Karcinoid crvuljka

С Википедије, слободне енциклопедије
Karcinoid crvuljka
SinonimiCarcinoid apendix veriformis
Specijalnostionkologija

Karcinoid crvuljka je najčešći tip tumora, koji čini 85% svih gastrointestinalnih endokrinih tumora.[1] Naziv karcinoid ovi tumori su dobili zbog sporog rasta i homogenog izgleda tumorskih ćelija, što je ranije ispitivače navelo da potcene njihov maligni potencijal. Uglavnom je asimptomatski i dijagnostikuju se kao slučajan nalaz u apendektomiji ili tokom drugih operacija u trbuhu. [2]

Epidemiologija[уреди | уреди извор]

Posle apendektomija, histopatološkim pregledom, primarne novotvorine su identifikovane u ~ 0,5% svih hirurški uklonjenih crvuljaka, s karcinoidnim tumorima koje čine > 50% svih novotvorina crvuljka bilo koje etiologije.[3][4][3]

Koliko su retki ovi tumori govori podatak da većina hirurga susretne sa ovim entitetom samo jednom u životu.[2][5]

Karcinoid crvuljka su mirnog toka, a interval između početka simptoma i postavljanje dijagnoze u proseku je oko 4,5 godine.

Etiopatogeneza[уреди | уреди извор]

Karcinoid crvuljka je najčešće lokalizovan na vrhu crvuljka, u obliku solidnog tumora promera do 1 cm. I pored intramuralne i transmuralna propagacija tumora, zahvatanje regionalnih limfnih čvorova je veoma retko.[6]

Karcinoidni tumori nastaju iz neuroendokrinih ćelija difuznog neuroendokrinog sistema, koje su identifikovane na mnogim lokacijama u organizmu ćovea, uključujući;

  • pluća (25,1%),
  • jajnike (0,5%),
  • bilijarni sistem (0,2%) i
  • gastrointestinalni traktt (73,4%).[7] Karcinoidni tumori crvuljka su retke neuroendokrine neoplazme koje se obično ponašaju kao benigni tumori, mada određeni oblici ove lezije imaju potencijal za malignitet i metastaziranje.[8]
Metastaze

Verovatnoća metastaziranja karcinoidnih tumora crvuljka je mala ~ 4,7% svih karcinoidnih tumora crvuljka.[9] Osnovni put širenje metastaza je kroz limfu, a najčešće lokalizacije metastaza su u jetri i limfnim čvorovima retroperitoneumu.[2] Osim u jetri i limfhim čvorovima metastaze karcinoida crvuljka mogu se javiti i u kostima, a nešto ređe u srcu, dojkama ili oku.

Rizik od metastatskog širenja je uslovljen veličinom tumora, pa se tako metastaze nalaze u:

  • manje od 2% tumora manjih od 1 cm,
  • skoro 100% kod tumora većih od 2 cm.

Klinička slika[уреди | уреди извор]

Klinička slika karcinoid crvuljka karakteriše se istim onim simptomima koji se javljaju i kod akutnog zapaljenja crvuljka, a broj i karakter manifestacija, odnosno simptoma zavisi od karakteristike samog tumora.

Kod karcinoida crvuljka ne postoji specifičan preoperativni klinički prikaz jer su ovi tumori ili asimptomatski ili su prisutni kao akutno zapaljenje crvuljka. Zato se dijagnostikuju slučajno tek tokom apendektomije, ili neke druge operacije u trbuhu.[10] Pored toga, karcinoidi crvuljka mogu rezultovati ponavljajućim epizodama bolova u trbuhu usled delimične opstrukcije lumena crvuljka tumorskom masom. Retko se javljaju neuroendokrini simptomi, uključujući povraćanje, dijareju i srčane bolesti.[11]

Karcinoidi crvuljkaci polako rastu, a svukupna prognoza je u načelu dobra.[12] Trenutna veličina tumora je najpouzdaniji pokazatelj za procenu malignog potencijala karcionoida.

Terapija[уреди | уреди извор]

Apendektomija

Kako je kod većine pacijenata sa karcinoidima crvuljka prečnik tumora < 1 cm, samo apendektomija je dovoljan tretman, jer karcinoidi retko metastaziraju. Za tumore prečnika 1-2 cm, hirurške mogućnosti zavise zahvaćenosti mezoappendiksa i histološke podvrsta lezije. Međutim, kako tumori prečnika ≥ 2 cm lokalizovan na bazi crvuljka, najćešče mogu metastazirati, to kod pacijenti sa tumorima ove veličine zahteva desnu hemikolektomiju.

Kandidati za desnu hemikolektomiju su oni sa lezijama kod kojih postoje histopatloški dokazi mezoapendikalne ekstenzije tumora lokalizovane u dnu crvuljka sa pozitivnim marginama ili zahvaćenošću slepog creva (cekuma) solidnim malignim karcinoidom.[13][14]

Opsežniji hirurški tretman preporučuje se i u situacijama kada tumor ima visok indeks proliferacije ili ako se proširio na mezenterične krvne sudove i limfne sudove crvuljka.[1]

Hemoterapija

Indikacije za adjuvantnu hemioterapiju su: veličina tumora preko 2 cm, goblet-tip karcinoida, kao i pozitivne resekcione margine.[1]

Prognoza[уреди | уреди извор]

Prognoza karcinoidnog tumora zavisi od lokalizacije i stadijuma bolesti u vreme postavljanja dijagnoze. Karcinoidi apendiksa retko ugrožavaju život.[2]

Iako u 80% slučajeva može doći do recidiva, apendektomija crvuljka daje dobre rezultate.[2]

Izvori[уреди | уреди извор]

  1. ^ а б в O’Donnell ME, Carson J, Garstin WI. Surgical treatment of malignant carcinoid tumours of the appendix. International journal of clinical practice. 2007;61(3):431-7.
  2. ^ а б в г д Jelena Antić, Klinički značaj minimalno invazivne hirurgije u terapiji akutnog apendicitisa u dečjem uzrastu, Doktorska disertacija, Univerzitet u Novom Sadu Medicinski fakultet, Novi Sad, 2016.
  3. ^ а б Pickhardt PJ, Levy AD, Rohrmann CA, Jr, Kende AI. Primary neoplasms of the appendix manifesting as acute appendicitis: CT findings with pathologic comparison. Radiology. 2002;224:775–781. doi: 10.1148/radiol.2243011545.
  4. ^ Deans GT, Spence RA. Neoplastic lesions of the appendix. Br J Surg. 1995;82:299–306. doi: 10.1002/bjs.1800820306. [PubMed] [CrossRef]
  5. ^ In’t Hof KH, van der Wal HC, Kazemier G, Lange JF. Carcinoid tumour of the appendix: an analysis of 1,485 consecutive emergency appendectomies. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2008;12(8):1436-8.
  6. ^ Christianakis E, Paschalidis N, Chorti M, Filippou G, Rizos S, Filippou D. Carcinoid tumour of the appendix in children: a case report. Cases journal. 2008;1(1):136.
  7. ^ Modlin IM, Sandor A. An analysis of 8305 cases of carcinoid tumors. Cancer. 1997;79:813–829. doi: 10.1002/(SICI)1097-0142(19970215)79:4<813::AID-CNCR19>3.0.CO;2-2.
  8. ^ Parkes SE, Muir KR, al Sheyyab M, II, Cameron AH, Pincott JR, Raafat F, Mann JR. Carcinoid tumours of the appendix in children 1957–1986: Incidence, treatment and outcome. Br J Surg. 1993;80:502–504. doi: 10.1002/bjs.1800800433.
  9. ^ Moertel CG, Weiland LH, Nagorney DM, Dockerty MB. Carcinoid tumor of the appendix: treatment and prognosis. N Eng J Med. 1987;317:1699–1701. doi: 10.1056/NEJM198712313172704.
  10. ^ Roggo A, Wood WC, Ottinger LW. Carcinoid tumors of the appendix. Ann Surg. 1993;217:385–390. doi: 10.1097/00000658-199304000-00010. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
  11. ^ Markgraf WH, Dunn TM. Appendiceal carcinoid with carcinoid syndrome. Am J Surg. 1964;107:730–732. doi: 10.1016/0002-9610(64)90301-0. [PubMed] [CrossRef] [Google Scholar]
  12. ^ Thirlby RC, Kasper CS, Jones RC. Metastatic carcinoid tumor of the appendix. Report of a case and review of the literature. Dis Colon Rectum. 1984;27:42–46. doi: 10.1007/BF02554075. [PubMed] [CrossRef] [Google Scholar]
  13. ^ Syracuse DC, Perzin KH, Price JB, Wiedel PD, Mesa-Tejada R. Carcinoid tumors of the appendix. Mesoappendiceal extension and nodal metastases. Ann Surg. 1979;190:58–63. doi: 10.1097/00000658-197907000-00013. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
  14. ^ Gouzi JL, Laigneau P, Delalande JP, Flamant Y, Bloom E, Oberlin P, Fingerhut A. The French Associations for Surgical Research: Indications for right hemicolectomy in carcinoid tumors of the appendix. Surg Gynecol Obstet. 1993;176:543–547. [PubMed] [Google Scholar]

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