CẬP NHẬT
CHẨN ĐOÁN và ĐIỀU TRỊ
K THỰC QUẢN
TS. BS. NGUYỄN TẠ QUYẾT
BỘ MÔN NGOẠI, KHOA Y
GIẢI PHẪU THỰC QUẢN
ĐẠI CƯƠNG
• Xuất độ:
Nam Mỹ: 20/100000 TH, 4% phát hiện mới hằng năm.
Nam phi, TQ: 160/100000.
• Nam/ Nữ: 3/1(tế bào gai). 15/1(biểu mô tuyến)
• UT tế bào vẩy:
ít gặp < 30t.
Hay gặp ở Nam, da đen
• UT biểu mô tuyến
ít gặp < 40t.
Phổ biến ở Nam giới, da trắng
ĐẠI CƯƠNG
• UT tế bào vẩy ở 1/3 trên & giữa: chiếm 70% TH.
• Yếu tố thuận lợi: hút thuốc lá, uống rượu. Chế độ ăn thiếu vit,
kẽm, . . .
• UT biểu mô tuyến chiếm 70% ở phương tây; do:
GERD.
Chế độ ăn nhiều chất béo.
Thuốc kháng acid.
• Bệnh lý tiền ung thư:
GERD
Barrett thực quản: 40 lần
Co thắt tâm vị: 16 lần
CHẨN ĐOÁN K THỰC QUẢN
CHẨN ĐOÁN K THỰC QUẢN
• Vị trí, chiều dài tổn thương.
• Đánh giá xâm lấn.
• Độ chính xác:
T: 57%.
N: 74%.
M: 83%
CHẨN ĐOÁN K THỰC QUẢN
• MRI: độ chính xác 74%
• Endoscopic Ultrasound:
Độ chính xác tăng theo giai đoạn u: 84%
(T1) → 95%(T4).
Khó phát hiện hạch KT ≤ 10mm
ĐÁNH GIÁ TRƯỚC MỔ
• Dinh dưỡng: sụt cân > 10% hay Albumin ≥ 35g/l.
• Chức năng hô hấp: nguy cơ về hô hấp khi
FEV1 < 1,2 L.
PaCO2 ≥ 45mmHg hay PaO2 < 55mmHg
• 20 – 30% TH K TQ có bệnh lý tim mạch
PHÂN GIAI ĐOẠN K THỰC QUẢN
PHÂN GIAI ĐOẠN K THỰC QUẢN
When the post‑resection ulcer is expected to involve ≥3/4th of the
esophageal circumference, a preventive measures against stenosis should
be considered, as such lesions are associated with a high risk of stenosis
after ER
There is evidence to strongly recommend oral prednisolone treatment,
submucosal triamcinolone injection, or concurrent oral prednisolone
treatment + submucosal triamcinolone injection for preventing stenosis after
endoscopic resection. (Consensus rate: 85.2% [23/27], strength of
evidence: C).
CQ5: Which is recommended, esophagectomy or definitive chemoradiotherapy,
in patients with cStage I (T1bN0M0) thoracic esophageal cancer?
There is weak evidence to recommend esophagectomy in patients with
cStage I (T1bN0M0) thoracic esophageal cancer, and there is also weak
evidence to recommend definitive chemoradiotherapy with adequate
follow‑up and salvage therapy in patients with cStage I who desire for
esophageal preservation. (Rate of consensus: 92.3% [24/26], strength of
evidence: C).
CQ6: Which is recommended as an
additional treatment—esophagectomy or
chemoradiotherapy—in cases
with a pT1a-MM lesion showing positive
vascular invasion or a pT1b-SM lesion
following endoscopic treatment for
superficial esophageal cancer?
There is evidence to recommend esophagectomy or chemoradiotherapy as an
additional treatment in patients identified as having a pT1a‑MM lesion with positive
vascular invasion or a pT1b‑SM lesion after endoscopic treatment for superficial
esophageal cancer; however, currently there is insufficient evidence to definitively
recommend one over the other. (Rate of consensus: 89.3% [25/28]; strength of
evidence: C).
CQ7: What should be recommended—primarily surgery, or definitive
chemoradiotherapy—in patients with cStage II or III esophageal cancer?
Recommendation statement
There is weak evidence to recommend primarily surgery for patients with
cStage II or III esophageal cancer. (Rate of consensus: 100% [28/28],
strength of evidence: C).
CQ8: Which is recommended — preoperative chemotherapy or preoperative
chemoradiotherapy — in cStage II or III esophageal cancer patients scheduled
to receive surgery as the primary treatment?
Recommendation statement
In patients with cStage II or III esophageal cancer who are scheduled to
receive surgery as the primary treatment, there is strong evidence to
recommend preoperative triplet chemotherapy with docetaxel + cisplatin +
5‑FU. (Rate of consensus: 84% [21/25], strength of evidence: A).
CQ9: Is postoperative adjuvant therapy recommended in cStage II or III
esophageal cancer patients who have undergone preoperative adjuvant
therapy plus surgery?
Recommendation statement
(1) In patients with cStage II or III esophageal cancer who failed to show a
pathologic complete response after preoperative chemoradiotherapy plus
surgery with radical resection, there is strong evidence to recommend
postoperative nivolumab therapy, regardless of the histologic type or tumor
expression level of programmed death ligand 1 (PD ‑L1). (Rate of
consensus: 81% [21/26], strength of evidence: A)
CQ9: Is postoperative adjuvant therapy recommended in cStage II or III
esophageal cancer patients who have undergone preoperative adjuvant
therapy plus surgery?
Recommendation statement
(2) In patients with cStage II or III esophageal cancer who have undergone
preoperative chemotherapy plus surgery with radical resection, but failed to
achieve a pathologic complete response, there is currently no evidence to
recommend postoperative nivolumab therapy. (Rate of consensus: 92%
[24/26], strength of evidence: D).
CQ11: Is salvage surgery recommended for residual or recurrent lesions after
chemoradiotherapy in patients with untreated resectable esophageal cancer?
Recommendation statement
There is weak evidence to recommend salvage surgery for residual or
recurrent lesions after chemoradiotherapy in patients with untreated
resectable esophageal cancer. (Rate of consensus: 96.4% [27/28], strength
of evidence: C).
CQ12: Is chemoradiotherapy recommended for unresectable cStage IVA
esophageal cancer?
Recommendation statement
There is only weak evidence to recommend definitive chemoradiotherapy
for the treatment of unresectable cStage IVA esophageal cancer. (Rate of
consensus: 100% [28/28]; strength of evidence: C).
CQ13: Is additional chemotherapy recommended for cStage II, III or IVA
esophageal cancer patients who show complete response after definitive
chemoradiotherapy?
Recommendation statement
There is only weak evidence to recommend additional chemotherapy for
cStage II, III, or IVA esophageal carcinoma patients who show complete
response to definitive. chemoradiotherapy. (Rate of consensus: 96.4%
[27/28]; evidence level: C)
CQ14: Is surgical resection recommended for patients with unresectable,
locally advanced esophageal cancer (cT4 [e.g., aorta, trachea, bronchus] N0-
3M0) that becomes resectable after definitive chemoradiotherapy or induction
chemotherapy?
Recommendation statement
There is only weak evidence to recommend surgical resection for patients
with unresectable, locally advanced esophageal cancer (cT4 [e.g., aorta,
trachea, bronchus] N0‑3M0) that becomes resectable after definitive
chemoradiotherapy or induction chemotherapy. (Rate of consensus: 89.3%
[25/28]; evidence level: C)
CQ15: What chemotherapy would be recommended as first-line therapy for
patients with unresectable, advanced/recurrent esophageal cancer?
Recommendation statement
① There is strong evidence to recommend pembrolizumab + cisplatin +
5‑FU therapy as first‑line therapy for the treatment of patients with
unresectable, advanced/recurrent esophageal cancer. (Rate of consensus:
92.3% [24/26]; strength of evidence: A).
CQ15: What chemotherapy would be recommended as first-line therapy for
patients with unresectable, advanced/recurrent esophageal cancer?
Recommendation statement
② There is strong evidence to recommend nivolumab + cisplatin + 5 ‑FU
therapy or nivolumab + ipilimumab therapy as first ‑line therapy for
unresectable, advanced/recurrent esophageal cancer, but the patient’s
general condition, tumor PD‑L1 expression level (tumor proportion score
[TPS]), and treatment tolerability should be taken into account. (Rate of
consensus: 88.0% [22/25]; strength of evidence: A).
Treatment Algorithm for
cStage IVB Esophageal Cancer
CQ18 Is palliative radiotherapy recommended for the treatment of patients with
cStage IVB esophageal cancer presenting with obstruction?
Recommendation statement
There is only weak evidence to recommend palliative radiotherapy for the
treatment of patients with cStage IVB esophageal cancer presenting with
obstruction. (Rate of consensus: 100% [28/28]; strength of evidence: C).
Chemotherapy Regimen
for cStage IVB Esophageal Cancer
PHẪU THUẬT MỞ NGỰC CẮT THỰC QUẢN
• PT mở ngực cắt thực quản (Ivor-Lewis).
• PT cắt thực quản không mở ngực.
• PTNS lồng ngực hỗ trợ cắt thực quản.
• PTNS xuyên hoành cắt thực quản
PHẪU THUẬT MỞ NGỰC CẮT THỰC QUẢN
PHẪU THUẬT MỞ NGỰC CẮT THỰC QUẢN
PHẪU THUẬT MỞ NGỰC CẮT THỰC QUẢN
PTNS CẮT THỰC QUẢN XUYÊN HOÀNH
PTNS CẮT THỰC QUẢN XUYÊN HOÀNH
