frequent mucus
Introduction
Introduction Carcinoma of esophagus is a malignant tumor mainly originating from the esophageal squamous epithelium and columnar epithelium. Squamous cell carcinoma accounts for about 90%, and adenocarcinoma accounts for about 10%. The most typical clinical manifestation of esophageal cancer is progressive dysphagia. In the early stage of esophageal cancer, local lesions are relatively early, and their symptoms may be local lesions that cause esophageal motility or paralysis caused by esophagus, or local inflammation, tumor infiltration, esophageal mucosal erosion, superficial ulcers, and symptoms are generally mild. The duration is short, often repeated, when it is light and heavy, there may be an asymptomatic intermittent period, which lasts for 1 to 2 years or even longer. Late symptoms: dysphagia is a typical symptom of esophageal cancer, often intermittent at the beginning, the general trend is persistent, progressive aggravation; reflux infiltration and inflammation of the esophageal cancer reflexively cause increased secretion of mucus in the esophageal gland and salivary gland, The patient can behave as a frequent mucus.
Cause
Cause
(1) Causes of the disease
The etiology of esophageal cancer may be related to the following factors:
1. Smoking and drinking, long-term smoking and heavy drinking, especially those who drink hard alcohol is much higher than those who do not smoke or drink.
2. Local damage of the esophagus, long-term treatment of esophagitis.
3. Food contains nitrosamines that are too high and moldy.
4. Fungal action, it has been proved that feeding small animals with aflatoxin, A. oxysporum, Fusarium, etc. can cause cancer.
5. Malnutrition and low trace elements.
6. Genetic factors.
7. Other factors: such as eating too fast, eating hard food, eating hot food, congenital disease of esophagus, long-term exposure to dust such as asbestos, sputum, lead and so on.
(two) pathogenesis
Pathological type
(1) Pathological types of early esophageal cancer: Patients with early esophageal cancer have no obvious symptoms of dysphagia. In the high-incidence area, early cases can be found by cytology and endoscopy. The macroscopic view of early esophageal cancer is mostly limited to the mucosal surface. No obvious lumps were found. Chinese scholars divided the early type of esophageal cancer into the following 4 types based on the pathology of surgically resected specimens combined with endoscopy and X-ray findings.
1 concealed type (or hyperemia type): mucosa redness at the cancerous stage (due to the intimal membrane papillary microvascular hyperplasia, hyperemia), no other obvious abnormalities, after the formaldehyde solution is fixed, the mucosal surface is slightly depressed and wrinkled, the range is below 1cm, histology Diagnosis of all intraepithelial neoplasia, the intrinsic membrane has more lymphocytes and plasma cells infiltration.
2 erosive type: the mucosa of the cancerous area is slightly erosive, the shape is irregular, the color of the erosion is deep, and it is fine granular. The microscopic examination shows that the cancerous epithelium is thin, the intrinsic membrane inflammation is more obvious, and the cancer tissue infiltration is mostly limited to the mucosal muscle layer.
3 plaque type: cancerous mucosa swelling and bulging, rough surface, showing the thickness of the granules and psoriasis-like appearance, esophageal folds are interrupted, the extent of lesions vary, individual cases of cancer invasion and the esophagus all circumference, half of the invasion Mucosal muscle layer and submucosa.
4 nipple type: the tumor has a prominent nodular bulge, papillary or scorpion-like. The above types are common with plaque type and erosion type, and nipple type and conceal type are less common.
(2) Pathological types of advanced esophageal cancer: The clinical pathological classification of esophageal cancer has certain clinical and prognostic significance. According to clinical symptoms, X-ray angiography (or other imaging examinations), gross specimens and pathological findings are classified into 4 types. .
1 medullary type: patients often have obvious dysphagia, esophageal angiography is more common symmetry stenosis or eccentric stenosis, the esophageal lumen above the lesion.
Gross specimens can be seen in the esophageal wall, infiltrating and thickening of the wall, involving all or most of the esophageal circumference to cause stenosis, the upper and lower mucosal surfaces are sloping, and the mucosa in the middle of the lesion There are often ulcers, the tumor surface on the cut surface is grayish white, uniform, hard and solid mass, the contour of the muscle layer disappears or becomes thick due to tumor infiltration, and the cancer tissue has penetrated the muscular layer and reached the esophageal fibrous membrane.
Microscopic examination: The mucosa of the tumor site often has ulcers. The cancer tissue is sneak infiltrated in the submucosa and muscle layer, forming a very thick mass. The connective tissue in the interstitial is generally not much, or mild to moderate hyperplasia. Inflammatory cells infiltrate lighter, this type is more common, because there is often more obvious invasion, the rate of surgical resection is lower, the prognosis of surgical treatment is poor, radiotherapy, chemotherapy effect is moderate, and the recurrence rate is also high.
2 ulcer type: clinically, the patient's dysphagia is not serious, but the pain behind the sternum is often obvious. The main feature of esophageal angiography is irregular edge, deeper, larger ulcers, and usually only a small amount of esophagus The wall is damaged, the expectorant passes smoothly, and the tumor seen in the mucosal surface is a depressed and well-defined deep ulcer. It often reaches the muscular layer or penetrates most of the muscle layer. The tumor is thinner on the cut surface and the tissue at the bottom of the ulcer is thinner. There are not many tumor tissues around the ulcer.
Microscopic examination showed that the mucosal ulcer was mostly necrotic tumor tissue, and the hemorrhage and inflammatory cell infiltration were more obvious. The sneak infiltration at the edge of the tumor was not obvious, and there were more connective tissue and inflammatory cells in the interstitial. This type of esophageal cancer is rare, and other types of esophageal cancer often have ulcers. It should be noted that ulcerated esophageal cancer is often more obvious but less restrictive, and the resection rate is moderate. This type has perforation risk and chemotherapy effect is better. However, special attention should be paid to radiotherapy, chemotherapy or selective arterial infusion chemotherapy.
3 umbrella type: patients with dysphagia and other symptoms are milder, the medical history is longer, angiography shows that the upper and lower edges of the lesion are curved, the edges are clear and sharp, the middle of the lesion has a shallow and wide shadow, and the tumor on the mucosal surface is often oval. Flat shape, peripheral protrusion or eversion, the boundary is clear, like a mushroom, so the name is umbrella, the middle part of the lesion has a shallow and wide shadow, the cut surface can be seen that the tumor edge is bulged into the cavity, but the tumor is thin, the esophageal wall is thickened. obvious.
Microscopic examination: tumors on the mucosal surface often have protrusions. The cancer cells are in a large sheet shape, arranged in a block shape, and the infiltration is often limited. There are few connective tissues in the interstitium, and sometimes there are more blood vessels on the mucosal surface of the tumor. Infiltration with inflammatory cells.
The umbrella type is also more common. Because the external invasion is not obvious and has a high surgical resection rate, the radiation sensitivity is high, and the radiotherapy or chemotherapy effect is satisfactory.
4 narrowed type: the patient's progressive dysphagia is more prominent, esophageal angiography can see a shorter but significant centripetal stenosis, the elixir passes difficult, and the esophagus above it expands significantly. The tumor seen in the gross specimen infiltrated in the esophageal wall, forming a ring-shaped stenosis, generally about 3cm long, rarely more than 5cm, the tumor showed a concentric contraction, so that the upper and lower esophageal mucosa were radially shrunk, and the cancer tissue was visible on the cut surface. Harder, fibrosis is obvious.
Microscopic examination: for typical hard cancer, the cancer cells are arranged in a small and long cable. The multi-infiltrated esophageal muscle layer sometimes penetrates the whole layer. There is a large amount of fibrous tissue in the interstitial. The collagen fibers are often transparent and the inflammatory cells are not. many. This type of esophageal cancer is rare, although the lesion is short, but the external invasion is often more serious, the possibility of resection is general, non-surgical treatment is difficult to make the symptoms significantly relieved.
The characteristics of the above-mentioned esophageal cancer classification are not obvious in some advanced cases, which makes it difficult to type. In addition, a small number of esophageal cancers have pedicled polyps protruding into the esophagus, so some scholars believe that this is another esophageal cancer. Type - endoluminal type.
According to the analysis of a large number of pathological materials by many authors in China, it is agreed that the medulla type is the most common in all types of esophageal cancer, accounting for 56.7% to 58.5%; the paralyzed umbrella is the second, accounting for 17% to 18.4%; the ulcer type is second, accounting for 11% to 13.2%; the narrowest type is the least, accounting for 8.5% to 9.5%, and the other types are 2.9% to 5%.
2. Tissue type: According to the histological features of esophageal cancer, it can be divided into five types: squamous cell carcinoma, adenocarcinoma, adenoma, small cell undifferentiated carcinoma and carcinosarcoma, of which squamous cell carcinoma is the most common. About 90%, adenocarcinoma (including adenoma) followed by 7%, and other types are rare.
(1) squamous cell carcinoma: most of the esophageal squamous cell carcinoma is poorly differentiated, and there is little keratinization. Most invasive carcinomas have different degrees of keratinization, and are classified into grade 3 according to the degree of differentiation of cancer cells. Grade: Cancer cells often have obvious keratinization or cancer bead formation. The cancer cells are large in size, polygonal or round, with more cytoplasm and less morphicity. Nuclear division is rare. Grade II: keratinized beads are rare. The pleomorphism of cancer cells is obvious, and nuclear fission is more common. Grade III: Most of the cancer cells are fusiform, long elliptical or irregular, with smaller cancer cells, less cytoplasm, more common mitosis, and no keratinization. Or the formation of cancer beads, pleomorphism can be more obvious.
(2) adenocarcinoma: esophageal primary adenocarcinoma is relatively rare, domestic literature reports mostly in 3.8% to 8.8%, the diagnosis of lower esophageal adenocarcinoma, must exclude the possibility of gastric adenocarcinoma or gastric cardia adenocarcinoma to the esophagus, esophageal gland Two specific types of cancer are adenoid carcinoma and cystic adenoid cancer.
(3) Small cell undifferentiated carcinoma: similar to histological small cell carcinoma of the lung, domestic reports accounted for 0.18%, relatively rare, foreign reports accounted for 2.4%, and other small cell carcinoma, although often in cancerous Squamous cell carcinoma and adenocarcinoma components are also found in the middle, but most of the esophageal small cell carcinomas show differentiation into neuroendocrine tissues, suggesting that the primary tumors have the potential to differentiate in different directions.
(4) Carcinosarcoma: a tumor containing malignant transformation of both epithelial and mesenchymal tissues. Two major tumor components can be seen under the microscope. One of them is cancerous tissue, which is mostly distributed on the surface or base of the tumor and its vicinity. Most of the cancerous tissues are well-differentiated squamous cell carcinomas, and a few are undifferentiated carcinomas, basal cell carcinomas or cystic adenoid carcinomas. The sarcoma components are mostly shuttle-like cells, and often have abnormal tumor giant cells.
3. Diffusion and metastasis: There are three ways to spread esophageal cancer:
(1) Direct diffusion: Direct diffusion occurs at most in the submucosa at the earliest, and its diffusion range can usually be more than 1cm from the main body of the cancer. It is not uncommon to exceed 5cm. Most of the submucosal diffusion is not obvious in the naked eye. Only microscopic examination can confirm Therefore, the scope of surgery or radiotherapy should include the esophageal tissue detected by the naked eye above 5cm above and below the cancer. Most of the advanced esophageal cancer has muscle involvement at the time of diagnosis, but its range is smaller than that of the submucosa.
Because the esophagus has no serosal layer, the cancerous tumor penetrates the muscular layer and easily passes through the loose esophageal adventitia to reach adjacent organs. According to the tumor, the most common invasion in the esophagus is still trachea, bronchus, lung, pleura. , pericardium, aortic adventitia, large vein, thyroid, recurrent laryngeal nerve, diaphragm and left lobe of the liver.
(2) lymphatic metastasis: lymph node metastasis can present a "jump" phenomenon, but generally occurs first in the submucosal lymphatics, through the muscle layer to reach the lymph nodes corresponding to the tumor site, the upper esophageal cancer can invade the esophageal, after the throat Cervical depth and supraclavicular lymph nodes, middle esophageal cancer, when the local esophageal lymph node metastasis, can further invade the cervical lymph nodes, involving the lymph nodes around the gastric cardia, or along the trachea, parabronchial lymph nodes to the lungs The door expands, and the lower segment of the cancer, in addition to invading the local lymph nodes, often invades the gastric cardia, the left gastric and abdominal lymph nodes.
(3) Blood-borne metastasis: Although the submucosal layer of esophageal cancer is rich in wall venous plexus, and there are large veins in the periphery of the esophagus and nearby, 1/3 of the patients died due to local complications of esophageal cancer, at autopsy At the time of autopsy of 1535 cases of esophageal cancer, 38% of the cases had neither lymphatic metastasis nor hematogenous metastasis. The common sites of hematogenous metastasis were: liver, lung and pleura, bone, kidney, omentum and peritoneum. Adrenal gland and so on.
Examine
an examination
Related inspection
Upper digestive tract photography examination of upper digestive tract X-ray meal
Early symptoms
In the early stage of esophageal cancer, local lesions are relatively early, and their symptoms may be local lesions that cause esophageal motility or paralysis caused by esophagus, or local inflammation, tumor infiltration, esophageal mucosal erosion, superficial ulcers, and symptoms are generally mild. Short duration, often repeated, light and heavy, may have asymptomatic intermittent period, duration of up to 1 to 2 years, or even longer, the main symptoms are post-sternal discomfort, burning sensation or pain, when food passes There is a local sense of foreign body or friction. Sometimes swallowing food has a sense of stagnation or mild obstruction in a certain part. The lower part of the cancer can also cause discomfort under the xiphoid or upper abdomen, hiccups, and suffocation.
2. Late symptoms
(1) Dysphagia is a typical symptom of esophageal cancer: dysphagia is often intermittent at the beginning, can be aggravated by food blockage or local inflammation and edema, but also can be alleviated by tumor necrosis or inflammation, but the overall trend is persistent. Existence, progressive aggravation, if there is obvious dysphagia, the tumor often involves more than 2/3 of the esophageal circumference. The degree of dysphagia is related to the pathological type of esophageal cancer. The narrowed and medullary type of cancer is more serious. About 10% of patients have no obvious difficulty swallowing at the time of presentation.
(2) Infiltration and inflammation of reflux esophageal cancer reflexively cause increased secretion of mucus in esophageal glands and salivary glands. When tumor hyperplasia causes esophageal obstruction, mucus accumulates in the esophagus and causes reflux. Patients can express frequent mucus and spit. Mucus can be mixed with food, blood, etc., reflux can also cause cough, even aspiration pneumonia.
(3) Pain in the back of the sternum or between the back and shoulders often causes esophageal cancer to infiltrate, causing inflammation around the esophagus, mediastinal inflammation, pain can also be caused by deep esophageal ulcer caused by tumor; lower thoracic or cardia tumor The pain can be located in the upper abdomen.
(4) Other tumors invade large blood vessels, especially the thoracic aorta, causing fatal bleeding; tumor compression of the recurrent laryngeal nerve can cause hoarseness, invasion of the nerve can cause hiccups; compression of the trachea or bronchus can cause shortness of breath or dry cough; When the trachea or esophagus-bronchial spasm or tumor is located in the upper esophagus, it may often cause difficulty breathing or coughing when swallowing food.
3. Signs
Early signs are not obvious. In the advanced stage, due to difficulties in eating, the nutritional status is worsening. Patients may experience weight loss, anemia, malnutrition, water loss and cachexia. When the tumor has metastasis, a large amount of ascites may form.
4. Clinical staging program
At the National Esophageal Cancer Work Conference in 1976, the clinical pathological staging criteria based on the length range and metastasis of the lesions were adopted. The program divided them into early, middle, and late stages. Clinically, early stage esophageal cancer included phase 0 and In stage I, the symptoms are mild and intermittent; in the middle stage II, III, the symptoms of dysphagia are significant, progressively worse; late stage IV, severe symptoms, with cachexia or other complications, this staging plan is simple and clear It has been valuable for the selection of treatment methods and the estimation of prognosis. It has been widely used.
5. Comparison of TNM staging of international esophageal cancer and clinical cleanup staging in China
The TNM staging of esophageal cancer as listed in the 1987 International Union Against Cancer (UIC) "TNM Classification of Malignant Tumors" (Fourth Edition) is as follows:
(1) TNM classification of esophageal cancer: T-primary tumor, Tx primary tumor can not be measured, T0 has no primary tumor evidence, Tis carcinoma in situ, T1 tumor only invades mucosa lamina or submucosa, T2 tumor Invasion of the muscular layer, T3 tumor invasion and esophageal adventitia, T4 tumor invasion and adjacent organs, N-regional lymph nodes, cervical esophageal cancer: including the neck and supraclavicular lymph nodes; thoracic esophageal cancer: including mediastinum and periplasmic lymph nodes, Does not include the para-aortic lymph nodes. , NX regional lymph node can not be measured, NO no regional lymph node metastasis, N1 regional lymph node metastasis, M-distant metastasis, lymph node or organ metastasis outside the area of esophageal cancer, MX distant metastasis can not be measured, MO no distant metastasis, M1 There is a distant transfer.
(2) TNM staging is compared with the staging of esophageal cancer in China. According to the staging plan of TNM classification of esophageal cancer, the size of the tumor and the length of the lesion are irrelevant. The range of the primary tumor (T) is based on the invasion of the wall. Depending on the depth, the TNM staging system can more comprehensively reflect the stage and development of esophageal cancer. To perform this staging, careful pathological examination and surgical records are required.
Comparing the international TNM (1987) staging criteria with the clinical pathological staging in China, the 0 and I phases are the same, but the II, III, and IV phases in China have early premature phenomena. In order to adapt to the increasing international exchanges, the science of strengthening the clinical work of esophageal cancer is strengthened. Sexuality and predictability, the use of TNM system in China's esophageal cancer is imperative, and it is constantly summarized in the actual work to improve the accuracy and practicability of the staging criteria.
When the elderly have sternal discomfort, difficulty swallowing or sensation, the first thing to consider is to check the esophagus. The usual method is X-ray barium meal examination; convenient, less painful, economic, high diagnostic rate, esophagoscopy, Intuitive, high accuracy of live examination, as well as examination of esophageal exfoliated cells, advanced equipment examinations such as CT scan of esophageal cancer, have improved the detection rate of early esophageal cancer.
Diagnosis
Differential diagnosis
Frequent foaming: common in the esophageal atresia (atresia of oesophagus) and esophageal tracheal fistula (tracheoesophagealfistula) is not uncommon in the neonatal period, the child appears after the birth of saliva increased, constantly overflowing from the mouth, frequent spitting foam. All newborns have foaming at the mouth and vomiting or coughing and bruising after each feeding. After the mother has a history of excessive amniotic fluid or other congenital malformations, congenital esophageal atresia should be considered. may.
Sour acid: Where acid water is spread from the stomach, if it is not swallowed and spit out, it is called acid. Generally speaking, vomiting acid is a symptom of vomiting acid water, which is often seen in combination with stomach pain, but can also occur alone.
It is a clinical symptom of interstitial pneumonia. Also known as interstitial lung disease, diffuse lung disease, etc., as a disease name, only a history of more than ten years, as the name suggests it is a lung interstitial lesion. Interstitial pneumonia is not a single disease, but a general term for a large class of diseases. There are about a hundred kinds of diseases. A small number of causes are known, such as pneumoconiosis, drug pneumonia, radiation pneumonitis, etc.; but there are quite a few causes. Unknown, such as idiopathic pulmonary fibrosis, sarcoidosis. Although interstitial pneumonia is called "pneumonia", it is mainly not caused by infection by microorganisms such as bacteria and viruses.
Frequent vomiting and constipation: a common symptom of abdominal hernia. The intra-abdominal organ is called the intra-abdominal hernia from its original position, through a normal or abnormal channel or fissure in the abdominal cavity to an abnormal sulcus.
