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7MORPHOLOGICAL CHANDES IN THE WALL OF ABDOMINAL PART OF ESOPHAGUS
IN ITS TUMOROUS LESION
Mironchev Anton O.,
PhD, Orenburg State Medical University, Russia, Department of Therapy, Department of Operative Surgery and Clinical Anatomy
name of S.S. Mikhailov Kagan Ilya I.,
MD, Professor, Orenburg State Medical University, Russia, Department of Operative Surgery and Clinical Anatomy name of S.S.
Mikhailov, Meritorious Science Worker of Russian Federation Samoilov Peter V.,
PhD, Orenburg State Medical University, Russia, Department of Radiological Diagnostics, Radiotherapy and Oncology
In the article features of morphological changes in the wall of the abdominal part of esophagus are described in two forms of its tumorous lesion: the squamous cell carcinoma and adenocarcinoma. Discusses the features of the germination and spread of tumors within the wall of the abdominal part of esophagus and cardial part of the stomach. Key words: esophagus, morphology, adenocarcinoma, squamous cell carcinoma
According to the monitoring EuRoCARE-2 in Europe, the five-year survival rate for cancer of the esophagus is about 10%, and dependence on the histological type of tumor and the degree of tumor differentiation were not found [1]. Such a poor prognosis in patients with cancer of the esophagus is caused by a number of specific reasons: 1) most of the clinical symptoms develop in the later stages of tumor development; 2) active lymphogenous metastasis is ensured by the presence of a large number of lymph vessels in the submucosal layer of the esophagus wall; 3) early invasive tumor in the mediastinum organs and surrounding tissue; 4) complexity and injury of a surgical intervention, especially at later stages [2].
As adopted by the world Health organization classification [3], following malignant tumors of epithelial nature are characteristic for esophageal localization: adenocarcinoma, mukoepydermoid cancer, adenocystic cancer, glandular-squamous cell carcinoma, squamous cell carcinoma, verrucous squamous cancer, basaloid carcinoma, spindle cell squamous cell carcinoma, small cell carcinoma, undifferentiated carcinoma and carcinoid.
until recently, the most common tumor of the following was squamous cell carcinoma, which amounted up to 90-95% of all malignant tumors of the esophagus [3]. over the past few decades, the structure of malignant tumors of the esophagus has changed. In Russia, the uSA, europe and some Asian countries there is a trend growth rate of esophageal adenocarcinoma localization [4].
In Russia, the ratio of adenocarcinoma to squamous cell esophageal cancer has changed from 1: 9 to 1: 4 [5,6]. according to data of Gantzev Sh.H. (2006) in 97-99% of cases by histological structure is esophageal squamous cell cancer of varying degrees of ripeness: with keratinization and without keratinization, and glandular forms in 1-3% of cases.
Since in the submucosa of the esophagus, as already mentioned, there is a powerful lymphatic plexus, that's why metastasis is carried out due to the spread of intramural lymphatic "at a distance of 4-5, and sometimes even 10 cm from the edge of the visible tumor" [7].
we carried out an analysis of the abdominal part of the esophagus when it defeats two types of cancer: squamous cell carcinoma and adenocarcinoma of the esophagus.
when analyzing histotopograms with tumor lesions of the abdominal esophagus are not judged morphological features of tumors themselves, and those macro- microscopically changes in the wall of the esophagus that occur during the growth of
tumors, depending on their type and nature of germination.
As material for such analysis were longitudinal histotopograms of abdominal part of an esophagus with the capture of the cardia of the stomach, made with resected esophagus after surgery such as Lewis and studied at 8-32-fold increase in the stereoscopic microscope.
These operative interventions were performed to 15 patients, including 14 men and one woman. The age of patients ranged from 49 to 74 years. From the operated patients, 5 patients were diagnosed with squamous cell carcinoma of the esophagus, and adenocarcinoma in 10 patients. Microscopically visible tumor length ranged from 5 to 10 centimeters.
According to the histological structure of the 5 patients there was a ceratinous and nonceratinous microinvasive squamous cell carcinoma. From 5 observations in three cases cancer was within the abdominal part of esophagus. In two cases, it grows into the gastric cardia.
In the studied group of observations have been two kinds of growth of malignant esophageal epithelium. The first version of the esophageal epithelium growth occurred along its length, without submerged growth expressed in the deeper layers of the esophageal wall. Because of this, changed esophageal mucosa forms on its inner surface multiple transverse folds, is well-defined on the longitudinal histotopograms. This mucosa have folded or pectinated views. As illustration of this are the two observations (Fig. 1 and 2).
in observation №1 in men 57 years took place ceratinous squamous cell carcinoma of the lower third of the esophagus stage ii, length of 7 cm. Figure 1 shows the major folds and outgrowth of mucosa into the lumen of the esophagus. The epithelium of this place is thickened irregularly and there are initial signs of submerged growth.
The submucosa throughout a tumor is expressed irregularly. in the redistribution of the resulting folds it sharply thickened and forms the basis of such folds. The muscular coat of the esophagus throughout the tumor is not changed.
Figure 2 shows a longitudinal histotopogram of observation №2 male 52 years, which shows that the growth of the epithelium occurs within mucosa with formation of multiple successive epithelium folds. in the surface layers of the burgeoning epithelium neighboring epithelial folds merging, and form a continuous epithelial integument, mainly in the proximal parts of the tumor.
The height of the folds of the mucosa in the range of 1000 to 2000 microns. Submucosa thickened to the limit of 2500
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© mironchev Anton o., Kagan ilya i., Samoilov Peter V., 2016
microns. Its layer, adjacent to the muscular coat, loosened.
Attract attention groups of expanded, congestive plethoric blood vessels. The muscular coat of the esophagus within tumor all along saved. There are visualized some tongue-shaped ingrowth of connective tissue submucosa between the muscle bundles of the circular layer.
Both observations in common, firstly, by preferential growth of epithelium over the surface of the esophagus with formation of transverse folds of the mucosa. Secondly, by complete safety of the muscular coat within the tumor. These observations are distinguished by the presence in the observation №1 initial signs of submerged growth. Furthermore, in the observation №2 observed more pronounced changes in the blood vessels of the submucosa. Such differences may be caused by a variety of tumor stage, since the observation №2 was stage I, and in the observation №1 - II stage.
In the case of adenocarcinoma in the zone of esophageal-gastric junction common to all observations is the occurrence of the tumor within the stomach (its cardiac parts) and tumor invasion up to the abdominal part of esophagus. Morphological differences in adenocarcinomas were in varying degrees of differentiation, like: low differentiated, moderately differentiated, and well differentiated.
The most revealing in terms of the nature of the growth of the tumor in the esophagus and the changes that it produces in its wall, is the observation №3, in which a woman 69 years old diagnosed with adenocarcinoma, with germination of all layers of the wall of the stomach and into the esophagus. Full histotopogram of resected longitudinal section shown in Fig. 3.
The right side of the histotopogram holds portion of the cardia of the stomach, in which observed generalized (widespread) submersible growth of adenocarcinoma into the entire depth of gastric wall, with destruction of muscle coat.
In the direction of the esophageal-gastric junction occurs a growth in the primary tumor node in the submucosa of abdominal esophagus. above this node, and somewhat to the left is the junction between the esophageal and gastric epithelium. Gastric epithelium at this point changed and is part of the tumor growing into the esophagus. on it there is a few thinned layer of the esophageal epithelium. To this layer of gastric epithelium
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adjoins saved proper connective plate of mucosa, which within the main tumor node completely destroyed.
In the wall of an esophagus adjoining to a tumor it is possible to note a little changed esophageal epithelium where signs of anatomic disorganization are observed. The submucosa is thickened and loosened. In it quite large number of blood vessels is defined. The muscular coat is kept and has no essential anatomic changes at magnifications of a stereoscopic microscope.
In addition to the gastric epithelium in adenocarcinomas macro- microscopically significant changes occur in the submucosa of the affected parts of the abdominal esophagus. They consist in a significant increase in its thickness by the development of coarse fibrous connective tissue. In its depth develops increasing of the number of congestive plethoric blood vessels, lymphatic vessels are identified and dilated lymphatic entire cavity located directly beneath the mucosa.
within the abdominal esophagus in the area adjacent to the main node of the tumor metastases detected in the form of separate units, completely destroying or replacing the muscular layer of the esophagus.
Thus, gastric adenocarcinoma, grows into the esophagus, characterized by a expressed submersible growth, mainly in the submucosa and focal destruction of muscular coat.
Performed analysis showed that for squamous cell carcinoma of the esophagus is most typically growth within the mucous coat on the surface of the esophagus, with forming of the transversal folding. a secondary is spread of the tumor in the submucosa and in the center of the tumor to muscular coat.
For adenocarcinomas of the stomach, germinating to esophagus, is characteristically changes in gastric epithelium, located in the esophagus and gastroesophageal junction, and the parallel growth of the tumor in the submucosa of the esophagus. For these tumors is characteristically more frequent and extensive damage of muscular coat.
Submucosa of the esophagus is the main layer in which there are significant changes in the esophagus tumor lesions, both within tumor and in adjacent areas of the esophageal wall. They are expressed in her considerable thickening, development of fibrous connective tissue, increasing the amount of blood and lymph vessels.
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Fig. 1. Squamous cell carcinoma of the abdominal part of the esophagus, stage II. Longitudinal histotopogram. Painting by Van-Gieson. Photo by MBS-10. Ok.8. Ob.2.
Fig. 2. Squamous cell carcinoma of abdominal part of the esophagus, stage I. Longitudinal histotpogram. Colouring with hematoxylin-eosin. Photo by MBS-10. A - Ok.8. Ob.1, B - part of A, Ok.8. Ob.2.
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Fig. 3. Adenocarcinoma, germinating in the abdominal part of the esophagus. Longitudinal histotopogram. Colouring with hematoxylin-eosin. United picture of 4 vision fields of MBS-10. Ok.8. Ob.1.
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