelwe ukuthi isifo sizoziphatha kanjani ngokuhamba kwesikhathi noma ukuthi sizosabela kanjani ekwelashweni okunikeziwe. Nge-adenocarcinoma yomphimbo, ama-biomarker ahlolelwe afaka i-HER2, amaprotheni okulungisa ukungalingani (MMR) kanye ne-PD-L1.
HER2 iwuhlobo olukhethekile lweprotheyini olubizwa ngokuthi i-receptor. I-HER2 iziphatha njengeswishi evumela amaseli ukuthi akhule futhi ahlukanise. Amanye amaseli wesimila akhiqiza inani elengeziwe le-HER2 eliwavumela ukuthi akhule futhi ahlukane ngokushesha kakhulu kunamaseli avamile.
Isigameko esisodwa kwezinhlanu ze-esophageal adenocarcinoma sikhiqiza i-HER2 eyengeziwe futhi ukwelashwa okuqondile kuyatholakala ezigulini ezinezimila ezikhiqiza i-HER2. Ngalesi sizathu, udokotela wakho wezifo angase acele ukuhlolwa ukuze abone ukuthi isimila sikhiqiza i-HER2 eyengeziwe.
Ukuhlola okuvamile okusetshenziselwa ukubheka i-HER2 ku-adenocarcinoma kubizwa i-immunohistochemistry.
Imiphumela engaba khona ye-HER2 immunohistochemistry:
Ukulungiswa kokungafani (MMR) kuwuhlelo olungaphakathi kwawo wonke amaseli avamile, anempilo okulungisa amaphutha kuzakhi zethu zofuzo (DNA). Uhlelo lwakhiwe ngamaprotheni ahlukene futhi amane avamile abizwa nge-MSH2, MSH6, MLH1, ne-PMS2.
Amaprotheni amane okulungisa ukungafani i-MSH2, i-MSH6, i-MLH1, ne-PMS2 asebenza ngamabili ukuze alungise i-DNA eyonakele. Ngokukhethekile, i-MSH2 isebenza ne-MSH6 futhi i-MLH1 isebenza ne-PMS2. Uma iphrotheni eyodwa ilahleka, umbhangqwana awukwazi ukusebenza ngendlela evamile. Ukulahlekelwa enye yala maprotheni kwandisa ingozi yokuba nomdlavuza.
Izazi ze-pathology ziyala ukuhlolwa kokulungisa ukungafani ukuze kubonakale ukuthi amaprotheni alahlekile yini esimila. Uma ukuhlolwa kokulungiswa kokungafani ku-odwe kusampula yethishu, imiphumela izochazwa embikweni wakho we-pathology.
Ukuhlolwa kwe-Mismatch repair (MMR) kwenziwa ku-adenocarcinoma yomminzo ukuhlonza iziguli okungenzeka ukuthi zine-Lynch syndrome, eyaziwa nangokuthi i-hereditary nonpolyposis colorectal cancer (HNPCC). I-Lynch syndrome iyinkinga yofuzo eyandisa ingozi yokuba nezinhlobo ezahlukene zomdlavuza, okuhlanganisa umdlavuza womphimbo, umdlavuza wekoloni, umdlavuza we-endometrial, umdlavuza wesibeletho, umdlavuza wesisu, nezinye.
Indlela ejwayelekile kakhulu yokuhlola amaprotheni okulungisa ukungafani ukwenza ukuhlolwa okubizwa i-immunohistochemistry. Lokhu kuhlola kuvumela ama-pathologists ukuthi abone ukuthi ama-tumor cells akhiqiza wonke amaprotheni amane okulungisa ukungafani. Umphumela ojwayelekile uzosho ukuthi iphrotheni igcinwe noma ivezwe. Umphumela ongavamile uzosho ukuthi kukhona ukulahlekelwa amaprotheni noma ukuthi iphrotheni iyashoda.
I-PD-L1 (I-Programmed Death-Ligand 1) iyiphrotheni etholakala phezu kwamaseli avamile, anempilo kanye namanye amangqamuzana omdlavuza. Ibizwa ngokuthi i-immune checkpoint protein ngoba yenza ukwehlisa umsebenzi wamaseli omzimba abizwa ngokuthi T cells okuvamise ukubona amangqamuzana angajwayelekile njengamaseli omdlavuza bese ewakhipha emzimbeni. Amangqamuzana omdlavuza aveza le phrotheni aphunyuka ekuhlaselweni ama-T cell ngokwenza kusebenze iphrotheni ku-T cell ebizwa ngokuthi i-PD-1.
Odokotela bahlola le phrotheni ukuze basize ukunquma ukuthi yiziphi iziguli ezingazuza ekwelashweni okuqondiswe kumzila we-PD-1/PD-L1, njengama-immune checkpoint inhibitors. Ukuhlola isisho se-PD-L1, odokotela bezifo ngokuvamile benza ukuhlolwa okubizwa ngokuthi i-immunohistochemistry (IHC) kusampula yethishu ephuma esimila. Kulokhu kuhlolwa, i-antibody ethile emelene ne-PD-L1 isetshenziswa engxenyeni yethishu bese itholwa kusetshenziswa i-antibody yesibili enamathiselwe kudayi.
Izinga lokusho amaprotheni libe selibalwa futhi linikezwe amaphuzu ngokusekelwe kubukhulu kanye nephesenti lamaseli amahle. Ngomdlavuza womminzo, umphumela ubikwa njengemiphumela emihle ehlanganisiwe (CPS) namaphuzu> 1 athathwa njengephozithivu.
Ukuhlasela kwe-Perineural yigama elithi pathologists elisetshenziswa ukuchaza amangqamuzana omdlavuza anamathele noma ngaphakathi kwenzwa. Igama elifanayo, ukuhlasela kwe-intraneural, lisetshenziselwa ukuchaza amangqamuzana omdlavuza ngaphakathi kwenzwa. Imizwa ifana nezintambo ezinde ezakhiwe ngamaqoqo amangqamuzana abizwa ngokuthi ama-neurons. Imizwa itholakala kuwo wonke umzimba futhi inesibopho sokuthumela ulwazi (njengokushisa, ukucindezela, nobuhlungu) phakathi komzimba wakho nobuchopho bakho. Ukuhlasela kwe-Perineural kubalulekile ngoba amangqamuzana omdlavuza angasebenzisa inzwa ukusakazeka ezithweni ezizungezile kanye nezicubu. Lokhu kwandisa ingozi yokuthi isimila sikhule kabusha ngemva kokuhlinzwa.
Ukuhlasela kwe-lymphovascular kusho ukuthi amangqamuzana omdlavuza abonwa ngaphakathi kwesitsha segazi noma isitsha se-lymphatic. Imithambo yegazi amashubhu amade azacile athwala igazi emzimbeni wonke. Imithambo ye-lymphatic ifana nemithambo yegazi emincane ngaphandle kokuthi ithwala uketshezi olubizwa ngokuthi i-lymph esikhundleni segazi. Imikhumbi ye-lymphatic ixhuma nezitho ezincane zokuzivikela ezibizwa ngokuthi ama-lymph nodes atholakala kuwo wonke umzimba. Ukuhlasela kwe-lymphovascular kubalulekile ngoba amangqamuzana omdlavuza angasebenzisa imithambo yegazi noma imithambo ye-lymphatic ukuze asakaze kwezinye izingxenye zomzimba ezifana ama-lymph node noma isibindi.
Ku-pathology, umkhawulo wunqenqema lwesicubu esisikwa lapho kususwa isimila emzimbeni. Amamajini achazwe embikweni we-pathology abaluleke kakhulu ngoba akutshela ukuthi isimila sisusiwe sonke noma ukuthi esinye isimila sishiywe ngemuva. Isimo semajini sizonquma ukuthi yikuphi (uma kukhona) ukwelashwa okwengeziwe ongakudinga.
Imibiko eminingi ye-pathology ichaza kuphela amamajini ngemva kwenqubo yokuhlinzwa ebizwa ngokuthi i- ukuziqhenya or ukukhishwa kabusha kwenziwe ngenhloso yokukhipha sonke isimila. Ngalesi sizathu, amamajini awavamile ukuchazwa ngemva kwenqubo ebizwa ngokuthi a i-biopsy kwenziwa ngenhloso yokukhipha ingxenye kuphela yesimila.
Izazi ze-pathologists zihlola ngokucophelela ama-margin ukuze zibheke amaseli wesimila emaphethelweni asikiwe ezicubu. Uma amaseli wesimila ebonakala emaphethelweni asikiwe ezicubu, umkhawulo uzochazwa njengephozithivu. Uma engekho amaseli wesimila abonwa emaphethelweni asikiwe ezicubu, umkhawulo uzochazwa njengenegethivu. Ngisho noma wonke amamajini engemihle, eminye imibiko ye-pathology izohlinzeka ngesilinganiso samaseli wesimila aseduze onqenqemeni lwethishu.
Imajini ephozithivu (noma esondele kakhulu) ibalulekile ngoba kusho ukuthi amaseli e-tumor kungenzeka ukuthi ayeshiywe ngemuva emzimbeni wakho lapho isimila sikhishwa ngokuhlinzwa. Ngenxa yalesi sizathu, iziguli ezinomkhawulo omuhle zingase zinikezwe okunye ukuhlinzwa ukuze kususwe sonke isimila noma ukwelashwa ngemisebe endaweni yomzimba enemajini eqondile.
Ukuze ukukhishwa kwe-endoscopic lapho kukhishwe khona ingxenye encane yangaphakathi yomminzo, amamajini azohlanganisa:
Ukuze izibonelo ze-esophagectomy lapho ingxenye yonke ye-esophagus isusiwe, amamajini azofaka:
Izindawo ezinama-lymph amasosha omzimba amancane atholakala kuwo wonke umzimba. Amangqamuzana omdlavuza angasakazeka esuka esimila kuye kuma-lymph nodes ngokusebenzisa imikhumbi emincane ebizwa ngokuthi i-lymphatics. Ngenxa yalesi sizathu, ama-lymph nodes avame ukususwa futhi ahlolwe ngesibonakhulu ukuze kubhekwe amangqamuzana omdlavuza. Ukuhamba kwamangqamuzana omdlavuza ukusuka esimila ukuya kwenye ingxenye yomzimba njenge-lymph node kubizwa ngokuthi a i-metastasis.
Amaseli omdlavuza ngokuvamile asakazeka kuqala kuma-lymph nodes eduze kwesimila nakuba ama-lymph nodes akude nesimila nawo angabandakanyeka. Ngenxa yalesi sizathu, ama-lymph nodes okuqala asusiwe ngokuvamile aseduze nesimila. Ama-lymph nodes aqhelelene nesimila avame ukususwa kuphela uma ekhulisiwe futhi kukhona izinsolo eziphakeme zomtholampilo zokuthi kungase kube namaseli omdlavuza ku-lymph node.
Uma noma imaphi ama-lymph node akhishiwe emzimbeni wakho, azohlolwa ngesibonakhulu udokotela wezifo futhi imiphumela yalokhu kuhlolwa izochazwa embikweni wakho. Imibiko eminingi izobandakanya inani eliphelele lama-lymph nodes ahloliwe, lapho emzimbeni kutholwe khona ama-lymph nodes, kanye nenombolo (uma ikhona) equkethe amaseli omdlavuza. Uma amangqamuzana omdlavuza abonwa ku-lymph node, usayizi weqembu elikhulu kunawo wonke lamaseli omdlavuza (okuvame ukuchazwa ngokuthi “ukugxila” noma “idiphozithi”) nawo uzofakwa.
Ukuhlolwa kwama-lymph nodes kubalulekile ngenxa yezizathu ezimbili. Okokuqala, lolu lwazi lusetshenziselwa ukunquma isigaba se-pathologic nodal (pN). Okwesibili, ukuthola amangqamuzana omdlavuza ku-lymph node kwandisa ingozi yokuthi amangqamuzana omdlavuza azotholakala kwezinye izingxenye zomzimba esikhathini esizayo. Ngenxa yalokho, udokotela wakho uzosebenzisa lolu lwazi lapho enquma ukuthi kuyadingeka yini ukwelashwa okwengeziwe okufana ne-chemotherapy, i-radiation therapy, noma i-immunotherapy.
Izazi zezifo zivame ukusebenzisa igama elithi “positive” ukuchaza i-lymph node equkethe amangqamuzana omdlavuza. Isibonelo, i-lymph node equkethe amangqamuzana omdlavuza ingase ibizwe ngokuthi “positive for malignancy” noma “positive for metastatic carcinoma”.
Izazi zezifo zivame ukusebenzisa igama elithi “negative” ukuchaza i-lymph node engenawo amangqamuzana omdlavuza. Isibonelo, i-lymph node enganawo amaseli omdlavuza ingase ibizwe ngokuthi “negative for malignancy” noma “negative for metastatic carcinoma”.
Wonke ama-lymph nodes azungezwe ungqimba oluncane lwezicubu okuthiwa i-capsule. Ukunwetshwa kwe-Extranodal kusho ukuthi amangqamuzana omdlavuza ngaphakathi kwe-lymph node agqekeze i-capsule futhi asakazeka esicutshini esingaphandle kwe-lymph node. Ukunwetshwa kwe-Extranodal kubalulekile ngoba kwandisa ingozi yokuthi isimila sizophinde sikhule endaweni efanayo ngemva kokuhlinzwa. Kwezinye izinhlobo zomdlavuza, ukunwetshwa kwe-extranodal futhi kuyisizathu sokucabangela ukwelashwa okwengeziwe okufana nokwelashwa ngamakhemikhali noma ukwelapha ngemisebe.
Uma uthole ukwelashwa (okungaba i-chemotherapy noma i-radiation therapy) yomdlavuza wakho ngaphambi kokuba isimila sikhishwe, udokotela wakho wezifo uzohlola zonke izicubu ezilethiwe ukuze abone ukuthi singakanani isimila esisaphila (siyasebenza).
Umphumela wokwelapha uzobikwa esikalini se-0 kuye ku-3 kanti u-0 ungekho amangqamuzana omdlavuza asebenzayo (wonke amangqamuzana omdlavuza afile) futhi oku-3 kungumdlavuza ogcwele osele ngaphandle kokuhlehla okusobala kwesimila (wonke noma iningi lamaseli omdlavuza uyaphila). Izindawo ezinama-lymph namaseli omdlavuza nawo azohlolelwa imiphumela yokwelashwa
Isigaba se-pathologic se-adenocarcinoma yomphimbo sisekelwe ohlelweni lwesiteji lwe-TNM, uhlelo olwaziwayo emhlabeni wonke olwakhiwe ekuqaleni I-American Joint Committee on Cancer. Lolu hlelo lusebenzisa ulwazi mayelana nesimila esiyinhloko (T), ama-lymph node (N), futhi kude i-metastatic isifo (M) ukucacisa isigaba esiphelele se-pathologic (pTNM). I-pathologist yakho izohlola izicubu ezithunyelwe bese inika ingxenye ngayinye inombolo. Ngokuvamile, inani eliphakeme lisho isifo esithuthuke kakhulu kanye nesibi kakhulu isibikezelo.
I-Adenocarcinoma yomphimbo inikezwa isigaba sesimila phakathi kuka-1 no-4 ngokuya ngebanga amaseli wesimila asabalale asuka kuwo. mucous endaweni engaphakathi yomphimbo odongeni lomgudu
I-adenocarcinoma yomphimbo inikezwa isigaba se-nodal phakathi kuka-0 no-3 ngokusekelwe ekubeni khona kwamangqamuzana ethumba endaweni. i-lymph node kanye nenani lama-lymph nodes ahilelekile.
I-Adenocarcinoma yomphimbo inikezwa isigaba se-metastatic esingu-0 noma esingu-1 ngokusekelwe ekubeni khona kwamaseli wesimila endaweni ekude emzimbeni (ngokwesibonelo amaphaphu). Isigaba se-metastatic singanqunywa kuphela uma izicubu ezivela endaweni ekude zihanjiswa ukuze zihlolwe ukugula. Ngenxa yokuthi lesi sicubu asivamile ukuba khona, isigaba se-metastatic asikwazi ukunqunywa futhi sibhalwe njenge-Mx.
Lesi sihloko sabhalwa odokotela ukuze bakusize ufunde futhi uqonde umbiko wakho we-pathology. Xhumana nathi uma unemibuzo mayelana nalesi sihloko noma umbiko wakho we-pathology. Funda lesi sihloko ukuze uthole isingeniso esijwayelekile ezingxenyeni zombiko we-pathology ojwayelekile.