Stomach and intestinal cancer
Lecture plan.
1 Stomach cancer
1.1 Prevalence, statistics. Risk factors
1.2. Clinical manifestations
1.3. Treatment methods.
1.4. Treatment results, prognosis and prevention
2. Colorectal cancer
2.1. Prevalence, risk factors
2.2. Clinical manifestations.
2.2.1. Ascending Colon Cancer Symptoms
2.2.2. Descending colon cancer symptoms
2.2.3. Rectal cancer
2.3. Colorectal cancer treatment
2.4. Bowel cancer prevention.
Stomach cancer
Prevalence
Every year in our country, 48.8 thousand new cases of stomach cancer are counted, which is a little more than 11% of all malignant tumors. About 45 thousand Russians die from stomach cancer every year. In the overwhelming majority of countries of the world, the incidence of men is 2 times higher than that of women. The maximum incidence of stomach cancer (114.7 per 100 thousand of the population) was noted in men in Japan, and the minimum (3.1 per 100 thousand of the population) - in white women in the United States.
In 2000, 876 thousand new cases of stomach cancer were detected (8.4% of all cancer cases), and today it ranks 4th in the global structure of oncological diseases, behind lung cancer (1.2 million), cancer breast (1.05 million) and colorectal cancer (945 thousand) However, mortality from stomach cancer has consistently ranked second for many decades, second only to lung cancer
The most rapid decline in the incidence of stomach cancer over the past 10 years has been observed in those countries that have eradicated helicobacter pylori infection of almost the entire population. For example, in Belgium, where, in fact, primary prevention of stomach cancer was carried out
The differences between the average age of patients with and deaths from stomach cancer in Russia are negligible: 62.7 and 63.3 years for men, 67.2 and 68.3 years for women, which is consistent with the low life expectancy of such patients, as well as small differences between morbidity and mortality rates from stomach cancer (from 100: 90 to 100: 95).
Risk factors
The nature of the diet. The incidence of stomach cancer is higher in those regions where they mainly consume starch-rich foods (bread, potatoes, flour products), and not enough animal proteins, milk, fresh vegetables and fruits
The predominant consumption of pork increases the risk of disease in relation to those consuming lamb by 2.1 times, and beef - by 4.6 times.
2.5 times higher risk of stomach cancer among those who consume animal oil daily
The risk of the disease is increased by a disturbance in the rhythm of nutrition by 3.7 times, insufficient chewing of food by 1.6 times, overeating by 2 times. The risk of illness is 1.5 - 3.4 times higher for alcohol abusers, and it significantly increases for many and frequent smokers.
The relative risk of the disease in persons who have been breastfed by their mother for less than a year is 3.4 times higher,
More often they get cancer where the content of copper, molybdenum, cobalt in the soil is higher, less often zinc and manganese
To date, the following significant risk factors have been identified
Geography
Nutritional nature
Bile reflux
Atrophic gastritis
Polyposis of the stomach - malignancy in 24-28%
Menetrie's disease
Pernicious anemia
Helicobacteriosis
Chronic gastric ulcer is malignant in 15-20%
Stomach resection
Heredity (blood group A (II))
Smoking
Carcinogens
Nitrosoamines (nitrates + hyporsecretion)
Aromatic compounds
Overcooked fats
Excess table salt
Sources of nitrates.
Beer, whiskey, and many other alcoholic beverages contain gastric carcinogens called nitrosamines. Alcohol alone may increase the risk of stomach cancer, according to some researchers.
Vegetables are the main source of nitrates and nitrites (89%) in human food.
Additional, but less significant, sources of nitrates and nitrites are dried and smoked foods. A significant amount of these substances is also found in cheeses, beer and some other alcoholic beverages, mushrooms, and spices. Smoking and cosmetics are non-food sources of nitrates and nitrites entering the human body.
Precancerous diseases
The likelihood of a tumor increases with epithelial dysplasia. It is assessed by microscopy and is divided into 3 grades. Dysplasia 3 tbsp. most often turns into cancer. Dysplasia occurs against a background of diseases that are considered to be precancerous:
- Atrophic gastritis
- 2. Polyps and polyposis of the stomach
- Stomach ulcer
- Menetrie's disease (giant hyperplastic gastritis)
- Condition after gastric resection (risk increases 10 years after surgery)
Patients with precancerous diseases are subject to dispensary observation 2 times a year.
Classification.
Clinically, stomach cancer is divided into cardiac cancer, body cancer and gastric outlet cancer, which is due to the peculiarities of the symptoms. The histological classification is complicated, among all forms it is advisable to distinguish adenocarcinoma, squamous cell carcinoma, undifferentiated cancer. Occasionally, sarcomas and lymphoid tumors are found in the stomach.
Clinical manifestations
The clinical picture of the disease is determined by the localization of the tumor, and the symptoms of obstruction are in the foreground: in the cardiac section it is dysphagia, in the output section - symptoms of obstruction of the gatekeeper (belching rotten, vomiting of food eaten the day before, pronounced weight loss). The tumor in the body of the stomach does not show for a long time, which predisposes to late diagnosis.
Early diagnosis is facilitated by careful collection of anamnesis, aimed at identifying nonspecific symptoms of tumor intoxication:
Dyspepsia, changes in signs of antecedent gastric disease
Fever (subfebrile condition)
"Small signs" (according to A.I.Savitsky)
- Weakness, fatigue
- Depression, mental discomfort
- Change in appetite
- Stomach discomfort
- Unexplained weight loss, pallor
Pain (if not associated with a previous stomach disorder) is usually a late symptom.
Quite often, bleeding is a companion of stomach cancer:
- Pallor
- Vomiting of "coffee grounds"
- Melena
- Weakness
- Laboratory (low NV, high ESR, positive Gregersen R.)
Metastasis of stomach cancer to regional (perigastric) lymph nodes, from distant lymphogenous metastases, Virchowski (to the supraclavicular node on the left) deserves attention, metastasis to the navel, and to the ovary - Krukenberg's, which can simulate ovarian cancer. Hematogenous gastric cancer metastases most often to the liver, because the veins of the stomach flow into the portal system. Less common are metastases in the lungs, pleura, pancreas, kidneys. By implantation, cancer cells spread along the peritoneum, causing ascites, sometimes infiltrating the pararectal tissue (Schnitzler metastases).
Diagnostic methods
EGD + biopsy
Fluoroscopy of the stomach (including double contrasting)
Specific markers (carbohydrate antigen CA 19-19, CA 72-4 and some others).
Radionuclide methods PET-positron emission tomography *
Laparascopy *
- * - used to diagnose metastases
Stomach cancer treatment
The main method is surgical
- Subtotal resection
- Gastrectomy
Radiation therapy is useful to improve surgical outcomes or, for palliative purposes, to treat persistent metastases and recurrences.
Chemotherapy for stomach cancer is ineffective. Randomized studies have shown that doing it after surgery does not increase the rate of recovery, but lengthens the lifespan in 20-30% of cases.
Postoperative treatment
1) complete parenteral (hydrolysin, aminocrovin, casein, aminopeptide, etc.) or enteral tube feeding; it is necessary that there are 30 calories per 1 g of protein introduced. The use of fat emulsions (lipofundin) is very beneficial. The volume of injected solutions per day is 2-3 liters
2) antibacterial therapy;
3) measures aimed at preventing complications from the cardiovascular and bronchopulmonary systems;
4) measures to prevent violations of the motor-evacuation function of the gastrointestinal tract;
Treatment results
Only a third of all initially diagnosed patients can be radically operated on, and only 30-35% of this third have timely surgery. The rest die within the next years from relapse or metastases.
Timely treatment significantly improves the prognosis:
in Japan, on the island of Hokkaido, all persons over 40 years of age underwent fibrogastroscopy. Treatment of patients identified in the preclinical period (stage 1) gave a striking efficiency approaching 100% complete recovery
At the 1st stage there are 85-100% of complete cures, at the 2nd stage - 70-80%, at the 3rd stage - 20%.
Palliative care. In advanced cases, to eliminate painful phenomena (pylorus stenosis, obstruction of the cardia, pain syndrome) and prolong life, palliative operations are performed, consisting in the imposition of bypass anastomoses, alcoholization of the celiac nerves, recanalization of the cardia, etc.
Prevention of stomach cancer
Elimination of risk factors
Identification of risk groups
- Chronic ulcer
- Atrophic gastritis
- Polyposis
- Operated stomach
Dispensary observation
Cancer stomach (7)
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Stomach cancer.doc
STOMACH CANCER
In worldwide rock stomach is one of the most common causes of death from malignant tumors. Symptoms at an early or curable stage are minimal or absent, and therefore patients visit a doctor too late and therefore only 15% of them survive 5 years, despite the increase in diagnostic capabilities and improvement of treatment methods.
EPIDEMIOLOGY. Most often stomach cancer occurs in the inhabitants of Japan, the Central and Southern Andes and some regions.
Of Eastern Europe. Stomach cancer has become much less common in the United States and Western Europe. Stomach cancer is 2 times more likely to develop in men over 50 years of age. After 70 years, the incidence of this disease decreases significantly.
ETIOLOGY. The causes of stomach cancer are unknown. It is assumed that N-nitrous compounds are involved in the mechanism of the development of the disease, formed during the conversion of food nitrates into nitrates, which in the stomach interact with secondary or tertiary amines. There is a hypothesis that a change in the consumption of saturated salts, pickled foods and smoked meats with food is a factor contributing to the disease. It is noted that people who abuse alcoholic beverages, smoke a lot, irregularly eat, eat excessively hot food, food after prolonged heat treatment, coarse food, mechanically injuring the mucous membrane, eating overheated fats, develop cancer stomach most commonly.
Predisposing factors include atrophic gastritis, gastric polyposis, and callous stomach ulcers.
^ Localization of stomach cancer
CLASSIFICATION
I. Exophytic tumors:
1. Polypoid;
2. Mushroom;
3. Saucer-shaped.
II. Endophytic tumors:
1. Ulceratively infiltrative;
2.infiltrating diffuse: - fibrous (sclera);
Colloidal.
III. Transitional forms: has a mixed picture of endo- and exophytic
IV. Cancersitu:
Superficial cancer (mucosal localization)
Invasive cancer (localization no deeper than the submucosal layer). ^ HISTOLOGICAL CLASSIFICATION
1. Undifferentiated forms.
2. Differentiated forms:
Diffuse polymorphic cell;
Glandular;
Colloidal;
Solid;
Fibrous.
Sometimes a tumor in different areas can have a different histological origin and structure, including various forms of cancer in various combinations. Tumors can be dimorphic, trimorphic. Rare forms of cancer include squamous cell carcinomas (cancroids), adenoacanthomas (adenocancroids). The first consists of a dystonic epithelium of the esophagus, and the second consists of glandular tissue and stratified squamous epithelium. Osteoplastic cancer, adenocarcinoma from the ciliated epithelium and carcinosarcoma (a tumor that has elements of both cancer and sarcoma) are described as rare.
GROWTH AND DISTRIBUTION OF GASTRIC CANCER. Cancer growth occurs due to the multiplication of its own cells. The cells surrounding the tumor are not involved in the process of tumor growth. Metastasis in gastric cancer occurs mainly through the lymphatic system. Spread from tumors located in the upper right part of the stomach occurs to nodes along the left gastric artery, from tumors of the left upper part of the stomach - to nodes along the splenic artery, from tumors of the lower third of the stomach - to nodes along the branches of the hepatic artery. First, to the nearest regional nodes located near the wall of the stomach at the greater and lesser curvature, then together with the lymph it is sent to the system of more distant nodes, and from there - through the thoracic lymphatic duct into the superior vena cava. The lymphatic pathways of the stomach are widely anastomosed with each other, the slightest obstacle to the outflow of lymph in the prescribed direction leads to the fact that it begins to flow into the vessels of the neighboring area. Accordingly, the direction of the metastatic pathways changes. Metastasis of stomach cancer can also occur in the hematogenous way when the tumor grows into the lumen of the vessels and its cells, breaking off, move with the blood stream. Most often they are directed to the portal vein system. The spread of metastases can also occur by implantation from the surface of a tumor that grows through the serous membrane of the stomach, and enter the abdominal cavity, settle on the parietal or visceral peritoneum, most often in the lower part of the stomach.
^ CLASSIFICATION OF GASTRIC CANCER BY DEGREE OF PREVALENCE
Stage 1- The tumor does not extend beyond the mucous membrane, is clearly limited and does not have regional metastases.
Stage 2 - The tumor is large, spreads to all layers of the stomach wall, except for the serous, the stomach is mobile and is not welded to the adjacent organs. Single mobile metastases are found only in the nearest regional nodes.
Stage 3 - A tumor that grows through all layers of the stomach wall, grows together with the surrounding organs, and has multiple regional metastases.
Stage 4 - A tumor of any size and any spread in the presence of distant metastases.
^ INTERNATIONAL CLASSIFICATION OF GASTRIC CANCER
1. On the basis of T (primary tumor).
That - the primary tumor is not determined;
Ti - a tumor of any size, affects only the mucous membrane or involves also under the mucous membrane;
Tg - the tumor infiltrates the stomach wall to the subserous membrane;
Tg - the tumor grows into the serous membrane without invasion of neighboring organs;
T4 - a tumor that grows through the entire thickness of the gastric wall, tumors that spread to neighboring organs.
2. On the basis of N (regional lymph nodes).
Nx - insufficient data to assess the state of regional lymph nodes;
Ni - metastases only in the nearest nodes;
N2 - a more extensive lesion of nodes that can be removed;
N3 - non-removable nodes along the aorta, a.illiaca.
" 3. On the basis of M (distant metastases).
Mx - insufficient data to determine distant metastases;
Mq - no distant metastases;
"mi - there are distant metastases.
CLINIC. Clinical manifestations of stomach cancer are very diverse and depend on the size and shape of tumor growth, its location, stage of the disease, as well as on the background on which the tumor lesion occurs.
Local and general manifestations of the disease are conditionally distinguished. Local symptoms include dull pain in the upper abdomen, nausea, vomiting, belching, loss of appetite, up to aversion to certain types of food (meat dishes), heaviness in the epigastric region after eating, stomach discomfort, fast satiety when taken food, dysphagia. The above symptoms are characteristic of advanced gastric cancer. The frequency of their detection depends on the location and size of the tumor.
General manifestations of the disease - unmotivated general weakness, weight loss, decreased performance, fatigue, lethargy, apathy, irritability, irritability develop before the onset of local manifestations of stomach cancer. The presence of common symptoms often indicates a late stage of the disease.
In the early stages of the development of stomach cancer, for a rather long time, the clinical manifestations of the disease are absent or mildly expressed, without causing serious inconvenience to the patient, which is the main reason for the patient's late visit to the doctor (80% of patients are admitted to the hospital with advanced stages of stomach cancer) ...
Cancer pyloric The stomach is manifested by various symptoms caused by a narrowing of the outlet from the stomach and a violation of the evacuation of its contents. The most common symptoms are heaviness, a feeling of fullness in the epigastric region and rapid satiety after a meal. Belching quickly joins with air, and subsequently - with food. With a pronounced violation of the evacuation of food appears belching "rotten", vomiting of undigested food. With repeated vomiting, severe violations of the water-electrolyte balance and CBS develop (dehydration, decreased BCC, hypo-potassium, hypochloremia, hyponatremia, metabolic alkalosis).
^ Cancer of the proximal stomach. It is asymptomatic for a long time. The most common symptom is pain in the epigastric region, radiating to the left half of the chest and is often paroxysmal in the type of angina pectoris. When the tumor spreads to the cardiac ring and the abdominal part of the esophagus, dysphagia appears, which manifests itself in the difficulty of passing food.
^ For localization of cancer in the cardiac part salivation, prolonged persistent hiccups due to the growth of phrenic nerve branches by the tumor, as well as vomiting of mucus and recently eaten undigested food are characteristic.
^ Cancer of the body of the stomach. A long latent course is characteristic. Often, the first symptom of cancer of the body of the stomach is profuse gastric bleeding, manifested by vomiting of blood or liquid of the color of "coffee grounds". Melena is often noted.
^ Cancer of the greater curvature, stomach. Characteristic clinical symptoms are absent for a long time. Local manifestations of the disease are determined in the later stages. Germination of cancer of the greater curvature of the stomach into the transverse colon leads to the formation of a fistula. Clinically, the complication manifests itself in the form of diarrhea with an admixture of undigested food, vomiting of gastric contents with a smell - feces. Sometimes a tumor, growing into the large intestine (without the formation of a fistula) narrows its lumen, which is manifested by partial or complete intestinal obstruction.
^ Total damage to the stomach with cancer. It is observed in the endophytic form of tumor growth and manifests itself clinically in the form of constant dull pain in the epigastric region, a feeling of heaviness, overflow, rapid satiety after eating. Patients also have various general symptoms of gastric cancer.
In the clinical picture of the disease, it is customary to distinguish a number of syndromes.
1. Syndrome of "small signs of Savitsky", which includes:
Change in the patient's well-being with the appearance of unmotivated general weakness;
Mental depression;
Unmotivated persistent loss of appetite up to aversion to food;
Phenomena of "gastric discomfort";
Unreasonable progressive weight loss, accompanied by pallor of the skin and other phenomena of anemization.
2. Syndrome of violation of the patency of the gastric canal.
3. Syndrome of violation of the evacuation function of the stomach and gastric dyspepsia.
4. General dystrophic syndrome.
5. Pain syndrome.
6. Astheno-neurotic syndrome.
7. Syndrome of tumor compression of surrounding organs and tissues.
8. Syndrome of lymphoid metastasis.
9. Syndrome of tumor intoxication.
10. Syndrome of erosive bleeding.
Thus, the clinical picture of the disease is quite variable. In this regard, the staff of the N.N. N.N. Petrov proposed to divide all cases of gastric cancer in accordance with the clinical course into 4 main groups:
1. Disease proceeding with a predominance of local gastric
Manifestations.
2. Disease proceeding with a predominance of general manifestations.
3. Disease proceeding with a picture of the pathology of other organs.
4. Asymptomatic cancers.
At the same time, there is no doubt that the peculiarities of clinical manifestations and differences in the clinical course of gastric cancer most of all depend on the localization of the tumor and almost always all stomach cancers should be divided into cancers of the upper third of the stomach (cancer of the entrance section), cancers of the middle third of the stomach (cancers of the body) and cancers of the lower third of the stomach (cancers of the outlet section).
COMPLICATIONS
1. Bleeding.
2. Neoplasm followed by infected mucosa.
3. Perforation of the organ wall.
4. Phlegmon of the gastric wall and other complications (purulent lymphadenitis, thrombophlebitis, phlegmon of retroperitoneal tissue, etc.) DIAGNOSTICS. Complaints, anamnesis, clinical manifestations are often nonspecific, especially in the early stages of the development of the disease. Physical examination sometimes reveals the tumor by palpation, and sometimes metastases. Basically, stomach cancer is confirmed using special research methods.
1.Fibrogastroscopy allows you to clarify the type of tumor, its prevalence, take a biopsy material, diagnose the appearance of complications. Contraindications:
Acute inflammatory diseases of the mouth and pharynx;
Diseases of the esophagus, accompanied by dysphagia;
Acute myocardial infarction;
Acute violation of cerebral circulation;
Insufficiency of blood circulation of the 3rd stage;
Mental disorders.
The final diagnosis of cancer is possible on the basis of the visual picture of atypia, gastroscopy and cytology data. 2.X-ray of the stomach. Contrast examination of the stomach usually includes the study of the esophagus and the main indicators of the state of the stomach (relief of the mucous membrane, position, shape and displacement of the organ, motor-evacuation function). Along with this, the condition of all parts of the duodenum is assessed. Radiographic signs of stomach cancer:
A) thickening of folds in combination with their rigidity, conversion, breakage in a certain area, bumpy nature of the surface;
B) decreased elasticity and rigidity of the stomach wall;
C) loss of peristalsis in the affected area;
D) a defect in filling the contour with the formation of a tuberous "niche" and deformation of the adjacent portion of the muscle layer. The edges of the "niche" are usually not high, without an inflammatory shaft;
E) deformation of the fornix or fundus of the stomach with the presence of nodes against the background of a gas bubble;
E) deformation of the abdominal esophagus with dysfunction in the cardia;
G) cascade bend of the stomach at the level of the cardia;
H) the presence of ulceration in the subcardial region. , H. Thermography. The method is based on the registration of heat radiation from the surface of the skin, which changes significantly with the development of corresponding vascular reactions and changes in metabolism in the tissues of the diseased organ. An increase in heat radiation from the surface of the skin area corresponding to the location of the tumor is considered typical for a tumor. Computed tomography allows you to get detailed information about the spread of the tumor to neighboring organs.
4. ultrasound organs of the abdominal cavity allows you to determine the metastases in the liver and the presence of ascitic fluid. Morphological confirmation of metastatic liver damage can be obtained by percutaneous puncture of the tumor under ultrasound control followed by cytological examination of the material.
5.Using laparoscope-uu you can examine the anterior surface of the stomach, determine the tumor's germination of its serous layer, examine the anterior and lower surface of the liver, spleen, and ovaries.
TREATMENT. The only effective treatment is complete surgical removal of all tissue affected by the cancer. An extended gastrectomy is usually performed.
An absolute contraindication to performing the operation is stage IV of the disease (in the absence of severe complications of the disease - perforation, profuse bleeding, stenosis, when it is necessary to perform palliative interventions).
The relative contraindications for surgery include diseases of vital organs with decompensation of their functional state.
The results of surgical treatment of gastric cancer depend on the stage of tumor development, its size, growth form, histological structure and the depth of the lesion of the gastric wall. In recent years, the greatest advances in the treatment of stomach cancer have been made in Japan.
Palliative operations include palliative gastric resections. These operations are usually performed for various complications of inoperable gastric cancer (profuse bleeding, perforation, pyloric stenosis) if it is technically possible to remove the tumor within healthy tissues, in young and middle-aged patients without severe concomitant diseases. To improve the results of treatment of patients with gastric cancer, chemotherapy with fluoride derivatives (5-fluorouracil, fluorofur) is used.
Radiation treatment of malignant tumors of the stomach due to its low efficiency has very limited application. More favorable results were observed in patients with cancer of the cardiac part of the stomach (especially in squamous cell carcinoma).
FORECAST. In most patients, the prognosis is poor. A small part of the patients who underwent radical surgery are recovering from this formidable disease.
One of the most important factors affecting the long-term results of the operation is the presence of metastases in the regional lymph nodes, as well as the proliferation of the tumor of the serous layer of the stomach and adjacent organs.
PREVENTION of stomach cancer consists in the timely detection and treatment of precancerous diseases (chronic achilic gastritis, gastric ulcer, stomach polyps). Dispensary observation is necessary per this group of patients with the use of modern instrumental research methods (X-ray and endoscopic).
LITERATURE
1. Clinical oncology. Ed. N.N.Blokhin, B.E. Peterson. - M.: Medicine, 1979. - T.2. - S. 148-247.
2. Okorokov A.N. - Treatment of diseases of internal organs:
Practical guidance: In 8v. T.I. - Mn. Vysh.shk., Belmedkniga, 1997.
3. Rusanov A.A. Stomach cancer. - M .: Medicine, 1988 .-- 232p.
4. Guide to gastroenterology in 3 volumes, edited by RAMA FI Komarov and Corresponding Member. RAMS A.L. Grebenev. - M .:
Medicine, 1995. - S. 571-601.
LECTURE: Tumors of the gastrointestinal tract: clinical picture, diagnosis, treatment.
The lecture was discussed at the methodological meeting of the department
"___" _________ 2016
Minutes No. _________
Head of the Department
Prof |. Chetverikov S.G.
Minutes No. _________
Head of the Department
Reapproved: "___" _________ 201___.
Minutes No. _________
Head of the Department
______________________________________
Odessa 2016
Lecture topic: Tumors of the gastrointestinal tract: clinical picture, diagnosis, treatment.
1. Relevance of the topic:
Approximately 90-95% of gastric tumors are malignant, and of all malignant tumors, 95% are carcinomas. Stomach cancer, according to the statistics of 2011, takes the 2nd place. Frequency. Previously, carcinoma of the stomach was considered the most common form of malignant stomach diseases, now in the United States, the incidence has decreased. However, the incidence remains high in Eastern Europe, where there is an inverse relationship with the incidence of bowel carcinoma. In men, gastric carcinoma is detected 2 times more often, usually at the age of 50-75 years.
Despite | despite | the fact that over the past 20 years there has been a certain trend towards | before | decrease | deduction | morbidity on gastric cancer, the total number of patients and mortality from this disease remain high, and the possibility of early detection | detection | the tumor is not fully realized. Therefore, the problem of improving the methods of diagnosis and treatment of this disease remains relevant.
In the last decade, colorectal cancer has come out on top among malignant tumors of the digestive tract in Europe and North America, accounting for more than half of all cases of gastrointestinal (GIT) cancer. Due to the aging of the world's population, the situation is expected to worsen in the future. In Europe, the proportion of colon and rectal cancer among gastrointestinal tumors is now 52.6%, about 300 thousand new cases are recorded annually. Scientists estimate that more than 5% of the population will develop colorectal cancer during their lifetime.
Ukraine belongs to the countries with an average prevalence of colorectal cancer, which is 36.5 new cases per year per 100 thousand population. As in Europe as a whole, in Ukraine, colorectal cancer is the most common tumor of the gastrointestinal tract, the second most common malignant tumor among men (after bronchopulmonary cancer) and the third most frequent among women (after bronchopulmonary cancer and breast cancer). In 2015, 17,400 new cases of CRC were recorded in Ukraine.
2. Whole lectures:
Learning Objective:
a). To acquaint students with different | different | benign and malignant tumors of the stomach (I), colon and rectum (I).
b | b |). To familiarize students with precancerous | diseases of the stomach (I). colon and rectum (I).
v). To give basic information about the diagnosis and treatment of cancer of the stomach, colorectal zone with a typical | typical | and its atypical course (II).
G). Based on the learned | learned | of lecture material to be able to carry out the differential diagnosis of tumor and precancerous diseases of the stomach, colon and rectum (III).
e). To be able to determine the treatment tactics for different | different | stages of cancer of the stomach, colon and rectum (III).
Educational purpose:
a). To educate a student oncological alertness on the basis of knowledge of precancerous | diseases of the gastrointestinal tract.
b | b |). To instill in the student a sense of responsibility for fate | share, fate | patient due to the decisive factor of time in the treatment of cancer patients.
v). Emphasize the principles of deontology | and medical | medicinal | ethics in the examination and treatment of patients with tumors of the gastrointestinal tract.
Plan and organizational structure of the lecture.
№ з / п The main stages of the lecture and their content Objectives in levels of abstraction Lecture type, methods and ways of activating students, equipment Distribution | division | time Preparatory phase Setting educational goals Ensuring positive | positive | motivation Main stage Presentation of lecture material, plan: 1. Benign epithelial and non-epithelial tumors of the stomach. 2. Malignant non-epithelial tumors of the stomach 3. Precancerous diseases of the stomach. 4.Pathological characteristics of stomach cancer. 5. Stages of stomach cancer 6. Clinical manifestations of stomach cancer 7. Diagnosis of stomach cancer. 8. Treatment of stomach cancer. 9. Long-term results of treatment 10. Contributing factors, precancerous diseases of the colon and rectum. Primary and secondary prevention. 11.Pathological characteristics. Colorectal cancer stages. 12. Clinical manifestations. 13. Diagnosis of colon and rectal cancer. 14. Treatment of colon and rectal cancer. Final stage Lecture summary, general conclusions. Answers to possible questions. Task | task | for self-training of students. a = I | a = I | a = I | a = II | | a = II | a = III | a = III | a = II a = II a = I | | a = I | | a = II | a = III | a = II | | Equipment: slide projector |, slides, negatoscope, radiographs | radiograph | Thematic lecture. Methods of activation: Slides, case patients, radiographs | radiographs |, analysis of situational tasks. List of literature, questions. Task | task |. 5 minutes | 5 min 5 min 5 min 5 min 5 min 10 min 5 min | 10 minutes | 5 minutes | 5 min 5 min 5 min 5 min 5 min 5 min 4. Lecture text:
Stomach cancer. Approximately | Approximately | 90-95% of all malignant tumors of the stomach are | carcinoma, about | near | 5% - lymphosarcomas, 1-2% accounted for | proven | on a particle | share, part | squamous cell carcinoma, carcinoid | tumors and leiomyosarcoma. However, in addition to malignant tumors, there are a number of benign tumors.
BENEFITS OF THE STOMACH.
Epithelial and non-epithelial benign tumors are found in the stomach.
Epithelial benign tumors (polyps and polyposis) - Polyps stomach make up 5-10% of all tumors of the stomach, are more common in people over 40 years of age. Numerous | uncountable | observations show the possibility of transition | transition | polyps in cancer, this indicator varies widely | border, line | (2.8% - | 60%).
Pathological anatomy of polyps: There are polyps that arise in the mucous membrane on the soil | soil, ground | regenerative | regenerator | disorders (passionately reactive hyperplasia) and tumor polyps (fibradenomas |). Depending on the content in the mass of the polyp of glands, blood vessels and granulation tissue, glandular, angiomatous, respectively | and granulation polyps. More often stomach polyps are localized in the antrum | section of the stomach (80%), but can develop in other sections.
The main classification of polyps is distribution | division | for benign and malignant.
ON. Kraevsky divided the polyps of hollow organs into certainly benign, relatively benign, and certainly malignant.
Clinic: Possibly the existence of polyps without clinical symptoms | symptom |. Pain syndrome with stomach polyps is usually associated with | with symptoms of gastritis, on the background | on the background | which | what | discovered | reveals, reveals | polyps. More often pains are localized in the epigastric region. If the polyp closes the exit from | s | stomach, then the patient may experience vomiting | vomiting |. In the case of a long leg, the polyp can fall out into the duodenum and be impaired in the pylorus |. In this case, there are attacks of sharp cramping pains in the epigastrium with irradiation throughout the abdomen. When the polyp is covered with ulcers, gastric bleeding is possible, often of low intensity.
Malignancy of the polyp develops imperceptibly: there is a loss of appetite, general weakness, emaciation, that is, signs characteristic of stomach cancer develop.
Diagnostics: Diagnosis of stomach polyps is carried out on the basis of a set of measures, which | what | includes the collection of complaints, anamnesis, physical | examination, laboratory methods (study of feces for occult blood, determination of tumor markers - PEA), instrumental diagnostic methods (X-ray of the stomach, fibrogastroscopy with biopsy).
Treatment: With the development of endoscopic techniques, stomach diseases have become visual. Fibrogastroscopy allows you to detect | identify, show |, evaluate | evaluate | size, localization of the polyp and choose | choose | correct treatment tactics. When detecting | detecting | single diameter polyps | up to 1.5-2 cm is performed | performs | endoscopic polypectomy. With a larger polyp or multiple polyps, the patient is subject to surgical treatment. The operation of choice is subtotal gastric resection.
Colorectal cancer.
CONTRIBUTING FACTORS. The appearance of a tumor is associated with the influence of carcinogenic substances formed in the intestinal contents from the components of the flora. Stool contains a huge amount of bacteria. It amounts to billions per gram of substance. Enzymes secreted by microorganisms take part in the metabolism of proteins, phospholipids, fatty and bile acids, bilirubin, cholesterol, etc. Under the influence of the bacterial flora, ammonia is released from amino acids, nitrosamines, volatile phenols are formed, and primary fatty acids (cholic and chenodeoxycholic) are converted into secondary (lithocholic, deoxycholic).
Many tests have proven the carcinogenic, mutagenic and activating effect of secondary bile acids. They play a leading role in the development of colon cancer; toxic metabolites of amino acids have a lesser effect.
The transformation of primary bile acids into secondary ones occurs under the action of the enzyme cholanoin-7-dehydroxylase, produced by some anaerobic intestinal bacteria. The enzyme activity increases with an increase in the concentration of bile acids. The concentration of bile acids depends on the nature of the diet: it increases with the intake of food rich in proteins and especially fats. Therefore, in developed countries with a high consumption of meat and animal fats, the incidence of colon cancer is higher than in developing countries.
The opposite, inhibiting carcinogenesis effect is exerted by food containing a large amount of vegetable fiber and saturated with vitamins A and C. Vegetable fiber contains the so-called dietary fiber. This term refers to substances that are resistant to metabolic processes in the body. These include cellulose, hemicellulose, pectins, algae products. They are all carbohydrates. Dietary fiber increases the volume of stool. They stimulate peristalsis and accelerate the transport of contents through the intestines. In addition, they bind bile salts, reducing their concentration in the feces. Rye flour, beans, green peas, millet, prunes and some other plant products are characterized by a high content of dietary fiber.
In developed countries, dietary intake of coarse fiber has declined over the past decades. This has led to an increase in the incidence of chronic colitis, polyps and colon cancer.
Genetic factors play a certain role in the occurrence of cancer. This is evidenced by cases of colon cancer among blood relatives.
The same factors contribute to the occurrence of rectal cancer as colon cancer. Dietary habits explain the higher morbidity among the urban population, as well as the increased incidence of rectal cancer among population groups with a high socio-economic level.
PRECANCERAL DISEASES. Colon cancer in most cases develops from polyps.
Classification of polyps according to V.D. Fedorov:
Group 1: polyps (single, group)
a) glandular and glandular villous (adenomas and adenopapillomas)
b) juvenile (cystic granulating)
c) hyperplastic (miliary)
d) rare non-epithelial polypoid formations.
Group 2: villous tumors.
Group 3: diffuse polyposis
a) true (familial diffuse polyposis)
b) secondary pseudopolyposis.
Polyps are growths of the glandular epithelium and the underlying connective tissue in the form of small papillae or round formations that rise above the surface of the mucous membrane. They arise as a result of a productive inflammatory process (hyperplastic or regenerative polyps) or are benign neoplasms (glandular or adenomatous polyps). Hyperplastic polyps are found much more often than adenomatous ones, but the danger of their malignancy is doubtful.
Hamartoma polyps are formed from normal tissues in an unusual combination or with a disproportionate development of any tissue element. Juvenile (juvenile) polyps are the most characteristic representatives of hamartoma colon polyps. In pediatric practice, they are the most common cause of gastrointestinal bleeding and obstruction due to intussusception.
Adenomatous polyps are considered precancerous diseases of the colon. They look like rounded formations, pinkish-red in color, soft consistency, located on a narrow stem or broad base with a smooth or velvety surface (villous tumor). Morphologically, they are pallar or tubular growths of glandular tissue with a stroma that differs from the stroma of the original mucous membrane. Their cells are characterized by polymorphism, dysplasia, increased mitotic activity and complete or partial loss of the ability to differentiate.
Adenomatous polyps are more often localized in the rectum, then the sigmoid, blind and descending colon follow in descending order.
Polyps can be single or multiple. Their size varies from a few millimeters to 3-4 cm or more. With an increase in the size of polyps, their hairiness and the degree of dysplasia, the likelihood of malignant transformation increases. Polyps with a diameter of less than 1 cm are malignant in isolated cases, while in polyps larger than 2 cm, malignancy is found in 40-50%. Large villous polyps become malignant more often than smooth polyps. Severe dysplasia increases the risk of malignancy regardless of the size of the polyps. Distinguish between single and multiple polyps and diffuse polyposis. In the presence of several polyps (no more than 7) in one anatomical section of the large intestine, including the rectum, if the family and hereditary nature of the disease is excluded, it is more correct to diagnose "group polyps".
Single and group polyps of the rectum develop, as a rule, asymptomatically, are malignant much less often than a polyp with diffuse polyposis, and in most cases are found by chance during routine examinations during sigmoidoscopy for other diseases. Glandular and glandular villous polyps belong to facultative precancer. The frequency of malignancy of single polyps, depending on the size, the presence of the leg, the histological structure of the
It ranges from 2 to 12-15%. The main position in the treatment of single polyps is the need to remove them as soon as they are found.
"Villous tumors" are benign, the nose has a high malignancy index (up to 90%). It is important to note that a biopsy for villous tumors does not provide comprehensive information and cannot be the basis for choosing a treatment method. The clinical picture is characterized by diarrhea with a large amount of mucus, causing electrolyte imbalance. Many oncologists believe that villous tumors in patients over 60 years of age should be treated in the same way as cancer. Macroscopically, two forms of villous tumors are exterminated: nodular and creeping. The villous tumors are stained in reddish tones, which is due to the abundance of blood vessels in the ichstroma. Villous tumors are easily traumatized and bleed, so bleeding itself is not a sign of malignancy.
The classic symptoms of a villous tumor are:
7.bleeding during and outside bowel movements
8.excessive discharge of mucus from the anus
9. false desires for the bottom, abdominal pain, diarrhea.
Surgical treatment of villous tumors.
Obligate precancer of the colon is diffuse (familial) polyposis (or familial adenomatous polyposis - FAP), in which almost 100% (malignancy index) of cases develop cancer (slide 1). This is an autosomal dominant disease. Approximately 50% of children whose parents are affected by diffuse familial polyposis inherit this disease. In untreated patients, this disease becomes fatal, because after 40 years, 100% of patients develop cancer. In FAP polyposis, there is also the presence of abdominal desmoid tumors. Several syndromes have been described in this disease. Gardner's Syndrome- a kind of familial polyposis. It is inherited in an autosomal dominant manner. Diffuse polyposis of the small and large intestine is combined with benign tumors of bones and soft tissues, epidermal cysts, tumors of the upper gastrointestinal tract. Turco's syndrome a rare variant of familial colon polyposis, which is combined with malignant brain tumors.
All patients with the FAP gene develop future colon cancer if they are left in the same state and have not received treatment. Colonoscopy screening should be started in patients from 10 years of age and continued until they reach 40 years of age. In the diagnosis of Gardner's syndrome, endoscopy of the upper gastrointestinal tract is assisted, which makes it possible to identify duodenal adenomatous polyps that develop in a patient from the age of 30. Treatment consists of a complete proctocolectomy with ileostomy or with the creation of a pockets of the anal anastomosis. Sulindak can cause polyps to regress.
Peutz-Jeghers Syndrome- characterized by numerous hamartoma polyps, completely affecting the gastrointestinal tract with external manifestations such as point pigmentation of the mucocutaneous border of the lips, skin of the palms and feet. The risk of developing cancer of the gastrointestinal tract is 2-13%. Treatment of polyposis is operative. Depending on the volume of the lesion, bowel resection or subtotal colectomy is performed. In the future, every 6 months, an endoscopic examination with electrocoagulation of newly formed polyps is performed.
Villous tumors, multiple or single polyps, ulcerative colitis, and Crohn's disease are considered facultative colorectal precancers. Polyps undergo electrocoagulation or resect the affected area of the intestine. Subsequently, an endoscopic study is performed every 6 months. Crohn's disease, ulcerative colitis are subject to conservative treatment. Endoscopic examination is performed annually. In the absence of the effect of drug treatment and the progression of dysplasia, bowel resection is resorted to.
.PRIMARY PREVENTION colon cancer is reduced to a rational diet with the inclusion of foods containing a sufficient amount of dietary fiber (at least 25 g per day), as well as vegetables and fruits rich in vitamins A and C. Leading world experts, based on the results of studies (evidence-based medicine), have determined colonoscopy (a visual examination of the walls of the colon) is the most effective screening method for colorectal cancer.
In 90% of cases, colorectal cancer is diagnosed in people over 50 years old. Therefore, colorectal screening should be done annually for all women and men after age 50 and after age 40 for those at high risk (with polyps and a family history of colon cancer).
An annual colonoscopy has been shown to reduce the risk of colon and rectal cancer by 74%.
SECONDARY PREVENTION consists in clinical examination and treatment of patients with diffuse polyposis, early detection and treatment of villous tumors, multiple and single polyps, ulcerative colitis and Crohn's disease, clinical examination of blood relatives of patients with colon cancer.
Colon cancer often occurs in places where feces are retained for a long time. The tumor is more often located in the sigmoid (30-40%) and cecum (20-25%) gut, other parts are less often affected. In 4-8% of cases, there are multiple primary lesions of various parts of the colon.
MACROSCOPIC FORMS ... By the nature of growth, exophytic and endophytic tumors are distinguished. Exophytic tumors grow into the intestinal lumen in the form of a polyp, node, or villous formation that resembles a cauliflower. When an exophytic tumor decays, saucer-shaped cancer appears, which looks like an ulcer with a dense bottom and roller-like edges above the surface of the unaffected mucosa.
ENDOPHYTIC (INFILTRATIVE) cancer grows mainly in the thickness of the intestinal wall. The tumor spreads along the perimeter of the intestine and covers it circularly, causing a narrowing of the lumen.
With the decay of endophytic cancer, an extensive flat ulcer is visible, located around the circumference of the intestine with slightly raised dense edges and an uneven bottom (ulcerative or ulcerative-infiltrative form).
There is a pattern in the nature of tumor growth in different parts of the intestine. In the right half of the colon, exophytic tumors are usually found, in the left 3/4 of all neoplasms grow endophytic.
HISTOLOGICAL STRUCTURE ... Colon cancer in 70-75% of cases
teas have a history of adenocarcinoma, less often solid or mucous cancer. The last two forms are more malignant.
According to the histological structure, 90% of rectal tumors are adenocarcinomas, the remaining 10% are mucous, solid, squamous, undifferentiated and scirrosal forms.
GROWTH AND METASTASING. Colon cancer is characterized by slow growth and late metastasis. The growth of the tumor occurs mainly in the transverse direction of the intestinal wall. Cancer cells in exophytic forms do not penetrate beyond the visible borders of the tumor. With endophytic growth, atypical cells can be detected at a distance of 2 or 3 cm from the edge of the neoplasm.
By direct invasion, colon cancer can spread into the retroperitoneal tissue, the abdominal wall, the loops of the small intestine, and other organs and tissues.
The main route of metastasis is lymphogenous. The frequency of lymphogenous metastasis depends on the location, form of growth and histological structure of the tumor. Metastases to the lymph nodes are more common in tumors of the left half of the colon, endophytic growth, solid and mucous cancer.
Vein spread is rare. It is caused by the direct invasion of the tumor into the venous vessels. Leads to distant liver metastases.
The most often affected are the retroperitoneal lymph nodes, the liver, and occasionally the lungs, the adrenal glands, and the peritoneum (slide 2).
The features of the local spread of rectal cancer are close to the features of the entire colon. By direct germination, the tumor can spread to the peri-rectal tissue and adjacent organs (the posterior wall of the vagina, prostate gland, bladder, uterus, peritoneum).
Lymphogenous metastasis in rectal cancer occurs in three directions. C / 3 and in / 3 metastases along the lymphatic vessels along the superior rectal artery (superior rectal nodes - stage 1, retroperitoneal lymph nodes - stage 2). From n / 3 of the rectum, metastases spread in the direction of the middle rectal arteries to the lateral walls of the pelvis to the upper rectal and iliac lymph nodes, as well as along the lower rectal vessels to the inguinal lymph nodes (slide No. 3).
Distant metastases in cancer of the colon and rectum during surgery are detected in 20-25% of patients, more often with tumors of the left half of the intestine. The most often affected are the retroperitoneal lymph nodes, the liver, less often the lungs, adrenal glands, and the peritoneum.
Allocate four STAGES OF COLUMN AND RECTAL CANCER .
Stage I - a tumor that occupies less than half of the circumference of the colon, limited by the mucous membrane and submucosa, without metastases to the lymph nodes.
Stage II - a tumor that occupies more than half of the intestinal circumference or grows into the muscle layer, without (IIa) or with single metastases to the lymph nodes (IIb).
Stage III - a tumor that occupies more than half the circumference of the intestine, invading the serous membrane, or any tumor with multiple metastases to regional lymph nodes.
Stage IV - an extensive tumor that grows into adjacent organs and tissues, or a tumor with distant metastases (slide No. 4).
TNM classification.
TNM clinical classification (6th edition, 2002).
102.1. T - primary tumor
TX - insufficient data to assess the primary tumor.
T0 - the primary tumor is not detected.
Тis - pre-invasive carcinoma (carcinoma in situ): intraepithelial invasion or invasion of the lamina propria of the mucous membrane.
T1 - the tumor infiltrates the submucosa.
T2 - the tumor infiltrates the muscularis. 2
T3 - the tumor infiltrates the subserous base or pararectal tissue.
T4 - the tumor spreads to other organs or structures and / or invades the visceral peritoneum.
Note: a tumor that grows macroscopically into other organs or structures is classified as T4. However, if invasion of adjacent organs and structures is not microscopically confirmed, the tumor is classified as pT3.
102.2. N - regional lymph nodes.
Regional lymph nodes are perirectal, as well as lymph nodes located along the lower mesenteric, rectal and internal iliac arteries.
NX - insufficient data to assess the state of regional lymph nodes.
N0 - no signs of metastatic lesions of regional lymph nodes.
N1 - metastases in 1-3 regional lymph nodes.
N2 - metastases in 4 or more regional lymph nodes.
102.3. M - distant metastases.
MX - insufficient data to determine distant metastases.
M0 - distant metastases are not detected.
M1 - there are distant metastases. (slide number 5)
102.4. pTNM pathological classification.
102.4.1. рN0 12 and more regional lymph nodes should be examined histologically. If the examined lymph nodes are without tumor growth, but their number is less, then category N is classified as pN0.
102.5. Summary.
T1 - submucosa.
T2 - muscularis.
T3 - subserosis, non-peritoneal peri-intestinal tissue.
T4 - other organs and structures, visceral peritoneum.
N1 - ≤ 3 regional lymph nodes.
N2 -> 3 regional lymph nodes.
Grouping by stages (table).
Stage 0 TIS N0 M0 Stage I T1, T2 N0 M0 Stage IIA T3 N0 M0 Stage IIB T4 N0 M0 Stage IIIA T1, T2 N1 M0 Stage IIIB T3, T4 N1 M0 Stage IIIC Any T N2 M0 Stage IV Any T Any N M1 Dukes' classification modified by Estler and Koller (1953)
Stage A. The tumor does not go beyond the mucous membrane.
Stage B1. The tumor invades the muscle, but does not affect the serous membrane. Regional lymph nodes are not affected.
Stage B2. The tumor invades the entire intestinal wall. Regional lymph nodes are not affected.
Stage C1. Regional lymph nodes are affected.
Stage C2. The tumor invades the serous membrane. Regional lymph nodes are affected.
Stage D. Distant metastases.
CLINICAL PICTURE ... There are no characteristic signs on the basis of which colon cancer can be detected in the initial period. A tumor that has arisen on the intestinal mucosa does not cause concern at first. Complaints arise only from the time when intestinal disorders or general symptoms of the disease appear. Late diagnosis is usually associated with a variety of clinical manifestations and common symptoms with various diseases of the abdominal organs. The detection of a tumor in a neglected state largely depends on the insufficient oncological alertness of medical personnel when examining patients, as well as on errors in the methodology of their examination.
SMPTOMAS OF RIGHT COLONAL CANCER. Their 5 main symptoms are: pain, anemia, loss of appetite, general weakness and the presence of a palpable tumor.
1.Pain occurs in 90% of patients, is the most frequent and early symptom. It is felt in the right side of the abdomen or has no clear localization. The nature and intensity of pain is not the same. Usually it is a dull, aching, not very intense pain caused by the inflammatory process or the growth of a tumor outside the intestinal wall. In some cases, the pain manifests itself in the form of short-term acute attacks, reminiscent of attacks of acute appendicitis or cholecystitis. This nature of pain is associated with a violation of the obturator function of the Bauginia flap. In this case, the intestinal contents from the cecum are thrown into the distal ileum, and the spastic contraction of the latter causes pain. At the same time, a tumor of this localization is accompanied by general symptoms (intoxication, low-grade fever, weakness, fatigue, weight loss, anemia). 2. Anemia ... In these cases, the disease is manifested by a progressive increase in hypochromic anemia. It can be expressed so intensely that patients come to the doctor with complaints of progressive weakness, dizziness, headache. It is believed that anemia is not associated with intraintestinal bleeding, and this can be explained by intoxication due to the absorption of infected intestinal contents and tumor decay products.
3.An important symptom is the presence of a palpable tumor ... By the time of admission to the clinic, the tumor can be palpated in about 70-80% of patients. It is easier to palpate exophytic tumors. With endophytic growth, it is more difficult to identify the neoplasm. The palpable tumor has a dense or densely elastic consistency, its surface is often bumpy. In the absence of inflammatory complications, the tumor is painless or slightly sensitive to palpation, has clear contours and slightly rounded edges. The displacement of the neoplasm depends on the mobility of the affected part of the intestine and on the growth of the tumor into the surrounding tissues. The most mobile tumors of the transverse colon, less mobility is noted with tumors of the blind. Neoplasms of the right bend and the ascending colon are inactive. The percussion sound over the tumor is usually dull, but with neoplasms affecting the posterior wall, especially the cecum, dullness may not be detected
4.Intestinal discomfort syndrome - nausea, belching, sometimes vomiting, discomfort in the mouth, swelling in the epigastric region, stomach dysfunction.
5.Fever occurs in 1/5 of patients with colon cancer, can last for a long time, have high numbers. Rarely, fever is the first sign of a tumor.
The main manifestation of cancer LEFT HALF OF THE COLOR are violations of the functional and motor activity of the intestine. In the early stage of the disease, there are symptoms of intestinal discomfort. The appearance of abdominal pain, bloating, rumbling, stool retention followed by diarrhea should attract the attention of a doctor. Such complaints in patients who have not previously suffered from intestinal dysfunction should be the basis for suspicion of colon cancer and the reason for an X-ray examination. Constipation is sometimes replaced by frequent loose stools mixed with blood and mucus. Diarrhea, replacing constipation, is a consequence of the fact that fecal masses accumulate above the narrowing of the intestine. And due to the abundance of flora, decay processes are intensively occurring, causing increased mucus secretion by the inflamed mucous membrane. The mucus liquefies dense feces that pass through the narrowed area of the tumor in the intestine.
With a significant narrowing of the intestinal lumen in patients, there are phenomena of intestinal obstruction, more often chronic, manifested by periodic retention of stool and gases, short-term pain and bloating. In other cases, intestinal obstruction occurs acutely in the form of an attack of sharp cramping pain in the abdomen, accompanied by a sudden retention of stool and gas, increased visually visible intestinal peristalsis, abdominal distension, painful palpation of stretched bowel loops, some muscle tension and not sharply expressed
Shchetkin's symptom.
Bowel obstruction in the early stages of tumor development is rare. It usually occurs with neoplasms that reach significant sizes or circularly narrow the intestinal lumen. Despite this, the presence of chronic or acute intestinal obstruction is not a sign of cancer inoperability.
Bowel obstruction can occur with a tumor located in any part of the colon, but in most of these patients, the neoplasm is located in the sigma.
Symptoms such as PAIN IN THE FOCUS AND A POSSIBLE NEW FORMATION, with cancer of the left half of the colon, occur 2-3 times more often than in the right, but their presence greatly facilitates the diagnosis.
CURRENT OF COLOR CANCER .
Cancer of the right half of the colon is characterized by a tendency towards a gradual progression of the process and an increase in the number and severity of clinical symptoms. With tumors of the distal sections, this pattern is less common, often the disease manifests itself suddenly by intestinal obstruction.
CLINICALLY FORMS.
5) Toxic-anemic form manifests itself as malaise, weakness, fatigue, fever, pallor of the skin and the development of progressive anemia. Typical for cancer of the blind and ascending colon.
6) Enterocolitic form (left half) is characterized by a complex of symptoms of intestinal disorders, long-term difficult to eliminate constipation, sometimes alternating with diarrhea, bloating, rumbling in the abdomen, the appearance of mucous membranes, bloody mucous and purulent discharge from the intestine.
7) Dyspeptic form characterized by functional disorders of the gastrointestinal tract, abdominal pain, loss of appetite, nausea, belching, occasional vomiting, feeling of heaviness and swelling in the epigastric region.
8) Obturation form (left half) is characterized by early manifestation of intestinal obstruction. Bo
Department of Oncology and Radiation Therapy with a VET course Topic: Stomach Cancer Lecture 4 for non-oncological residents studying in the specialty - Oncology of students in the specialty - Oncology Lecturer: Doctor of Medical Sciences, Professor Dykhno Yuri Alexandrovich Krasnoyarsk, 2012
Lecture plan: Lecture plan: 1. Relevance of the topic 2. Epidemiology of stomach cancer 3. Risk factors for stomach cancer 4. Precancerous diseases of the stomach 5. Classification and clinic of stomach cancer 6. Main methods of diagnosing stomach cancer 7. Methods of treating stomach cancer 8. Long-term results treatment of stomach cancer 9. Medical and social expertise 10. Conclusions
Risk factors for stomach cancer Perennial infection Perennial H. pylori infection Alcohol and table salt abuse Reflux of duodenal contents into the stomach (secondary bile acids) Reflux of duodenal contents into the stomach (secondary bile acids) Carcinogens from food and water (nitrosamines, polycyclic carcinogens) with water and food (nitrosamines, polycyclic hydrocarbons) hydrocarbons)
Environmental factors The condition of the gastric mucosa Dietary factors of H. pylori (+) Smoking (+) Alcohol (+) Impaired absorption of vitamins (+) Salt (+) Nitrates (+) -carotenes (-) Vitamin C (-) Vitamin E ( -) Se, Zn (-) Table salt (+) Nitrates (+) Vitamin C (-) Table salt (+) -carotenes (-) Normal mucosa Superficial gastritis Atrophic gastritis Metaplasia Dysplasia Cancer Scheme of gastric cancer pathogenesis T. Wadstorm, 1995
Classification of gastric polyps and the frequency of their transition to cancer Group Localization Polyp size% of malignancy I Antral section Up to 1 cm 2.9 II Antral section 1-2 cm 9.1 III Antral section More than 2 cm 18 Stomach body Regardless of size 40.5 IV
Syndrome of small signs of stomach cancer (A.I.Savitsky, 1947) Decreased ability to work, rapid fatigue, weakness Decreased ability to work, rapid fatigue, weakness Mental depression, loss of interest in work and others, apathy, alienation Mental depression, loss of interest in work and others , apathy, aloofness Unmotivated loss of appetite, aversion to food Unmotivated loss of appetite, aversion to food "Stomach discomfort" - a feeling of overflow, bloating, heaviness, soreness "Stomach discomfort" - a feeling of overflow, bloating, heaviness, soreness Unreasonable weight loss, pallor , pallor In patients with peptic ulcer and gastritis - modification and appearance of new symptoms In patients with peptic ulcer and gastritis - modification and appearance of new symptoms - pronounced 70% - insufficient 18% - not 12%
Clinical forms of stomach cancer 1. Gastralgic (painful) 2. Dyspeptic 3. Stenotic 4. Anemic 5. Cardiac 6. Bulemic 7. Enterocolitic 8. Ascitic 9. Hepatic 10. Pulmonary 11. Metastatic 12. Febrile 13. Asymptomatic
Spread of stomach cancer Contact pathway (tumor cells spread by 6-8 cm in infiltrative tumors, and by 2-3 cm from the visible borders of the tumor with exophytic tumors) (tumor cells spread by 6-8 cm in infiltrative tumors, and by exophytic tumors by 2-3 cm from the visible borders of the tumor) Implantation (Schnitzler metastases) Lymphogenous (metastases to the navel, Virchow, Krukenberg, etc.) Hematogenous (more often the liver is affected, less often the lungs, pleura, pancreas, kidneys)
Methods of gastric cancer treatment Surgical - Subtotal gastrectomy - Radical gastrectomy - Gastro-, enterostomy Radiation - Preoperative (40-45 Gy) - Intraoperative (15 Gy) - Postoperative (45-60 Gy, radioactive gold) Chemotherapy - 5-fluorouracil - Ftorafur - Mimomycin C - Adriamycin - UVT, S-1 - Polychemotherapy: FAP, FAM, EAP, EFL, etc. proximal distal
Reasons for late diagnosis of gastric cancer Lack of oncological alertness of general practitioners Lack of oncological alertness of general practitioners The practice of diagnosing chronic gastritis without X-ray and endoscopic examination is preserved The practice of diagnosing chronic gastritis without X-ray and endoscopic examination is preserved Low throughput of X-ray rooms Low throughput of X-ray rooms Lack of an extensive network gastric centers Lack of an extensive network of gastric centers
Labor prognosis for stomach cancer Hard physical labor is contraindicated Hard physical labor is contraindicated Light labor, including administrative and economic Light labor, including administrative and economic Diet food every 2 - 3 hours Diet food every 2 - 3 hours Compliance with the sanitary and hygienic regime, additional breaks Compliance with the sanitary and hygienic regime, additional breaks Exemption from business trips, city trips Exemption from business trips, city trips
MSEC for gastric cancer I group of disability: I group of disability: - patients with stage IV, - with relapse and distant metastases, - with severe agastral asthenia. - patients with stage IV, - with relapse and distant metastases, - with severe agastral asthenia. II group of disability: II group of disability: - after extirpation of the stomach and combined operations (upon re-examination after a year, it is possible to appoint III group for life for anatomical defect). - after extirpation of the stomach and combined operations (with re-examination in a year, it is possible to appoint group III for life for anatomical defect).
MSEC after gastric resection at stages I - II Sick leave for months Sick leave for months III group of disability - for those who performed light physical labor III group of disability - for those who performed light physical labor II group of disability - for those who performed heavy physical labor II group of disability - for those who perform hard physical labor
Literature: Main 1) Davydov, MI Oncology: textbook / MI Davydov, Sh. H. Gantsev, -M. GEOTAR-Media, Supplementary 1) Oncology: national guidelines / ch. ed. V. I. Chissov [and others]; scientific. ed. GA Frank [and others]. - M .: GEOTAR-Media,) Oncology / per. from English A. A. Moiseev; ed. D. Casciato [and others]. - M .: Practice,) Oncology: modular workshop: textbook / MI Davydov, LZ Velsher, BI Polyakov [and others]. - M .: GEOTAR-Media,) Cherenkov, V.G. Clinical oncology: a tutorial / V.G. Cherenkov. - 3rd ed., Rev. and add. - M .: Medical book, Electronic resources: 1) IHD KrasSMU 2) MedArt database 3) Medicine database 4) Ebsco database 5) Doctor's consultant. Oncology [Electronic resource]. - M.: GEOTAR-Media, (CD-ROM) Oncology Oncology: modular workshop Clinical Oncology Consultant physician. Oncology
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