食管疾病谢课件.pptx

1、The First Clinical College of Gannan medical university Gannan medical university CAI 食管癌食管癌 贲门失弛缓症贲门失弛缓症 The First Clinical College of Gannan medical university Gannan medical university CAI 概概 述述流行病学及病因学流行病学及病因学 解剖及病理解剖及病理临床表现与诊断临床表现与诊断鉴别诊断鉴别诊断预预 防防治治 疗疗Gannan medical university CAI The First Clin

2、ical College of Gannan medical university The First Clinical College of Gannan medical university Gannan medical university CAI Gannan medical university CAI The First Clinical College of Gannan medical university 生理侧曲生理侧曲上段偏左上段偏左:最凸处约在第最凸处约在第3 3胸椎平面胸椎平面,在颈部偏在颈部偏向左侧向左侧;中段偏右中段偏右:凸向右凸向右,其最凸处约在第其最凸处约在第

3、7 7胸椎平面胸椎平面;下段偏左下段偏左:食管裂孔处在中线偏左侧食管裂孔处在中线偏左侧.第一狭窄第一狭窄位于咽与食管交界处位于咽与食管交界处,距上门齿约距上门齿约15cm;常处于闭合状态常处于闭合状态.第三狭窄第三狭窄为食管通过食管裂孔处为食管通过食管裂孔处,距距上门齿约上门齿约3740cm;常处于闭合状态常处于闭合状态.第二狭窄第二狭窄位于胸骨角平面位于胸骨角平面,由主动脉弓和左主支由主动脉弓和左主支气管跨越食管前面所致气管跨越食管前面所致;上门齿距食管与主动脉上门齿距食管与主动脉弓交错处约弓交错处约25cm,距左主支气管交错处约距左主支气管交错处约27cm;是食管异物易存留处及食管癌的好发

4、部位是食管异物易存留处及食管癌的好发部位.成人食管长约成人食管长约2530cm,直径直径1.52.5cm,上门齿上门齿距贲门约距贲门约45cm-颈段颈段5cm5cm、胸段、胸段17cm17cm、腹段、腹段3cm.3cm.起自第起自第6颈椎水平环状软骨下缘至第颈椎水平环状软骨下缘至第10胸椎处穿过膈肌与胃相连胸椎处穿过膈肌与胃相连Gannan medical university CAI The First Clinical College of Gannan medical university 胸上段：胸廓上口至气胸上段：胸廓上口至气管分叉平面管分叉平面.胸中段：气管分叉平面胸中段：气管分叉

5、平面至贲门口全长的上一半至贲门口全长的上一半.胸下段：气管分叉平面胸下段：气管分叉平面至贲门口全长的下一半至贲门口全长的下一半.食管癌以食管中段最多见食管癌以食管中段最多见,下段下段次之次之,而上段最少而上段最少.Gannan medical university CAI The First Clinical College of Gannan medical university Esophageal Carcinoma 诊断与临床表现(Diagnose and Clinic representation)肿瘤发生的部位以食管中段最多见，下段次之，而上段最少。内科治疗：病情轻者可用解痉药如硝

6、酸异山梨酯（消心痛）、硝苯地平（心痛定）等，并少吃多餐，细嚼慢咽，饭后散步等。流调显示人群分布与以下几个因素有关：年龄、性别、职业、种族、地理、生活环境、饮食生活习惯、遗传易感性等有关。The First Clinical College of Gannan medical university放射治疗未控或复发病例,尚无局部明显外侵或远处转移征象;Gannan medical university CAI局部管腔扩张正常,内镜可见隆起于正常粘膜下的圆形肿物,在食管蠕动时可见在粘膜下“滑动”现象.The First Clinical College of Gannan medical univ

7、ersityEsophageal Carcinoma 诊断与临床表现(Diagnose and Clinic representation)Gannan medical university CAIGannan medical university CAI79/10万,而云南省的发病率仅为1.Esophageal Carcinoma 诊断与临床表现(Diagnose and Clinic representation)无咽下困难，与食管炎、食管憩室和食管静脉曲张鉴别。年龄一般不超过70岁,少数高龄接近80岁,但生理年龄较小的病例也可慎重考虑.在中国，高发地区分布在河南、广东东部、四川西部、太行

8、山区和苏北地区；The First Clinical College of Gannan medical universityThe First Clinical College of Gannan medical university禁止热吃热饮,避免食用刺激性强及含致癌物的食物.The First Clinical College of Gannan medical university Gannan medical university CAI 食管鳞状细胞癌病理图片食管鳞状细胞癌病理图片 The First Clinical College of Gannan medical univ

9、ersity Gannan medical university CAI 食管癌的扩散方式食管癌的扩散方式:直接浸润直接浸润:最先侵及粘膜下层最先侵及粘膜下层,然后向周围扩散然后向周围扩散,侵及粘膜、肌层、外膜及其邻近器官侵及粘膜、肌层、外膜及其邻近器官.淋巴转移淋巴转移:癌转移主要经淋巴途径癌转移主要经淋巴途径:可以较早经淋巴管转移到食管旁淋巴结可以较早经淋巴管转移到食管旁淋巴结,再向远处淋再向远处淋巴结转移巴结转移.上段食管癌上段食管癌-气管旁、颈深及锁骨上淋巴结气管旁、颈深及锁骨上淋巴结;中段食管癌中段食管癌-食管旁，肺门、气管及其分叉、主动脉弓下和心包旁淋巴结，食管旁，肺门、气管及其分

10、叉、主动脉弓下和心包旁淋巴结，向上至胸顶纵隔淋巴结，向下至下段食管引流的淋巴结向上至胸顶纵隔淋巴结，向下至下段食管引流的淋巴结;下段食管癌下段食管癌-食管旁、心包旁食管旁、心包旁,肺下韧带及贲门周围淋巴结肺下韧带及贲门周围淋巴结,可向下转移至贲可向下转移至贲门癌引流的淋巴结门癌引流的淋巴结.纵隔淋巴结与奇静脉及胸导管有交通，癌细胞还可经淋巴管进入血循环纵隔淋巴结与奇静脉及胸导管有交通，癌细胞还可经淋巴管进入血循环.血行转移血行转移:较晚发生较晚发生.晚期可以转移到各脏器晚期可以转移到各脏器:肝肝30%,30%,肺肺(胸膜胸膜)20%,)20%,骨骨8%,8%,还有少数转移还有少数转移到肾、大网

11、膜到肾、大网膜(腹膜腹膜)、肾上腺、脑、心、肾上腺、脑、心(心包心包)及脾等及脾等.Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university

12、Gannan medical university CAI The First Clinical College of Gannan medical university 食管癌食管癌TNMTNM分期标准分期标准(Tumor stages):):Stage 0：TisN0M0 Stage I：T1N0M0 Stage IIa:T2N0M0,T3N0M0 Stage IIb:T1N1M0，T1N2M0，Stage :T3N1M0，T4 any N、M0，Stage IV:any T、any N、M1 该分期法的不足之处在于淋巴结转移情况分得不够细，没有区该分期法的不足之处在于淋巴结转移情况分得不

13、够细，没有区分第一、第二站，有待今后改进。分第一、第二站，有待今后改进。T:T:原位癌原位癌T1:T1:肿瘤仅侵及粘膜下层肿瘤仅侵及粘膜下层 或固有层或固有层T2:T2:肿瘤侵及肌层肿瘤侵及肌层T3:T3:肿瘤侵及食管外膜肿瘤侵及食管外膜T4:T4:肿瘤侵及邻近器官肿瘤侵及邻近器官N0:N0:无区域淋巴结转移无区域淋巴结转移N1:N1:有区域淋巴结转移有区域淋巴结转移M0:M0:无远处转移无远处转移M1:M1:有远处转移有远处转移Gannan medical university CAI The First Clinical College of Gannan medical universi

14、ty b晚期症状晚期症状:呕吐呕吐因肿瘤形成梗阻而食管上段扩张因肿瘤形成梗阻而食管上段扩张.吞咽食物时胸背部疼痛吞咽食物时胸背部疼痛因原发癌的外侵因原发癌的外侵.远处转移远处转移:锁骨上淋巴结转移锁骨上淋巴结转移,原发灶可不大原发灶可不大.肝脏转移可有多发结节性肿块肝脏转移可有多发结节性肿块.骨转移骨转移,转移部位有剧痛转移部位有剧痛.癌肿侵犯气管引起咳嗽、呛咳、肺炎等癌肿侵犯气管引起咳嗽、呛咳、肺炎等.食管气管瘘表现为进食后呛咳不止食管气管瘘表现为进食后呛咳不止,呼吸困难、肺炎、高热呼吸困难、肺炎、高热.喉返神经受累有声音嘶哑喉返神经受累有声音嘶哑,多发生在左侧多发生在左侧.膈神经受累有膈肌

15、麻痹膈神经受累有膈肌麻痹.体重减轻体重减轻,消瘦消瘦,脱水乃至脱水乃至恶病质恶病质.Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university 食管癌食管癌(髓质型髓质型)中下段不对称充盈缺损中下段不对称充盈缺损,不规则狭窄不规则狭窄,管壁僵硬管壁僵硬,近侧食管扩张近侧食管扩张.Gannan medical uni

16、versity CAI The First Clinical College of Gannan medical university 食管癌食管癌(溃疡型溃疡型)中段不规则龛影、中段不规则龛影、粘膜皱襞紊乱、粘膜皱襞紊乱、粗糙、中断粗糙、中断.Gannan medical university CAI The First Clinical College of Gannan medical university CT表现表现UICC分期中的0、A、B及期中的T3N1M0；内科治疗：病情轻者可用解痉药如硝酸异山梨酯（消心痛）、硝苯地平（心痛定）等，并少吃多餐，细嚼慢咽，饭后散步等。肝脏转移可有

17、多发结节性肿块.Esophageal Carcinoma 病理分期(TNM分期法)The First Clinical College of Gannan medical university胸上段：胸廓上口至气管分叉平面.基因治疗(Gene therapy)Esophageal Carcinoma 鉴别诊断(differential diagnosis)禁止热吃热饮,避免食用刺激性强及含致癌物的食物.胃代食管术.Gannan medical university CAIThe First Clinical College of Gannan medical university重度贲门失弛症

18、，增粗的食管表现为纵隔增宽Gannan medical university CAIThe First Clinical College of Gannan medical universityGannan medical university CAIGannan medical university CAI综合治疗手段：1.X线所见病变部位稍窄发僵有较大溃疡,周围的充盈缺损及粘膜破坏等不如癌那样明显.横结肠代食管术.锁骨上淋巴结转移,原发灶可不大.b食管镜检查可获得组织学上的确诊食管镜检查可获得组织学上的确诊.Gannan medical university CAI The First C

19、linical College of Gannan medical university 鉴别诊断鉴别诊断(differential diagnosis)Gannan medical university CAI The First Clinical College of Gannan medical university 鉴别诊断鉴别诊断(differential diagnosis)Gannan medical university CAI The First Clinical College of Gannan medical university b食管结核食管结核 食管结核比较少见食

20、管结核比较少见,感染途径有感染途径有:结核菌直结核菌直接侵入食管粘膜接侵入食管粘膜;由喉或咽部结核向下蔓延由喉或咽部结核向下蔓延;血行感血行感染染;脊柱结核侵及食管脊柱结核侵及食管;食管周围的纵隔淋巴结结核食管周围的纵隔淋巴结结核干酪性变侵蚀食管壁干酪性变侵蚀食管壁.其中尤以第项最为常见其中尤以第项最为常见.临床表临床表现多有进食发噎史现多有进食发噎史.平均年龄小于食管癌患者平均年龄小于食管癌患者.X.X线所见线所见病变部位稍窄发僵有较大溃疡病变部位稍窄发僵有较大溃疡,周围的充盈缺损及粘膜周围的充盈缺损及粘膜破坏等不如癌那样明显破坏等不如癌那样明显.b食管裂孔疝并发反流性食管炎食管裂孔疝并发反

21、流性食管炎 有长期吞咽疼痛、反有长期吞咽疼痛、反酸、烧心等症状酸、烧心等症状,然后由于炎症反复然后由于炎症反复,局部发生瘢痕狭窄局部发生瘢痕狭窄而出现吞咽困难而出现吞咽困难.X.X线可见下段食管管腔轻度狭窄线可见下段食管管腔轻度狭窄,呈对呈对称性边缘较光滑称性边缘较光滑,有一定扩张度有一定扩张度,粗乱胃粘膜经裂孔延入粗乱胃粘膜经裂孔延入胸内胸内.鉴别诊断鉴别诊断(differential diagnosis)Gannan medical university CAI The First Clinical College of Gannan medical university b食管平滑肌瘤食

22、管平滑肌瘤 典型病例的吞咽困难症状轻进展慢典型病例的吞咽困难症状轻进展慢,X,X线线见突向管腔的光滑圆形或见突向管腔的光滑圆形或“生姜生姜”样壁在性充盈缺损样壁在性充盈缺损,表面粘膜展平呈表面粘膜展平呈“涂抹征涂抹征”但无溃疡但无溃疡.局部管腔扩张正局部管腔扩张正常常,内镜可见隆起于正常粘膜下的圆形肿物内镜可见隆起于正常粘膜下的圆形肿物,在食管蠕动在食管蠕动时可见在粘膜下时可见在粘膜下“滑动滑动”现象现象.有时和生长在一侧壁有时和生长在一侧壁,主主要向粘膜下扩展的表面粘膜改变轻微的食管癌不易区别要向粘膜下扩展的表面粘膜改变轻微的食管癌不易区别,但后者在内镜下见不到但后者在内镜下见不到“滑动滑动

23、”.b食管良性狭窄食管良性狭窄 一般有吞酸碱史一般有吞酸碱史,X,X线可见食管狭窄、粘线可见食管狭窄、粘膜褶消失、管壁僵硬膜褶消失、管壁僵硬,狭窄与正常食管段逐渐过渡狭窄与正常食管段逐渐过渡.临床临床上要警惕在长期炎症基础上发生癌变的可能上要警惕在长期炎症基础上发生癌变的可能.鉴别诊断鉴别诊断(differential diagnosis)Gannan medical university CAI The First Clinical College of Gannan medical university b食管外压改变食管外压改变 某些疾病如肺癌纵隔淋巴结转移、纵隔某些疾病如肺癌纵隔淋巴结

24、转移、纵隔肿瘤、纵隔淋巴结炎症等可压迫食管造成部分或严重狭肿瘤、纵隔淋巴结炎症等可压迫食管造成部分或严重狭窄，产生严重吞咽困难，有时误诊为食管癌。窄，产生严重吞咽困难，有时误诊为食管癌。b食管静脉曲张食管静脉曲张 病人吞咽困难轻，病人吞咽困难轻，X X线可见食管下段粘线可见食管下段粘膜皱褶增粗、迂曲或呈串珠状充盈缺损、管壁柔软膜皱褶增粗、迂曲或呈串珠状充盈缺损、管壁柔软,管管腔扩张度不受限，食管镜下可见典型的粘膜下迂曲血管。腔扩张度不受限，食管镜下可见典型的粘膜下迂曲血管。Gannan medical university CAI The First Clinical College of G

25、annan medical university b戒烟戒烟.b禁止热吃热饮禁止热吃热饮,避免食用刺激性强及含致癌物的避免食用刺激性强及含致癌物的食物食物.b整治环境污染整治环境污染.b宣教和普及防癌知识宣教和普及防癌知识.b高发人群定期普查高发人群定期普查.治治 疗疗(therapy)Gannan medical university CAI The First Clinical College of Gannan medical university b预后：预后：5 5、1010年生存率分别约为年生存率分别约为:22.536.8%、17.219.7%。Gannan medical uni

26、versity CAI The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university 成人食管长约2530cm,直径1.流调显示人群分布与以下几个因素有关：年龄、性别、职业、种族、地理、生活环境、饮食生活习

27、惯、遗传易感性等有关。鳞癌敏感，适合中上段，内科治疗：病情轻者可用解痉药如硝酸异山梨酯（消心痛）、硝苯地平（心痛定）等，并少吃多餐，细嚼慢咽，饭后散步等。E、腔内型：3%.喉返神经受累有声音嘶哑,多发生在左侧.Gannan medical university CAI重要脏器有严重合并症如肺功能低下，心脏疾病伴心力衰竭或半年以内的心肌梗死等。D、缩窄型：10%.Gannan medical university CAIThe First Clinical College of Gannan medical university下段食管癌患者可有剑突下或上腹部食后饱胀不适、疼痛.Gannan m

28、edical university CAI国际抗癌联盟(UICC)制订：T_ primary tumor Tx:T cannot be assessed T0:No evidence of primary tumor Tis:Ca in situ T1:T Invades lamina propria or submucosa T2:muscularis propria T3:adventitia T4:adjacent structures N_ Regional lymph node Nx:N cannot be assessed N0:No N metastasis N1:N metas

29、tasis M_ Distant metastasis M0:NO M M1:M(including positive celiac nodes)癌组织坏死脱落,梗阻症状可暂时减轻.胃代食管术.The First Clinical College of Gannan medical university锁骨上淋巴结转移,原发灶可不大.副作用：血像降低，骨髓抑制，脱发，肝肾损害，心肌损害.(二)临床病理分型：2中晚期(临床期):A、髓质型：60%.癌转移主要经淋巴途径:可以较早经淋巴管转移到食管旁淋巴结,再向远处淋巴结转移.内科治疗：病情轻者可用解痉药如硝酸异山梨酯（消心痛）、硝苯地平（心痛定）

30、等，并少吃多餐，细嚼慢咽，饭后散步等。Gannan medical university CAIGannan medical university CAIGannan medical university CAI重度贲门失弛症，增粗的食管表现为纵隔增宽癌肿侵犯气管引起咳嗽、呛咳、肺炎等.N1:有区域淋巴结转移B、蕈伞型：15%.The First Clinical College of Gannan medical university无咽下困难，与食管炎、食管憩室和食管静脉曲张鉴别。是一种发生于食管上皮的常见消化道恶性肿瘤，在我国其发病率仅次于胃癌，居恶性肿瘤的第二位；食管癌 Esophag

31、eal Carcinoma鉴别方法:吞钡X线食管造影和纤维食管镜检查。The First Clinical College of Gannan medical universityEsophageal Carcinoma外科手术治疗(Operation)The First Clinical College of Gannan medical university平均年龄小于食管癌患者.咽下疼痛，胸骨后沉重感或阻塞感。骨转移,转移部位有剧痛.Gannan medical university CAI5cm,上门齿距贲门约45cm-颈段5cm、胸段17cm、腹段3cm.Gannan medical

32、 university CAI The First Clinical College of Gannan medical university b手术径路手术径路 消化道重建消化道重建 左胸切口左胸切口.右胸、腹部二切口右胸、腹部二切口.颈、胸、腹三切口颈、胸、腹三切口.b切除范围切除范围 食管大部：长度距肿瘤上、下食管大部：长度距肿瘤上、下58cm.切除广度：肿瘤周围纤维组织及所有淋巴结切除广度：肿瘤周围纤维组织及所有淋巴结.b姑息性手术：对晚期食管癌、不能根治或放射治姑息性手术：对晚期食管癌、不能根治或放射治疗、进食困难者疗、进食困难者.食管腔内置管术食管腔内置管术.食管胃转流吻合术食管胃

33、转流吻合术.食管结肠转流吻合术食管结肠转流吻合术.胃造瘘术胃造瘘术.Gannan medical university CAI The First Clinical College of Gannan medical university b食管癌切除术后的并发症食管癌切除术后的并发症:吻合口并发症吻合口并发症 肺部并发症肺部并发症 乳糜胸乳糜胸 心律不齐心律不齐 单纯脓胸单纯脓胸 膈疝膈疝 胃扭转胃扭转 伪膜性肠炎伪膜性肠炎Gannan medical university CAI The First Clinical College of Gannan medical university

34、 Gannan medical university CAI The First Clinical College of Gannan medical university 左胸切口左胸切口Gannan medical university CAI The First Clinical College of Gannan medical university 右胸、腹部二切口右胸、腹部二切口颈、胸、腹三切口颈、胸、腹三切口Gannan medical university CAI The First Clinical College of Gannan medical university 胃

35、代食管术胃代食管术横结肠代食管术横结肠代食管术Gannan medical university CAI The First Clinical College of Gannan medical university 食管腔内置管术食管腔内置管术胃造瘘术胃造瘘术空肠造瘘术空肠造瘘术食管胃转流吻合术食管胃转流吻合术放射治疗：放射治疗：鳞癌敏感，适合中上段，鳞癌敏感，适合中上段，与手术联合应用。与手术联合应用。b副作用：放射性肺炎副作用：放射性肺炎 肺纤维化肺纤维化.b重度肺气肿重度肺气肿 肺功能不肺功能不全者慎用全者慎用.Gannan medical university CAI The Fir

36、st Clinical College of Gannan medical university 化学治疗：化学治疗：适用于各种病理类型的食适用于各种病理类型的食管癌，加用中医中药等，管癌，加用中医中药等，单独效果差。单独效果差。b副作用：血像降低，骨副作用：血像降低，骨髓抑制，脱发，肝肾损髓抑制，脱发，肝肾损害，心肌损害害，心肌损害.综合治疗手段：综合治疗手段：1.1.手术手术+放疗放疗+药物药物;2.;2.放疗放疗+手术手术+放疗放疗(+(+药物药物););3.3.放疗放疗+药物药物.Gannan medical university CAI The First Clinical Coll

37、ege of Gannan medical university 思思 考考 题题Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university The First Clinical College of Gannan medical university Gannan medical university CAI T

38、he First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medica

39、l universityGannan medical university CAI呕吐因肿瘤形成梗阻而食管上段扩张.The First Clinical College of Gannan medical universityEsophageal Carcinoma 临床分部及分段(Clinic Type)中段偏右:凸向右,其最凸处约在第7胸椎平面;第二狭窄位于胸骨角平面,由主动脉弓和左主支气管跨越食管前面所致;上门齿距食管与主动脉弓交错处约25cm,距左主支气管交错处约27cm;是食管异物易存留处及食管癌的好发部位.The First Clinical College of Gannan m

40、edical universityGannan medical university CAIThe First Clinical College of Gannan medical university骨转移,转移部位有剧痛.YOU!The First Clinical College of Gannan medical university肝脏转移可有多发结节性肿块.食管鳞状细胞癌病理图片5cm,上门齿距贲门约45cm-颈段5cm、胸段17cm、腹段3cm.Esophageal Carcinoma 病理分型(Pathological Type)Gannan medical universit

41、y CAI有明显的蒂部,恶行程度最低.E、腔内型：3%.锁骨上淋巴结转移,原发灶可不大.术前全面准确的评估和及时纠治病人的体质状况、营养状态、脏器功能、内科疾病是确保手术成功与安全必不可少的重要环节。重度贲门失弛症，增粗的食管表现为纵隔增宽重度贲门失弛症，增粗的食管表现为纵隔增宽 The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical un

42、iversity CAI 图示：轻度贲门失弛图示：轻度贲门失弛症，黑色箭头标出鸟症，黑色箭头标出鸟嘴样贲门影像，白色嘴样贲门影像，白色箭头标出的食管内钡箭头标出的食管内钡剂潴留的气液平。剂潴留的气液平。The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI Heller术后加做抗反流术式术后加做抗反流术式 Th

43、e First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI 思思 考考 题题Gannan medical university CAI The First Clinical College of Gannan medical university THANK YOU!The First Clinical College

44、 of Gannan medical university The First Clinical College of Gannan medical university Gannan medical university CAI 食管癌的扩散方式食管癌的扩散方式:直接浸润直接浸润:最先侵及粘膜下层最先侵及粘膜下层,然后向周围扩散然后向周围扩散,侵及粘膜、肌层、外膜及其邻近器官侵及粘膜、肌层、外膜及其邻近器官.淋巴转移淋巴转移:癌转移主要经淋巴途径癌转移主要经淋巴途径:可以较早经淋巴管转移到食管旁淋巴结可以较早经淋巴管转移到食管旁淋巴结,再向远处淋再向远处淋巴结转移巴结转移.上段食管癌上段食管

45、癌-气管旁、颈深及锁骨上淋巴结气管旁、颈深及锁骨上淋巴结;中段食管癌中段食管癌-食管旁，肺门、气管及其分叉、主动脉弓下和心包旁淋巴结，食管旁，肺门、气管及其分叉、主动脉弓下和心包旁淋巴结，向上至胸顶纵隔淋巴结，向下至下段食管引流的淋巴结向上至胸顶纵隔淋巴结，向下至下段食管引流的淋巴结;下段食管癌下段食管癌-食管旁、心包旁食管旁、心包旁,肺下韧带及贲门周围淋巴结肺下韧带及贲门周围淋巴结,可向下转移至贲可向下转移至贲门癌引流的淋巴结门癌引流的淋巴结.纵隔淋巴结与奇静脉及胸导管有交通，癌细胞还可经淋巴管进入血循环纵隔淋巴结与奇静脉及胸导管有交通，癌细胞还可经淋巴管进入血循环.血行转移血行转移:较晚发

46、生较晚发生.晚期可以转移到各脏器晚期可以转移到各脏器:肝肝30%,30%,肺肺(胸膜胸膜)20%,)20%,骨骨8%,8%,还有少数转移还有少数转移到肾、大网膜到肾、大网膜(腹膜腹膜)、肾上腺、脑、心、肾上腺、脑、心(心包心包)及脾等及脾等.Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gannan medical university Gannan

47、medical university CAI The First Clinical College of Gannan medical university b晚期症状晚期症状:呕吐呕吐因肿瘤形成梗阻而食管上段扩张因肿瘤形成梗阻而食管上段扩张.吞咽食物时胸背部疼痛吞咽食物时胸背部疼痛因原发癌的外侵因原发癌的外侵.远处转移远处转移:锁骨上淋巴结转移锁骨上淋巴结转移,原发灶可不大原发灶可不大.肝脏转移可有多发结节性肿块肝脏转移可有多发结节性肿块.骨转移骨转移,转移部位有剧痛转移部位有剧痛.癌肿侵犯气管引起咳嗽、呛咳、肺炎等癌肿侵犯气管引起咳嗽、呛咳、肺炎等.食管气管瘘表现为进食后呛咳不止食管气管瘘

48、表现为进食后呛咳不止,呼吸困难、肺炎、高热呼吸困难、肺炎、高热.喉返神经受累有声音嘶哑喉返神经受累有声音嘶哑,多发生在左侧多发生在左侧.膈神经受累有膈肌麻痹膈神经受累有膈肌麻痹.体重减轻体重减轻,消瘦消瘦,脱水乃至脱水乃至恶病质恶病质.鉴别诊断鉴别诊断(differential diagnosis)Gannan medical university CAI The First Clinical College of Gannan medical university Gannan medical university CAI The First Clinical College of Gann

49、an medical university Gannan medical university CAI The First Clinical College of Gannan medical university 胃代食管术胃代食管术横结肠代食管术横结肠代食管术Esophageal Carcinoma 思 考 题（Question）最先侵及粘膜下层,然后向周围扩散,侵及粘膜、肌层、外膜及其邻近器官.食管良性狭窄 一般有吞酸碱史,X线可见食管狭窄、粘膜褶消失、管壁僵硬,狭窄与正常食管段逐渐过渡.下段食管癌患者可有剑突下或上腹部食后饱胀不适、疼痛.The First Clinical Colle

50、ge of Gannan medical university食管气管瘘表现为进食后呛咳不止,呼吸困难、肺炎、高热.鳞癌敏感，适合中上段，成人食管长约2530cm,直径1.第二狭窄位于胸骨角平面,由主动脉弓和左主支气管跨越食管前面所致;上门齿距食管与主动脉弓交错处约25cm,距左主支气管交错处约27cm;是食管异物易存留处及食管癌的好发部位.对可疑病例,作食管吞稀钡X线双重对比造影.理想的治疗方案和措施的选择，是基于病人的临床因素和分子生物学机制而制定的个性化治疗。年龄一般不超过70岁,少数高龄接近80岁,但生理年龄较小的病例也可慎重考虑.Stage 0：TisN0M0 Stage I：T1N