Lectures on oncology surgery. Clinical lectures on oncology - Laletin V.G. Symptoms of cancer lectures from institutes
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 of 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 - shape and number. 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. Different tumors have different degrees of anaplasia.
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 - expansive growth (exophytic) and c) with a mixed type of growth.
Features of malignant tumors 4. Metastasis is a method of spreading cancer cells by separation from the main focus and transfer through the bloodstream, lymphatic tract, and also 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 predetermined 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, that persistently disrupt the composition and structure of tissues and cells and change their metabolism.”
Polyetiological theory of N.N. Blokhin: “So, malignant growth is a multi-stage process, including at least three stages - initiation, promotion and progression. At the core is one cell that has exogenous viral or cellular oncogenes. Carcinogenic influences lead to high expression of various genes, a second occurs phase - promotion, which will be followed by progression of tumor growth.
CLASSIFICATION OF TUMORS 1. Benign tumors. 2. Malignant tumors. 3. Tumor-like diseases (dishormonal hyperplasia (mastopathy) and foci of excessive regeneration, malformations; cysts - cavities with a wall and liquid contents, hyperregenerative polyps, condylomas.
Epithelial tumors Benign Locally destructive Papilloma Basalioma Adenoma Malignant (cancer) 1. Differentiated Squamous cell carcinoma Adenocarcinoma Differentiation according to the formed structures: alveolar, tubular, cribriform, solid, etc. According to 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 Fibroma a) desmoid Myxoma b) dermatofibroma Lipoma c) some types of tumors Chondroma Osteoma Malignant Leiomyoma (sarcoma) Rhabdomyoma fibrosarcoma, or po-, chondro- osteo-leiomyosarcoma, Ewing's sarcoma
U1. TUMORS FROM THE ARID SYSTEM (APUDOMAS) 1. Adenomas of the endocrine glands (pituitary gland, pineal gland, pancreas - insulinoma). 2. Carcinoids: a) hormonally active, b) hormonally inactive. 3. Paragangliomas: a) chromaffin (pheochromocytoma) b) non-chromaffin (chemodectoma). 4. Small cell lung cancer, medullary thyroid cancer. 5. Thymoma. 6. Melanoma.
Tumors of the maxillofacial region Tumors of the lip 1. Benign a) Epithelial (papilloma, keratoacanthoma). b) Non-epithelial (fibroma, poma, angioma). 2. Malignant Cancer of the lip (squamous cell keratinizing, non-keratinizing, rarely - basal cell, undifferentiated).
Tumors of the oral mucosa Tumors of the cheeks, floor of the mouth, alveolar edges of the jaws, hard and soft palates, uvula and palatine arches. 1. Benign (papillomas). 2. Malignant tumors Cancer (squamous cell keratinizing, non-keratinizing, undifferentiated, glandular, mucoepidermoid, columnar cell).
Tumors of the parotid and other salivary glands 1. Benign a) Epithelial: adenomas, adenolymphomas, mixed tumors, mucoepidermoid. b) Nonepithelial (angiomas, pomas, neuromas). 2. Malignant tumors a) Cancer (cylindroma, adenocarcinoma). b) Mucoepidermoid cancer. c) Squamous cell carcinoma. d) Poorly differentiated cancer.
Tumors of the lower jaw 1. Benign tumors a) Odontogenic (epulis (supragingival), adamantinoma, odontoma, cementoma). b) Non-odontogenic (osteoblastoclastoma, osteoma, osteoid-osteoma, chondroma, fibroma, hemangioma). 2. Malignant tumors a) Primary cancer of the lower jaw (squamous cell) (Rarely develops from epithelial islands of the Hertweg membrane located deep in the bone substance of the lower jaw). b) Secondary tumors of the lower jaw (when cancer of the oral mucosa spreads to the lower jaw). c) Sarcomas (osteogenic sarcomas, chondrosarcomas).
Epidemiology of malignant diseases Studies the characteristics of the spread and causes of human diseases with 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 polyps of the intestine, 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 measures: a) on a national scale: combating soil, air, water pollution, carrying out hygienic measures to eliminate pollution; 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 - practically healthy people cured of cancer. Subject to observation after 3, 6 months, annually - tertiary prevention, rehabilitation; 1U - patients with advanced disease (stage 1U). Subject to symptomatic and palliative treatment.
GENERAL PRINCIPLES OF TUMOR DIAGNOSIS Early diagnosis is an important condition for the 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 - refer to the appropriate institution; - thorough examination of each patient to exclude cancer; - in difficult cases - raising suspicion of cancer.
DIAGNOSTICS Early, timely, late Complaints and anamnesis, heredity. Objective examination - lymphatic system, paraneoplastic conditions. Laboratory research methods. X-ray methods: R-scopy, graphy, tomography, computed tomography, NMR. Ultrasound examination. Radioisotope diagnostics. Endoscopic methods. Morphological: cytology, histology. Examination of sputum and fluids; biopsy results - puncture, 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 - tumor, N - metastases in regional lymph nodes, M - distant metastases, P - depth of tumor germination, G - 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 3.
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 according to Gr. within days. Total dose Gr. Varying radiosensitivity of the tumor. High - hematopoietic and lymphoid tumors, small cell lung cancer, thyroid cancer. Radiosensitive - squamous cell cancer of the 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. (The active CH2 group - alkyl - combines with nucleic acids and proteins of the cell, 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 1U. Herbal preparations: colhamine, vinblastine, vincristine (mitotic poisons - block cell mitosis). U. Other antitumor drugs: nitrosomethylurea, natulan, chloditan, myelosan; platinum preparations: cis-platinum, CCNU, BCNU, platidiam and others. U1. 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 1st clinical group – 1st disability group and symptomatic treatment are given: painkillers, heart medications, etc.; Palliative chemotherapy and herbal medicine can be performed. III clinical group - after treatment - sick leave for months depending on the disease, method of treatment, volume of surgery, etc. Follow-up examination after a month.
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, sanatorium treatment. Avoid thermal procedures, massage of affected organs, etc. Rehabilitation departments serve this purpose; It is necessary to involve psychologists in working with these patients. Deontology in oncology
^ Lecture No. 24. NURSING PROCESS IN NEW PLACES
Oncology is the science that studies tumors.
1/5 of cases are detected during clinical examinations.
The role of the nurse is extremely important in the early diagnosis of tumors, who communicates closely with patients and, having a certain “oncological alertness” and knowledge of the issue, she has the ability to promptly refer the patient to a doctor for examination and clarification of the diagnosis.
The nurse should help prevent cancer by recommending and explaining the positive role of a healthy lifestyle and the negative role of bad habits.
Features of the oncological process.
A tumor is a pathological process that is accompanied by the uncontrolled proliferation of atypical cells.
Tumor development in the body:
the process occurs where it is completely undesirable;
tumor tissue differs from normal tissues by its atypical cellular structure, which changes beyond recognition;
a cancer cell behaves differently from other tissues; its function does not meet the needs of the body;
being in the body, the cancer cell does not obey it, lives at the expense of it, takes away all the vitality and energy, which leads to the death of the body;
in a healthy body, there is no place for the location of a tumor; for its existence, it “conquers” a place and its growth is either expansive (pushing apart the surrounding tissues) or infiltrating (growing into the surrounding tissues);
The cancer process itself does not stop.
Viral theory (L. Zilber). According to this theory, the cancer virus enters the body in the same way as the influenza virus does, and the person becomes ill. The theory assumes that the cancer virus is initially present in every body, and not everyone gets sick, but only the person who finds himself in unfavorable living conditions.
Irritation theory (R. Virchow). The theory suggests that the tumor occurs in those tissues that are more often irritated and injured. Indeed, cervical cancer is more common than uterine cancer, and rectal cancer is more common than other parts of the intestine.
Germ tissue theory (D. Konheim). According to this theory, during the process of embryonic development, more tissue is formed somewhere than is required to form the organism, and then a tumor grows from these tissues.
Theory of chemical carcinogens (Fischer-Wasels). The growth of cancer cells is caused by chemicals that can be exogenous (nicotine, metal poisons, asbestos compounds, etc.) and endogenous (estradiol, folliculin, etc.).
Immunological the theory says that weak immunity is not able to restrain the growth of cancer cells in the body and a person gets cancer.
^ Classification of tumors
The main clinical difference between tumors is benign and malignant.
Benign tumors: slight deviation of the cellular structure, expansive growth, has a membrane, growth is slow, large in size, does not ulcerate, does not recur, does not metastasize, self-healing is possible, does not affect the general condition, interferes with the patient's weight, size, appearance.
Malignant tumors: completely atypical, infiltrating growth, does not have a membrane, growth is rapid, rarely reaches a large size, the surface is ulcerated, recurs, metastasizes, self-healing is impossible, causes cachexia, life-threatening.
A benign tumor can also be life-threatening if it is located near a vital organ.
A tumor is considered recurrent if it occurs again after treatment. This suggests that there is a cancer cell left in the tissue that can give rise to new growth.
Metastasis is the spread of cancer in the body. With the flow of blood or lymph, the cell is transferred from the main focus to other tissues and organs, where it produces new growth - metastasis.
Tumors vary depending on the tissue from which they originate.
Benign tumors:
Epithelial:
papillomas" (papillary layer of skin);
adenomas (glandular);
cysts (with a cavity).
Muscular - fibroids:
rhabdomyomas (striated muscle);
leiomyomas (smooth muscle).
Fatty ones - lipomas.
Bone - osteomas.
Vascular - angiomas:
hemangioma (blood vessel);
lymphangioma (lymphatic vessel).
Connective tissue - fibromas.
From nerve cells - neuromas.
From brain tissue - gliomas.
Cartilaginous - chondromas.
Mixed - fibroids, etc.
Epithelial (glandular or integumentary epithelium) - cancer (carcinoma).
Connective tissue - sarcomas.
Mixed - liposarcoma, adenocarcinoma, etc.
Exophytic, which have exophytic growth, have a narrow base and grow away from the wall of the organ.
Endophytes, which have endophytic growth, infiltrate the wall of the organ and grow along it.
T - indicates the size and local spread of the tumor (can be from T-0 to T-4;
N - indicates the presence and nature of metastases (can be from N-X to N-3);
M - indicates the presence of distant metastases (can be M-0, i.e. absence, and M, i.e. presence).
Additional designations: from G-1 to G-3 - this is the degree of malignancy of the tumor, the conclusion is given only by a histologist after examining the tissue; and from P-1 to P-4 - this is applicable only for hollow organs and shows the tumor has invaded the organ wall (P-4 - the tumor extends beyond the organ).
^ Stages of tumor development
There are four stages:
stage - the tumor is very small, does not grow into the wall of the organ and does not have metastases;
stage - the tumor does not extend beyond the organ, but there may be a single metastasis to the nearest lymph node;
stage - the size of the tumor is large, it grows into the wall of the organ and there are signs of decay, it has multiple metastases;
stage - either germination into neighboring organs, or multiple distant metastases.
Stage 1 – interview, observation, physical examination.
History: duration of the disease; ask what the patient discovered (the tumor is visible on the skin or in soft tissues, the patient himself discovers a certain formation), the tumor was found by chance during fluorography, during endoscopic examinations, during a clinical examination; the patient noticed the appearance of discharge (usually bloody), gastric, uterine, urological bleeding, etc.
Symptoms of cancer depend on the organ affected.
General symptoms: the onset of the process is imperceptible, there are no specific signs, increasing weakness, malaise, loss of appetite, pallor, vague low-grade fever, anemia and accelerated ESR, loss of interest in previous hobbies and activities.
It is necessary to actively identify signs of a possible disease in the patient.
History: chronic inflammatory diseases, for which he is registered. Such diseases are considered “precancer”. But not because they necessarily turn into cancer, but because a cancer cell, entering the body, is embedded in chronically altered tissue, i.e., the risk of a tumor increases. The same “risk group” includes benign tumors and all processes of impaired tissue regeneration. The presence of occupational hazards that increase the risk of cancer.
Observation: movements, gait, physique, general condition.
Physical examination: external examination, palpation, percussion, auscultation - notes deviations from the norm.
In all cases of suspected tumor, the nurse should refer the patient for examination to an oncology clinic to an oncologist.
Using the knowledge of medical psychology, the nurse must correctly present to the patient the need for such an examination by an oncologist and not cause him stress, categorically writing in the direction an oncological diagnosis or suspicion of it.
Stage 2 - nursing diagnosis, formulates the patient's problems.
Physical problems: vomiting, weakness, pain, insomnia.
Psychological and social - fear of learning about the malignant nature of the disease, fear of surgery, inability to take care of oneself, fear of death, fear of losing a job, fear of family complications, depressing state from the thought of staying forever with an “ostomy”.
Potential problems: formation of bedsores, complications of chemotherapy or radiation therapy, social isolation, disability without the right to work, inability to eat by mouth, threat to life, etc.
Stage 3 – draws up a plan to solve the priority problem.
Stage 4 – implementation of the plan. The nurse plans activities based on the nursing diagnosis. Therefore, according to the action plan, the problem implementation plan will also change.
If the patient has an ostomy, the nurse instructs the patient and family on how to care for it.
Stage 5 - evaluate the result.
^ The role of the nurse in examining a cancer patient
Examination: to make a primary diagnosis or as an additional examination to clarify the disease or stage of the process.
The decision on examination methods is made by the doctor, and the nurse draws up a referral, conducts a conversation with the patient about the purpose of a particular method, tries to organize the examination in a short time, gives advice to relatives about psychological support for the patient, and helps the patient prepare for certain examination methods.
If this is an additional examination in order to resolve the issue of a benign or malignant tumor, then the nurse will highlight the priority from all problems (fear of detecting a malignant process) and will help the patient solve it, talk about the possibilities of diagnostic methods and the effectiveness of surgical treatment and advise giving consent to the operation in the early stages .
For early diagnosis use:
X-ray methods (fluoroscopy and radiography);
computed tomography;
ultrasound examination;
radioisotope diagnostics;
thermal imaging research;
biopsy;
endoscopic methods.
^ The role of the nurse in the treatment of cancer patients
The decision on the method of treating the patient is made by the doctor. The nurse must understand and support the doctor’s decisions to perform or refuse surgery, about the timing of surgery, etc. Treatment will largely depend on the benign or malignant nature of the tumor.
If the tumor benign, then, before giving advice about the operation, you need to find out:
Location of the tumor (if it is located in a vital or endocrine organ, then it is operated on). If it is located in other organs, then check:
b) whether it is constantly injured by the collar of clothes, glasses, a comb, etc. If it is a defect and is injured, then it is removed promptly, and if not, then only observation of the tumor is required.
Effect on the function of another organ:
b) compresses blood vessels and nerves;
c) closes the lumen;
If there is such a negative effect, then the tumor must be removed promptly, and if it does not disrupt the function of other organs, then there is no need to operate.
Is there confidence that the tumor is benign: if it is, then they do not operate; if not, then it is better to remove it.
Surgery - the most effective method of treatment.
Danger: spread of cancer cells throughout the body, danger of not removing all cancer cells.
There are concepts of “ablastic” and “antiblastic”.
Ablastika is a set of measures aimed at preventing the spread of tumor cells in the body during surgery.
This complex includes:
do not injure the tumor tissue and make an incision only along healthy tissue;
quickly apply ligatures to vessels in the wound during surgery;
bandage the hollow organ above and below the tumor, creating an obstacle to the spread of cancer cells;
delimit the wound with sterile napkins and change them during the operation;
changing gloves, instruments and surgical linen during surgery.
Such events include:
use of a laser scalpel;
irradiation of the tumor before and after surgery;
use of antitumor drugs;
treating the wound surface with alcohol after tumor removal.
If it is impossible to perform a radical operation, a palliative operation is performed; it does not require ablastics, antiblastics, or zonality.
Radiation therapy . Radiation only affects the cancer cell; the cancer cell loses its ability to divide and multiply.
RT can be both the main and additional method of treating a patient.
Irradiation can be carried out:
external (through the skin);
intracavitary (uterine cavity or bladder);
interstitial (into tumor tissue).
on the skin (in the form of dermatitis, itching, alopecia - hair loss, pigmentation);
general reaction of the body to radiation (in the form of nausea and vomiting, insomnia, weakness, heart rhythm disturbances, lung function and changes in blood tests).
Groups of drugs used to treat cancer patients:
cytostatics that stop cell division;
antimetabolites that affect metabolic processes in a cancer cell;
antitumor antibiotics;
hormonal drugs;
means that enhance immunity;
drugs affecting metastases.
Cytokines are protein cellular regulators of the immune system: interferons , colony-stimulating factors.
monoclonal antibodies.
The disease is considered cured if: the tumor is completely removed; no metastases were detected during surgery; within 5 years after the operation the patient has no complaints.
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 enters the circulatory or lymphatic system, as well as into 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 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.
EPIDEMIOLOGY
In the overall structure of the incidence of malignant neoplasms in Russia, skin cancer accounts for approximately 10%. In 2007, the absolute number of patients diagnosed for the first time in their lives in our country was 57,503 people. The incidence of skin cancer over time tends to increase - in 1997 the intensive rate was 30.5 per 100 thousand population, and in 2007 - 40.4. Among the regions of Russia, the maximum standardized incidence rates of non-melanoma skin tumors were in Adygea (49.5 per 100 thousand men and 46.4 - 100 thousand women), the Jewish Autonomous Region (59.8 and 34.0, respectively), Chechnya (46 .4 per 100 thousand men) and the Stavropol Territory (38.9 per 100 thousand women), minimal - in Karelia (7.1 per 100 thousand men and 4.9 - 100 thousand women) and Tyva (5. 8 per 100 thousand men). Skin cancer occurs mainly in old age. People with fair skin who live in southern countries and regions and spend a lot of time outdoors are more often affected. Mortality rates from skin cancer are among the lowest among all nosological forms of malignant neoplasms.
ETIOLOGY
Among the factors contributing to the occurrence of skin cancer, the first to be noted is prolonged and intense exposure to solar radiation on the skin. This circumstance can explain the fact that in almost 90% of cases, skin cancer is localized in open areas of the skin of the head and neck area, which are most exposed to insolation. Local exposure to various groups of chemical compounds that have a carcinogenic effect (arsenic, fuels and lubricants)
rials, tar), ionizing radiation are also factors contributing to the occurrence of skin cancer. Mechanical and thermal injuries to the skin, leading to the formation of scars, against which the development of a malignant process is possible, can be considered factors that increase the risk of skin tumors.
Facultative and obligate skin precancer
The occurrence of skin cancer is preceded by various precancerous diseases and pathological processes, which are called precancer. Obligate precancer almost always undergoes malignant transformation. Obligate skin precancer includes the following diseases:
Xeroderma pigmentosum;
Bowen's disease;
Paget's disease;
Erythroplasia of Keir.
Facultative precancer can sometimes turn into cancer - due to the confluence of certain unfavorable factors of both the external and internal environment of the body. Optional precancer includes:
Senile (solar, actinic) keratosis;
Cutaneous horn;
Keratoacanthoma;
Senile (seborrheic) keratoma;
Late radiation ulcers;
Trophic ulcers;
Arsenous keratosis;
Skin lesions due to tuberculosis, systemic lupus erythematosus, syphilis.
Let us dwell on the characteristics of individual forms of precancerous skin diseases in more detail.
Xeroderma pigmentosum is a disease with an autosomal recessive mode of inheritance. Its first manifestations are observed in early childhood. It is characterized by pathological sensitivity of the skin to UV radiation. There are 3 periods during the course of the disease:
1) erythema and pigmentation;
2) atrophy and telangiectasia;
3) neoplasms.
Exposed areas of the body exposed to sunlight are covered with freckles and red spots in xeroderma pigmentosum. Even short-term exposure to the sun leads to swelling and hyperemia of the skin. Subsequently, the erythematous spots increase in size and darken. Peeling and skin atrophy appear. The skin takes on a mottled appearance due to alternating red and brown spots, scarring, atrophic areas and telangiectasia. Subsequently, papillomas and fibromas are detected. Malignancy of xeroderma pigmentosum into cancer, melanoma or sarcoma occurs in 100% of cases. Most patients die at the age of 15-20 years.
Bowen's disease Elderly men are more often affected. Any part of the body is affected, but most often the torso. The disease manifests itself in the form of a single plaque of pale pink or purple color with a diameter of up to 10 mm. The edges of the tumor are clear, slightly raised above the skin level, the surface is covered with crusts and peels, in places eroded and atrophic. The disease is characterized by slow growth of the lesion. Bowen's disease in 100% of cases degenerates into squamous cell carcinoma and can be combined with cancer of internal organs.
Paget's disease most often localized in the area of the nipple of the mammary gland, less often in the genital area, in the perineum, and armpits. Macroscopically, it is a red or cherry-colored plaque, oval in shape, with clear boundaries. The surface of the plaque is eroded, wet, and in places covered with crusts. Patients are bothered by burning and itching. When the mammary gland is affected, it is characterized by one-sidedness of the lesion, retraction of the nipple and serous-bloody discharge from it. This is a special type of cancer. Cancer cells (Paget's cells) are found in the epidermis and in the ducts of the sweat or mammary glands. In the dermis, only signs of chronic inflammation are observed.
Erythroplasia Keira is a variant of Bowen's disease with localization on the mucous membranes. Men who have not undergone circumcision are more often affected. This is a fairly rare disease. Macroscopically, it appears as a bright red plaque with sharp boundaries and slightly raised edges. When transitioning to squamous cell carcinoma, the borders of the plaque become uneven, erosion appears, then an ulcer covered with a fibrinous film or hemorrhagic crusts.
Senile (solar, actinic) keratosis It is observed more often in men over 50 years of age and is localized in open areas of the body. The changes look like a cluster of keratinized scales of a yellow-brown color, round in shape, with a diameter of no more than 1 cm. Removing the scales is difficult, since they are fused to the underlying skin and are painful. When the scales are removed, an erosive surface or an atrophic spot is exposed. Malignant transformation into squamous cell carcinoma is indicated by the appearance of itching, soreness, infiltration, ulceration and bleeding in the area of the lesion.
Cutaneous horn considered as a variant of actinic keratosis. Usually occurs in areas of frequent skin trauma. It is a dense cylindrical or cone-shaped formation, rising above the surface of the skin, yellow-brown or gray in color, tightly fused to the underlying skin. It is characterized by slow growth and can reach 4-5 cm in length. With malignancy, redness, induration and pain appear in the area of the base of the cutaneous horn.
Senile (seborrheic) keratoma- This is an epithelial tumor that is often found in elderly and senile people. Located on closed areas of the body. The lesions are multiple, grow slowly, reaching a diameter of 1-2 cm. Senile keratoma is a flat or lumpy plaque, oval or round in shape, with clear boundaries, brown or gray-black in color. The surface of the plaque is covered with easily removable fatty crusts, finely lumpy, as it contains horny cysts (clogged hair follicles). Malignancy of senile keratoma occurs rarely. Malignancy is characterized by the appearance of erosion on the surface and compaction of its base.
Skin cancer prevention measures
1. Timely treatment of precancerous skin diseases.
2. Avoiding prolonged and intense insolation.
3. Compliance with safety precautions when working with sources of ionizing radiation.
4. Compliance with safety measures in the production of chemicals (nitric acid, benzene, polyvinyl chloride, pesticides, plastics, pharmaceuticals).
5. Compliance with personal hygiene measures when working with household chemical products.
Histological types of skin cancer
Skin cancer originates from the cells of the germinal layer of the epidermis. Basal cell carcinoma (basal cell carcinoma) accounts for up to 75% of all skin cancers. Its cells are similar to the cells of the basal layer of the skin. The tumor is characterized by slow, locally destructive growth and does not metastasize. Can germinate and destroy surrounding tissue. In 90% of cases it is located on the face. Primary multiple basal cell carcinomas may be observed.
Squamous cell carcinoma is much less common than basal cell carcinoma and often develops against the background of chronic skin diseases. Consists of atypical cells resembling spinous ones. The tumor can be localized in any area of the skin. It has infiltrative growth and is capable of metastasis. Lymphogenously metastasizes to regional lymph nodes in 5-10% of cases. Hematogenous metastases most often affect the lungs and bones.
Even less common are skin adenocarcinomas that arise from the sweat and sebaceous glands of the skin.
INTERNATIONAL CLASSIFICATION
BY TNM SYSTEM (2002)
Applicable for the classification of skin cancer of the entire surface of the body with the exception of the eyelids, external female genitalia and penis. In addition, this classification is not applicable to melanoma of the skin, including the skin of the eyelids.
Classification rules
The classification below is only applicable to cancer. In each case, histological confirmation of the diagnosis and identification of the histological type of tumor are necessary.
Anatomical regions
Skin of the lips, including the vermilion border.
Skin of the eyelids.
Skin of the ear and external auditory canal.
Skin of other and unspecified parts of the face.
Skin of the scalp and neck.
Skin of the trunk, including the perianal area.
Skin of the upper limb, including the shoulder girdle area.
Skin of the lower limb, including the hip area.
Skin of the female external genitalia.
Skin of the penis.
Skin of the scrotum.
Regional lymph nodes
The location of regional lymph nodes depends on the primary tumor.
Unilateral tumors
Head, neck: ipsilateral preauricular, inferior
non-maxillary, cervical and supraclavicular lymph nodes.
Chest: ipsilateral axillary lymph nodes
tic nodes.
Upper limbs: ipsilateral ulnar and axillary lymph nodes.
Abdomen, buttocks and groin: ipsilateral inguinal lymph nodes.
Lower limbs: ipsilateral popliteal and inguinal lymph nodes.
Perianal region: ipsilateral inguinal lymph nodes.
Border zone tumors
Lymph nodes adjacent to the border zone on both sides are considered regional. The border zone extends 4 cm from the following landmarks:
End of table.
Any metastases to other lymph nodes should be considered M1.
Clinical classification of TNM
T - primary tumor
Tx - assessment of the primary tumor is impossible. T0 - no primary tumor detected. Tis - cancer in situ.
T1 - tumor up to 2 cm in greatest dimension.
T2 - tumor measuring 2.1-5 cm in greatest dimension.
T3 is a tumor larger than 5 cm in greatest dimension.
T4 - tumor affecting deep structures - cartilage, muscles
or bones. Pay attention!
In the case of multiple simultaneous tumors, the maximum T value is indicated, and the number of tumors is indicated in parentheses, for example: T2(5).
N - regional lymph nodes
The condition of regional lymph nodes cannot be assessed.
N0 - no metastases in regional lymph nodes.
N1 - there are metastases in regional lymph nodes.
M - distant metastases
Mx - the presence of distant metastases cannot be assessed.
M0 - no distant metastases.
M1 - presence of distant metastases.
Pathomorphological classification of pTNM
For the purpose of pathomorphological assessment of the N index, six or more regional lymph nodes are removed. It is currently accepted that the absence of characteristic tissue changes during pathological examination of biopsies of a smaller number of lymph nodes allows confirmation of the pN0 stage.
G - histopathological differentiation
Oh - the degree of differentiation cannot be established.
G1 - high degree of differentiation.
G2 - average degree of differentiation.
G3 - low degree of differentiation.
G4 - undifferentiated tumors.
Grouping by stages
Clinical variants of basal cell carcinoma and squamous cell carcinoma
Basal cell carcinoma
The following clinical forms of basalioma are distinguished: nodular, superficial, ulcerative, cicatricial. The clinical picture of basal cell carcinoma depends on the location and shape of the tumor. Patients complain of the presence of an ulcer or tumor that slowly enlarges over several months or years, is painless, and is sometimes accompanied by itching.
The nodular form is the most common form of basal cell carcinoma (Fig. 9.1, 9.2). It looks like a hemispherical node with a smooth surface, pink-pearl color, and dense consistency. There is a depression in the center of the node. The node slowly increases in size, reaching a diameter of 5-10 mm. Telangiectasia can often be seen on its surface. The basalioma node looks like a pearl. All other clinical forms develop from the nodular form of basal cell carcinoma.
Rice. 9.1. Basalioma of the skin of the right thigh (nodular form, atypical localization)
Rice. 9.2. Basalioma of the skin of the right leg (nodular form, atypical localization)
The superficial form looks like a plaque with characteristic clear, raised, dense, waxy-shiny edges (Fig. 9.3). The diameter of the lesion ranges from 1 to 30 mm, the outlines of the lesion are irregular or rounded, and the color is red-brown. Telangiectasias, erosions, and brown crusts are visible on the surface of the plaque. The superficial form is characterized by slow growth and a benign course.
The cicatricial form of skin basalioma looks like a flat, dense scar, gray-pink in color, located below the level of the surrounding skin (Fig. 9.4, a). The edges of the hearth are clear, raised, with mother-of-pearl
Rice. 9.3. Skin cancer of the right leg (superficial form)
Rice. 9.4. Back skin cancer:
a - scar form; b - ulcerative form
shade. Along the periphery of the formation, at the border with normal skin, there are 1 or several erosions covered with pink-brown crusts. Some erosions scar, and some spread over the surface to healthy areas of the skin. In the development of this form of basal cell carcinoma, periods can be observed when scars predominate in the clinical picture, and erosions are small or absent. Extensive, flat, crusty erosions with small scars around the periphery of the lesion may also be observed.
Against the background of a nodular or superficial form of basal cell carcinoma, ulcers may appear (Fig. 9.4, b). The ulcerative form of basal cell carcinoma is characterized by destructive growth with destruction of surrounding soft tissues and bones. An ulcer with skin basal cell carcinoma can be round or irregular in shape. Its bottom is covered with a gray-black crust, greasy, lumpy, under the crust - red-brown. The edges of the ulcer are raised, roll-shaped, pink-pearl-colored, with telangiectasia.
Primary multiple basal cell carcinomas also occur. Gorlin syndrome is described, characterized by a combination of multiple skin basal cell carcinomas with endocrine, mental disorders and skeletal pathology.
Squamous cell carcinoma
The clinical course of squamous cell skin cancer differs from basal cell carcinoma. With squamous cell carcinoma, patients complain of a tumor or ulcer of the skin that quickly increases in size. With extensive damage to the skin and underlying tissues and the addition of an inflammatory component due to infection, pain occurs.
The development of squamous cell carcinoma follows the path of formation of an ulcer, node, plaque (Fig. 9.5-9.10). The ulcerative form of squamous cell skin cancer is characterized by sharply raised, dense edges surrounding the ulcer on all sides in the form of a cushion. The edges of the ulcer descend steeply, giving it the appearance of a crater. The bottom of the ulcer is uneven. An abundant serous-bloody exudate is released from the tumor, which dries out in the form of crusts. The tumor emits an unpleasant odor. A cancerous ulcer progressively increases in size - both in width and depth.
The cancerous node in appearance resembles a cauliflower or a mushroom on a wide base, its surface is coarse
Rice. 9.5. Skin cancer of the scalp (with ulceration and disintegration)
Rice. 9.6. Skin cancer of the right foot
risqué. The color of the tumor is brown or bright red. The consistency of both the node itself and its base is dense. There may be erosions and ulcers on the surface of the node. This form of squamous cell skin cancer grows rapidly.
A cancerous tumor in the form of a plaque, usually of dense consistency, with a finely lumpy surface, red in color, bleeds, quickly spreads over the surface, and later into the underlying tissue.
Rice. 9.7. Skin cancer of the back (exophytic form)
Rice. 9.8. Forehead skin cancer
Cancer on the scar is characterized by its compaction, the appearance of ulcerations and cracks on the surface. Lumpy growths are possible.
In areas of regional metastasis (in the groin, armpit, neck), dense, painless, mobile lymph nodes may appear. Later they lose mobility, become painful, adhere to the skin and disintegrate with the formation of ulcerated infiltrates.
Rice. 9.9. Neck skin cancer
Rice. 9.10. Squamous cell carcinoma of the face
DIAGNOSTICS
The diagnosis of skin cancer is established on the basis of examination, medical history, objective examination data and the results of additional examination methods. A thorough examination of not only the area of the pathological process, but also all skin, and palpation of regional lymph nodes is necessary. When examining pathological areas on the skin, a magnifying glass should be used.
Cytological and histological examination is the final stage in the diagnosis of skin cancer. Material for cytological examination is obtained by a smear, scraping or puncture of the tumor. A smear or scraping is performed for ulcerative cancer. First, crusts are removed from the surface of the tumor ulcer. A smear-imprint is obtained by applying a glass slide to the exposed ulcer (with light pressure). Imprints are made on several slides from different areas of the ulcer. To obtain a scraping, use a wooden spatula to scrape the surface of the ulcer. Next, the resulting material is evenly distributed in a thin layer over the surface of the glass.
If the integrity of the epidermis above the tumor is not compromised, puncture is performed. A puncture biopsy is performed in a procedural or dressing room, and all principles of asepsis must be observed (as with any surgical intervention). The skin in the puncture area is thoroughly treated with alcohol. The tumor is fixed with the left hand, and a needle with a pre-attached syringe is inserted into it with the right hand. After the needle enters the tumor, they begin to pull back the piston with their right hand, and with their left hand, with rotational movements, they move the needle either deeper or toward the surface of the tumor. Usually all the punctate is in the needle, not in the syringe. Fixing the needle in the tumor, the syringe is removed with the piston pulled out as much as possible, after which the needle is removed. With the piston pulled back, the needle is put back on, its contents are blown onto a glass slide with a quick push of the piston, and a smear is prepared from the resulting drop of punctate.
If the tumor is small, it is excised completely within healthy tissue under local anesthesia. For large tumors, a wedge-shaped section of the tumor is excised so as to capture part of the unchanged tissue at the border with the tumor focus. The excision is carried out quite deeply, because on the surface of the tumor there is a layer of necrotic tissue, without tumor cells.
TREATMENT
The following methods are used in the treatment of skin cancer:
Ray;
Surgical;
Drug;
Cryodestruction;
Laser coagulation.
The choice of treatment method depends on the histological structure of the tumor, stage of the disease, clinical form and location of the tumor.
Radiation treatment is used for the primary tumor focus and regional metastases. They use close-focus radiotherapy, remote or interstitial gamma therapy. Close-focus radiotherapy as an independent radical method is used for small superficial tumors (T1) in a single focal dose (FOD) of 3 Gy and a total focal dose (TLD) of 50-75 Gy. For large and infiltrative tumors (T2, T3, T4), combined radiation treatment is used (first, external gamma therapy, then close-focus radiotherapy (SOD - 50-70 Gy) or external gamma therapy as a component of combined treatment. When treating regional metastases, external gamma therapy (SOD - 30-40 Gy), as a stage of combination treatment.
Surgical treatment is also used for the primary lesion and regional metastases and is used as an independent method of radical treatment of the primary tumor (T1, T2, T3, T4), for relapses after radiation therapy, cancer arising against the background of a scar, and as a component of combined treatment for the size of the primary tumors T3, T4. The tumor is excised within healthy tissues, retreating from the edge of basal cell carcinoma by 0.5-1.0 cm, for squamous cell carcinoma - by 2-3 cm. A method has been developed for assessing the radicality of surgery for skin cancer using the radicalism coefficient, which is the ratio of the tumor area to the area of excision of skin and fascia. The operation is considered radical if the coefficient is >2-3.
It should be noted that during surgical treatment of skin cancer in the face and neck area, the principles of plastic surgery should be followed, in particular, incisions should be made along the skin lines to avoid the formation of rough scars. For small skin defects, plastic surgery with local tissues is used; Large defects are covered with a free skin flap.
If there are metastases in regional lymph nodes, lymphadenectomy is performed.
Local chemotherapy (ointments: 0.5% omaine, prospidinic, 5-fluorouracil) is used to treat small tumors and recurrent basal cell carcinomas.
Laser destruction and cryotherapy are quite effective for small tumors (T1, T2) and relapses. These methods should be preferred for tumors located near bone and cartilage tissues.
When small basaliomas are localized in the area of the nose, eyelid, or inner corner of the eyes, certain difficulties arise in conducting radiation therapy due to the close location of the so-called critical organs (lens, nasal cartilage, etc.), as well as in surgical removal of these tumors due to the peculiarities blood supply and lack of local tissue for subsequent plastic surgery. In this situation, positive results can be obtained using PDT.
FORECAST
The prognosis is determined by the stage of the disease and largely depends on the histological structure and degree of differentiation of the tumor, the growth pattern and size of the tumor, and the presence of metastases. In stages I-II, cure occurs in 100% of skin cancer patients.
Questions for self-control
1. What are the trends in skin cancer incidence in Russia?
2. Name the factors that contribute to the occurrence of skin cancer.
3. What diseases and pathological conditions are classified as obligate and facultative skin cancer?
4. Describe the histological types of skin cancer.
5. Give the classification of skin cancer by stages.
6. What clinical variants of basal cell carcinoma and squamous cell skin cancer do you know?
7. How are patients with suspected skin cancer examined?
8. Describe the methods of treating skin cancer.
9. Indicate the immediate and long-term results of treatment of patients with skin cancer.
introductory
definition
Oncology is the science of the causes,methods of diagnosis, treatment and
tumor prevention.
Cancer incidence in
Russia, as in all economically
developed countries tends to
growth. Malignant
neoplasms are the third most
significant cause of mortality
population after injuries and cardiovascular diseases
definition
OOtumor (syn.: neoplasm,neoplasia, neoplasm) -
pathological process,
presented by the newly formed
tissue in which changes
genetic apparatus of cells
lead to dysregulation
their growth and differentiation.
Types of tumors
All tumors are divided into twomain groups:
benign tumors,
malignant tumors.
Benign tumors
Benign (mature,homologous) tumors consist of
cells differentiated into such
to the extent that it is possible to determine from which
tissue they grow. For these tumors
characterized by slow expansive
growth, absence of metastases, absence
general effect on the body (lipoma).
Benign tumors can
malignize (turn into
malignant).
Malignant tumors
Malignant (immature,heterologous) tumors consist of
moderately and poorly differentiated
cells. They may lose their resemblance to
the tissue from which they come. For
malignant tumors are characteristic
rapid, often infiltrating growth,
metastasis and recurrence,
presence of a general effect on the body Types of Tumor Growth
Depending on the nature of the interaction
growing tumor with surrounding elements
fabrics:
expansive growth - the tumor grows on its own
from oneself”, pushing apart the surrounding tissues, tissues
at the border with the tumor they atrophy,
stromal collapse occurs - formation
pseudocapsule;
infiltrating growth (invasive,
destructive) - tumor cells grow into
surrounding tissues, destroying them;
appositional tumor growth occurs during
due to neoplastic cell transformation
surrounding tissue into tumor tissue.
continuation
Depending on the attitude to the lumenhollow organ:
exophytic growth - expansive
tumor growth into the lumen of a hollow organ,
the tumor covers part of the lumen
organ, connecting to its wall
leg;
endophytic growth -
infiltrating tumor growth deep into
organ walls.
continuation
Depending on the number of lesionstumor occurrence:
unicentric growth -
the tumor grows from one focus;
multicentric growth -
tumor growth from two or more
foci.
Tumor metastasis
Metastasis - processspread of tumor cells from
primary focus to other organs with
formation of secondary (subsidiary)
tumor foci (metastases).
hematogenous - route of metastasis
using tumor emboli,
spreading through the bloodstream;
lymphogenous - the route of metastasis when
the help of tumor emboli,
spreading through the lymphatics
vessels;
continuation
implantation (contact) - waymetastasis of tumor cells
serous membranes adjacent to
tumor focus.
intracanicular - way
metastasis by natural
physiological spaces
(synovial vagina, etc.)
perineural (special case
intracanicular metastasis) - by
the course of the nerve bundle.
continuation
Characteristic for different tumorsdifferent types of metastasis.
The histological type of metastases is as follows:
the same as tumors in the primary site
Typically, metastatic foci
grow faster than the primary tumor
therefore they may be larger than her.
The effect of a tumor on the body
Local influence iscompression or destruction (in
depending on the type of tumor growth)
surrounding tissues and organs.
General effect on the body
typical for malignant
tumors, manifests itself in various
metabolic disorders, up to
before cachexia develops
Etiology of tumors
The etiology of tumors has not yet been studiedend. Currently leading
counts
mutation theory of carcinogenesis
A
.
Below are the main
historically established theories.
continuation
Viral genetic theorycrucial role in tumor development
allocates to oncogenic viruses, to
which include: herpes-like
Epstein-Barr virus, herpes virus,
papillomavirus, retrovirus, viruses
hepatitis B and C.
continuation
Physico-chemical theorythe main reason for the development
tumors considers the impact
various physical and
chemical factors on cells
body (
x-ray and gamma radiation,
carcinogenic substances), which
leads to their oncological transformation.
continuation
Dishormonal theorycarcinogenesis examines various
hormonal imbalance in
body (estrogen imbalance
exchange cancer female reproductive
systems)
Dysontogenetic theory of cause
tumor development considers disorders
embryogenesis of tissues, which is under the influence
provoking factors can lead to
to oncological transformation of tissue cells.
mutation theory of carcinogenesis
Malignanttransformation is developing
as a result of numerous
not subject to correction
DNA changes that
lead to irreparable
violations of the structure and
cell functions.
continuation
Malignant tumor in itsdevelopment passes 3
successive stages:
initiation, promotion and
progression.
Cell malignancy is often
causes dysfunction
suppressor genes, especially the gene
p53, and activation of oncogenes. Initiation lies in the emergence
persistent disorders in genes,
regulating life activity
cells. As a result of these violations
structure and properties may change
cells.
The promotion is
subsequent stage of development
neoplasms. It lies in
activation of transformed cells
and their acquisition of properties inherent
malignant tumor cells Progression is
the final stage of development
malignant
neoplasms.
Molecular basis of carcinogenesis
The genome of each cell containsfull hereditary
information about this organism.
It has been established that the human genome
has about 30,000 genes and
3.5 billion nucleotides.
Genes encode and regulate
passage of a cell through cellular
cycle.
continuation
The cell cycle consists of 4successive phases
intracellular changes
mitosis phase (M) - 1 hour
presynthesis phase (Gj) - 10-30 hours
nucleic acid synthesis phase
acids
(S) - 20-40 hours
premitosis phase (GT) - 2 hours
continuation
Error-free controlcell cycle progression
carried out by genes in each
phase of the cycle.
For this purpose, the cell cycle is
certain phase
is suspended and
resumes when error free
passing the stage.
Types of genes.
Oncogenes - disrupting genescell cycle is caused
tumor formation and growth
Tumor suppressors (syn.
antioncogenes) - genes, function
which is
activity restrictions
oncogenes, which leads to
suppression of tumor growth. As a result of cell genome disorders
happens:
loss of natural properties by cells
apoptosis (death), which leads to
unlimited cell division and
progression (growth) of the tumor;
loss of contact braking properties
(connection between cells) manifests itself in
acquiring the ability to grow invasively
and metastasis;
new formation of blood vessels,
providing blood supply and nutrition
tumor cells;
disruption of cellular metabolism, affecting
on the general condition of the patient. Apoptosis - genetically
programmed death
cells after a certain
number of divisions. Precancerous diseases
There are diseases in which
increased likelihood of developing a tumor.
They are characterized by the following signs:
Proliferation - tissue growth
organism through neoplasm and
cell proliferation
Dysplasia - disruption of tissue structure
with pathological proliferation and
cell atypia.
Metaplasia - pathological
proliferation with cell acquisition
structure and properties of other fabrics. By degree of distribution
neoplasms in Russia approved
division of malignant tumors into 4
stages. The higher the stage, the worse it is
forecast.
At the same time, they use international
classification according to the TNM system, in which
separately assess the size of the tumor,
state of regional lymphatic
nodes and the presence of distant metastases.
The assessment is carried out twice: first
after a clinical examination, then
results of intraoperative and
pathological report. Most often a neoplasm
arises as a consequence
mutations of one cell, but
sometimes the source of the tumor
is a group of cells. In such
cases develop primarily
multiple tumors.
Morphological classification of tumors
Both are formed from the same tissuebenign and malignant
tumors. Depending on the type of fabric from which
a tumor occurs and is isolated:
epithelial tumors
Connective tissue
Muscular
Nervous
tumors of the blood system;
pigment
Teratomas (embryonic tumors in which
hair, muscle tissue may be present,
bone tissue, less often more complex organs -
eyes, torso, limbs.
Classification by stages
Stage 1 - small tumorsizes, usually up to 2 cm,
limited to one or two
layers of organ walls (for example,
mucous membrane and
submucosa), without
metastases to lymph nodes.
continuation
Stage 11 - several tumorslarge sizes (2-5 cm) without or with
single metastases in
regional lymph nodes.
Stage 111 - significant size
a tumor that has grown into all layers of the organ, and
sometimes surrounding tissues, or
tumor with multiple
metastases to regional
lymph nodes.
continuation
Stage IV - large tumor,sprouted on a significant
throughout the surrounding
organs and tissues, immobile,
irremovable by surgery,
or a tumor of any size with
unremovable metastases in
lymph nodes or
metastases to distant organs.
Classification according to the TNM system
This classification usesnumerical designation of various
categories to indicate
spread of the tumor, as well as
presence or absence of local
and distant metastases.
T - tumor tumor. Describes and
classifies the main focus
tumors.
continuation
Tis or T0 - so-called carcinoma“in situ” - that is, not germinating
basal layer of epithelium.
T1-4 - varying degrees of development of the lesion.
For each of the organs there is
separate transcript of each
indexes.
Tx - practically not used.
Displayed only for the time when
metastases detected, but not identified
main focus.
continuation
N - nodulus - node. Describes andcharacterizes the presence of regional
metastases, that is, to regional
lymph nodes.
Nx - detection of regional metastases
has not been carried out, their presence is unknown.
N0 - No regional metastases
discovered during
research to discover
metastases.
N1 - Regional metastases were detected.
continuation
M - metastasisCharacteristics of the presence of distant
metastases, that is, to distant
lymph nodes, other organs, tissues
(excluding tumor germination).
Mx - detection of distant metastases
has not been carried out, their presence is unknown.
M0 - No distant metastases
discovered during research
for the purpose of detecting metastases.
M1 - Distant metastases were detected.
Degree of differentiation
Tumors of the same histologicalTumors of the same histological
buildings vary in degree
cell differentiation. Select 4
histological gradations:
G1 - high degree of differentiation;
G2 - average degree of differentiation;
G3 - low degree of differentiation;
G4 - undifferentiated tumors.
The lower the degree of differentiation
cells, the worse the prognosis.
Oncological alertness
Knowing the symptomsKnowledge of precancerous diseases
Identification of risk groups
Thorough examination of everyone
patient
The habit of thinking with atypical
course of the disease about
cancer
Precancerous conditions
Chronic inflammationDevelopmental defects
Chronic ulcers
Cervical erosion
Nodular mastopathy
Gastrointestinal polyps
Precancerous diseases
Depending on frequencycancer occurrence precancerous
diseases are divided into
obligate and
optional. Obligate precancer of the disease, due to which
always or mostly
malignant
tumor,
optional - diseases, with
which cancer develops
relatively rare, but more often than
in healthy people.
continuation
Cancer in situ - an area of tissue inwhich has normal epithelium
replaced by atypical cells, not
sprouted basement membrane.
"Invasive cancer" - malignant
epithelial tumor, germinated
basement membrane.
continuation
Obligate precancers are:xeroderma pigmentosum;
Bowen's disease;
Paget's disease (except
localization in
nipple area);
Keir's erythroplasia;
familial colon polyposis.
