TNM classification of malignant tumors: stages and general provisions. Fundamentals of Oncology

Petrozavodsk State University Classification of malignant tumors by stages and TNM system Compiled by Bakhlaev I.E., Associate Professor Tolpinskiy A.P., Professor Petrozavodsk, 1999 on the clinical course of the disease, prognosis and approach to treatment tactics. The classification by stages is based on the prevalence of the neoplasm at the time of diagnosis. Along with this, the size of the tumor, the nature of the involvement of the underlying tissues in the process, the transition to neighboring anatomical regions, the presence or absence of regional and distant metastases- single, multiple, displaceable, non-displaceable. All these criteria are the basis of two parallel existing classifications. malignant neoplasms: dividing them into 4 stages and the so-called TNM system developed by a special committee of the International Anti-Cancer Union (IPRC). The stage of malignant neoplasms is determined based on the data obtained during the examination on the prevalence of the tumor process and is indicated by Roman numerals I, II, III, IV, reflecting both the size of the tumor and the spread of the tumor within the organ or beyond its borders. The letters of the Russian alphabet indicate the absence ("a") or the presence ("b") of regional and distant metastases. The TNM system (5th edition published in 1997, in Russia - in 1998), adopted to describe the anatomical spread of a lesion, is based on 3 components: T - spread of the primary tumor, m - absence or presence of metastases in regional lymph nodes and the degree of their damage, M - the presence or absence of distant metastases. To these three components are added numbers indicating the prevalence of the malignant process: T0, T1, T2, TK, T4, N0, N1, N2, N3, M0, Ml Pathological classification(post-surgical, pathohistological classification), denoted pTNM, based on data obtained before treatment and additional information during surgery or examination of surgical material. Once the T, N, M and/or pT, pN and pM categories have been determined, staging can be performed. In most cases Additional Information, relating to the primary tumor, may be marked with the symbol G (1-4), reflecting the degree of differentiation of the tumor. Contents 1. Classification by stages 2. Clinical classification of TNM 3. Anatomical regions and localizations 4. TNM clinical classification 5. pTNM pathological classification 6. Histopathological differentiation 7. Classifications by organs Literature CLASSIFICATION BY STAGE Lip cancer Stage I. Localized tumor or ulcer 1 cm in diameter in the thickness of the mucous membrane and submucosal layer of the red border of the lips without metastases. Stage II. a) A tumor or ulcer, limited to the mucous membrane and submucosal layer, up to 2 cm in size, occupying no more than half of the red border of the lips; b) a tumor or ulcer of the same size or smaller, but in the presence of a single displaceable metastasis in the regional lymph nodes. Stage III. a) Tumor or ulcer up to 3 cm in diameter, occupying most lips, with germination of its thickness or spread to the corner of the mouth, cheek and soft tissues chin b) a tumor or ulcer of the same size or less spread, but with the presence of limitedly displaceable metastases in the chin, submandibular regions. Stage IV a) A decaying tumor, occupying most of the lip, with germination of its entire thickness and spreading not only to the corner of the mouth, chin, but also to the bone skeleton of the jaw. Non-displaceable metastases in regional lymph nodes; b) a tumor of any diameter with metastases. Cancer of the tongue Stage I. Tumor of the mucous membrane or submucosal layer up to 1 cm in diameter, without metastases. Stage II. a) Tumor up to 2 cm in diameter, not extending beyond the midline of the tongue, without metastases; b) the same size tumor, but with the presence of single displaced regional metastases. Stage III. a) A tumor or ulcer up to 3 cm in diameter, passing beyond the midline of the tongue, to the bottom of the oral cavity, without metastases; b) the same with the presence of multiple displaceable or single non-displaceable metastases. Stage IV a) The tumor affects most of the tongue, spreads to adjacent soft tissues and to the jaw bone, with multiple limitedly displaceable or single non-displaceable metastases; b) a tumor of the same size with non-displaceable regional or distant metastases. Cancer of the larynx Stage I. Tumor or ulcer limited to the mucosa and submucosa and does not spread beyond one part of the larynx. Stage II. A tumor or ulcer occupies almost the entirety of any one section of the larynx, but does not go beyond it, the mobility of the larynx is preserved, a displaceable metastasis is determined on the neck on one side. Stage III. The tumor passes to the underlying tissues of the larynx, causes the immobility of its corresponding half, there are single or multiple mobile metastatic nodes on the neck on one or both sides. Stage IV An extensive tumor occupying most of the larynx, infiltrating the underlying tissues, growing into neighboring organs with infiltration of the underlying tissues. Crayfish thyroid gland Stage I. Localized tumor within the thyroid gland. Stage II. A tumor of the same size with single metastases to regional lymph nodes. Stage III. The tumor grows into the capsule of the gland, there are metastases in the regional lymph nodes. Stage IV The tumor grows into neighboring organs, there are distant metastases. Skin cancer Stage I. Tumor or ulcer no more than 2 cm in diameter, limited to the epidermis and the dermis proper, completely mobile with the skin (without infiltration of neighboring tissues) and without metastases. Stage II. Tumor or ulcer more than 2 cm in diameter, growing through the entire thickness of the skin, without spreading to neighboring tissues. In the nearest lymph nodes there may be one small mobile metastasis. Stage III. a) Significantly limited mobile tumor that has grown through the entire thickness of the skin, but has not yet passed to the bone or cartilage, without metastases; b) the same tumor or smaller, but in the presence of multiple mobile or one inactive metastasis. Stage IV a) A tumor or ulcer that spreads widely over the skin, has grown into the underlying soft tissues, cartilage or bone skeleton; b) a smaller tumor, but in the presence of fixed regional or distant metastases. Skin melanoma Stage I. A malignant nevus or a limited tumor up to 2 cm in size in the largest diameter, flat or warty pigmented, growing only in the skin without underlying tissues. Regional lymph nodes are not affected by metastases. Stage II. a) Pigmented tumors of a warty or papillomatous nature, as well as flat ulcerative ones, larger than 2 cm in the largest diameter, with infiltration of the underlying tissue without metastases in the regional lymph nodes; b) the same tumors as in the stage of Pa, but with damage to the regional lymph nodes. Stage III. a) Pigmented tumors of various sizes and shapes, growing into the subcutaneous tissue, limited displacement, without metastases; b) melanomas of any size with multiple regional metastases. Stage IV Primary tumor of any size, but with the formation in the adjacent areas of the skin of small pigmented metastatic formations of satellites (lymphogenic dissemination) or the presence of distant metastases. Breast cancer Stage I. The tumor is small (less than 3 cm), located in the thickness of the breast, without moving to the surrounding tissue and skin without metastases. Stage II. Tumors not exceeding 5 cm in largest diameter, with a transition from breast tissue to fiber, with a symptom of adhesion to the skin, without metastases; b) a tumor of the same or smaller size with lesions of single lymph nodes of the first stage. Stage III. a) Tumors more than 5 cm in diameter, with germination (ulceration) of the skin, penetration into the underlying fascial-muscular layers, but without metastases in the regional lymph nodes; b) tumors of any size with multiple axillary or subclavian and subscapular metastases; c) tumors of any size with metastases in the supraclavicular lymph nodes with identified parasternal metastases. Stage IV Widespread breast lesion with dissemination in the skin, tumors of any size, germinating chest wall tumors with distant metastases. Lung cancer Stage I. Small localized tumor of the large bronchus with endo or peribronchial growth, and such small tumor small or smallest bronchi without damage to the pleura, without metastases. Stage II .. Tumor of the same or large size, but without damage to the pleura in the presence of single metastases in the nearest regional lymph nodes. Stage III. A tumor that invades the pleura, grows into one of the neighboring organs, in the presence of multiple metastases in the regional lymph nodes. Stage IV A tumor with extensive spread to the chest wall, mediastinum, diaphragm, with dissemination along the pleura, with extensive regional or distant metastases. Cancer of the esophagus Stage I. A well-circumscribed small tumor that invades only the mucosal and submucosal layers. The tumor does not narrow the lumen of the esophagus, hinders the passage of food a little. Metastases are absent. Stage II. A tumor or ulcer that grows into the muscular layer of the esophagus, but does not extend beyond its wall. The tumor significantly impairs the patency of the esophagus. There are single metastases in regional lymph nodes. Stage III. A tumor or ulcer that occupies more than the semicircle of the esophagus or envelops it circularly, growing through the entire wall of the esophagus and the surrounding tissue, soldered to neighboring organs. Passability of a gullet is broken considerably or completely. There are multiple metastases in regional lymph nodes. Stage IV A tumor that affects the esophagus circularly extends beyond the organ, causing perforation into the nearest organs. There are conglomerates of immobile regional lymph nodes and metastases in distant organs. Gastric cancer Stage I. A small tumor localized in the mucous and submucosal layers of the stomach without regional metastases. Stage II. A tumor that invades the muscular layer of the stomach, but does not invade the serous membrane, with solitary regional metastases. Stage III. A tumor of considerable size, germinating the entire wall of the stomach, soldered or germinated into neighboring organs, limiting the mobility of the stomach. The same or smaller tumor, but with multiple regional metastases. Stage IV Tumor of any size with distant metastases. Crayfish colon Stage I. A small tumor infiltrating the mucosal and submucosal layers of the intestinal wall in the absence of metastases. Stage II. a) A tumor of a larger size, occupying no more than a semicircle of the intestine, not going beyond it and not sprouting into neighboring organs, without metastases; b) a tumor of the same or smaller size, but with the presence of metastases in the regional lymph nodes. Stage III. a) The tumor occupies more than the semicircle of the intestine, grows through its entire wall or adjacent peritoneum, without metastases; b) a tumor of any size with the presence of multiple regional metastases. Stage IV An extensive tumor that has grown into neighboring organs, with multiple regional metastases, or any tumor with distant metastases. Rectal cancer Stage I. A small, well-circumscribed mobile tumor or ulcer, localized in a small area of ​​the mucous membrane and submucosal layer, not extending beyond, without metastases. Stage II. a) A tumor or ulcer occupies up to half of the circumference of the rectum, without going beyond its limits, without metastases; b) a tumor of the same or smaller size with solitary mobile regional metastases. Stage III. a) The tumor occupies more than the semicircle of the rectum, grows into the wall or is soldered to the surrounding organs and tissues; b) a tumor of any size with multiple metastases in regional lymph nodes. Stage IV Extensive decaying immobile tumor, germinating surrounding organs and tissues, with regional or distant metastases. Adenocarcinoma of the kidney Stage I. The tumor does not extend beyond the kidney capsule. Stage II. Damage to the vascular pedicle or perirenal tissue. Stage III. Tumor involvement of regional lymph nodes. Stage IV The presence of distant metastases. Bladder cancer Stage I. The tumor does not extend beyond the bladder mucosa. Stage II. The tumor infiltrates the inner muscle layer. Stage III. The tumor grows all the walls of the bladder; there are metastases in regional lymph nodes. Stage IV, Tumor invades neighboring organs, there are distant metastases. Testicular cancer Stage I. The tumor does not extend beyond the albuginea of ​​the testicle, does not enlarge or deform it. Stage II. The tumor, without going beyond the albuginea, leads to deformation and enlargement of the testicle. Stage III. The tumor grows albuginea and extends to the epididymis, there are metastases in the regional lymph nodes. Stage IV The tumor spreads beyond the testis and its epididymis, grows into the scrotum and/or spermatic cord; there are distant metastases. Prostate cancer Stage I. The tumor occupies less than half of the prostate gland without sprouting its capsule, there are no metastases. Stage II. a) The tumor occupies half of the prostate gland, does not cause its enlargement or deformation, there are no metastases; b) a tumor of the same or smaller size with single remote metastases in regional lymph nodes. Stage III. a) The tumor occupies the entire prostate gland or a tumor of any size invades the capsule, there are no metastases; b) a tumor of the same or lesser degree of spread with multiple retractable regional metastases. Stage IV a) A tumor of the prostate gland grows into the surrounding tissues and organs, there are no metastases; b) a tumor of the same degree of local spread with any variants of local metastasis or a tumor of any size in the presence of distant metastases. Cervical cancer Stage I. a) The tumor is limited to the cervix with invasion into the stroma of no more than 0.3 cm with a diameter of no more than 1 cm; b) the tumor is limited to the cervix with an invasion of more than 0.3 cm, there are no regional metastases. Stage II. a) The tumor extends beyond the cervix, infiltrates the vagina within the upper 2/3 or extends to the body of the uterus, regional metastases are not detected; b) a tumor of the same degree of local spread with cellular infiltration on one or both sides. Regional metastases are not defined. Stage III. a) The tumor extends to the lower third of the vagina and / or there are metastases in the uterine appendages, there are no regional metastases; b) the tumor spreads from one or both sides to the parametric tissue to the pelvic walls, there are regional metastases in the pelvic lymph nodes. Stage IV a) The tumor invades the bladder and/or rectum, regional metastases are not detected; b) a tumor of the same degree of spread with regional metastases, any spread of a tumor with distant metastases. Cancer of the body of the uterus Stage I. The tumor is limited to the body of the uterus, regional metastases are not detected. It has three options: a) the tumor is limited to the endometrium, b) invasion into the myometrium up to 1 cm, c) invasion into the myometrium more than 1 cm, but there is no germination of the serous membrane. Stage II. The tumor affects the body and cervix, regional metastases are not detected. Stage III. It has two options: a) cancer with infiltration of the parametrium on one or both sides, which has passed to the pelvic wall; b) cancer of the body of the uterus with germination of the peritoneum, but without involvement. nearby organs. Stage IV It has two options: a) cancer of the body of the uterus with the transition to the bladder or rectum; b) cancer of the body of the uterus with distant metastases. Ovarian cancer Stage I. Tumor within one ovary. Stage II. Both ovaries, uterus, fallopian tubes are affected. Stage III. In addition to the appendages and uterus, the parietal peritoneum is affected, metastases in regional lymph nodes, in the omentum, ascites is determined. Stage IV Neighboring organs are involved in the process: the bladder, intestines, there is dissemination in the parietal and visceral peritoneum of metastasis to distant lymph nodes, omentum; ascites, cachexia. CLINICAL CLASSIFICATION OF TNM The TNM system adopted to describe the anatomical extent of a lesion is based on 3 components: T, extent of the primary tumor; N - absence or presence of metastases in regional lymph nodes and the degree of their damage; M - absence or presence of distant metastases. To these three components are added figures indicating the prevalence of the malignant process: T0, T1, T2, T3, T4 N0, N1, N2, N3 M0, Ml General rules applicable to all localizations of tumors 1. In all cases, there must be histological confirmation of the diagnosis, if not, then such cases are described separately. 2. For each location, two classifications are described: a) The clinical classification is applied before the start of treatment and is based on clinical, radiological, endoscopic examination, biopsy, surgical methods of investigation and a number of additional methods . b) Pathological classification (post-surgical, pathohistological classification), designated pTNM, is based on data obtained before the start of treatment, but supplemented or modified on the basis of information obtained during surgical intervention or examination of surgical material. Pathological assessment of the primary tumor (pT) necessitates a biopsy or resection of the primary tumor for possible assessment of the highest grade of pT. For a pathological assessment of the state of regional lymph nodes (pN), their adequate removal is necessary, which makes it possible to determine the absence (pN0) or to assess the highest limit of the pN category. For pathological assessment of distant metastases (RM), their microscopic examination is necessary. 3. After determining the T, N M and (or) pT, pN and pM categories, grouping by stages can be performed. The established degree of spread of the tumor process according to the TNM system or by stages should remain unchanged in the medical records. The clinical classification is especially important for the selection and evaluation of treatment methods, while the pathological classification provides the most accurate data for the prognosis and evaluation of long-term results of treatment. 4. If there is doubt about the correctness of the definition of categories T, N or M, then the lowest (ie less common) category should be chosen. This also extends to the grouping by stages. 5. In the case of multiple synchronous malignant tumors in one organ, the classification is based on the evaluation of the tumor with the highest T category, and the multiplicity and number of tumors are indicated additionally T2 (m) or T2 (5). When synchronous bilateral tumors of paired organs occur, each tumor is classified separately. In tumors of the thyroid gland, liver and ovary, multiplicity is a criterion for the T category. 6. The definition of T NM categories or staging may be used for clinical or research purposes as long as the classification criteria are not changed. ANATOMICAL AREAS AND LOCATIONS The location of malignant tumors in this classification is determined by the International Classification of Oncological Diseases number code (ICD-0, 2nd edition of WHO, 1990). Each area and part is described according to the following table of contents: Classification rules with methods for determining T, N and M. Anatomical area with its parts (if any). Definition of regional lymph nodes. TNM Clinical classification pT N M Pathological classification G Histopathological differentiation. Grouping by TNM stages CLINICAL CLASSIFICATION In all cases, the following are used: general principles: T - Primary tumor Tx It is not possible to estimate the size and local spread of the primary tumor T0 The primary tumor is not defined Tis Preinvasive carcinoma (Carcinoma in situ) T 1, T2, T3, T4 Reflects the increase in the size and / or local spread of the primary tumor N - Regional lymph nodes Nx Insufficient data to evaluate regional lymph nodes

We have already learned. Today we will get to know classification of malignant tumors and find out whether all malignant tumors can be called cancer.

All malignant tumors are divided into groups depending on the type of fabric from which they originated:

• cancer (carcinoma)- a malignant tumor epithelial tissue. If cells highly differentiated(less malignant), name to be specified by type of fabric: follicular cancer, keratinizing squamous cell carcinoma, adenocarcinoma, etc.

  If the tumor has poorly differentiated cells, the cells are called by their shape: small cell carcinoma, cricoid cell carcinoma, etc.

  Blood is not an epithelial tissue, but a type of connective tissue. So say " blood cancer» is incorrect. In the 3rd year, during the study of pathological anatomy, we were told that such a phrase, spoken aloud at the exam, automatically causes removal from the exam with a deuce. It was remembered. Correct names: leukemia (leukemia, hemoblastosis), is a tumor of hematopoietic tissue that develops throughout circulatory system. Leukemias are acute and chronic. If a tumor from the hematopoietic tissue is localized only in a certain part of the body, it is called lymphoma(Remember in the first part of the photo with Burkitt's lymphoma?).

  The lower the cell differentiation, the faster the tumor grows and the earlier it metastasizes. I already wrote about this in the second part of the series.

• sarcoma- a malignant tumor of connective tissue, with the exception of blood and hematopoietic tissue. For example, a lipoma is a benign tumor of adipose tissue, and liposarcoma- a malignant tumor from the same tissue. Similarly: fibroids and myosarcomas, etc.

Now generally accepted are international TNM classification and clinical classification malignant tumors.

TNM classification

Used all over the world. For a malignant tumor, a separate characteristic of the following parameters is given:

1. T (tumor)- the size of the tumor.
2. N (nodes)- the presence of metastases in regional (local) lymph nodes.
3. M (metastasis)- the presence of distant metastases.

Then the classification was expanded with two more characteristics:

4. G (gradus, degree)- the degree of malignancy.
5. P (penetration, penetration)- the degree of germination of the wall of a hollow organ (used only for tumors of the gastrointestinal tract).

Now in order and in more detail.

1. T (tumor) - tumor.
   It characterizes the size of the formation, the prevalence in the departments of the affected organ, the germination of surrounding tissues. Each organ has its own specific gradations of these features.

   For example, for colon cancer:

   • T o - there are no signs of a primary tumor.
   • T is (in situ) - intraepithelial tumor. About her below.
   • T 1 - the tumor occupies a small part of the intestinal wall.
   • T 2 - the tumor occupies half the circumference of the intestine.
   • T 3 - the tumor occupies more than 2/3 or the entire circumference of the intestine, narrowing the lumen.
   • T 4 - the tumor occupies the entire intestinal lumen, causing intestinal obstruction and (or) grows into neighboring organs.

   For a breast tumor, gradation is carried out by tumor size(in cm), for stomach cancer - according to the degree of wall germination and distribution to the parts of the stomach.

   Degree of organ wall invasion and TNM.
   Designations (from top to bottom):
   mucous - submucosal -
   muscular layer - subserous layer -
   serous membrane - surrounding organs.

   Particular emphasis should be in situ cancer(cancer in situ). At this stage, the tumor is located only in the epithelium (intraepithelial cancer), does not germinate the basement membrane, which means that the blood and lymphatic vessels do not germinate. At this stage of development, a malignant tumor is still devoid of infiltrating character growth and fundamentally cannot metastasize. That is why in situ cancer treatment gives most favorable results.

   Stages of cancer development.
   Designations (from left to right): a cell with a gene mutation - hyperplasia -
   pathological growth - cancer "in situ" - cancer with infiltrating growth.

   It should be noted that morphologically (that is, under a microscope) there are many transitional stages between a normal and a malignant cell. Dysplasia- violation proper development cells. Hyperplasia- a pathological increase in the number of cells. Not to be confused with hypertrophy(this is a compensatory increase in cell size during their hyperfunction, for example, the growth of muscle tissue after exercising with dumbbells).

   Stages of epithelial dysplasia:
   normal cell - hyperplasia -
   mild dysplasia - cancer "in situ" (severe dysplasia) -
   cancer (invasive).

2. N (nodes) - nodes (lymph nodes).

   characterizes changes in regional (local) lymph nodes. As you know, the lymph flowing from the organ first enters the nearest regional lymph nodes (collector of the 1st order), after which the lymph goes to a group of more distant lymph nodes (collectors of the 2nd and 3rd orders). Lymph from the entire organ and even several organs at once gets into them. Groups of lymph nodes have their own name, which is given by their location.

   For example, for stomach cancer:

   • N x - no data on the presence of metastases in regional lymph nodes (the patient is underexamined).
   • N o - there are no metastases in regional lymph nodes.
   • N 1 - metastases in the collector of the 1st order (along the greater and lesser curvature of the stomach).
   • N 2 - metastases in the collector of the 2nd order (prepyloric, paracardial, lymph nodes of the greater omentum).
   • N 3 - metastases affect the para-aortic lymph nodes (collector of the 3rd order, near the aorta), which cannot be removed during surgery. At this stage, it is impossible to completely remove the malignant tumor.

   So, the gradations N o and N x are common for all localizations, N 1 - N 3 are different.

3. M (metastasis).
   Characterizes the presence distant metastases.
   • M o - no distant metastases.
   • M 1 - there is at least one distant metastasis.

Additional TNM classification options:

4. G (gradus) is the degree of malignancy.
   Determined histologically (under a light microscope) by degree of differentiation cells.
   • G 1 - low-grade tumors (highly differentiated).
   • G 2 - medium malignancy (poorly differentiated).
   • G 3 - high degree of malignancy (undifferentiated).
5. P (penetration) - penetration.
   Only for tumors of hollow organs. Shows degree germination of their walls.
   • P 1 - within the mucosa.
   • P 2 - grows into the submucosa.
   • P 3 - grows into the muscle layer (to serous).
   • P 4 - sprouts the serous membrane and goes beyond the organ.

According to the TNM classification, the diagnosis may sound, for example, like this: caecal cancer T 2 N 1 M 0 G 1 P 2. This classification is convenient, as it characterizes the tumor in detail. On the other hand, it does not provide generalized data on the severity of the process and the possibility of a cure. Therefore, the clinical classification of tumors is also used.

Clinical classification of tumors

Here are all the parameters of a malignant neoplasm (the size of the primary tumor, the presence of regional and distant metastases, germination in surrounding organs) taken together.

Allocate 4 stages of cancer:

• 1st stage: the tumor is small, occupies a limited area, does not germinate the wall of the organ, there are no metastases.
• 2nd stage: the tumor is large, does not spread outside the organ, single metastases to regional lymph nodes are possible.
• 3rd stage: a large tumor, with decay, germinates the entire wall of the organ or a smaller tumor with multiple metastases to regional lymph nodes.
• 4th stage: germination of the tumor in the surrounding tissues, including non-removable (aorta, vena cava, etc.) or any tumor with distant metastases.

The possibility of curing a malignant tumor depends on the stage: the higher the stage, the less likely be cured. That's why you need to detect a malignant tumor as soon as possible, and for this, do not be afraid to go to be examined, especially if there are suspicions, which will be discussed in the 4th part of this cycle.

Relative 10-year survival rate for cancer patients
mammary gland depending on the stage of cancer.

Currently under oncology most physicians understand the science of cancer. Abroad, this science is called carcinology.

A tumor (blastoma, neoplasm) is pathological formation in tissues, which is characterized by autonomous growth, polymorphism and atypia of cells.

one). autonomous growth- division of tumor cells is not subject to any regulatory mechanisms; not controlled by the body.

2). Cellular polymorphism- the presence in the structure of the tumor of young cells, heterogeneous in structure.

3). Cell atypia- this is the difference between these young cells from the cells of the tissue or organ from which they originated (i.e., low differentiation or lack of differentiation).

The last 2 signs are more characteristic of malignant tumors.

As a cause of death, malignant tumors take 2nd place (20% of total mortality) after diseases of cardio-vascular system. According to the WHO, every year 6 million people fall ill with oncological diseases, and about 5 million people die from them every year. Men get sick 1.5 times more often than women.

The most common location of tumors also depends on gender.:

• In men, it is more common: cancer of the lung, stomach, prostate, colon and rectum.
• In women, more common: cancer of the breast, stomach, uterus, lung, rectum and colon, skin.

Etiology

Several theories have been proposed for the development of tumors:

one). Annoyance theory(R. Virkhov, 19th century) - tumors occur in places of greatest trauma (cardiac stomach, rectum, cervix, etc.), because this accelerates cell division and at some point may occur tumor transformation.

2). germ theory(D. Kongeym) - “unclaimed” cells remain in the embryo, which are in a dormant state, but under the influence of certain factors begin to grow, turning into a tumor. This mechanism is valid only for disembryonic tumors.

3). Regeneration-mutation theory(Fischer, Vasels) - under the influence of various factors (carcinogens), destructive processes occur in the body, leading to regeneration, during which tumor transformation of cells (due to mutations) most often occurs.

four). virus theory(L.A. Zilber, 1946) - the virus, entering the cell, disrupts the regulation of mitosis, which leads to tumor transformation. At present, the role of oncoviruses has been proven only in certain diseases (for example, the Epstein-Barr virus leads to the development of Burkitt's lymphoma). There is also theory of transformation of viruses 1 into another.

5). immunological theory- in the body, as a result of mutations, the formation of tumor cells is constantly occurring, but the immune system quickly finds and destroys them. If a weakened immune system does not destroy at least 1 cell, it can cause the development of a tumor.

Currently, no theory can fully explain the causes of the development of tumors. Modern scientists adhere to the views on the polyetiology of tumors.

The main etiological factors in the development of tumors (carcinogenic theory of L.M. Shabad) :

one). Chemical carcinogens- local and general exposure to chemicals. For example, with persistent smoking, as a result of exposure to polycyclic aromatic hydrocarbons, lung cancer develops. Other examples: scrotum cancer in chimney sweeps, pleural mesothelioma in asbestos work.

2). Physical carcinogens:

• Ultraviolet rays (causes squamous cell carcinoma of the skin).
• Ionizing radiation - x-rays, gamma rays, elementary particles of the atom (cause bone cancer, thyroid cancer, leukemia).

3). Hereditary (genetic) factors.

A small number of tumors are genetically determined (for example, colon polyposis, retinoblastoma, tumors of the endocrine glands - Sipple's syndrome, etc.). Breast cancer in the daughters of patients occurs 3 times more often than in the rest of the population. Communication with oncogenes ("tumor" genes) has been proven in 50 types of tumors.

four). Geographic factors- an unexplained phenomenon so far: certain forms of tumors are more common in certain geographical areas and affect other ethnic groups when they move there. It can be seen that many factors play a role here: dietary habits, climate, etc.

In certain cases, the so-called hereditary trace reaction(i.e. when changing the place of residence, the frequency of tumors in a population group initially remains the same, but then begins to gradually decrease, although it remains somewhat higher than in others. Sometimes it happens the other way around.

5). infectious factors(oncogenic viruses).

For example, Epstein-Barr virus causes Burkett's lymphoma, hepatitis B virus causes hepatocellular liver cancer, herpes simplex virus type 2 causes cervical cancer.

According to the polyetiological theory of one presence etiological factors is not sufficient for tumor development, there must be a genetic predisposition and (or) a disorder immune system.

Classification

Tumors are classified according to 3 main criteria: the type of tissue in which the tumor develops; localization; morphological features and ability to spread.

one). According to the nature of growth and clinical course all tumors are divided into:

• benign- characterized by the presence of a capsule, expansive, slow, non-invasive growth, as well as the absence of metastases and relapses after radical surgery.
• Malignant- do not have a capsule and are characterized by invasive growth, as well as the ability to metastasize.

There is also an intermediate form - Crayfish "in situ” (in place), which does not grow into the surrounding tissues and does not give metastases.

2). Depending on the tissue in which the tumor develops, there are:

• Epithelial tumors (adenoma, cancer, etc.).
• Connective tissue (sarcoma, fibroma, etc.).
• Muscular (myoma, myosarcoma, etc.).
• Vascular (angiomas).
• Fat (lipoma).
• Nervous (neurinoma).
• Mixed (lipofibroma, neurofibroma, fibroadenoma, etc.).

3). For the affected organ:

Tumors of the stomach, lung, bones, skin, etc.

four). Upon emergence:

• Congenital (teratoma, teratoid, dermoid cysts).
• Acquired.

When naming benign tumors the suffix -oma is added to the name of the tissue from which they originated: lipoma, fibroma, myoma, chondroma, osteoma, angioma, etc.

Malignant tumors are divided into cancer (tumors from epithelial tissue) and sarcoma (tumors from connective tissue and its varieties). When naming a malignant tumor, the suffix -carcinoma (tumors from the epithelium - adenocarcinoma) or -sarcoma (tumors from the connective tissue: myosarcoma, osteosarcoma, angiosarcoma, etc.) is added to the name of the tissue.

Some tumors have their own names: melanoma, lymphoma, ganglioma, etc.

ClassificationTNM

The TNM classification makes it possible to compare groups of patients, evaluate various methods treatment and predict long-term outcomes.

T - Tumor - primary tumor

Corresponds to the largest size of the neoplasm:

• Tis - intraepithelial tumor, "cancer in place" (in situ).
• T0 - primary tumor is not detected.
• T1, T2, T3, T4 - reflects an increase in the size and (or) local spread of the tumor.
• Tx - it is impossible to evaluate the tumor.

For the intestine, the gradation of degrees is carried out according to how much the tumor captures the circumference and narrows the lumen. For the mammary gland, the gradation is in the size of the tumor itself (in centimeters).

N - Nod uli - Changes in regional lymph nodes

Determines the degree of involvement in the tumor process of regional lymph nodes:

• N0 - no signs of metastases in regional lymph nodes.
• N1, N2, N3 - reflect varying degrees of metastases in regional lymph nodes;
• N4 - metastases in juxtaregional lymph nodes;
• Nx - it is not possible to determine the state of the lymph nodes.

M - Metastasis (Metastases) - indicates screening of tumor cells in other organs and tissues:

• M0 - no signs of distant metastases;
• M1 - there are distant metastases.

Later, several more symbols were added to the TNM classification:

G - Gradus - Degree of differentiation of tumor cells:

• G1 - high degree of differentiation (1 degree of malignancy).
• G2- average degree differentiation (grade 2 malignancy).
• G3 - low degree of differentiation or undifferentiated tumors (grade 3).
• Gx - the degree of differentiation is not established.

P - Punctum - The degree of germination of the wall of hollow organs (only for tumors of the gastrointestinal tract).

• P1 - tumor in the mucosa.
• P2 - tumor in the submucosa.
• P3 - the tumor grows into the muscle layer.
• P4 - the tumor grows into the serosa.

In addition to the parameters T, N, M, G, P, the factor C is sometimes used.

Factor C - Information about the applied research methods :

• C1 - the diagnosis was made solely on the basis of clinical examination.
• C2 - laboratory and instrumental research methods were used.
• C3 - the diagnosis was made after a trial surgical intervention.
• C4 - the diagnosis was made after removal of the tumor and its histological examination.
• C5 - the diagnosis was made after a pathoanatomical autopsy.

Pathogenesis

The pathogenesis of tumors can be divided into three periods:

one). The period of preblastomatous (precancerous) state.

2). The period of preclinical cancer.

3). period of clinical cancer.

During the period of preblastomatous state- there is no tumor yet, but there is one of the diseases that often turns into a tumor (the so-called precancer).

Precancer(precancerous, preblastomatous conditions) - common name congenital or acquired changes, on the basis of which the development of malignant tumors is possible. Allocate:

• Obligate precancer- always turns into a tumor (phylloid mastopathy, xeroderma pigmentosa, etc.).
• Optional precancer - does not always turn into a tumor (fistulas, stomach ulcers, atrophic gastritis, polyps of the stomach and intestines, dyshormonal mastopathy, cervical erosion, trophic ulcers, papillomas, etc.

Patients with precancerous diseases should be registered in the dispensary.

During preclinical cancer There is already a tumor, but it does not manifest itself clinically.

During clinical cancer clinical manifestations appear - a violation of the function of the affected organ.

Differences between benign and malignant tumors

Clinic of benign tumors

consists of local symptoms:

one). There is a swelling of a rounded shape, with a smooth surface, slowly increasing in size.

2). On palpation, the tumor is usually painless.

3). May develop dysfunction affected organ, life threatening:

• A large polyp in the intestine can cause mechanical intestinal obstruction.
• A brain tumor causes an increase in intracranial pressure.
• A tumor of the adrenal glands (pheochromocytoma) produces catecholamines, which cause hypertension.
• Some thyroid tumors can cause thyrotoxicosis, etc.

Clinic of malignant tumors

A characteristic feature of oncological diseases is the gradual increase in symptoms.

one). Syndrome of small signs(for the first time for stomach cancer suggested A.I. Savitsky, 1947):

Usually these are the most early manifestations malignant tumor, although they can appear in late stages(cancer intoxication, cancerous exhaustion).

• Weakness, fatigue.
• Weight loss.
• Bad appetite. For cancer of the stomach is characterized by aversion to meat food.
• Progressive anemia, increased ESR.
• Unexplained fever.

2). Plus tissue syndrome:

The tumor is found as new, extra tissue in a place where it should not be. This syndrome is revealed by palpation. Sometimes it is possible to palpate even deep tumors (in abdominal cavity, in the retroperitoneal space). Plus-tissue syndrome can also be detected by additional methods.

3). Syndrome of pathological discharge:

In malignant tumors, atypical discharge is often detected:

• Bloody discharge (gastric, uterine bleeding, hemoptysis, hematuria, etc.) - due to the germination of blood vessels by a tumor.
• Mucous or mucopurulent discharge - due to reactive inflammation around the tumor.

four). Organ dysfunction syndrome.

Its manifestations depend on the affected organ and may be different:

• With bowel cancer - intestinal obstruction.
• With stomach cancer - dyspeptic disorders (vomiting, heartburn, belching "rotten", etc.).
• With cancer of the esophagus - dysphagia, etc.

5). The appearance of metastases

occurs due to cells that have broken away from the "maternal" tumor and got into other organs and tissues, causing the growth of "daughter" tumors (metastases) there. Metastases in structure usually do not differ from the primary tumor, although sometimes (rarely) they can be more malignant, because cell proliferation is faster.

The main ways of metastasis:

• Lymphogenic pathway (the most common) - it can be retrograde or antegrade. Usually metastases appear in the lymph nodes.
• Hematogenous route - metastases usually appear in the internal organs (for example, in the lungs with bone sarcoma).
• Implantation - usually associated with the entry of tumor cells into the serous cavity (abdominal, pleural) after germination of the organ wall.
• Liquor path - through the spinal cerebrospinal fluid.
• Metastasis through interstitial spaces.
• Mixed way of metastasis.

Different tumors have different tendencies to metastasize, for example: cancer of the larynx and lower lip rarely metastasize, and lung cancer often has distant metastases when first detected.

In some tumors, typical localization of metastases is described, for example: in case of stomach cancer - metastases to the lymph nodes above the left clavicle (Virchow's metastasis), in case of stomach cancer in women - to the navel (Nurse Joseph metastasis), ovaries (Krukenberg metastasis) and to the vesico-rectal region. fiber (Schnitzler metastasis).

Differential diagnosis of benign and malignant tumors

Domestic clinical classification of malignant tumors

Stage 1 - the tumor is localized, occupies a limited area, does not germinate the wall of the organ, there are no metastases.

Stage 2 - the tumor is large, but does not spread outside the organ, single metastases to regional lymph nodes are possible.

Stage 3 - a large tumor, with decay, germinates the entire wall of the organ (or a smaller tumor with numerous metastases to regional lymph nodes).

Stage 4 - germination of the tumor in the surrounding organs (non-removable tumors), as well as any tumor with distant metastases.

The stage of the tumor process is set 1 time and persists until the end of the patient's life, even if there is no recurrence.

Clinical groups of cancer patients

Clinical groups should be distinguished from the clinical stages of the disease, which are introduced for the convenience of accounting for oncological patients and ensuring dispensary observation. Patients can move from one group to another, but the stage remains unchanged.

1 clinical group- patients with an unclear clinical picture, but with a suspicion of a malignant tumor (1a) and patients with benign tumors (1b).

In group 1a, the doctor is given 10 days to reject or confirm the diagnosis. After that, patients are either removed from the register or transferred to other groups.

In group 1b, the doctor is given no more than 30 days to cure a benign tumor.

2 clinical group - patients with malignant tumors requiring radical treatment. In it, some distinguish a subgroup 2a - these are patients who require special radical treatment.

3 clinical group- it's practically healthy people who underwent radical treatment. During the first year they visit an oncologist once a quarter, in 2-3 years - once every six months, then - once a year until the end of their lives. In the event of relapses and metastases and the possibility of radical treatment, they are transferred to group II, if radical treatment is impossible - to clinical group IV.

4 clinical group - patients with advanced stages malignant tumors subject to only symptomatic treatment. These patients are followed up on a case-by-case basis.

Additional methods for diagnosing tumors

one). Laboratory research:

• Determination of the morphological composition of blood.
• Determination of enzymes.
• Carrying out special tests.

2). Immunological diagnostics- reveal:

• Monoclonal antibodies. They are produced by hybridomas obtained by fusion of immune B-lymphocytes and myeloma cell culture. Monoclonal antibodies are used in the differential diagnosis and staging of leukemias, as well as for their treatment. In addition, they can be used to purify the cell culture of one's own bone marrow before reintroducing it into the body after chemotherapy.
• tumor markers- These are normal differentiation antigens of a glycoprotein or glycolipid structure located on the membrane of malignant tumor cells. In other words, these antigens are also present in the norm, but with tumors their number increases dramatically. This property is used for mass screening of the population in Western countries, for which ELISA methods are used.

In addition to tumor markers, there are other markers that make it possible to determine the tissue nature of a metastasis in an undetected primary focus:

3). Instrumental examination methods:

• Endoscopic examination (FGDS, colonoscopy, bronchoscopy).
• X-ray examination - simple or contrast.
• Radionuclide diagnostics.
• Ultrasound procedure.
• CT scan.
• Nuclear magnetic resonance.
• Thermography.

Methods for verifying an oncological diagnosis

one). Cytological examination- allows you to give an answer in 92% of cases.

• The smear method.
• scarification method.
• Examination of the fluid obtained by puncture (more precisely, sediment after centrifugation).
• fine needle biopsy method.

2). Histological examination- allows you to give an answer in 99.8% of cases.

Tissues are taken for histological examination by biopsy.

Biopsy is an in vivo sampling of tissue for diagnostic microscopic examination. There are 3 types of biopsies:

• Incisional biopsy - excision of a piece of tissue.
• Puncture biopsy - the material is obtained by puncturing the tumor with thick needles.
• Total biopsy - removal of the entire tumor with subsequent histological examination.

Biopsy Rules:

one). The puncture or incision made during the biopsy should not further complicate specialized surgical treatment;

2). Careful attitude to surrounding healthy tissues;

3). Prevention and stop bleeding;

four). Competent processing, marking and transportation of material.

Only melanoblastomas cannot be biopsied, as in these tumors, trauma accelerates the growth and dissemination of cells.

It must be remembered that positive result(detection of tumor cells) confirms the diagnosis, but a negative answer does not reject it.

Principles of diagnosis of malignant tumors

For malignant tumors, there is a clear dependence of the prognosis on the stage at which the tumor was detected: for example, with stage 1 cancer, the 5-year survival rate is more than 90-97%, with stage 3 cancer, 25-30%. Therefore, in the work of each doctor, 3 principles must be observed:

one). Oncological alert.

2). The principle of overdiagnosis.

3). The principle of early diagnosis.

Cancer alertness characterized by:

• Knowledge of precancerous conditions.
• Knowledge of the primary clinic of the main tumors.
• Rapid referral of a patient with a suspected malignant tumor for examination to an oncologist to establish a final diagnosis.
• Every doctor must remember the inevitability of death in a malignant tumor, so the mistake is unforgivable.

Thus, every doctor, when examining any patient, should ask himself the question: could these symptoms be caused by a tumor? After that, the doctor must confirm or reject his suspicions.

The principle of overdiagnosis:

In all doubtful cases, a more serious diagnosis should be made and the most radical methods of treatment should be applied. It is believed that it is better to assume a later stage of the tumor than to "miss" the existing one.

The principle of early diagnosis:

In oncology, there are the following levels of diagnosis of malignant tumors: ultra-early, early, timely and late.

• Ultra-early diagnostics - prenatal diagnosis of a tumor (for example, some forms of leukemia) in the study of fetal tissues and amniotic fluid.
• Early diagnosis- this is the detection of a tumor in the initial stage, when the tumor transformation of cells has already occurred, but so far there is only cancer “in situ” (intraepithelial) or the process is in the first clinical stage of the disease. Such tumors do not metastasize and, after adequate treatment, more than 90% of patients recover.
• Timely diagnosis - covers patients from the second (sometimes from the third) clinical stage tumors (i.e. T1, T2, N0, M0). Most of these patients can be cured, but some still die from the progression of the disease.
• Late diagnosis- this is the detection of a tumor at the third or fourth stage (i.e. with metastases).

Diagnosis of preclinical cancer

It consists in active detection by conducting preventive examinations population:

• Detection of precancerous diseases. These patients should undergo an examination by an oncologist and special examination methods once a year.
• Identification of asymptomatic tumors. These patients should be treated immediately.
• It is necessary to identify groups of people with increased risk on cancer (for example, those whose relatives suffered from oncological pathology).

The most common methodological technique underlying the identification of such risk groups is the questionnaire method of questioning and collecting information about harmful factors and the state of people's health (screening method).

Treatment of benign tumors

The main method of treating benign tumors is surgical (removal). Only in some cases (for hormone-dependent tumors) is hormonal chemotherapy used.

Benign tumors that do not cause harm to the patient do not need to be removed (especially if this is a patient with severe comorbidities).

Indications for surgery:

one). Violation of the functions of the affected organ (for example, a benign tumor can clog the lumen of the bronchus, intestines, etc.).

2). cosmetic defect- especially for tumors of the face, neck, mammary glands.

3). Localization of the tumor in some places (scalp, lower back, foot, etc.), where it is subjected to constant trauma. This creates a threat of malignancy of a benign tumor.

four). Precancerous nature of the lesion.

5). Lack of confidence that the tumor is not malignant (for example, with tumors of the thyroid or breast). In this case, the operation performs the role of an excisional biopsy, the material is sent for urgent histological examination, after which the issue of the extent of the operation is decided.

The operation for a benign tumor is to remove it within healthy tissues. In this case, the tumor must be removed entirely, together with the capsule. The surgical material is sent for histological examination. The operation completely cures the patient.

Treatment of malignant tumors

Treatment methods for malignant tumors are:

one). operational method.

2). Radiation therapy.

3). Chemotherapy.

four). In recent years, immunotherapy has been increasingly used.

These methods can be used alone or in combination. (combined treatment).

In addition, allocate combined treatment when 2 or more similar effects are applied (for example, intracavitary and interstitial radiation therapy).

Surgery and radiation therapy affect the primary tumor and regional lymph nodes, but do not affect metastases.

Chemotherapy and immunotherapy are systemic treatments that can also affect metastases.

Treatment of tumors can be radical, palliative or symptomatic.

radical treatment

It is aimed at removing the tumor along with the affected organ, regional lymph nodes and cellular spaces, and suggests the possibility of a complete or temporary recovery. Radical surgeries include:

• Operations in which the tumor and the main regional lymph nodes are removed.
• Advanced surgeries that increase the amount of tissue removed.
• Combined operations in which another organ (or part of it) is removed, into which the tumor grows.

The fourth stage of cancer of any localization is not subject to radical surgical treatment.

Palliative care

It is used when it is impossible to carry out a radical operation and is aimed at lengthening the duration and improving the quality of life. Such treatment, however, does not cure the patient completely.

Palliative operations consist in the removal of the primary tumor, leaving obviously affected regional lymph nodes, which will be affected by other methods (radiation therapy, etc.).

This can also be attributed indirect operations- these are interventions on organs that are not affected by a tumor, for example: removal of the ovaries for breast cancer, orchiectomy for prostate cancer.

Symptomatic operations

These are interventions that eliminate the leading symptom that threatens the life of the patient. The tumor is not removed. With such operations, it is possible to eliminate intestinal obstruction (resection of the intestine or impose a colostomy), eliminate jaundice, reduce intoxication, etc. This also includes the so-called sanitation operations, aimed at removing part of the tumor.

Features of operations for malignant tumors

Operations for malignant tumors are based on 4 oncological principles:

one). Ablastic

These are measures to prevent the spread of tumor cells during surgery:

• Incisions are made only within healthy tissues (with an exophytic nature of growth - a retreat of 5-6 cm from the border, with an endophytic one - a retreat of 8-10 cm or more). The tumor is removed as a single block along with the surrounding tissue and regional lymph nodes.
• Avoid injury to the tumor during surgery.
• Early ligation of the veins that drain blood from the tumor.
• Ligation of tubular organs above and below the tumor (to prevent cell migration through the lumen).
• Before manipulations with the affected organ, it must be isolated with gauze napkins.
• After removal of the tumor, it is necessary to change tools and gloves, as well as delimiting napkins.

2). antiblast

These are measures aimed at destroying tumor cells during surgery:

• Physical ablastics- the use of an electric knife, electrocoagulation, laser, ultrasound, as well as irradiation of the tumor before surgery and in the postoperative period.
• Chemical antiblast- treatment of the wound after removal of the tumor with 70% alcohol and other antiseptics, intravenous administration anticancer drugs right on the operating table, regional (targeted) administration of anticancer drugs.

3). Zoning

This is an operating technique in which not only the tumor itself is removed, but also the surrounding area, in which individual tumor cells may be located, as well as regional lymph nodes, in which there may be unnoticed metastases (for example, in breast cancer, the pectoralis major muscle and fiber are removed together with axillary, supraclavicular and subclavian lymph nodes). In accordance with the principle of zoning, the entire affected organ or most of it is usually removed.

four). Case

This is a technique for operating within anatomical fascial cases, because they are anatomical barriers to tumor growth (for example, in thyroid cancer, it is removed along with the fascial sheath).

Radiation therapy

Some patients require radiotherapy at one of the stages of treatment. The effect of radiation therapy is based on the fact that tumor cells have a more intensive metabolism and, therefore, are more sensitive to ionizing radiation. Therefore, it is necessary to choose exactly such a mode and dose of radiation, in which only tumor cells are damaged, and not the surrounding healthy tissues.

Sensitivity to radiation in different tumors very different:

More sensitive - low-, moderately differentiated and undifferentiated tumor cells. In this way:

• Highly sensitive to radiation therapy - lymphosarcoma, seminoma, cancer of the skin, lips, larynx, bronchi, esophagus, cervix. If the tumor is small, then radiation therapy in this case can become a radical method of treatment (for example, with Hodgkin's disease).
• Low sensitive to radiation therapy - cancer of the stomach, kidney, pancreas, intestines, melanoma, myosarcoma, osteosarcoma, chondrosarcoma. In these cases, radiation therapy is only palliative (for example, for pain relief).

Radiation sources:

one). X-rays.

2). Gamma rays are radioactive isotopes of cesium, cobalt, radium, iodine.

3). Corpuscular radiation - alpha and beta rays.

The main methods of radiation therapy:

one). External exposure(most common) - produced using X-ray therapy (X-rays are used) and gamma therapy (radioactive cesium and cobalt are used). External irradiation is especially effective for superficial tumors.

2). Intracavitary irradiation- the radiation source is introduced through natural openings into the bladder, uterine cavity, oral cavity, etc. In this case, the tumor itself is irradiated as much as possible, and not the surrounding tissues.

3). Interstitial irradiation- carried out with the help of special needles and tubes with a radioactive substance. Sometimes radioactive capsules are left in the tissues after surgery. A variation of interstitial irradiation is the introduction of radioactive iodine in thyroid cancer: iodine accumulates in the gland and has a destructive effect on the tumor, as well as on its metastases.

In some cases, radiation therapy is combined with chemotherapy: for example, pyrimidine acts on the tumor as a radiation sensitizer.

Possible Complications of Radiation Therapy:

one). General complications

They bear the name " radiation sickness” and are expressed in weakness, insomnia, loss of appetite, shortness of breath, tachycardia and bone marrow damage (primarily leukopenia, then anemia, thrombocytopenia).

To prevent this, radiation therapy should be carried out only under the control of a blood test (at least 1 time per week).

2). Skin complications

- associated with the damaging effect of radiation on the tissues surrounding the tumor.

• Reactive epidermitis - mild swelling, hyperemia and itching of the skin.
• Radiation dermatitis - severe hyperemia and edema, blistering, hair loss, subsequently developing skin atrophy, telangiectasia.
• Radiation indurative edema - develops due to obliterating lymphangitis and sclerosis of the lymph nodes.
• Radiation necrotic ulcers - are characterized by severe pain and lack of a tendency to heal.

Treatment of skin lesions: avoid sunlight, treat with antiseptics (hydrogen peroxide with saline - 1: 1), ointments with vitamins A, D, corticosteroids.

3). Gastrointestinal reactions

Radiation gastritis, enteritis, proctitis.

four). radiation pneumonia.

The drug of choice for her treatment is prednisolone 15 mg x 4 times a day with gradual withdrawal.

5). CNS lesions

Headache, increased intracranial pressure, vomiting, memory impairment, drowsiness syndrome.

Prevention of local complications is right choice method, dose and field of exposure, as well as the exclusion of the effects of rays on vital organs (for example, on the spinal cord). In addition, it is recommended to gradually reduce the field area during the course of treatment.

Chemotherapy

This is a therapeutic effect on the tumor with the help of various drugs. This method is highly effective only for leukemia and tumors of hormone-dependent organs (mammary gland, prostate gland, etc.). In other tumors, chemotherapy is much less effective than surgery and beam methods, and assigned only in the following cases:

one). In the combined treatment of tumors with multiple metastases, if it is impossible to apply surgical or radiation exposure.

2). In some cases, chemotherapy (sometimes combined with radiation) is given before, during, and/or after surgery. This increases the effectiveness of the treatment of a number of malignant neoplasms.

3). Sometimes chemotherapy is used in patients with advanced stages of the tumor, when other palliative measures have been exhausted, and allows them to somewhat alleviate their suffering.

Possible Complications of Chemotherapy:

• Inhibition of hematopoiesis - leukopenia, thrombocytopenia and anemia. If the level of leukocytes falls to 2.5 x 10 9 /l and below, chemotherapy should be discontinued.
• Kidney damage - kidney failure may develop.
• Liver damage - developing toxic hepatitis.

With the combined use of anticancer drugs, their side effects can be summarized. Doses of drugs are selected taking into account the phase of development of the tumor cell (presynthetic, synthetic, resting phase, mitosis phase, etc.) and concomitant pathology.

Classification of anticancer chemotherapy drugs:

one). Cytostatics

Inhibit the reproduction of tumor cells:

• Alkyrating agents (ThioTEF, cyclophosphamide, embichin, carmustine, busulfan, dacarbazine);
• Plant alkaloids (vinblastine, vincristine);

2). Antitumor antibiotics

They are produced by microorganisms (mainly actinomycetes) and inhibit the activity of tumor cells.

Representatives: mitoxantrone, doxorubicin, carminomycin, mitomycin, actinomycin, dactinomycin, sarcolysin, rubromycin.

3). Antimetabolites

They inhibit the metabolism in tumor cells due to the fact that they are antagonists of purine and pyrimidine bases or folic acid.

Representatives: methotrexate, 5-fluorouracil, ftorafur, mercaptopurine, cytarabine, pentostatin.

Often antimetabolites are used in combination with cytostatics in the form of special schemes. An example is the Cooper regimen for the treatment of breast cancer (CMFVP):

• On the operating table - IV cyclophosphamide.
• The first 2 weeks after surgery, daily - cyclophosphamide and prednisolone, with the gradual withdrawal of prednisolone by the 25th day.
• Against the background of the described treatment, on the 1st, 8th and 15th days - methotrexate, 5-florouracil and vincristine.

This course is repeated 3-4 times with an interval of 4-6 weeks.

four). Hormonal drugs

Used in the treatment of hormone-dependent tumors:

• Estrogens (sinestrol, diethylstilbestrol, fosfestrol, megestrol) are used in prostate cancer.
• In breast cancer, androgens (proloteston, omnadren) are used, as well as antiestrogenic drugs (tamoxifen, toremifene).

Hormone therapy can also include operations on the endocrine glands, for example, orchiectomy for prostate cancer.

5). Platinum preparations

Cisplatin, carboplatin, platidiam, etc. Mechanism: interaction with DNA with the formation of interstrand bonds, the formation of bonds with nuclear and cytoplasmic proteins, which leads to metabolic disorders.

6). Other chemotherapy agents

Hydroxyurea, procarbazide, etoposide (VP-16-213).

Immunotherapy

is divided into several types:

one). Nonspecific immunotherapy.

Immunomodulators are effective in some diseases (for example, in some kidney tumors).

Representatives: gamma globulin, roncoleukin, zymosan, manosin, propermil, glucan, prodigiosan, pyrogenal, alpha-interferon, thymus preparations (thymalin, T-activin), levamisole, phytopreparations (gotu-kola, etc.), cat's claw, shark cartilage, vlairin.

2). Topical application of vaccines.

The BCG vaccine is used, but it is effective only for recurrent superficial cancer Bladder. Its introduction into the bladder, followed by its resection, reduces the frequency of tumor recurrences. A common side effect is a flu-like condition during the first days after administration.

3). Cells showing a direct cytotoxic or cytostatic effect

For example, bone marrow transplants, transfusion of T-lymphocytes.

four). Hematopoietic growth factors

a group of proteins that regulate the proliferation and differentiation of blood cells, impaired due to chemotherapy:

• Interleukins (IL-1, IL-3, IL-6) - damage immature cells, regulate the development of lymphocytes.
• Colony stimulating factors (erythropoietin, platelet and macrophage CF).

5). specific immunotherapy.

For this, there are vaccines and immune sera. Some of them are already used (for example, in breast cancer), others are in clinical trials.

Existing cancer vaccines:

6). Local immunotherapy- aimed at activating immune responses in the tumor itself. A well-studied method is the introduction of the BCG vaccine into the tumor node and in the area adjacent to it. The tumor into which BCG is injected develops inflammatory response with infiltration by monocytes and histiocytes, which ends with the formation of granular tissue that replaces the tumor.

Depending on the clinical course and morphological characteristics of the tumor are divided into benign and malignant.

Benign tumors are characterized by slow expansive growth, a clear demarcation from the surrounding tissues (the presence of a capsule), morphological similarity with the tissues from which they originated and, as a rule, do not threaten the patient's life.

Malignant tumors are characterized by rapid invasive growth, morphological atypism, the ability to metastasize and, as a rule, threaten the life of the patient.

Of particular importance for the practical activities of the oncological service is the histogenetic classification of tumors, which determines the tissue from which the neoplasm has developed: epithelium, connective, hematopoietic tissue, endothelium, tissues nervous system, APUD systems, embryonic islets, trophoblastic tumors, hamartomas. Each given morphological substrate can be affected by benign and malignant tumors. An exception is hematopoietic tissue, which is affected by only malignant diseases.

I. EPITHELIAL TUMORS

benign

1. Papilloma - a tumor from squamous epithelium

2. Adenoma - a tumor from the glandular epithelium

Papillomas and adenomas protruding into the lumen of a hollow organ (on a stalk or broad base) are called papillary or adenomatous polyps, respectively.

Malignant (cancer - cancer, crab)

1. Squamous cell carcinoma with or without keratinization.

2. Adenocarcinoma (glandular cancer).

II. CONNECTIVE TISSUE TUMORS

benign

1) Lipoma 2) Fibroma 3) Myxoma 4) Chondroma 5) Osteoma 6) Leiomyoma 7) Rhabdomyoma.

Malignant (sarcoma)

1) Liposarcoma 2) Fibrosarcoma 3) Myxosarcoma 4) Chondrosarcoma 5) Osteosarcoma 6) Leiomyosarcoma 7) Rhabdomyosarcoma.

III. TUMORS FROM HEMOPOETIC TISSUE (HEMOBLASTOSIS)

1. Systemic hemoblastosis (malignant)

1.1. Acute leukemia; 1.2. Chronic leukemia.

2. Tumors (sarcomas)

2.1. Lymphogranulomatosis; 2.2. Lymphosarcoma; 2.3. plasmacytoma;

2.4. reticulosarcoma; 2.5. malignant lymphomas.

IV. TUMORS FROM ENDOTHELIUM AND MESOTHELIUM

benign

1. Hemangioma;

2. Lymphangioma;

3. Benign synovioma;

4. Localized mesothelioma.

Malignant

1. Hemangiosarcoma;

2. Lymphangiosarcoma;

3. Malignant synovioma;

4. Diffuse mesothelioma.

V. TUMORS OF NERVOUS TISSUE

benign

1. Neurofibroma; 2. Neurinoma; 3. Ganglioneuroma; 4. Oligodendroglioma; 5. Astrocytoma; 6. Meningioma.

Malignant

1. Neurofibrosarcoma; 2. Malignant neuroma; 3. Ganglioneuroblastoma; 4. Sympathoganglioma; 5. Astroblastoma; 6. Medulloblastoma; 7. Spongioblastoma; 8. Epindymoblastoma; meningeal sarcoma.

VI. TUMORS FROM APUD CELLS - SYSTEMS (APUDOMS)

The APUD system is a functionally active system that includes neuroendocrine cells scattered throughout the body.

benign

1. Adenomas of the endocrine glands; 2. Carcinoids; 3. Paragangliomas (pheochromocytoma, chemodectoma); 4. Thymomas.

Malignant

1. small cell cancer lung; 2. Medullary thyroid cancer; 3. Melanoma; 4. Carcinoid malignant.

VII. TUMORS FROM EMBRIONAL ISLANDS (RUDs, REMAINS)

benign

1. Teratoma - a tumor consisting of tissues characteristic of the affected organ, and also contains tissue components that are not normally found in this area and cannot arise due to metaplasia; 2. Dermoid cyst.

Malignant

1. Teratoblastoma; 2. Wilms tumor (nephroblastoma).

VIII. TROPHOBLASTIC TUMORS

benign

bubble skid

Malignant:

chorionepithelioma

IX. HEMARTOMAS (DISEMBRIOGENETIC TUMORS) - tumors consisting of tissues characteristic of the affected organ: vascular hemangiomas, vascular and pigmented skin nevi, congenital neurofibromatosis, exostoses, familial intestinal polyposis, etc.

CLINICAL GROUPS OF ONCOLOGICAL PATIENTS

In order to unify the record, analyze the prevalence and frequency of oncological diseases, as well as determine the effectiveness of the oncological service, all patients are divided into 6 clinical groups.

Group Ia - patients with a suspicion of a malignant disease. Patients of this group are subject to an in-depth examination within no more than 14 days, and as the diagnosis is established, they are transferred to another group or removed from the register.

Group Ib - patients with precancerous diseases and benign tumors. Patients of this group are subject to clinical examination and rehabilitation (sanation). According to the number of patients registered and the number deregistered after treatment, the intensity and effectiveness of the work of each specialist and institution for the medical prevention of malignant neoplasms is determined.

Group II - patients with malignant diseases subject to special methods of treatment (hemoblastosis).

Group IIa - patients with malignant tumors subject to radical treatment.

Group III - practically healthy people, cured of a malignant tumor, who have been registered at the dispensary for at least 5 years.

Group IV - patients with malignant tumors in the late stages of the disease, when palliative or symptomatic treatment is indicated.

PRINCIPLES OF DIAGNOSIS

All patients with suspected cancer undergo a comprehensive examination, including laboratory and special research methods. When making a diagnosis, complaints, anamnesis and objective data are carefully analyzed.

The clinic and diagnostics of specific oncological diseases are so diverse that they are studied in each field of medicine independently, therefore, these sections are presented in the relevant manuals or oncology textbooks. At the same time, there are general principles for making a diagnosis, which provide a unified approach and unification of the assessment of relevant data.

1. The diagnosis of oncological disease must be confirmed by cytological or pathomorphological examination. Without histological verification, the diagnosis of a malignant tumor remains doubtful.

Only melanoma should not be biopsied, as this contributes to its dissemination. Morphological study of melanoma produced after its radical excision.

2. For all malignant tumors, two diagnoses are made:

Clinical diagnosis based on clinical, radiographic, endoscopic, biopsy and a number of additional research methods; this diagnosis determines the method of treatment for a particular patient;

Pathological (post-surgical, pathohistological) diagnosis based on data obtained before the start of treatment, but supplemented by information obtained during surgical intervention or morphological (cytological) examination of the surgical material. This diagnosis determines the prognosis and long-term results.

3. When making a diagnosis of a tumor, the localization, nature and stage of the disease are indicated.

The existing clinical and morphological classification provides for the division of patients with malignant neoplasms, depending on the degree of prevalence of the process, into 4 stages, indicated by Roman numerals I, II, III, IV.

This division is based on the TNM system developed by a special committee of the International Cancer Union, therefore this classification is called international, it is accepted in most countries of the world.

Symbol T (tumor, tumor) - the primary tumor for most localizations has 7 options:

T0 - the primary tumor is not detected (not detected using known research methods), although there are tumor metastases;

Tis - preinvasive carcinoma (Carcinoma in situ) - the tumor is located within the layer of origin ("intraepithelial cancer", non-infiltrating intraductal carcinoma of the breast).

T1 - a small tumor (depending on the organ up to 1 cm, but not more than 2 cm in diameter), limited to the original tissue;

T2 - a small tumor (depending on the organ from 2 to 5 cm in diameter), not extending beyond the affected organ;

T3 - a tumor larger than 5 cm, extending beyond the affected organ, germinating serous membranes and capsules;

T4 - a tumor of any size, growing into neighboring organs and tissues.

TX is a tumor, the size and boundaries of which cannot be accurately determined.

Symbol N (nodulus, node) - indicates the defeat of the lymph nodes, has 5 options.

NX - insufficient data to determine the extent (degree) of lymph node involvement;

N0 - no signs of damage to the lymph nodes;

N1 - defeat of one regional lymph node with a diameter in the largest dimension less than 3 cm, at a distance from the primary tumor up to 3 cm;

N2 - defeat of one or more lymph nodes, less than 3 cm in diameter, but located at a distance of more than 3 cm from the primary tumor or one node with a diameter of 3-6 cm;

N3 - defeat of one regional lymph node with a diameter of more than 6 cm or several nodes with a diameter of 3-6 cm, located at a distance of more than 3 cm from the primary tumor.

Symbol M (metastases) - indicates the presence of distant metastases, due to hematogenous or lymphogenous dissemination. Metastasis to non-regional (juxta-regional) lymph nodes is considered as distant metastasis.

The hematogenous (venous) path of metastasis from the systems of the superior and inferior vena cava most often leads to damage to the lungs, in the portal system - to the liver.

The symbol M has three meanings:

MX - insufficient data to establish the likelihood of distant metastases;

MO - there are no signs of distant metastases;

M1 - there are single or multiple distant metastases.

All combinations of T1-4 N0-3 M0-1 give 32 categories, which is completely unacceptable for practice, so the grouping of patients by stages is used. The principle of determining the stage of the disease of a malignant tumor can only be formulated in a general form.

Stage I - a small or small tumor that does not extend beyond the affected organ in the absence of regional metastases. According to the TNM system, the first stage includes: T1-2 N0 M0 (T1 N0 M0; T2 N0 M0).

Stage II - a small or small tumor that does not extend beyond the affected organ in the presence of a single regional lymphatic metastasis. According to the TNM system, the second stage includes: T1-2 N1 M0 (T1 N1 M0; T2 N1 M0).

Stage III - a tumor that extends beyond the affected organ, germinating serous membranes and capsules, or a small tumor with the presence of multiple regional metastases. According to the TNM system, the third stage includes all combinations that include T1-3 N0-3 M0, not included in stages I and II (T1 N2 M0; T1 N3 M0; T2 N2 M0; T2 N3 M0; T3 N0 M0; T3 N1 M0 ; T3 N2 M0; T3 N3 M0).

Stage IV - a large tumor that grows into neighboring organs and tissues or a tumor of any size in the presence of distant metastases.

According to the TNM system, the fourth stage includes all combinations, including N1-4 T0-3 M0-1, not included in the previous stages (N1

N0 M1; T1 N1 M1; T1 N2 M1; T1 N3 M1; T2 N0 M1; T2 N1 M1; T2 N2 M1; T2 N3 M1; T3 N0 M1; T3 N1 M1; T3 N2 M1; T3 N3 M1; T4 N0 M0; T4 N1 M0; T4 N2 M0; T4 N3 M0; T4 N0 M1; T4 N1 M1; T4 N2 M1; T4 N3 M1).

The above classification is quite consistent with the diagnosis of cancer of the esophagus, stomach and lungs. For other localizations, the grouping of TNM by stages may differ somewhat.

It should be borne in mind that the size of the tumor, which determines, to some extent, the stage of the disease, is a relative value. So, for the stomach and eye, the size of the tumor is equal to 2 cm in diameter in the first case, a small tumor, in the second, a very large one.

4. When making a diagnosis, there is often doubt about the stage of the disease. For solitary tumors, a lower TNM value is chosen, since this most often orients towards radical treatment.

In the presence of multiple synchronous tumors, the stage is determined by the highest category T and N among all tumors present.

OUTCOMES AND HAZARDS OF MALIGNANT

NEOPLASMS

1. Destruction of tissue in the focus of localization of the primary tumor, and as a result, a decrease or loss of the corresponding function.

2. Spread (dissimination) of the tumor and damage to the vital important organs(lungs, liver, adrenal glands, etc.).

3. Intoxication due to the decay of tumor tissue and infection - the formation of endotoxins.

4. Depletion due to inhibition of enzyme systems and competition in the use of plastic and energy substrates.

5. Bleeding due to vascular erosion.

6. Thromboembolism associated with impaired rheological properties

stv blood and hypercoagulability.

GENERAL PRINCIPLES AND METHODS OF TREATMENT

ONCOLOGICAL PATIENTS

Depending on the goal, treatment can be radical, palliative and symptomatic.

Radical treatment is a therapy aimed at the complete elimination of all foci of tumor growth. Evaluation of the results of radical tumor treatment is performed immediately after its completion ( clinical evaluation), and then according to long-term results (biological assessment - B.E. Peterson, 1980). Conditionally long-term results are determined by a five-year life after treatment.

Palliative care is a therapy directed directly or indirectly to the tumor, which provides life extension. It is used in cases where a radical cure is unattainable.

Symptomatic treatment- this is the therapy of patients with stage IV of the disease, aimed at eliminating or weakening painful or life-threatening complications for the patient.

Treatment methods for cancer patients:

1. Surgical (operational) method

2. Radiation therapy.

3. Chemotherapy.

4. Hormone therapy.

5. Supportive therapy.

6. Combined therapy.

7. Combined treatment.

8. Comprehensive treatment.

Surgical treatment tumors

Types of surgical interventions used in the treatment of cancer patients:

1. Radical operations (typical, extended, combined).

2. Palliative operations.

3. Symptomatic operations.

4. Rehabilitation operations.

A typical radical operation involves the removal of the affected organ or part of it within obviously healthy tissues, together with the regional lymphatic apparatus and the surrounding tissue in one block.

An extended radical operation, along with a typical radical operation, involves the removal of third-order lymph nodes (N3-lymphadenectomy).

A combined radical operation is performed in cases where two or more adjacent organs are involved in the process, so the affected organs and their lymphatic apparatus are removed.

The principle of determining the volume of surgical intervention in radical operations can only be formulated taking into account the nature of growth and the degree of anaplasia:

For small exophytic, highly differentiated tumors, a major operation should be performed;

With large exophytic, highly differentiated tumors, a very large operation should be performed;

With small infiltrative undifferentiated tumors, the largest operation should be performed;

With large infiltrative undifferentiated tumors, the operation should not be performed (B.E. Peterson, 1980).

Palliative operations are performed in cases where a radical operation cannot be performed. In these cases, the primary tumor is removed in the scope of a typical radical operation, which ensures the continuation of life.

Symptomatic operations are used in advanced process, when there is a pronounced dysfunction of the organ or complications, life threatening patient, but which can be eliminated by surgery.

Rehabilitation operations are performed for medical and social rehabilitation cancer patients. They can be plastic, cosmetic and restorative.

When performing operations for oncological diseases, it is necessary to observe, along with asepsis and antisepsis, the principles of area and antiblastic.

Ablastics is a system of measures aimed at preventing implantation metastases, dispersion of tumor cells in the area of ​​the surgical wound.

Ablastics includes the following activities:

Careful delimitation of the manipulation zone from the surrounding tissues, repeated change of surgical linen;

The use of a laser or electric scalpel;

One-time use of tupfers, napkins, balls;

Repeated change or washing during the operation of gloves and surgical instruments;

Ligation and intersection of blood vessels that provide blood supply to the organ affected by the tumor, beyond its limits before the start of mobilization;

Removal of a tumor within known healthy tissues, corresponding to the boundaries of the anatomical zone, as a single block with regional lymph nodes and the surrounding tissue.

Antiblastics is a system of measures aimed at combating tumor elements that can enter the wound during surgery and creating conditions that prevent the development of implantation metastases.

Antiblastics includes the following activities:

Stimulation of body resistance (immune, non-specific);

Preoperative radiation and/or chemotherapy;

Creation of conditions preventing adhesion cancer cells: introduction of heparin or polyglucin into the abdominal (thoracic) cavity before the mobilization of the affected organ, treatment of the surgical wound 96o ethyl alcohol;

Intraoperative use of cytostatics (into the cavity, infiltration of tissues to be removed);

Radiation exposure (radiation, isotopes) and chemotherapy in the early postoperative period.

Along with surgical methods, cryosurgery (destruction of affected tissues by freezing) and laser therapy ("evaporation", "incineration" of the tumor with a laser) are currently used.

RADIATION THERAPY OF TUMORS.

Radiation therapy is carried out using various sources (installations) of ionizing (electromagnetic and corpuscular) radiation.

Remote methods of radiation therapy are static or mobile irradiation using gamma units containing cobalt-60, a betatron or a linear accelerator as an emitter.

Contact methods of radiation therapy (selective isotope accumulation method) - intracavitary, radiosurgical and application irradiation, as well as close-focus X-ray therapy.

X-ray therapy can be static and mobile (rotational, pendulum, tangential).

Combined methods of radiation therapy is the use of one of the methods of remote and contact irradiation.

Irradiation modes

1. Simultaneous irradiation - the required dose is carried out in one session (rarely used).

2. Continuous - irradiation by the contact method (intracavitary, interstitial and application).

3. Fractional irradiation is performed using remote gamma therapy and X-ray therapy. The method provides for the division of the total course dose of radiation (according to the radical program - 60 Gy for the tumor and 55-60 Gy for regional metastasis zones) into small fractions (2 Gy per day), enlarged fractions (4 Gy per day) or large fractions (5-60 Gy per day). 6 Gy per day). Irradiation is carried out with an interval of 2-3 days.

4. Method of a split course of remote gamma therapy. The method provides for the division of the therapeutic course dose into 2 equal cycles of fractional irradiation with a break of 3-4 weeks. This makes it possible to increase the total course radiation dose by 10-15 Gy.

In radiation therapy, the determination of the course therapeutic dose is based on in general terms on the law of Bergonier and Tribando, which states: "The sensitivity of tissues to radiation is directly proportional to mitotic activity and inversely proportional to cell differentiation."

Malignant tumors are divided into 5 groups according to their sensitivity to ionizing radiation (Mate, 1976).

Group I - highly sensitive tumors: hematosarcomas, seminomas, small cell undifferentiated and poorly differentiated cancer.

Group II - radiosensitive tumors: squamous cell carcinoma of the skin, oropharynx, esophagus and bladder.

III group- Tumors with medium sensitivity: vascular and connective tissue tumors, astroblastomas.

Group IV - tumors with low sensitivity: adenocarcinomas of the breast, pancreas, thyroid glands, kidneys, liver, colon, lympho-, chondro-, osteosarcomas.

Group V - tumors with very low sensitivity: rhabdo- and leiomyosarcomas, ganglioneuroblastomas, melanomas.

CHEMOTHERAPY FOR MALIGNANT NEOPLASMS

All drugs that act directly on the tumor are grouped into the group of cytostatics, although in their action they can delay cell division (cytostatic effect) or destroy it (cytotoxic effect).

Currently, two mechanisms of action on the tumor are mainly used in chemotherapy: direct damage and slowing down the time of tumor cell generation.

Classification of anticancer drugs

1. Alkylating compounds - interact with other substances through an alkylation reaction, i.e. replacement of the hydrogen of a compound by an alkyl group. Micro- and macromolecules undergo alkylation, but the main thing in the antitumor effect is their interaction with DNA. This group includes: embikhin, novembikhin, cyclophosphamide, sarcolysin, thiophosfamide (ThioTEF), etc.

2. Antimetabolites - block the synthesis of substances necessary for cell function. Of greatest interest are: methotrexate, a folic acid antagonist; mercaptopurine, thioguanine - purine antagonists; fluorouracil, fluorofur, cytarabine are pyrimidine analogues.

3. Antitumor antibiotics - inhibit the synthesis of nucleic acids. This group includes: dactinomycin, adriamycin, rubomycin, carminomycin, bleomycin, olivomycin, etc.

4. Herbal preparations - cause denaturation of the tubulin protein, which leads to mitosis arrest. This group includes: kolhamin, vinblastine, vincristine, etoposide, teniposide.

5. Enzymes. This group includes - asparaginase (krasnitin), used in leukemia, whose cells do not synthesize asparagine, their needs are met by asparagine present in the blood. The introduction of asparaginase leads to the destruction of asparagine, and the cells that need it die.

6. Compounds with an alkylating and antimetabolite action component - platinum complex compounds: cisplatin, platinol.

Chemotherapy, depending on the nature and extent of the tumor process, can be the main method of treatment (hemoblastoses, disseminated forms of solid tumors) or a component of combined or complex treatment, in particular as postoperative adjuvant (additional) therapy.

Types of chemotherapy

1. Systemic - general drug exposure by administering drugs orally, intravenously, intramuscularly or subcutaneously.

2. Regional - medicinal effect on a certain area by isolated perfusion or endolymphatic infusion.

3. Local - medicinal effect by injection into the cavity (intrapleurally, intraperitoneally), intrathecally (into the cerebrospinal fluid space), intravesically (into the bladder), directly on the tumor or tumor ulcers.

Classification of tumors according to sensitivity to cytostatics

1. Tumors are highly sensitive - the frequency of stable remission after treatment is achieved in 60-90% of patients. This group includes: chorionepithelioma, acute lymphoblastic leukemia in children, Burkitt's tumor, lymphogranulomatosis, malignant testicular tumors.

2. Tumors are relatively sensitive - the frequency of remission is observed in 30-60% of patients, real opportunity life extension. This group includes: acute leukemias, multiple myeloma, erythremia, Ewing's sarcoma, cancer of the breast and prostate, ovaries, lung (small cell), uterine body, Wilms' tumor, embryonic rhabdomyosarcoma in children, lymphosarcomas.

3. Tumors are relatively resistant - the frequency of remission is in the range of 20-30% of patients, an increase in life expectancy is observed in a small part of patients. This group includes: cancer of the stomach, colon and rectum, larynx, thyroid gland, bladder, squamous cell skin cancer, chronic leukemia, melanoma, neuroblastoma in children, soft tissue sarcoma, osteogenic sarcoma, glioblastoma, corticosteroma.

4. Resistant tumors - remission is possible in a small part (less than 20%) of patients, in the vast majority of cases - partial and short-lived. This group includes: cancer of the esophagus, liver, pancreas, kidney, cervix, vagina, lung (not small cell).

It should be emphasized that even effective chemotherapy most often leads only to clinical remission for a longer or shorter period, regardless of the sensitivity of the tumor to cytostatics.

Side effects chemotherapy

Side effects of cytostatics according to clinical manifestations are very diverse. However, the toxic effect of their systemic use is manifested primarily in actively proliferating tissue: bone marrow, lymphatic system, epithelium of the gastrointestinal tract, reproductive organs.

For patients with a large mass of tumor tissue, chemotherapy may do more harm than good.

Clinical classification of chemotherapy complications

1. Toxic effect of cytostatics.

1.1. Local irritating effects: toxic dermatitis, phlebitis, thrombophlebitis, cystitis, serositis, neuropathy, etc.

1.2. Systemic complications: myelodepression, dyspeptic syndrome (nausea, vomiting, diarrhea), alopecia (baldness), aminorrhea.

1.3. Systemic specific complications: neuritis, polyneuritis, encephalopathy, psychosis, toxic hepatitis, liver cirrhosis, pancreatitis, myocardial dystrophy, cystitis, glomerulonephritis, etc.

II. Complications associated with immune imbalance.

2.1. Immunosuppression: different kinds intercurrent infection, exacerbation of chronic infection, development of secondary tumors.

2.2. allergic reactions: dermatitis, eczema, anaphylaxis.

III. Complications associated with cytostatic intolerance: fever, swelling of the face, larynx, shortness of breath, severe myelodepression, independent of the dose, tachycardia, fainting.

IV. Complications caused by the interaction of cytostatics with other drugs used - increased toxicity of cytostatics or other drugs, the emergence of new side effects.

HORMONOTHERAPY

Some malignant neoplasms are able to change their growth and development under the influence of certain hormones. These tumors are united in the "hormone-dependent" group.

Of greatest practical importance are preparations of male (androgens) and female (estrogens, progestins) sex hormones. The exception is glucocorticoids, which have a positive effect in acute and chronic lymphocytic leukemia, lymphogranulomatosis, and especially in malignant lymphomas.

Hormone therapy includes not only hormones, but also non-hormonal substances that block the action of certain hormones.

Despite the undoubted success of hormone therapy in a number of malignant neoplasms, this method (monotherapy) is still regarded as a palliative treatment for primary and disseminated forms of tumors, as well as for relapses and metastases. However, it is widely used as a component of complex therapy.

The principle of prescribing hormones is to determine the individual sensitivity of the tumor to the corresponding hormone. At the same time, hormone-dependent tumors in men (prostate cancer, breast cancer), as a rule, are sensitive to extragens; hormone-dependent tumors in women (breast cancer, cancer of the body of the uterus) - to androgens. In order to enhance the effect of hormone therapy at the beginning of treatment, indirectly acting surgical interventions - castration - are very widely performed.

ADDITIONAL THERAPY

Under the adjuvant therapy of malignant tumors, various effects are understood that do not independently affect the course of the disease, but they can enhance the effect of radiation, chemohormonal therapy or increase the body's resistance.

Auxiliary methods include: stimulation of the natural and immunological resistance of the body, correction of metabolism, hyperthermia, hyperglycemia, stabilization of lipid peroxidation reactions, etc.

COMBINATION THERAPY

Combination therapy is understood as a combination of actions within one of the treatment methods. So, the combined effect is widely used in chemotherapy, when two or three drugs are prescribed simultaneously or sequentially. Similar treatment is used for hormone and radiation therapy.

COMBINED TREATMENT

Under combined treatment understand any combination of the two fundamentally different methods treatment (chemo-radiation, chemo-hormonal, operative radiation, etc.), which are applied simultaneously or sequentially.

COMPLEX TREATMENT

Under complex treatment understand the combination of three or more fundamentally different methods of treatment, including various methods of adjuvant therapy. This method is most often used in the treatment of malignant tumors.

PREVENTION OF TUMORS

Prevention of malignant neoplasms is based on epidemiological data. So, for most European countries, the most common factors in the development of cancer are:

1. Nutrition 35%

2. Smoking 30%

3. Violation of the function of the genital organs 10%

4. Solar radiation, ultraviolet 5%

5. Environmental pollution 4%

6. Occupational hazards 4%

7. Ionizing radiation 3.5%

8. Alcohol 2.5%

9. Hereditary factors 2.3%

10. Reasons not established 3.7%

In the conditions of the Republic of Belarus, environmental pollution, occupational hazards, as well as ionizing radiation and alcohol are undoubtedly of greater importance.

With all these factors in the development of cancer, the psycho-emotional state is of great importance, as the background against which carcinogens are realized. Of particular importance is chronic emotional stress, since negative emotions reduce the body's natural resistance, and on the other hand, steroid hormones, the level of which rises sharply during stress, acting through receptors located in the cytoplasm, affect the degree of DNA methylation, so they can derepress silent" oncogenes.

Based on the foregoing, the real ways of cancer prevention can be represented as follows.

1. Correction of the psycho-emotional state.

2. Rational nutrition.

3. Limitation (elimination) of the action of carcinogenic factors.

4. Mode of work and rest.

5. Correction of the mechanisms of reactivity and resistance of the body.

6. Treatment of precancerous diseases.

1. Psycho-emotional factors in the pathogenesis of cancer.

According to psychologists, psychoneurologists, psychotherapists, for the normal functioning of the central nervous system (CNS), including its regulatory mechanisms, a balanced intake of various stimuli is necessary. It has been established that the optimal variant that ensures the stable functioning of adaptive reactions, including the immune system, is the following ratio of stimuli: about 60% of emotionally neutral ones should enter the CNS; emotionally positive - 35% and only 5% emotionally negative.

Stress adversely affects all organs when it is very intense or long enough.

Consequently, both acute and chronic stress can cause disorganization of the regulatory function of the CNS. However, chronic stress, despite its small amount of force, always has a more severe effect, up to and including exhaustion.

2. Nutrition plays an important role in the development of malignant neoplasms and not only in the gastrointestinal tract. At the same time, nutritional factors can have both negative and positive effects. Nutritional factors are not so much the initiators of carcinogenesis as they form a functional precancer-cancrophilia in the body - the sum of metabolic disorders that increase the likelihood of malignant transformation of the cell.

Specific nutritional factors in the pathogenesis of neoplasms.

2.1. The ecological purity of consumer products is beyond doubt, since the content of PAHs, aflatoxins and other chemicals in food will undoubtedly affect the frequency of carcinogenesis.

2.2. Important role regularity of nutrition plays a role in the formation of cancrophilia, as this affects the function of the glands digestive tract, on the features of the excretory and endocrine function of a number of sections of the gastrointestinal tract. Of particular danger is the intake of very hot food and hasty food.

2.3. The method of food preparation has a very significant impact on the function of the gastrointestinal tract, as well as on the formation of modifying conditions for carcinogenesis. Fried food contains a number of very strong extractives, and re-fried food may contain carcinogens such as PAHs. Smoked meats always contain more or less chemical carcinogens.

2.4. Essential in carcinogenesis is the diet, which includes the following components.

2.4.1. The balance of food consumed, since it is known that an excess in the diet of any of the main ingredients of food (proteins, fats, carbohydrates) inevitably leads to cancrophilia.

2.4.2. Reasonable calorie restriction in accordance with the needs, including age. At overweight body increases the risk of developing cancer of the colon, liver, gallbladder, breast and prostate glands.

2.4.3. Fats, especially of animal origin, inhibit the detoxification function of a number of enzymes. An increase in the concentration of free fatty acids, low and very low density lipoproteins, cortisol, and insulin in the blood impairs the functioning of the DNA repair system and creates conditions conducive to the onset of cancer. Therefore, it is necessary to reduce the intake of fats, especially of animal origin, since epidemiological studies show that there is fairly strong evidence of a direct relationship between fat intake and the incidence of breast and colon cancer. A real preventive effect can be achieved by reducing dietary fat (in terms of calories) to 25-30%.

2.4.4. It is possible to change the diet more often, since a monotonous diet leads to a number of metabolic disorders.

2.4.5 Data from epidemiological and experimental studies show that there is an inverse relationship between the amount of plant foods consumed and the frequency of a number of cancers. So, cabbage and other vegetables contain indoles, which are inhibitors of carcinogens that can cause breast cancer; fruits, berries contain natural coumarins - inhibitors of various carcinogens; fruits, especially citrus fruits, vegetables rich in beta-carotene (a natural precursor of vitamin A found in in large numbers in carrots), as well as all foods containing vitamins C, E, B reduce the likelihood of developing cancer of the esophagus, larynx, stomach, lungs, and bladder. Vitamins C and E seem to be able to inhibit the synthesis of endogenous nitro compounds.

3. The role of carcinogens in the development of the tumor process is known, therefore, the natural task of the entire state, the sanitary and hygienic service, environmentalists, and all medical personnel is to protect members of society from the action of carcinogens or reduce their pathogenic effect. There are no universal methods for eliminating or limiting the negative effects of carcinogens.

Thus, the mechanical factors of carcinogenesis have special meaning for women and, in particular, traumatic injuries of the breast. In this regard, it is necessary to categorically oppose such types of women's sports when there is a real danger of repeated injuries to the mammary gland: boxing, kickboxing, sambo, etc.

Of the physical carcinogens, ultraviolet radiation is of particular importance, since it is universal and radioactive radiation, since it is the most dangerous. With the exception of catastrophes associated with nuclear fission, the effect of these factors is quite manageable.

UVR is a danger in the summer months, when people tend to tan, are for a long time with an open body in direct sunlight.

Radioactive and X-ray radiation are dangerous as occupational hazards, so the development and implementation of technologies that reduce radiation exposure is the main direction in reducing the pathogenic effect of this carcinogen.

carcinogens of the environment and the microclimate of the premises occurs during smoking, engine operation internal combustion, adverse household factors and environmentally dirty industries. According to WHO, tobacco smoke is a powerful carcinogenic factor and poses a huge danger to human health. A causal relationship has been established between smoking and lung cancer. Moreover, smoking increases the risk of developing cancer of the lips, larynx, esophagus, gallbladder, and pancreas.

The smoke generated in the kitchen due to burning food, burning stoves, pans, etc., has a carcinogenic effect. With insufficient ventilation of the room, conditions are created for the accumulation of various toxic substances in the air.

Therefore, the fight against smoking, the elimination adverse factors life is a real way to prevent cancer.

Very dangerous situation occurs when the environment is polluted with exhaust gases from internal combustion engines, especially when running unregulated or worn motors. Control over this type of pollution lies with the sanitary service and the traffic police.

Environmentally dirty industries significantly increase the content of carcinogens in the environment, so it is the duty of the sanitary service, technologists, environmentalists to monitor the design of industries, their location, and also control their work.

4. Mode of work and rest in the pathogenesis of neoplasms.

Factors that increase the likelihood of developing a tumor:

Overload: physical, mental;

Night shifts;

Passive rest;

Excess solar radiation.

Factors that reduce the likelihood of developing a tumor:

Labor is joy;

Alternation of mental and physical labor;

Leisure;

Having a hobby.

5. Resistance of the organism in the pathogenesis of neoplasms.

Factors that increase the likelihood of developing neoplasms:

Congenital or acquired immunological deficiency;

Decreased natural resistance due to hypovitaminosis, chronic intoxication, exhaustion.

Therefore, if the body's resistance is impaired, stimulation of nonspecific defense mechanisms (anabolites, vitamins, biostimulants) and the immunocompetent system (interferon, interleukin-2, thymalin, levomisole, etc.) will undoubtedly reduce the risk of developing malignant neoplasms.

6. Cancer, as a rule, does not arise on unchanged soil, this is preceded by various pathological conditions accompanied by active cell proliferation (precancer). Based on this, a medical direction for the prevention of malignant neoplasms was formulated - the improvement of patients with precancerous diseases. This function is performed by doctors of all specialties by detecting precancerous diseases in a polyclinic, hospital, and professional examinations. These patients are taken into account, their purposeful treatment is carried out.

The given system of prevention allows us to state that potential opportunities prevention of tumor development is quite significant, but its effectiveness depends on social conditions and lifestyle of the individual.

Classifications of tumors can be varied depending on the principles of distribution: according to the localization of the tumor itself, biological traits, according to clinical manifestations, according to the degree of prevalence, histological structure and etc.

The distribution of tumors on individual groups According to the so-called stages of the process, it is based on the fact that with localized tumors, the immediate and long-term results of treatment are much better than with lesions that extend beyond the organ. Accordingly, these stages are referred to as “early” or “late”, meaning the sequence of development of the tumor process. In fact, the stage of the process at the time of diagnosis can reflect not only the extent and growth rate of the tumor, but also its type and the ratio of the organism to the tumor.

Unlike non-neoplastic diseases in cancer patients clinical diagnosis can only be considered definitive if, by means of special characters the stage of tumor growth is indicated. The definition and designation of the stage of the disease is necessary both for choosing the most rational treatment regimen and for establishing the prognosis for each individual patient.

Since 1956, the USSR adopted a general grouping of malignant tumors into 4 stages of development, which was modified and supplemented by stages depending on specific conditions.

For example, the domestic four-stage classification of tumors of the oral mucosa is as follows:

І stage: limited tumor process of the mucous membrane and submucosal layer up to 1 cm in diameter without damage to regional lymph nodes and germination of surrounding tissues.

II stage:

a) a tumor up to 2 cm in the largest dimension, which grows into the tongue up to 1 cm deep, for other localizations - deeper than the submucosal layer. Regional metastases are absent;

b) a tumor of the same or smaller size with the presence of homolateral single mobile regional metastases.

III stage:

a) the tumor is larger than 2 cm in the greatest dimension. On the tongue, the infiltration passes beyond the midline or onto the oral mucosa. In other localizations of cancer of the oral mucosa, infiltration extends to one of the neighboring anatomical sites or structures. Regional metastases are not defined;

b) a tumor of the same size or a lesser degree of local spread with single limited displaceable or multiple mobile homo-, contra- or bilateral metastases.

IV stage:

a) the tumor affects the entire anatomical site, spreads to the surrounding soft tissues and bones of the facial skeleton without regional metastases ( note: with limited germination of cancer of the mucous membrane of the hard palate or alveolar processes of the upper or lower jaw in the bone, the tumor can be classified as stage III);

b) a tumor of the same degree of local spread with any variants of local metastasis, or a tumor of a lesser degree of local spread with non-displaceable regional metastases, or a tumor of any degree of local spread with clinically defined distant metastases.

Classifications by stages are built similarly for other cancer localizations. This classification has played a significant role in the development of clinical oncology, although it is not without some drawbacks. It lacks a definition of more early stages, it is not very suitable for determining the stage of cancer of the internal organs. The same tumor process is sometimes referred to by different clinicians as different stages. More specifically and stereotyped on the basis of certain clinical signs Tumor growth is characterized by classification according to the TNM system. The basic principles of this classification can be applied to all sites, regardless of the chosen method of treatment. The clinical classification can be successively supplemented by data obtained as a result of histopathological examination and/or surgical intervention data.

The TNM system, which is used to describe the anatomical distribution of cancer, is based on 3 components:

T - the prevalence of the primary tumor;

N - the state of regional, and in some localizations and extra-regional lymph nodes;

M - the presence or absence of distant metastases.

To these 3 components are added figures that indicate the prevalence of the malignant process: T 0 , T 1 , T 2 , T 3 , T 4 ; N 0 , N 1 , N 2 , N 3 , N 4 ; M 0 , M 1 . Other additional characters are used in special cases.

The general rules of the TNM system are as follows:

1) in all cases there should be histological confirmation of the diagnosis. If not, then such cases should be described separately;

2) for any localization, two classifications are applied, namely:

a) clinical classification of TNM, which is based on data from clinical, radiological, endoscopic and other types of research and is determined for treatment. In some cases, it may be based on additional data obtained using surgical diagnostic methods;

b) post-surgical, pathohistological classification, which is called pTNM and is based on data obtained at the beginning of treatment, but supplemented or modified on the basis of data obtained during surgery or the study of the surgical preparation;

4) the minimum requirements of the TNM system (for treatment) are the definition of all three factors: the primary tumor, regional and extra-regional lymph nodes, distant metastases;

5) after determining the severity of T, N and M, grouping by stages is performed;

6) since the TNM system is a dual classification system (clinical - for treatment, surgical, histopathological - after surgery), it should be remembered that the clinical classification of TNM is of paramount importance for assessing the prevalence of malignant neoplasms;

7) if there is doubt about the correctness of the definition of the category T, N or M, the lowest (that is, the less common category) should be chosen. This also applies to stage grouping. When synchronous bilateral tumors occur, each tumor is classified separately.

For example, the clinical classification of TNM tumors of the lip and tissues of the oral cavity (the classification is used for squamous cell carcinoma of the red border of the lips and cancer of the oral cavity) is as follows:

T - primary tumor

T x - insufficient data to evaluate the primary tumor

T 0 - the primary tumor is not determined

Тis - preinvasive carcinoma (carcinoma in situ)

T 1 - tumor up to 2 cm in greatest dimension

T 2 - tumor up to 4 cm in greatest dimension

T3 - tumor over 4 cm in greatest dimension

T 4 - Lip: tumor spreads to adjacent structures (for example, cortical bone, inferior alveolar nerve, fundus oral cavity, facial skin).

Oral cavity: Tumor invades underlying structures (eg, bones, deep muscles of the tongue, maxillary sinus, skin).

N- regional lymph nodes

N x- insufficient data to assess the status of regional lymph nodes

N0- no signs of involvement of regional lymph nodes

N 1- metastases in one homolateral lymph node up to 3 cm in greatest dimension

N 2- metastases in a single homolateral lymph node up to 6 cm in greatest dimension or numerical metastases in homolateral lymph nodes, none of which exceeds 6 cm in greatest dimension, or bilateral or contralateral lymph nodes up to 6 cm in greatest dimension

N 2a- metastasis in the homolateral lymph node up to 6 cm in greatest dimension

N 2b- Numerous metastases in homolateral lymph nodes, none of which exceeds 6 cm in greatest dimension

N 2s- bilateral or contralateral metastatic lymph nodes up to 6 cm in greatest dimension

N 3- metastases in lymph nodes larger than 6 cm in greatest dimension

Note: lymph nodes in the midline of the body are considered homolateral

Grouping by stages

Stage 0 Т іs N 0 М 0

Stage I T 1 N 0 M 0

Stage II T 2 N 0 M 0

Stage III T 3 N 0 M 0

T 1, T 2, T 3 N 1 M 0

Stage IVA T 4 any T N 0 , N 1 N 2 M 0 M 0

Any T N 0 , N 3 M 0

Any T any N M 1

Highly importance has a pathohistological examination of the tumor, which is the main, arbitration and final criterion for determining the stage and other morphological and functional characteristics of the tumor. Morphological verification of the process is necessary both to determine the degree of tumor differentiation, which is very important both for choosing a treatment method and for prognosis. Therefore, in addition to classifying tumors according to anatomical localization, international histological classifications have been created, among which are:

Number 3. Histological classification of soft tissue tumors;

No. 4. Histological classification of tumors of the oral cavity and oropharynx;

No. 5. Histological classification of odontogenic tumors, jaw bones and related lesions;

No. 6. Histological classification of bone tumors;

No. 7. Histological classification of tumors of the salivary glands.

For example, consider the international histological classification of tumors of the oral cavity and oropharynx:

I. Tumors originating from stratified squamous epithelium * .

B. Malignant:

1. Intraepithelial carcinoma (carcinoma in situ).

2. Squamous cell carcinoma:

a) vercose carcinoma;

b) spindle cell carcinoma;

c) lymphoepithelioma.

II. Tumors derived from glandular epithelium(detailed in the Histological classification of tumors of the salivary glands).

III. Tumors originating from soft tissues.

B. Malignant:

1. Fibrosarcoma

2. Liposarcoma

3. Leiomyosarcoma

4. Rhabdomyosarcoma

5. Chondrosarcoma

6. Malignant hemangioendothelioma (angiosarcoma)

7. Malignant hemangiopericytoma

8. Malignant lymphangioendothelioma (lymphangiosarcoma)

9. Malignant schwannoma

IV. Tumors originating from the melanogenic system.

B. Malignant:

1. Malignant melanoma

V. Tumors of controversial or unexplained histogenesis.

B. Malignant:

1. Malignant granular cell tumor (malignant granular cell “myoblastoma”)

2. Alveolar soft tissue sarcoma (malignant organoid granular cell “myoblastoma”)

3. Kaposi's sarcoma.

Morphologically, among the malignant neoplasms of the oral cavity, tumors of epithelial origin occupy a prominent place. The vast majority of them (94.8%) have the structure of squamous cell carcinoma of varying degrees of differentiation, with keratinized squamous cell carcinomas predominating (75.5%). Other histological types of tumors occur much less frequently - low-grade cancers, adenocarcinomas, sarcomas, malignant melanomas ( Polyakov P.Yu. , 1984).