Oncology ONCOLOGY is the science of tumors. Its main tasks in our time are the study of the etiology and pathogenesis of malignant tumors, the prevention of cancer, the organization and development of methods for early and timely diagnosis, the improvement of surgical, radiation, medicinal, combined and complex methods treatment and rehabilitation.
BIOLOGICAL PROPERTIES OF TUMORS A. Benign - favorable course, consist of mature cells, grow slowly, have a capsule, clear boundaries, expand tissue without destroying, do not recur, do not metastasize. But... they can become malignant! B. Malignant - unfavorable course, tumor cells have a number of features that distinguish them from normal cells.
Features of malignant tumors 1. Autonomy - uncontrolled growth, relative independence from regulatory mechanisms. Hormone-dependent tumors are subject to the control influence of hormones. 2. Anaplasia (more precisely, cataplasia) or persistent dedifferentiation of tumor cells - loss of the ability to form specific structures and produce specific substances.
Anaplasia of tumor cells Associated with anaplasia is A) Cell atypia: variability in the size and shape of cells, the size and number of organelles, nuclei, DNA content, chromosomes - shapes and numbers. B) Atypism of structures - tissue atypia. C) Functional anaplasia - complete or partial loss of the ability of tumor cells to produce specific products (for example: hormones, secretions, fibers). Associated with functional anaplasia are a) Biochemical anaplasia - loss of biochemical components. b) Immunological anaplasia - loss of antigenic components. U different tumors The degree of anaplasia varies.
Features of malignant tumors 3. Infiltrative, or invasive, growth - the ability of tumor cells to grow and destroy surrounding healthy tissue. a) tumors with a predominantly infiltrative type of growth (endophytic), b) tumors with minimal infiltration and expansive growth (exophytic) and c) with a mixed type of growth.
Features of malignant tumors 4. Metastasis - a method of spread of cancer cells by separation from the main focus and transfer through the bloodstream, lymphatics, and mechanically. Reason: loss of the ability of cancer cells to adhere (stick together). 5. Recurrence. 6. Progression of tumors - as they grow, the signs of tumors (invasiveness, metastasis, etc.) increase!
ETIOPATHOGENESIS OF MALIGNANT TUMORS Embryonic theory of Conheim - Ribbert. Virchow's theory of irritation. Spemann's "organizer" theory. The theory of biological evasion. "Mutation and transformation of cells." Fischer-Wasels theory. "Development of a tumor at a prepared site". Theory of chemical carcinogenesis. Virogenetic theory of the origin of tumors. Polyetiological theory.
Polyetiological theory N. A. Velyaminov, N. N. Petrov - the occurrence of malignant tumors can be caused by several etiological factors: chemical agents, physical factors (radiation, ultraviolet radiation) and viruses. N. N. Petrov: “A tumor is a dystrophic proliferative reaction of the body to various harmful factors, external and internal, persistently disrupting the composition and structure of tissues and cells and changing their metabolism."
Polyetiological theory N. N. Blokhin: “So, malignant growth is a multi-stage process, including at least three stages of initiation, promotion and progression. It is based on one cell that has exogenous viral or cellular oncogenes. Carcinogenic influences lead to high expression different genes, the second phase begins - promotion, followed by progression tumor growth.
CLASSIFICATION OF TUMORS 1. Benign tumors. 2. Malignant tumors. 3. Tumor-like diseases (dishormonal hyperplasia (mastopathy) and foci of excessive regeneration, malformations; cavity cysts with a wall and liquid contents, hyperregenerative polyps, condylomas.
Epithelial tumors Benign Papilloma Adenoma Locally destructive Basalioma Malignant (cancer) 1. Differentiated Squamous cell carcinoma Adenocarcinoma Differentiation by formed structures: alveolar, tubular, cribriform, solid, etc. By the ratio of parenchyma and stroma: medullary cancer, simple, scirrhus. 2. Undifferentiated oat cell, round cell, large cell, polymorphic cell, etc.
II. CONNECTIVE TISSUE TUMORS Benign Locally destructive a) desmoid b) dermatofibroma c) some types of lipomas Fibroma Myxoma Lipoma Chondroma Osteoma Leiomyoma Rhabdomyoma Malignant (sarcomas) fibrosarcoma, lipo-, chondroosteo-leiomyosarcoma, Ewing's sarcoma
III. TUMORS FROM ENDOTHELIUM AND MESOTHELIUM Benign Hemangioma Lymphangioma Localized mesothelioma Malignant Hemangiosarcoma (hemangioendothelioma) Lymphangiosarcoma Synovioma (synovial sarcoma) Diffuse mesothelioma
1 U. TUMORS FROM HEMAPOIETIC TISSUE (HEMOBLASTOSES) Systemic diseases Leukemia Tumors a) acute b) chronic Hematosarcomas Lymphogranulomatosis, lymphosarcoma, plasmacytoma Unclassified malignant lymphomas
U. TUMORS FROM THE NERVOUS SYSTEM Benign Neurofibroma Neurolemmyoma (neurinoma) Ganglioneuroma Oligodendroglioma Astrocytoma Meningioma
U. TUMORS FROM THE NERVOUS SYSTEM Malignant Neurofibrosarcoma Neurofibrosarcoma Ganglioneuroblastoma Sympathogonoma Astroblastoma Medulloblastoma Glioblastoma multiforme, (spongioblastoma) Epindymoblastoma Meningeal sarcoma
IN 1. TUMORS FROM THE ARIDSYSTEM (APUDOMA) 1. Adenomas of the endocrine glands (pituitary gland, pineal gland, pancreas - insulinoma). 2. Carcinoids: a) hormonally active, b) hormonally inactive. 3. Paragangliomas: a) chromaffin (pheochromacytoma) b) non-chromaffin (chemodectoma). 4. Small cell lung cancer, medullary cancer thyroid gland. 5. Thymoma. 6. Melanoma.
UP. TUMORS FROM EMBRYONAL REMAINS. Benign Teratoma Dermoid cyst Malignant Teratoblastoma Nephroblastoma (Wilms tumor)
Tumors of the US. TROPHOBASTIC TUMORS Benign Hydatidiform mole Malignant Chorionepithelioma 1 X. MIXED TUMORS X. HAMARTOMAS (conditional tumors) Excess tissue characteristic of the affected organ.
Epidemiology malignant diseases Studies the characteristics of the spread and causes of human diseases by malignant tumors, geographical and mineralogical features of the habitat, household traditions, bad habits, professional factors, hygienic living conditions of a person. There has been a tendency towards an increase in the proportion of mortality from malignant tumors. The increase in morbidity and mortality from malignant tumors depends on: - an increase in average life expectancy; - autopsies are performed more often; - a true increase in incidence - cancer of the lung, colon, breast, leukemia.
Epidemiology of malignant diseases The incidence of lung cancer is increasing everywhere. Stomach cancer is common in Japan, China, Russia, Iceland, Chile; much less often - in the USA, the Baltic states, Indonesia, Thailand. Esophageal cancer - the incidence is increased on the coast of the Arctic Ocean, in the republics of Central Asia and Kazakhstan, Buryatia. Oral cancer - in Asia, India. Skin cancer - in southern countries. Breast cancer - reduced in Japan, increased in European countries.
Precancerous conditions (precancerous). 1. Precancerous conditions, or diseases, facultative precancer (chronic inflammatory diseases). 2. Pre-tumor changes - obligate pre-cancer, this is a morphological concept - dysplasia, pre-cancer as a disease. Obligate precancer: familial intestinal polyposis, xeroderma pigmentosum of the skin, Bowen's dermatosis, adenomatous polyp of the stomach, some types of mastopathy. Precancerous diseases of the stomach - polyposis, ulcer, atrophic-hyperplastic gastritis; esophagus - esophagitis, polyps, leukoplakia; uterus - cervical erosion, ectropion.
Prevention of cancer Primary prevention is the prevention of the occurrence of precancerous changes. Carrying out health-improving activities: a) on a national scale: combating soil, air, water pollution, hygiene measures on pollution elimination; b) maintaining personal hygiene, diet, food quality, normal lifestyle, giving up bad habits.
Prevention of cancer Secondary prevention Prevention of cancer in the presence of precancerous changes, treatment of chronic, precancerous, benign diseases. Tertiary prevention Prevention of tumor growth and spread; prevention of relapses and metastasis after treatment, herbal medicine, chemotherapy, radiation treatment, surgery, etc.
ORGANIZATION OF ONCAL SERVICES IN RUSSIA Directorate of the Ministry of Health, oncology institutes, oncology dispensaries, oncology departments, oncology rooms. Oncology dispensary Organizational and methodological office (department), clinic, hospital. X-ray service Laboratory Endoscopic Surgical, radiological, chemotherapy departments. Diagnosis, treatment, rehabilitation of patients, registration, observation, and medical examination are carried out.
clinical groups of cancer patients 1 -a - with suspicion of a malignant tumor, examination within 10 days; 1-b - precancerous diseases - are treated in the general medical network in terms of secondary prevention; P - patients with malignant tumors (stages 1, P, III) are subject to treatment; P-a - radical treatment; Sh - almost healthy people cured of cancer. Subject to observation after 3, 6 months, annually - tertiary prevention, rehabilitation; 1 U - patients with advanced disease (stage 1 U). Subject to symptomatic and palliative treatment.
GENERAL PRINCIPLES OF TUMOR DIAGNOSIS Early diagnosis - important condition effectiveness of treatment of any disease. Oncological alertness: knowledge of the symptoms of malignant tumors in the early stages; - knowledge of precancerous diseases and their treatment; - knowledge of the principles of organizing oncological care should be sent to the appropriate institution; - thorough examination each patient in order to exclude cancer; - V difficult cases- raising suspicion of cancer.
DIAGNOSTICS Early, timely, late Complaints and anamnesis, heredity. Objective examination - lymphatic system, paraneoplastic conditions. Laboratory methods research. X-ray methods: R-scopy, graphy, tomography, computed tomography, NMR. Ultrasound examination. Radioisotope diagnostics. Endoscopic methods. Morphological: cytology, histology. Examination of sputum and fluids; results of puncture biopsy, incisional, excisional, trephine biopsy; Study of surgical material. Diagnostic operations. Early diagnosis - medical examinations.
STAGES OF THE TUMOR PROCESS I - Small tumor limited to 1-2 layers, without metastases. II - Tumor within the organ + metastases in the regional lymph nodes of the first order. III - Tumors spreading to surrounding organs and tissues + metastases of the I - P order. IU - Tumor with distant metastases.
International classification T – (T 0, Tis, T 1, T 2, T 3, T 4) - tumor, N 1, 2, 3, 4 - metastases in regional lymph nodes, M+ - distant metastases, P 1, 2 , 3, 4 - depth of tumor germination, G 1, 2, 3 - degree, degree of malignancy. Thus, the oncological diagnosis should sound like this: Cancer of the body of the stomach, ulcerative infiltrative form, stage III, histologically: moderately differentiated adenocarcinoma, T 3, N 1, M O, P 4, G 2.
General principles and methods of treatment of malignant tumors. Each treatment method has its own indications and contraindications. Indications: local - tumor size and extent, degree of anaplasia; general - condition of the body (concomitant diseases, age, physical condition of the body); state of immunity, features of the patient’s hormonal profile, metabolic processes. Treatment can be: radical, conditionally radical, palliative, symptomatic. Radicality is determined clinically - after treatment, biologically - after 5 years.
Surgical treatment Surgical diseases: cancer of the esophagus, stomach, kidney, colon. For surgical treatment: electrosurgery, cryosurgery, laser. Principles of surgery: ablastic, antiblastic, zonal, cased. The tumor + metastases are removed en bloc. Contraindications to surgical treatment: Oncological order - according to the prevalence of the process. General order - according to concomitant diseases. Operability, resectability. Operations by nature: radical, conditionally radical, palliative, symptomatic. Operations by volume: regular (simple), combined, extended.
GENERAL PRINCIPLES OF RADIATION THERAPY 1. Remote methods of radiation therapy. A) Static and mobile gamma therapy (RAY, Rokus, Agat). B) Radiation - proton, electron, neutron; radiation from accelerators: betatron, linear accelerators, neutron accelerators. 2. Contact irradiation methods: intracavitary, interstitial, radiosurgical, application, close-focus radiotherapy, selective isotope accumulation method, intraoperative. 3. Combined methods 4. X-ray therapy: static, mobile.
RADIATION DOSAGE Various methods: A) small fractions 2 Gy. - 5 times a week, B) in large fractions of 5 - 10 - 20 Gy. within 1 - 5 days. The total dose is 50 - 70 Gy. Varying radiosensitivity of the tumor. High - hematopoietic and lymphoid tumors, small cell carcinoma lung, thyroid gland. Radiosensitive - squamous cell carcinoma skin, esophagus, oral cavity, pharynx. Medium - vascular, connective tissue tumors. Low - adenocarcinoma, lymphosarcoma, chondrosarcoma, osteosarcoma. Very low - rhabdomyosarcoma, leiomyosarcoma, melanoma.
DRUG METHODS FOR TREATING MALIGNANT TUMORS The following can be treated with chemotherapy: testicular seminoma, skin cancer, ovarian cancer, multiple myeloma, lymphogranulomatosis, Wilms tumor, lymphosarcoma. Treatment: uterine chorionepithelioma, malignant Burkett lymphoma, acute leukemia in children (especially lymphoblastic). For other tumors - a temporary effect, repeated courses, in combination with hormones and other chemotherapy drugs - polychemotherapy.
Antitumor drugs About 40 antitumor drugs are used. Chlorethylamines and ethyleneimines (alkylating drugs): embiquin, novembiquin, dopan, chlorobutyl, cyclophosphamide, sarcolysine, prospidine, thiophosphamide, benzotef, etc. (Active CH 2 group - alkyl combines with nucleic acids and cell proteins, damaging it).
Antitumor drugs P. Antimetabolites: methotrexate, 5 fluorouracil, ftorafur, cytosine arabinoside, 6 - mercaptopurine (disrupt DNA synthesis in tumor cells and lead to their death). Sh. Antitumor antibiotics: aurantine, dactinomycin, bruneomycin, rubomycin, carminomycin, bleomycin, mitamicin-C, adriamycin (cause disruption of DNA and RNA synthesis).
Antitumor drugs 1 U. Herbal drugs: colhamine, vinblastine, vincristine (mitotic poisons - block cell mitosis). U. Other antitumor drugs: nitrosomethylurea, natulan, chloditan, myelosan; platinum preparations: cisplatin, CCNU, BCNU, platidiam and others. In 1. Hormonal drugs (androgens, estrogens, corticosteroids, progestins).
Treatment of tumors Combined treatment: radiation + surgery, surgery + radiation. Complex: surgical + chemotherapy + hormonal, surgical + radiation + chemotherapy, surgical + chemotherapy + hormonal. INDICATIONS For a common process. For highly invasive tumors. For hormone-dependent tumors. Combined treatment: 2 or 3 types of the same type of therapy: a) polychemotherapy, b) radiation: external + contact - used before surgery or after surgery or during surgery.
VTE AND REHABILITATION OF CANCER PATIENTS 1 Clinical group – given 1st disability group and symptomatic treatment: painkillers, heart medications, etc.; Palliative chemotherapy and herbal medicine can be performed. III clinical group - after treatment sick leave for 4 - 6 -12 months depending on the disease, method of treatment, volume of surgery, etc. Control examination after 3 -6 -12 months.
REHABILITATION OF CANCER PATIENTS Disability group - depending on the state of health, the volume of the removed organ, the presence of metastases, and the nature of the work. If there is no suspicion of metastases, rehabilitation: plastic surgery, prosthetics, Spa treatment. Avoid thermal procedures, massage of affected organs, etc. Rehabilitation departments are used for this; It is necessary to involve psychologists in working with these patients. Deontology in oncology
tumor cell motility,
weakening intercellular interactions,
actions of lytic enzymes
type of body reaction.
Metastasis occurs in 3 stages:
Separation of tumor cells from the primary tumor and penetration into lymphatic and blood vessels
Movement of tumor cells and their emboli through blood vessels
Retention, engraftment and growth in lymph nodes and distant organs
Lymphogenic
Hematogenous
Implantation
Non-epithelial tumors (sarcomas) are characterized by a hematogenous route .
The name of benign tumors consists of two parts:
The first part indicates the source of the tumor (cells, tissue, organ),
The second part is the suffix “oma” (tumor).
lipoma - a tumor of adipose tissue,
fibroids - from muscle tissue,
osteoma - from bone tissue,
chondroma - made of cartilage tissue.
bronchial adenoma,
thyroid adenoma,
forearm fibroids.
Malignant tumors are distributed according to the main types of tissue:
epithelial,
connective tissue,
muscular
neurogenic.
PRE-CANCER DISEASES
Based on numerous clinical observations, it has emerged doctrine of preblastomatosis (V. Dubreuil, 1986; P. Menetrier, 1908; I. Orth, 1911), various aspects of which were discussed at numerous congresses. The postulates of this doctrine are
“cancer never arises in a previously healthy organ” (Borrmann R, 1926)
“every cancer has its own precancer” (Shabad L.M., 1967)
Currently, various changes in organs and tissues are considered precancer. Obligate skin cancers include xeroderma pigmentosum, Bowen's disease, actinic keratosis and cutaneous horn. Background (or optional) precancers are distinguished: tuberculosis, syphilis, varicose veins, fistulas due to osteomyelitis, scars after burns or mechanical injuries). Pigmented nevi are important in the origin of malignant melanomas. Precancers of the oral mucosa include leukoplakias, chronic ulcers, fissures, sclerosing glossitis, polished and warty tongue, papillitis, papillomas, erythroplasia, chronic inflammatory processes, cysts, lupus, syphilis, lichen planus, Bowen's disease, various benign tumors, dental granulomas and cysts, scars and fistulas.
Cancer of the lower lip is preceded by long-term atrophic, dystrophic and hypertrophic changes in the red border. Thyroid cancer can arise from pre-existing adenomas, thyroiditis, and Hashimoto's struma. Breast cancer is preceded by mastopathy, various forms of fibroadenomatosis, intraductal papillomas and cystadenopapillomas. Chronical bronchitis smokers, chronic pneumonia, chronic suppurative processes, pneumosclerosis, scars of tuberculous etiology can contribute to the occurrence of lung cancer.
Esophagitis, cicatricial strictures, peptic ulcers, papillomas, benign tumors, diverticula, cardiospasm, hernias contribute to the occurrence of esophageal cancer. hiatus, diaphragm and congenital short esophagus. Precancerous diseases of the stomach include chronic atrophic gastritis, chronic ulcers, polyps, pernicious anemia, intestinal metaplasia, Ménétrier's disease, condition after gastric resection. Colon and rectal cancer can occur against the background of chronic ulcerative colitis, anorectal fistula, diverticula and polyposis.
Patients with the above diseases should be under medical supervision. If the development of a malignant tumor is suspected, a biopsy of pathologically altered tissue is indicated. Prevention of a malignant tumor in these cases is timely treatment including surgery.
CLASSIFICATION OF TUMORS BY STAGE IN THE TNM SYSTEM
Classification of tumors by stage is an attempt to unite primary patients with malignant neoplasms of the same location into homogeneous groups according to the clinical course of the disease, prognosis and approach to treatment tactics.
Clinical experience has shown that the most important factor influencing the course and outcome of the disease is the extent of the tumor’s prevalence at the time of diagnosis.
Currently adopted by a special committee of the International Union Against Cancer, the American Joint Committee on Cancer and the Federation of Gynecologists and Obstetricians systemTNM. This classification is applicable to tumors of different locations, regardless of the planned treatment, and can be supplemented by data obtained from surgical intervention and pathohistological examination.
The classification uses three symbols:
T– spread of the primary tumor,
N– condition of regional and juxtaregional lymph nodes,
M– presence or absence of distant metastases.
The numbers added to each of the characters (T 0, T 1, T 2, T 3, T 4; N 0, N 1, N 2, N 3, M 0, M 1) indicate for T - dimensions and (or ) local spread of the primary tumor, for N varying degrees of involvement of regional or juxtaregional lymph nodes (N 4).
Symbol X means the impossibility of determining the size and local spread of the tumor (T X), condition of regional lymph nodes (N X), presence or absence of distant metastases (M X).
For each location, two parallel classifications are provided: clinical TNM and postsurgical or pathohistological pTNM.
Clinical classification is based on data from clinical, radiological, endoscopic, radionuclide, ultrasound and other types of studies conducted before treatment.
Postsurgical or pathohistological pTNM takes into account the results of the study of the postoperative specimen. The use of morphological data, degree of tumor differentiation, invasion of lymphatic vessels and veins, and lymph nodes is provided.
Symbol " WITH” carries information about the degree of classification reliability:
C 1 – clinical trial only,
C 2 – special diagnostic procedures,
C 3 – trial surgical intervention,
C 4 – data obtained by studying the surgical specimen obtained after radical surgery,
C 5 – data from a sectional study.
The reliability symbol is placed last in each category (T 2 C 2 N 2 C 2 M 0 C 1)
Extent of tumor at the time of diagnosis is divided into 4 stages
Stage I
Tumor no more than 3 cm in original tissue
There are no regional metastases
No distant metastases
Tumor from 3 to 5 cm without extending beyond the organ
Presence of single displaced regional metastases
No distant metastases
Tumor larger than 5 cm extending beyond the organ
Multiple displaced regional metastases
No distant metastases
The tumor spreads to neighboring organs
Presence of distant lymphogenous or hematogenous metastases
HISTOLOGICAL DIAGNOSIS METHODS
Only early detection malignant tumor can lead to successful treatment sick. Great value It has " cancer alertness” of a doctor examining a patient. This concept was formulated by the founders of oncology P. A. Herzen, N. N. Petrov, A. I. Savitsky, B. E. Peterson.
“Oncological alertness” includes:
knowledge symptoms of malignant tumors in the early stages;
knowledge precancerous diseases and their treatment;
knowledge organization of oncological care, networks of medical institutions and rapid referral of a patient with a detected or suspected tumor to its intended destination;
thorough examination every patient who consults a doctor of any specialty in order to identify a possible oncological disease;
habit in difficult diagnostic cases, think about the possibility of an atypical or complicated course of a malignant tumor.
The patient should be interviewed systematically, according to a specific plan, moving from organ to organ. Revealing pathological symptoms forces the doctor to change and deepen the survey towards the affected organs.
The identified symptoms may be manifestations of relapse or metastases of a previously removed tumor, which must be taken into account when collecting anamnesis.
If there is a visible tumor, it is necessary to find out the characteristics of its growth. Malignant tumors are characterized by rapid growth, a progressive increase in size, sometimes spasmodic. The absence of changes in tumor size over a long period does not exclude a malignant nature.
Suspicion about possible availability A malignant tumor can occur when the nature of sensations that have been present for a long period changes. In most cases, a thorough analysis of symptoms allows us to detect mild pain in the projection of the affected organ, which is constant or periodic in nature.
The absence of pain in the initial period of tumor development significantly increases the period before the patient consults a doctor. Severe pain in most cases is evidence of an advanced tumor with invasion of nerve trunks.
The growth of tumors into the lumen of hollow and tubular organs is accompanied by an inflammatory reaction, which in turn leads to increased production of secretions or excreta. Patients develop pathological discharge
salivation,
cough with sputum
mucus in stool.
Many doctors believe that a malignant tumor is necessarily accompanied by cachexia. In fact, significant weight loss is typical only for tumors digestive system. With sarcomas and tumors of other localizations, patients do not differ in appearance from healthy people for a long time.
The inflammatory process that accompanies many tumors, combined with the breakdown of tumor tissue, quite often causes fever. The temperature curve can be constant, intermittent, low-grade or indeterminate.
When collecting anamnesis, it is necessary to pay attention to paraneoplastic syndromes, divided into:
skin,
neurological,
vascular,
bone,
renal
homologous.
Neurological symptoms may occur with paraneoplastic hypercalcemia. Patients experience myoneuropathy, polyneuritis, symptoms of myasthenia gravis, and paresis.
Objective examination of the patient comprises inspection, palpation, auscultation and endoscopy.
Upon examination pay attention to the general appearance of the patient, skin color, puffiness of the neck and face, facial asymmetry, gait, position of individual parts of the body, defects of the face and limbs.
The doctor must examine the entire area of the patient’s skin and oral mucosa. At the same time, palpation of tumor zones of visual localizations is carried out: neck, thyroid gland, mammary glands. When examining the body, there is a retraction of the chest, a protrusion in the projection of the kidney, and visible peristalsis of the stomach or intestines.
Digital examination of the rectum, prostate gland and female genitalia (parallel examination by a gynecologist) is of great importance in the diagnosis of tumors.
Tumors are characterized by “ plus tissue syndrome" The size of the tumor is determined in millimeters and centimeters. When describing a tumor, it is necessary to indicate its shape, consistency, and mobility.
All areas of palpable lymph nodes should be examined. Metastatic nodes are usually enlarged, dense, often lumpy, adherent to surrounding tissues and painless.
It is important to remember that it is possible to detect regional or distant lymph node involvement without an identifiable primary tumor.
Percussion and auscultation complement the above research methods.
When diagnosing tumors, it is necessary to answer the following questions:
Localization of the primary tumor
identification of the affected organ
localization and boundaries of the tumor
Anatomical type of tumor growth
exophytic
endophytic
mixed
Histological structure of the tumor
histological identity of the tumor
degree of differentiation of cellular elements
Disease stage
size of the primary tumor
characteristics of regional lymph nodes
characteristics of distant lymph nodes and organs (exclusion of distant metastases).
X-ray studies(mammography, parietography, tomography, laterography, angiography, irrigoscopy, pneumopelviography, hysterosalpingography, lymphography, infusion and retrograde pyelography, cystography, pneumoencephalography, myelography, phlebography, pneumomyography, CT, NMR, etc.).
Radionuclide diagnostics(static and dynamic scintiography;
Ultrasound diagnostics
Endoscopic studies(esophagogastroduodenoscopy, sigmoidoscopy, fibrocolonoscopy, fibrolaryngobronchoscopy, calposcopy, hysteroscopy, cystoscopy, mediastinoscopy, thoracoscopy, laparoscopy)
Diagnostic operations
Tumor biopsy
A biopsy allows you to determine:
Nature of the pathological process
Histological identity of the tumor and the degree of its differentiation
Benign or malignant tumor
Distribution limits tumor process(radicality of the antitumor treatment)
Incisional biopsy is the most common. It is performed using a scalpel or a special punch. The material is obtained at the border of normal and pathological tissue.
Excisional biopsy performed in the presence of small tumors, by completely removing them in a single block within healthy tissue.
Aspiration biopsy is divided into two methods. In the first, thin needles are used and smears are prepared from the aspirated material for cytological examination. The second method uses large-diameter needles to obtain a core of tissue for a routine biopsy.
TREATMENT OF TUMORS
In oncology there is a distinction the following types treatment: radical, palliative and symptomatic.
Radical treatment aimed at the complete elimination of all foci of tumor growth.
Palliative care consists of direct or indirect impact on foci of tumor growth to change their mass and delay growth.
Symptomatic therapy is aimed at eliminating or reducing the painful manifestations of the underlying disease and its complications (or complications of antitumor treatment) for the patient.
Currently, for the treatment of malignant tumors, a combination of methods is usually used sequentially or simultaneously. Special terms are used to designate treatment options - combined, complex and combined treatment.
Combined treatment involves the use of two or more various methods having the same focus (surgical treatment, radiation therapy, cryodestruction, laser therapy, local chemotherapy, regional chemotherapy, local microwave therapy).
Complex treatmenttion includes methods of local-regional and general types of exposure (systemic chemotherapy, hormonal therapy, immunotherapy, general hyperthermia).
Combined treatment– this is the use within one method of various methods of its implementation or the use of antitumor drugs that differ in the mechanism of action during chemotherapy (polychemotherapy, remote Y-therapy, interstitial therapy, etc.).
Development therapeutic tactics and its practical implementation in patients requires the unification of specialists in various types antitumor treatment - surgeons, radiologists, chemotherapists, morphologists, gynecologists, etc.
Surgical method is the main method of treating cancer patients.
The presence of a tumor in a patient is an indication for surgical treatment.
Benign tumors are removed within healthy tissue.
When surgically treating malignant tumors, one should adhere to the rules developed over many years.
When performing surgical interventions, it is necessary to strictly observe ablastics and antiblastics.
Ablastika– this is the removal of a tumor within healthy tissues in accordance with the principles of anatomical zonation and casing. An anatomical zone in oncology is a biologically integral area of tissue formed by an organ or part thereof and related to it by regional lymph nodes and anatomical structures located along the path of spread of the tumor process.
Case limited to the junctions of the peritoneum and fascial sheets, layers of fatty tissue.
The tumor is removed en bloc within anatomical zone in a complete case with ligation of incoming and outgoing vessels outside the case.
Antiblastics– this is a set of measures that prevents delamination and the leaving of viable tumor elements in the wound.
Antiblastics include:
Preoperative radiotherapy.
Dressing great vessels before organ mobilization begins.
Application of electrosurgery for tissue dissection and hemostasis.
Ligation of tubular organs distal and proximal to the tumor.
Repeated hand washing throughout the operation.
Multiple changes of linen.
Disposable use of clips, wipes and balls
Cryogenic effects – destruction of the tumor focus by freezing.
Use of laser scalpels.
Absolute readings:
Absence of tumor growth into organs not subject to resection and absence of metastases beyond the regional lymphatic barrier.
Presence of complications life-threatening patient:
bleeding
asphyxia.
obstruction.
other complications, the elimination of which makes it possible to alleviate the patient’s condition and prolong his life
It is established before the operation operability– the ability to operate on this patient.
Resectability– this is the possibility of removing a tumor that is installed during surgery.
Surgical interventions in oncology are divided into diagnostic and therapeutic .
A diagnostic operation can turn into a therapeutic operation after a diagnosis has been established or clarified.
Therapeutic operations can be radical, conditionally radical and palliative.
Radical surgery from a biological point of view can be assessed after 5-10 years. From a clinical point of view, radicality is determined by the removal of the primary tumor within healthy tissues along with regional lymph nodes. These operations are often performed at stages I-II of tumor disease.
Conditionally radical operations performed at Stage III diseases when, with a significant spread of the tumor, it seems that all detected tumor foci have been removed.
Radical and conditionally radical operations are divided into standard, extended and combined.
Typical Operations– involve removal of the affected organ or part of it in a block with regional lymph nodes.
Advanced Operations– provide additional removal of extra-regional stages of lymphogenous metastasis to the standard operation.
Palliative operations performed in the presence of distant metastases. These surgical interventions are divided into two types:
surgeries that eliminate complications but do not involve tumor removal (gastrostomy, gastroenterostomy, colostomy, etc.)
palliative resections provide the scope of a standard intervention in the presence of distant metastases and the possibility of subsequent effective chemotherapy.
ORGANIZATION OF ONCOLOGICAL CARE.
Oncological service– a state system of institutions whose activities are aimed at the timely detection, prevention and treatment of cancer.
The basis for organizing the activities of the oncology service is the dispensary principle.
The main structural unit of the oncology network is the oncology clinic, which provides:
qualified specialized assistance,
dispensary observation of cancer patients in the region,
organizational and methodological management of treatment and prevention institutions on oncology issues,
specialization and advanced training of doctors and nursing staff in the diagnosis and treatment of patients with malignant tumors.
Oncology departments and offices are organized as part of outpatient clinics and outpatient departments of city and central district hospitals. The objectives of these structural divisions are:
organization of anti-cancer activities,
security timely treatment, registration and follow-up of cancer patients.
There are practically no malignant tumors whose progression could not begin many years after the end of antitumor treatment. However, practitioners need to adhere to certain periods of time to evaluate the results of the treatment.
The most common term is 5 years. For slow-onset tumors (breast cancer, cervical and uterine cancer), the period can be increased to 10 years, and for fast-onset tumors (pancreatic cancer, esophageal cancer), on the contrary, reduced to 3 years.
CLINICAL GROUPS DURING DISPENSARY OBSERVATION.
Group 1a– patients with a disease suspicious for malignant neoplasm. These patients are subject to in-depth examination and, as soon as the diagnosis is established, they are removed from the register or transferred to another group.
Group 1b– patients with precancerous diseases.
Group II– patients with malignant neoplasms who, as a result of the use of modern treatment methods, have real prospects for a complete cure or long-term remission. A subgroup is identified.
IIA– subject to radical treatment aimed at complete cure.
Group III– practically healthy as a result of radical treatment (surgical, radiation, combined, complex) of a malignant tumor in the absence of relapses and metastases.
Group IV– patients with common forms of malignant neoplasm for whom it is impossible to carry out radical treatment, but at the same time, combined surgical, complex, chemohormonal and other palliative or symptomatic treatment is indicated or planned.
LECTURE 37
PLASTIC AND RECONSTRUCTIVE SURGERY
INTRODUCTION
In medicine, there are situations when organs and tissues affected by a pathological process or damaged lose their function. In this case the only way to treat
the patient is replacement of damaged organs or tissues with healthy ones
.
Reconstructive or plastic surgery – a branch of surgery that deals with the correction and restoration of the form and function of tissues and organs in congenital or acquired defects.
The main method of plastic surgery are plastic surgery, which involve the movement (transplantation, transplantation) of organs and tissues or the implantation of materials replacing them.
IRKUTSK STATE MEDICAL UNIVERSITY
MINISTRY OF HEALTH AND SOCIAL DEVELOPMENT OF THE RF
CLINICAL LECTURES ON ONCOLOGY
Edited by prof. V.G. Laletina and prof. A.V.Shcherbatykh
IRKUTSK, 2009
BBK 54.5 ya73
Reviewers:
Head Department of Oncology
Russian State Medical University Dr. honey. Sciences, Professor Peterson S.B.
Head Department of Clinical Oncology and Radiation Therapy with a postgraduate course at Krasnoyarsk State Medical University, Honored Doctor of the Russian Federation, Doctor of Medical Sciences, Professor Dykhno Yu.A.
CLINICAL LECTURES ON ONCOLOGY/ ed. prof. V.G.Laletina and Prof. A.V. Shcherbatykh. – Irkutsk: Irkut. state honey. univ., 2009. – 149 p.
Clinical lectures on oncology are intended as teaching aid for students of all higher medical faculties educational institutions. This publication covers the main nosological forms tumor diseases oncology course programs, faculty and hospital surgery, organization of oncology service in the Irkutsk region, Russia, etc.
These lectures are not repetitions. individual chapters textbooks on oncology, because they contain, among other things, information from monographs, journal articles, decisions of surgical conferences and congresses of recent years. Therefore, separate sections for each nosological form in the lectures are presented in more detail, which will help students in preparing for practical classes, exams and, to practical work in the future.
The lectures may be useful for interns, surgical and oncologist residents, and medical practitioners.
Screen printing. Conditions-ed. l. 14.85. Conditional oven l. 13.5. Circulation 1000 copies.
EDITORIAL AND PUBLISHING DEPARTMENT of Irkutsk State University
664003, Irkutsk, b. Gagarina, 36; tel. (3952) 24–14–36.
Lecture 1. Organization of cancer care in Russia |
||
and Irkutsk region (V.G. Laletin).…………………………….….4 |
||
Lecture 2. Diagnosis of oncological diseases (V.G. Laletin, |
||
L. I. Galchenko, A. I. Sidorov, Yu.K. Batoroev, Yu.G. Senkin, |
||
L.Yu. Kislitsina)… |
..........................................……………………………..8 |
|
Lecture 3. General principles of treatment of malignant |
||
tumors (V.G. Laletin, N.A. Moskvina, D.M. Ponomarenko)…………24 |
||
Lecture 4. Skin cancer and melanoma (V.G. Laletin, K.G. Shishkin)………….40 |
||
Lecture 5 Thyroid cancer (V.V. Dvornichenko, |
||
M.V. Mirochnik)………………………………………………………...57 |
||
Lecture 6. Breast cancer (S.M. Kuznetsov, O.A. Tyukavin)………64 |
||
Lecture 7. Lung cancer (A.A. Meng)………………………………………………………..77 |
||
Lecture 8. Esophageal cancer (A.A. Meng)...…………………………………...82 |
||
Lecture 9. Stomach cancer (V.G. Laletin, A.V. Belonogov)…..............……..86 |
||
Lecture 10. Colon cancer (V.G. Laletin)……………………….92 |
||
Lecture 11. Rectal cancer (S.M. Kuznetsov, A.A. Bolsheshapov)…..98 |
||
Lecture 12. Liver cancer (S.V.Sokolova, K.A.Korneev)…………………111 |
||
Lecture 13. Pancreatic cancer (S.V. Sokolova)................................. |
||
Lecture 14. Bone tumors (V.G. Laletin, A.B. Kozhevnikov)…………126 |
||
Lecture 15. Malignant tumors of soft tissues (V.G. Laletin, |
||
A.B. Kozhevnikov)......................................................... ......... |
................................ |
|
Lecture 16. Lymphomas (V.G. Laletin, D.A. Bogomolov)................................. |
||
Literature………………………………………………………………..148 |
||
Founder of Russian oncology, academician N.N. Petrov
(1876-1964)
ORGANIZATION OF ONCOLOGICAL CARE IN RUSSIA AND IRKUTSK REGION
V.G.Laletin
The leading institution on the problem of “Malignant neoplasms” is the Moscow Scientific Research Oncology Institute named after. P.A. Herzen. Among its employees are more than 40 doctors and 100 candidates of science. The Institute is a leader in the development of organ-preserving, combined and complex treatment of malignant neoplasms. He provides methodological guidance to the work of regional and regional oncology clinics.
Within the Academy of Medical Sciences (AMS), the leading one is the Russian Oncological Research Center named after. N.N. Blokhin of the Russian Academy of Medical Sciences (RAMS). This is one of the largest medical institutions in the world, employing about 3,000 people, of which more than 700 are researchers. The center includes four institutes: Research Institute of Clinical Oncology, Research Institute of Children's Oncology and Hematology, Research Institute of Carcinogenesis, Research Institute of Experimental Diagnostics and Therapy of Tumors. The center has 5 departments of oncology. Extensive scientific collaboration is ongoing with international organizations in the field of oncology.
In St. Petersburg there is an Oncology Research Institute named after. N.N. Petrova and his staff represent all areas of clinical and experimental oncology.
Another largest oncology institution in Russia is the Rostov Oncology Research Institute.
Since 1979, the Oncology Research Institute of the Tomsk Scientific Center of the Siberian Branch of the Russian Academy of Medical Sciences has been operating in the Siberian region. The institute's staff numbers more than 400 people, of which more than 50 are doctors of medical sciences. Institute scientists studied cancer incidence in Siberia and the Far East. For the first time in clinical practice, they introduced the method of intraoperative irradiation using a small-sized betatron. For the first time in the country
a neutron therapy center was created for the treatment of cancer patients on a cyclotron at the Tomsk Institute of Nuclear Physics. The achievements of Tomsk oncologists in the treatment of head and neck tumors, tumors of the musculoskeletal system, etc. are well known.
The history of oncology, rich in the names of remarkable scientists, is described in detail in the relevant manuals, in particular, in the textbook by Sh.H. Gantsev - “Oncology” (2004) and in the textbook by V.I. Chissov and S.L. Daryalova “Oncology” (2007).
Students studying at ISMU naturally need information about oncological institutions in the Irkutsk region, about the organization of oncological care in the region where they will work. There are no such materials in textbooks, so we fill this gap whenever possible.
Structure of the oncological service of the Irkutsk region
Taking into account the prevalence of malignant neoplasms and the need for anti-cancer control, a Government resolution was adopted in 1945
USSR “On the organization of the state oncological service in the USSR.” In accordance with this decree, oncology departments and dispensaries began to be created in the country. Using the example of the Irkutsk Oncology Center, one can trace their development. In 1945 in Irkutsk on the basis of the faculty surgical clinic 30 beds were allocated for cancer patients and an X-ray therapy apparatus RUM - 17 was installed. In 1956, the base of the Irkutsk Oncology Dispensary expanded to 75 beds. In 1967, after the completion of the construction of a new building, specialized departments were established at the regional oncology clinic.
IN Currently, the Irkutsk Regional Oncology Center is a specialized medical institution, which is a methodological organizational center for providing medical care to cancer patients in the Irkutsk region. The dispensary operates a clinic for 400 visits per shift. Outpatient visits are conducted by oncologists - a thoracic surgeon, urologist, gynecologist, mammologist, proctologist, chemotherapist, doctors for the treatment of tumors of the head and neck, soft tissues and bones, etc.
There is also a clinical and biochemical laboratory, an X-ray department with a computed tomography room, endoscopy and endosurgery rooms, cytological laboratories, ultrasound rooms, and an organizational and methodological room.
IN The hospital has the following departments - thoracic, coloproctology, gynecological oncology, head and neck tumor department, urology - each with 40 beds. The radiology department has 60 beds, the chemotherapy department has 45 beds, and the mammology department has 30 beds.
Since 2006, oncology clinics Angarsk, Bratsk, Usolye-Sibirsky are branches of the Irkutsk Oncology Dispensary. In total, more than 900 beds have been deployed in the region for the treatment of patients with malignant neoplasms, of which 520 are
V Irkutsk. Oncology clinics are staffed by experienced specialists and equipped with modern equipment.
The structure of the oncology service in the Irkutsk region is presented in Table 1-1.
IN 2008 a new building was built East Siberian cancer center. The main objectives of the oncology clinic are:
1. Providing specialized assistance.
2. Clinical examination of cancer patients.
3. Organizational and methodological assistance medical institutions general profile on issues early diagnosis malignant tumors.
4. Systematic analysis of morbidity and mortality rates from malignant neoplasms of the corresponding territory.
The primary link in the structure of the oncology service is the oncology office. The main tasks of the oncology office are:
1. Organization of early diagnosis of malignant neoplasms.
2. Medical examination of cancer patients and persons from high-risk groups.
3. Rehabilitation of cancer patients.
4. Providing medical care to patients on the recommendation of oncological institutions. Examination rooms are one of the forms of preventive examinations
population.
1. The examination room is organized in an outpatient clinic.
2. The office is located in a separate room and equipped with special equipment.
3. Works in an average office medical worker, who has undergone special training in oncology.
4. Preventive examination of women includes examination of the skin and visible mucous membranes, examination and palpation of the thyroid and mammary glands, abdomen, peripheral lymph nodes, speculum examination of the cervix and vagina, bimanual examination of the uterus and appendages, digital examination of the rectum for women over 40 years of age and presence of complaints. All women who contacted the office had
swabs are taken from cervical canal and cervix and sent to cytological |
||||
laboratory. |
||||
Preventive examination for men includes |
examination of the skin and visible |
|||
mucous membranes, examination and palpation of the thyroid gland, mammary glands, |
||||
abdomen, peripheral lymph nodes, external genitalia, digital |
||||
examination of the rectum and prostate gland. |
||||
Table 1 |
||||
Usolye-Sibirskoye |
Fraternal branch |
|||
25thoracic |
40 department beds |
|||
45surgical |
palliative |
|||
20chemotherapy- |
||||
petic |
radiological |
|||
45radiological |
65 - surgical |
|||
40gynecolo- |
25chemotherapy- |
|||
gical |
petic |
|||
40 – clinical |
||||
diagnostic |
||||
department |
||||
Organizational and methodological |
||||
Oncology rooms |
Examination rooms |
|||
Key indicators of cancer care in the Irkutsk region |
||||
Malignant neoplasms occupy third place in the structure of causes of death |
||||
population of the Irkutsk region, which is reflected in life expectancy indicators. |
||||
The incidence rate of malignant neoplasms in the Irkutsk region for |
||||
over the past five years has increased by 25.3% and amounted to 351 people in 2007 |
||||
population (Table 1-2). Among |
8823 new cases of malignant neoplasms, |
|||
identified in the Irkutsk region in 2007, the leading role belongs to lung cancer, skin cancer with melanoma and breast cancer. The next places in the structure of cancer incidence are occupied by malignant neoplasms of the stomach and colon, lymphatic and hematopoietic tissue, kidney, cervix, uterine body, and pancreas. At the same time, the proportion of patients identified in stages 3 - 4 of the disease remains high. 1.5% of the region's population, every 65 residents of the region suffer from malignant neoplasms. 18,336 patients or 47.1% (RF - 49.4%) of all registered cancer patients were registered for 5 years or more. These figures could be significantly higher if diseases were detected in a timely manner.
Table 1-2 Main indicators of cancer care in the Irkutsk region
Incidence per 100,000 |
|||||||
population |
|||||||
General neglect |
|||||||
Mortality at first |
|||||||
Mortality per 100,000 |
|||||||
population |
|||||||
The analysis shows that the reasons for neglect in 50% of cases were untimely treatment, in 40% - medical errors, and only in 10% - a hidden course.
For the first time, patients usually turn to the general medical network. Therefore, it is important that every general practitioner has an oncological alertness, which presupposes knowledge of the cancer clinic of the main localizations.
IN Since 1976, ISMU has been running an oncology course on the basis of the regional oncology clinic (headed by Professor V.G. Laletin). The course staff perform medical and scientific work and teach oncology in medical, medical-prophylactic and pediatric faculties, train interns and residents.
IN In 1998, the Department of Oncology was opened at the Irkutsk State Institute of Medical Sciences (headed by Doctor of Medical Sciences V.V. Dvornichenko). Employees of this department provide postgraduate training in oncology to doctors not only in the Irkutsk region, but also in the Siberian region.
Dvornichenko Victoria Vladimirovna, chief physician of the Irkutsk Oncology Center, chief oncologist of the Siberian federal district, Doctor of Medical Sciences, Professor, Head of the Department of Oncology, Irkutsk State University of Institution.
DIAGNOSTICS OF ONCOLOGICAL DISEASES V.G.Laletin, L.I. Galchenko, A.I. Sidorov, Yu.K. Batoroev, Yu.G. Senkin,
L.Yu. Kislitsina
Basic principles of cancer diagnosis
Diagnostics is the basis of medical art. The well-known proverb of German doctors is “a diagnosis is made before treatment!”; the statement “who diagnoses well, treats well” is also true. Of course, some diseases can heal on their own or with improper treatment. But this does not apply to malignant neoplasms. With them, timely diagnosis is important, preferably in stages 1-2, when in most cases it is possible to carry out treatment with a favorable result.
It is necessary to note the high prevalence and diversity of oncological diseases. The principles of their diagnosis largely coincide with those that have developed in general medical practice and, in particular, are set out by the staff of the Department of Hospital Therapy of IGMU in the book “Algorithm of Clinical Thinking”, published in 2000 in Irkutsk under the editorship of Prof. T.P. Sizykh.
Stage 1 – survey, collection of complaints, symptoms according to the principle “from head to toe” (M.Ya. Mudrov).
Stage 2 – physical examination.
Stage 3 – conducting laboratory and instrumental methods.
In this case, accepted examination standards are taken into account. In the case of cancer, a morphological verification of the tumor is carried out and a stage is established according to the TNM system.
The algorithm for diagnosing malignant neoplasms is presented in Table 3. During active detection - screening, or when the patient contacts after the appearance
symptoms of the disease, a detailed history should be collected, paying attention to even seemingly minor complaints. Even advanced cancer can be asymptomatic. Find out bad habits, such as smoking, its duration, intensity. Occupational hazards noted: - radiation, contact with chemicals, etc. A life history, information about previous and concomitant diseases, and the nature of the operations undergone are collected. Next, they begin an objective examination “from head to toe,” inspection, palpation, and percussion.
Anamnesis and objective examination should be aimed at identifying tumor phenomena: obstruction, destruction, compression, intoxication, tumor formation. Obstruction occurs when the patency of tubular organs is impaired and, as a symptom, often accompanies cancer of the esophagus, bile ducts, bronchi, etc.
Destruction occurs when the tumor disintegrates and is manifested by bleeding. Compression is caused by the fact that the tumor tissue squeezes the blood and lymphatic vessels, as well as nerve trunks, causing swelling of the limbs and pain. The mediastinal form of lung cancer is known, in which the clinical manifestation of a tumor that metastasizes to the mediastinum is edema and swelling of the veins of the head and neck. Intoxication with tumor breakdown products can cause anemia and fever. In 10-15% of cancer patients, the primary focus cannot be identified, and the disease manifests itself as metastases. And yet, the first sign of a malignant neoplasm is most often
is the tumor itself, determined either visually, or palpation, or during instrumental research methods.
Laboratory research. Tumor markers
Changes peripheral blood are more often observed in advanced stages of malignant tumors: anemia, ESR acceleration over 30 mm/hour, leukopenia or leukocytosis, lymphopenia, thrombocytopenia or thrombocytosis. These changes are nonspecific, as are biochemical changes. In pancreatic cancer, there is an increase in lipase and amylase, alkaline phosphatase. To date, there is no single laboratory test that indicates the presence of a malignant tumor in the body.
At the same time, it has been established that malignant cells can secrete specific waste products into the body fluids. In 1848, Bence-Jones described an unusual precipitation reaction in the urine of patients with multiple myeloma. This was due to the tumor releasing immunoglobulin light chains. Bence-Jones myeloma proteins are specific monoclonal antibodies.
In 1848, biological methods made it possible to detect pheochromocytoma by the level of catecholamines in the blood, and chorionepithelioma by the excretion of human chorionic gonadotropin. Somewhat later, they learned to determine blood serotonin and its metabolites in urine in carcinoid syndrome.
A great achievement was the discovery of oncofetal antigens by Soviet scientists G.I. Abelov and Yu.S. Tatarinov (1963, 1964). Tumor markers reflect various aspects of the functional activity of malignant cells. These are enzymes, tumor-associated antigens, ectopic hormones, some proteins, peptides and metabolites. There are more than 50 of them and the number continues to increase. The characteristics of some tumor markers are presented in Table 2.
Table 1. Algorithm for diagnosing malignant neoplasms
SCREENING
Revealing
tumor
phenomena
Obturation
Destruction
Compression
Intoxication
Tumor-like
Endoscopy |
||||||||||
Radioisot |
||||||||||
Biochemical |
||||||||||
Intraopera |
||||||||||
diagnostics |
||||||||||
Tumor
markers PSA, hCG
Cytological Pathomorphological
STANDARDS |
FORMULATION OF DIAGNOSIS |
|||
WITH STAGE |
||||
SURVEYS |
||||
Oncology is a science that studies the problems of carcinogenesis (causes and mechanisms of development), diagnosis and treatment, and prevention of tumor diseases. Oncology pays close attention to malignant neoplasms due to their great social and medical significance. Oncological diseases occupy the second place among causes of death (immediately after diseases of the cardiovascular system). Every year, about 10 million people become ill with cancer, and half that number die from these diseases each year. At the present stage, the first place in morbidity and mortality is occupied by lung cancer, which has overtaken stomach cancer in men, and breast cancer in women. In third place is colon cancer. Of all malignant neoplasms, the vast majority are epithelial tumors.
Benign tumors, as the name implies, are not as dangerous as malignant ones. There is no atypia in the tumor tissue. The development of a benign tumor is based on the processes of simple hyperplasia of cellular and tissue elements. The growth of such a tumor is slow; the tumor mass does not grow into the surrounding tissues, but only pushes them aside. In this case, a pseudocapsule is often formed. A benign tumor never metastasizes, no decay processes occur in it, therefore intoxication does not develop with this pathology. Due to all of the above features benign tumor(with rare exceptions) does not lead to death. There is such a thing as a relatively benign tumor. This is a neoplasm that grows in a limited cavity, such as the cranial cavity. Naturally, tumor growth leads to increased intracranial pressure, compression of vital structures and, accordingly, death.
Malignant neoplasm characterized by the following features:
1) cellular and tissue atypia. Tumor cells lose their previous properties and acquire new ones;
2) the ability for autonomous, i.e., uncontrolled by organismal regulatory processes, growth;
3) rapid infiltrating growth, i.e. tumor germination of surrounding tissues;
4) ability to metastasize.
There are also a number of diseases that are precursors and harbingers of tumor diseases. These are the so-called obligate (a tumor necessarily develops as a result of the disease) and facultative (a tumor develops in a large percentage of cases, but not necessarily) precancers. These are chronic inflammatory diseases (chronic atrophic gastritis, sinusitis, fistulas, osteomyelitis), conditions accompanied by tissue proliferation (mastopathy, polyps, papillomas, nevi), cervical erosion, as well as a number of specific diseases.
2. Classification of tumors
Classification by tissue – source of tumor growth.
Epithelial.
1. Benign:
1) papillomas;
2) polyps;
3) adenomas.
2. Malignant (cancer):
1) squamous;
2) small cell;
3) mucous membranes;
Connective tissue.
1. Benign:
1) fibroids;
2) lipomas;
3) chondromas;
4) osteomas.
2. Malignant (sarcomas):
1) fibrosarcomas;
2) liposarcoma;
3) chondrosarcomas;
4) osteosarcoma.
Muscle.
1. Benign (fibroids):
1) leiomyomas (from smooth muscle tissue);
2) rhabdomyomas (from striated muscles).
2. Malignant (myosarcomas).
Vascular.
1. Benign (hemangiomas):
1) capillary;
2) cavernous;
3) branched;
4) lymphangiomas.
2. Malignant (angioblastomas).
Nervous tissue.
1. Benign:
1) neuromas;
2) gliomas;
3) ganglioneuromas.
2. Malignant:
1) medulloblastoma;
2) ganglioblastoma;
3) neuroblastoma.
Blood cells.
1. Leukemia:
1) acute and chronic;
2) myeloblastic and lymphoblastic.
2. Lymphomas.
3. Lymphosarcoma.
4. Lymphogranulomatosis.
Mixed tumors.
1. Benign:
1) teratomas;
2) dermoid cysts;
2. Malignant (teratoblastomas).
Pigment cell tumors.
1. Benign (pigmented nevi).
2. Malignant (melanoma).
International clinical classification by TNM
Letter T(tumor) In this classification, denotes the size and extent of the primary lesion. Each tumor location has its own criteria, but in any case tis (from lat. Tumor in situ- “cancer in situ”) - does not grow into the basement membrane, T1 - the smallest tumor size, T4 - a tumor of significant size with invasion of surrounding tissues and decay.
Letter N(nodulus) reflects the state of the lymphatic system. Nx – the condition of the regional lymph nodes is unknown, there are no distant metastases. N0 – the absence of metastases to the lymph nodes has been verified. N1 – single metastases to regional lymph nodes. N2 – multiple lesions of regional lymph nodes. N3 – metastases to distant lymph nodes.
Letter M(metastasis) reflects the presence of distant metastases. Index 0 – no distant metastases. Index 1 indicates the presence of metastases.
There are also special letter designations that are placed after pathohistological examination (it is impossible to set them clinically).
Letter R(penetration) reflects the depth of tumor invasion into the wall of a hollow organ.
Letter G(generation) in this classification reflects the degree of differentiation of tumor cells. The higher the index, the less differentiated the tumor and the worse the prognosis.
Clinical staging of cancer according to Trapeznikov
Stage I. Tumor within the organ, absence of metastases to regional lymph nodes.
Stage II. The tumor does not invade surrounding tissues, but there are single metastases to regional The lymph nodes.
Stage III. The tumor grows into surrounding tissues and there are metastases to the lymph nodes. The resectability of the tumor at this stage is already doubtful. It is not possible to completely remove tumor cells surgically.
Stage IV. There are distant tumor metastases. Although it is believed that only symptomatic treatment is possible at this stage, resection of the primary tumor site and solitary metastases can be performed.
3. Etiology, pathogenesis of tumors. Diagnosis of tumor disease
To explain the etiology of tumors, a large number of theories have been put forward (chemical and viral carcinogenesis, disembryogenesis). By modern ideas Malignant neoplasm occurs as a result of the action of numerous factors of both the external and internal environment of the body. The greatest value of the factors external environment have chemical substances– carcinogens that enter the human body with food, air and water. In any case, the carcinogen causes damage to the genetic apparatus of the cell and its mutation. The cell becomes potentially immortal. In case of insolvency immune defense the body continues to reproduce damaged cell and changes in its properties (with each new generation, cells become increasingly malignant and autonomous). A very important role in the development of tumor disease is played by disruption of cytotoxic immune reactions. Every day, about 10 thousand potentially tumor cells appear in the body, which are destroyed by killer lymphocytes.
After approximately 800 divisions of the initial cell, the tumor acquires a clinically detectable size (about 1 cm in diameter). The entire period of the preclinical course of a tumor disease takes 10-15 years. From the moment when a tumor can be detected, 1.5-2 years remain until death (without treatment).
Atypical cells are characterized not only by morphological, but also by metabolic atypia. Due to the distortion of metabolic processes, tumor tissue becomes a trap for the body's energy and plastic substrates, releases a large amount of under-oxidized metabolic products and quickly leads to exhaustion of the patient and the development of intoxication. In the tissue of a malignant tumor due to its rapid growth An adequate microcirculatory bed does not have time to form (vessels do not have time to grow behind the tumor), as a result, metabolic processes are disrupted and tissue respiration, necrobiotic processes develop, which leads to the appearance of foci of tumor decay, which form and maintain a state of intoxication.
In order to detect an oncological disease on time, the doctor must have an oncological alertness, i.e., during the examination it is necessary to suspect the presence of a tumor, based only on small signs. Establishing a diagnosis based on obvious clinical signs(bleeding, sharp pain, tumor disintegration, perforation into the abdominal cavity, etc.) is already overdue, since clinically the tumor manifests itself at stages II-III. For the patient, it is important that the neoplasm is detected as early as possible, at stage I, then the probability that the patient will live for 5 years after treatment is 80-90%. In this regard, screening examinations, which can be carried out during preventive examinations, become important. In our conditions, the available screening methods are fluorographic examination and visual detection of cancer in external locations (skin, oral cavity, rectum, breast, external genitalia).
The examination of a cancer patient must be completed with a pathohistological examination of a suspicious formation. The diagnosis of a malignant neoplasm is untenable without morphological confirmation. This must always be remembered.
4. Treatment of cancer
Treatment should be comprehensive and include both conservative measures and surgical treatment. The decision on the scope of future treatment for a cancer patient is made by a council consisting of an oncologist, a surgeon, a chemotherapist, a radiologist, and an immunologist.
Surgical treatment may precede or follow conservative measures, but a complete cure for a malignant neoplasm without removal of the primary lesion is doubtful (excluding tumor diseases of the blood, which are treated conservatively).
Surgery for cancer can be:
1) radical;
2) symptomatic;
3) palliative.
Radical operations mean complete removal pathological focus from the body. This is possible by following the following principles:
1) ablastics. During the operation, it is necessary to strictly observe ablastics, as well as asepsis. Ablasticity of the operation is to prevent the spread of tumor cells to healthy tissues. For this purpose, the tumor is resected within healthy tissue without affecting the tumor. In order to check ablasticity after resection, an emergency examination is performed. cytological examination smear-imprint from the surface remaining after resection. If tumor cells are detected, the extent of resection is increased;
2) zonality. This is the removal of nearby tissue and regional lymph nodes. The volume of lymph node dissection is determined depending on the extent of the process, but one must always remember that radical removal of lymph nodes leads to lymphostasis after surgery;
3) antiblastics. This is the destruction of locally spread tumor cells, which in any case disperse with surgical intervention. This is achieved by injecting the circumference of the pathological focus with antitumor drugs and regional perfusion with them.
Palliative surgery carried out if it is impossible to carry out radical surgery in full. In this case, part of the tumor tissue is removed.
Symptomatic operations are carried out to correct emerging disturbances in the functioning of organs and systems associated with the presence of a tumor node, for example, the application of an enterostomy or bypass anastomosis for a tumor obstructing the gastric outlet. Palliative and symptomatic operations cannot save the patient.
Surgical treatment of tumors is usually combined with other treatment methods, such as radiation therapy, chemotherapy, hormone therapy and immunotherapy. But these types of treatments can also be used independently (in hematology, radiation treatment of skin cancer). Radiation treatment and chemotherapy can be used in the preoperative period in order to reduce the volume of the tumor, relieve perifocal inflammation and infiltration of surrounding tissues. As a rule, the course of preoperative treatment is not long, since these methods have many side effects and can lead to complications in the postoperative period. The bulk of these therapeutic measures are carried out in the postoperative period. If the patient has II-III stages process surgery must necessarily be supplemented by systemic effects on the body (chemotherapy) in order to suppress possible micrometastases. Special schemes have been developed to achieve the maximum possible removal of tumor cells from the body without causing a toxic effect on the body. Hormone therapy is used for some tumors of the reproductive system.
Lead to the development of cancer intoxication up to the development of cancer cachexia (exhaustion).
The ability to invade and metastasize are the distinctive properties of malignant tumors; they are the main causes of death in this disease.
Metastasis is the process of transfer (elimination) of tumor cells from the primary focus to another organ, tissue, where they cause the growth of a secondary tumor (metastasis).
Lymphogenous is the most common route.
Hematogenous route. Associated with the entry of tumor cells into blood vessels.
Implantation path. Associated with the entry of tumor cells into the serous cavity (during germination of all layers of the organ wall) and from there to neighboring organs.
However, the fate of a malignant cell that has entered the circulatory or lymphatic system, as well as the serous cavity, is not completely predetermined: it can give rise to the growth of a secondary tumor, or it can be destroyed by macrophages.
Recurrence is the re-development of a tumor in the same area after surgical removal or destruction with radiation therapy or chemotherapy. The growth of a tumor after its incomplete removal is not considered a relapse, but is a manifestation of the progression of the pathological process.
LECTURE No. 30. Fundamentals of surgical oncology
1. General Provisions
Oncology is a science that studies the problems of carcinogenesis (causes and mechanisms of development), diagnosis and treatment, and prevention of tumor diseases. Oncology pays close attention to malignant neoplasms due to their great social and medical significance.
Oncological diseases occupy the second place among causes of death (immediately after diseases of the cardiovascular system). Every year, about 10 million people become ill with cancer, and half that number die from these diseases each year.
At the present stage, the first place in morbidity and mortality is occupied by lung cancer, which has overtaken stomach cancer in men, and breast cancer in women. In third place is colon cancer. Of all malignant neoplasms, the vast majority are epithelial tumors.
Benign tumors. as the name implies, they are not as dangerous as malignant ones. There is no atypia in the tumor tissue. The development of a benign tumor is based on the processes of simple hyperplasia of cellular and tissue elements.
The growth of such a tumor is slow; the tumor mass does not grow into the surrounding tissues, but only pushes them aside. In this case, a pseudocapsule is often formed. A benign tumor never metastasizes, no decay processes occur in it, therefore intoxication does not develop with this pathology.
Due to all the listed features, a benign tumor (with rare exceptions) does not lead to death. There is such a thing as a relatively benign tumor.
This is a neoplasm that grows in a limited cavity, such as the cranial cavity. Naturally, tumor growth leads to increased intracranial pressure, compression of vital structures and, accordingly, death.
1) cellular and tissue atypia. Tumor cells lose their previous properties and acquire new ones;
2) the ability for autonomous, i.e., uncontrolled by organismal regulatory processes, growth;
3) rapid infiltrating growth, i.e. tumor germination of surrounding tissues;
4) ability to metastasize.
There are also a number of diseases that are precursors and harbingers of tumor diseases. These are the so-called obligate (a tumor necessarily develops as a result of the disease) and facultative (a tumor develops in a large percentage of cases, but not necessarily) precancers.
These are chronic inflammatory diseases (chronic atrophic gastritis, sinusitis, fistulas, osteomyelitis), conditions accompanied by tissue proliferation (mastopathy, polyps, papillomas, nevi), cervical erosion, as well as a number of specific diseases.
2. Classification of tumors
Classification by tissue – source of tumor growth.
2) dermoid cysts;
2. Malignant (teratoblastomas).
Pigment cell tumors.
1. Benign (pigmented nevi).
2. Malignant (melanoma).
International clinical classification according to TNM
In this classification, the letter T (tumor) denotes the size and extent of the primary lesion. For each tumor location, its own criteria have been developed, but in any case, tis (from the Latin Tumor in situ - “cancer in place”) - does not grow into the basement membrane, T1 - the smallest tumor size, T4 - a tumor of significant size with invasion of surrounding tissues and decay .
The letter N(nodulus) reflects the state of the lymphatic system. Nx – the condition of the regional lymph nodes is unknown, there are no distant metastases. N0 – the absence of metastases to the lymph nodes has been verified.
The letter M (metastasis) reflects the presence of distant metastases. Index 0 – no distant metastases. Index 1 indicates the presence of metastases.
There are also special letter designations that are placed after pathohistological examination (it is impossible to set them clinically).
The letter P (penetration) reflects the depth of tumor penetration into the wall of a hollow organ.
The letter G(generation) in this classification reflects the degree of differentiation of tumor cells. The higher the index, the less differentiated the tumor and the worse the prognosis.
Clinical staging of cancer according to Trapeznikov
Stage I. Tumor within the organ, absence of metastases to regional lymph nodes.
Stage II. The tumor does not invade surrounding tissues, but there are single metastases to regional lymph nodes.
Stage III. The tumor grows into surrounding tissues and there are metastases to the lymph nodes. The resectability of the tumor at this stage is already doubtful. It is not possible to completely remove tumor cells surgically.
Stage IV. There are distant tumor metastases. Although it is believed that only symptomatic treatment is possible at this stage, resection of the primary tumor site and solitary metastases can be performed.
Loading...