Adenocarcinoma of the transverse colon. Combined operations for colon cancer. Classification and stages of colon cancer

is a malignant tumor of epithelial origin, localized in the colon. Initially, it is asymptomatic, later it manifests itself with pain, constipation, intestinal discomfort, impurities of mucus and blood in the fecal masses, deterioration and signs of cancer intoxication. Often a node is palpated in the projection of the organ. With progression, intestinal obstruction, bleeding, perforation, infection of the neoplasia and the formation of metastases are possible. Diagnosis is based on symptoms, radiography, CT, MRI, colonoscopy and other studies. Treatment - surgical resection of the affected part of the intestine.

ICD-10

C18 C19

General information

Crayfish colon- a malignant neoplasm originating from the cells of the mucous membrane of the large intestine. Ranks third in prevalence among oncological lesions digestive tract after tumors of the stomach and esophagus. According to various sources, it ranges from 4-6 to 13-15% of the total number of malignant tumors of the gastrointestinal tract. It is usually diagnosed at the age of 50-75 years, it is equally often detected in male and female patients.

Colon cancer is widespread in developed countries. The leading positions in the number of cases are occupied by the United States and Canada. Sufficiently high incidence rates are observed in Russia and European countries. The disease is rarely detected in residents of Asian and African states. Colon cancer is characterized by prolonged local growth, relatively late lymphogenous and distant metastasis. Treatment is provided by specialists in clinical oncology, proctology and abdominal surgery.

The reasons

Experts believe that colon cancer is a polyetiological disease. An important role in the development of malignant neoplasia of this localization is played by the peculiarities of the diet, in particular, an excess of animal fats, a lack of coarse fiber and vitamins. The presence of a large amount of animal fats in food stimulates the production of bile, under the influence of which the microflora of the large intestine changes. In the process of splitting animal fats, carcinogens are formed that provoke colon cancer.

An insufficient amount of coarse fiber leads to a slowdown in intestinal motility. As a result, the resulting carcinogens are in contact with the intestinal wall for a long time, stimulating the malignant degeneration of mucosal cells. In addition, animal fat causes the formation of peroxidases, which also Negative influence on the intestinal mucosa. The lack of vitamins, which are natural inhibitors of carcinogenesis, as well as stagnation of feces and constant traumatization of the mucosa by fecal masses in the areas of natural bowel bends exacerbate the listed adverse effects.

Recent studies indicate that sex hormones, in particular progesterone, play a role in the occurrence of colon cancer, under the influence of which the intensity of excretion decreases. bile acids into the intestinal lumen. It has been established that the risk of developing malignant neoplasia of this localization in women with three or more children is two times lower than in nulliparous patients.

There are a number of diseases that can transform into colon cancer. These diseases include Crohn's disease, ulcerative colitis, polyposis of various origins, solitary adenomatous polyps and diverticulosis. The likelihood of these pathologies degenerating into colon cancer varies greatly. With familial hereditary polyposis without treatment, malignancy occurs in all patients, with adenomatous polyps - in half of the patients. Intestinal diverticula are extremely rare.

Classification

Depending on the type of growth, exophytic, endophytic and mixed forms of colon cancer are distinguished. Exophytic cancer is nodular, villous-papillary and polypoid, endophytic - circular-strictoring, ulcerative-infiltrative and infiltrating. The ratio of endophytic and exophytic neoplasia is 1:1. Exophytic forms of colon cancer are more often detected in the right sections of the intestine, endophytic - in the left. Taking into account the histological structure, adenocarcinoma, cricoid, solid and scirrhous colon cancer are distinguished, taking into account the level of differentiation - highly differentiated, moderately differentiated and low-differentiated neoplasms.

According to the traditional four-stage classification, the following stages of colon cancer are distinguished.

• I stage- a node with a diameter of less than 1.5 cm is detected, not extending beyond the submucosal layer. There are no secondary foci.
• IIa stage- a tumor with a diameter of more than 1.5 cm is detected, spreading to no more than half the circumference of the organ and not extending beyond the outer wall of the intestine. No secondary foci
• IIb stage- Colon cancer of the same or smaller diameter is detected in combination with single lymphogenous metastases.
• IIIa stage- neoplasia extends to more than half the circumference of the organ, and extends beyond the outer wall of the intestine. There are no secondary foci.
• IIIb stage- Colon cancer of any diameter and multiple lymphogenous metastases are detected.
• IV stage- a neoplasm with invasion into nearby tissues and lymphogenous metastases or neoplasia of any diameter with distant metastases is determined.

Cancer Symptoms

Initially, colon cancer is asymptomatic. Subsequently, pain, intestinal discomfort, stool disorders, mucus and blood in the fecal masses are observed. Pain syndrome often occurs when the right intestine is affected. At first, the pain is usually mild, aching or dull. With progression, sharp cramping pains may appear, indicating the occurrence of intestinal obstruction. This complication is more often diagnosed in patients with damage to the left parts of the intestine, which is due to the peculiarities of the growth of neoplasia with the formation of a circular constriction that prevents the promotion of intestinal contents.

Many patients with colon cancer complain of belching, anorexia, and abdominal discomfort. The listed signs are more often found in cancer of the transverse, less often in lesions of the descending and sigmoid colon. Constipation, diarrhea, rumbling, and flatulence are typical of left-sided colon cancer, which is associated with an increase in the density of fecal masses in the left intestine, as well as with frequent circular growth of neoplasms in this area.

For neoplasia of the sigmoid colon, impurities of mucus and blood in the feces are characteristic. With other localizations of colon cancer, this symptom is less common, because when moving through the intestines, the secretions have time to be partially processed and evenly distributed over the fecal masses. Palpation of colon cancer is more often detected when located in the right intestine. It is possible to feel the node in a third of patients. The listed signs of colon cancer are combined with the general signs of cancer. Weakness, malaise, weight loss, pale skin, hyperthermia, and anemia are noted.

Complications

Along with the intestinal obstruction already mentioned above, colon cancer can be complicated by organ perforation due to germination of the intestinal wall and neoplasia necrosis. When foci of decay are formed, there is a danger of infection, the development of purulent complications and sepsis. With germination or purulent fusion of the vessel wall, bleeding is possible. In the event of distant metastases, there is a violation of the activity of the relevant organs.

Diagnostics

Colon cancer is diagnosed using clinical, laboratory, endoscopic, and x-ray findings. First, complaints are clarified, the anamnesis of the disease is clarified, a physical examination is performed, including palpation and percussion of the abdomen, and a rectal examination is performed. Then patients with suspected colon cancer are prescribed barium enema to detect filling defects. If intestinal obstruction or perforation of the colon is suspected, an abdominal radiography is used.

Patients undergo colonoscopy, which allows to assess the location, type, stage and type of growth of colon cancer. During the procedure, an endoscopic biopsy is performed, the resulting material is sent for morphological examination. Schedule a stool test for occult blood, a blood test to determine the level of anemia and a cancer embryonic antigen test. To detect lesions in the lymph nodes and distant organs, CT and ultrasound are performed abdominal cavity.

Colon cancer treatment

Treatment is operative. Depending on the prevalence of the process, radical or palliative surgery is performed. Radical operations for colon cancer are one-stage, two- or three-stage. When carrying out a one-stage intervention, a hemicolectomy is performed - resection of a section of the colon with the creation of an anastomosis between the remaining sections of the intestine. In multi-stage operations for colon cancer, a colostomy is first performed, then the affected intestine is removed (sometimes these two stages are performed at the same time), and after a while intestinal continuity is restored by creating a direct anastomosis.

With advanced colon cancer, extended interventions are carried out, the volume of which is determined taking into account the damage to the lymph nodes and nearby organs. If it is impossible to radically remove neoplasia, palliative operations are performed (imposition of a colostomy, formation of a bypass anastomosis). In colon cancer with the development of perforation, bleeding or intestinal obstruction, a stoma or bypass anastomosis is also applied, and after the patient's condition improves, a radical operation is performed. For colon cancer with distant metastases, chemotherapy is prescribed.

Forecast and prevention

The prognosis for colon cancer is determined by the stage of the oncological process. The average five-year survival rate in the first stage is from 90 to 100%, in the second - 70%, in the third - 30%. All patients who have undergone surgery for neoplasms of this localization should be under the supervision of a specialist oncologist, regularly undergo radiological and endoscopic studies to detect local recurrences and distant metastases.

EPIDEMIOLOGY

Colon cancer (RCC) occupies the 2nd-3rd place in the structure of malignant neoplasms of the gastrointestinal tract and accounts for 4-6% of all oncological morbidity. The predominant age of patients is over 50 years. In 2007, the number of patients with a diagnosis of ROC for the first time in their lives was 30,814 people: 12,709 men and 18,105 women. The incidence in 2007 in Russia as a whole was 21.7 per 100,000 population. Its highest rates in 2005 among men were registered in the Magadan region (35.9), among women - in the Chukotka Autonomous Okrug (32.1), the lowest - in the Republic of Tyva (for men - 4.7, for women - 4.8). In 2005, the death rate of men from ROK in Russia was 10.1 per 100 thousand of the population, among women - 7.7.

ETIOLOGICAL AND PATHOGENETIC FACTORS

According to most researchers, the following etiological and pathogenetic factors influence the increase in the incidence of ROK:

1) the nature of the population's nutrition: low-slag food with a predominance of animal fats, proteins and refined carbohydrates (sugar);

2) sedentary lifestyle - hypokinesia, obesity, age over 50;

3) hypotension and atony of the intestine in old age - chronic constipation;

4) the presence of endogenous carcinogens in the intestinal contents (indole, skatole, guanidine, metabolites of steroid hormones)

and their impact on the intestinal mucosa in conditions of prolonged stagnation stool; 5) chronic traumatization of the mucous membrane of the large intestine with feces in places of physiological bends.

PRECANCER DISEASES

Precancerous diseases include:

Chronic colitis, in particular chronic ulcerative colitis and granulomatous colitis (Crohn's disease), which constitute the main group of facultative precancerous diseases;

Diverticula (diverticulosis) of the colon (diverticulitis). Rarely malignant;

Polypous lesion of the colon (obligate precancer):

a) solitary polyps (adenomatous, villous), which are malignant in 45-50% of cases, especially polyps >2 cm in size; villous polyps become malignant more often;

b) multiple polyposis of the colon, which, in turn, can have the following forms:

genetically determined:

Familial and hereditary diffuse polyposis;

Peutz-Jeghers syndrome;

Turk's syndrome; non-hereditary:

Sporadic polyposis;

Combined polyposis;

Cronkhite-Canada Syndrome;

Familial hereditary polyposis (is an obligate precancer and leads to cancer in almost 100% of cases).

Crohn's disease is a chronic non-specific inflammation of the submucosal layer with ulceration of the mucous membrane, granulomatous changes (hence the other name - granulomatous colitis), fistulas, infiltrates, accompanied by narrowing of the lumen, inflammation, thickening of the intestinal wall. Pathology can be localized in the rectum, but most often - in terminal department ileum. Disease

may resemble sarcoidosis, fissures, ulcers of the rectum. The relief of the intestine resembles a "cobblestone pavement" with linear ulcers.

Polyps are hyperplastic (inflammatory) and adenomatous (glandular).

Morphologically, polyps are papillary and tubular growths of glandular tissue with a stroma that differs from the normal mucosa by polymorphism. cellular elements, high mitotic activity, complete or partial loss of the ability to differentiate.

Polyps are smooth and velvety (villous). It is advisable to distinguish two groups of colon polyposis - hereditary and non-hereditary, since in genetically determined forms it is necessary to examine relatives and all family members of the patient, even if there are no complaints of gastrointestinal dysfunction. At the same time, extraintestinal concomitant manifestations of Peutz-Jeghers, Gardner, Turk syndromes can be early diagnostic paraneoplastic signs of colon polyposis.

Thus, Peutz-Jeghers syndrome is characterized by a polyposis lesion of the gastrointestinal tract with small-spotted melanin hyperpigmentation of the mucous membrane of the cheeks and lips, as well as other natural anatomical openings of the human body. Gardner's syndrome is characterized by a combination of polyposis lesions of the colon with multiple benign tumors(bone exostoses, osteomas of the skull and mandible, epidermoid cysts and skin tumors) and postoperative cicatricial desmoids. For Turk syndrome, a combination of colon polyposis with tumors is typical. various departments nervous system (gliomas and glioblastomas).

With combined polyposis, polyps are found not only in the large intestine, but also in the stomach, duodenum and small intestine. A relatively rare variety of it is Cronkhite-Canada syndrome - a non-hereditary, generalized gastrointestinal polyposis in combination with total alopecia and atrophy of the nails. Therefore, taking into account the possibility of simultaneous localization of neoplasms in other parts of the gastrointestinal tract, its complex X-ray endoscopic examination is indicated even if a single polyp is found in the colon.

PREVENTION

1. Screening is essential to identify high-risk populations and early forms of colorectal cancer. Modern automated screenings involve the use of developed questionnaires with their subsequent processing on a computer. Of great importance in this case is the use of a hemocult test for the selection of high-risk groups for the purpose of subsequent endoscopic examination (sigmoidoscopy, fibrocolonoscopy with a morphological study of tumor biopsy specimens).

2. Clinical examination, observation and treatment of patients with precancerous diseases and benign tumors.

3. Formation and promotion of a healthy lifestyle, rational nutrition.

4. Improvement of the ecological situation.

5. In cured patients, taking into account the possibility of recurrence or the appearance of a second tumor, with primary multiple lesions, clinical examination is indicated, including periodic active examinations using X-ray, endoscopic, morphological and laboratory methods.

Pathological and anatomical characteristics

ROCK can be localized in any anatomical departments, but the frequency of their defeat is not the same. The predominant localization of ROK is the sigmoid colon - 50%, the caecum is in the 2nd place - 21-23%. Other departments are surprised much less often. In 1-3% of cases, there is a primary multiple localization of the tumor.

According to the clinical material of the RCRC (Knysh V.I. et al., 1996), tumors were localized in the right half of the colon in 34.3% of patients, in the left - in 59.3%, i.e. much more often.

Clinical and anatomical forms of ROK:

1) exophytic (polypoid, villous-papillary, nodular);

2) endophytic (infiltrating, ulcerative-infiltrative, circular-stricturing);

3) transitional or mixed.

Cancer with a predominantly exophytic form of growth is more often observed in the right half of the colon, and with a predominantly infiltrating growth pattern - in the left.

According to the domestic histological classification, the following forms of colon tumors are distinguished: adenocarcinoma, solid cancer, mucous (ring-shaped) and scirrhous cancer. There are also 3 degrees of differentiation of cancer: highly differentiated, medium degree of differentiation and low-differentiated.

Here is the International Morphological Classification

1. Adenocarcinoma:

a) highly differentiated;

b) moderately differentiated;

c) undifferentiated.

2. Mucous adenocarcinoma:

a) mucoid cancer;

b) mucous cancer;

c) colloid cancer.

3. Ring cell cancer - mucocellular.

4. Undifferentiated cancer (carcinoma simplex, medullary, trabecular).

5. Unclassified cancer.

Patterns of metastasis

ROK metastasis has its own characteristics.

lymphatic pathway. There are 3 stages of metastasis to regional lymph nodes:

Stage I - epicolic or paracolic lymph nodes;

Stage II - intermediate or proper mesenteric lymph nodes;

Stage III - para-aortic, in the region of the root of the mesentery of the colon.

Further, the lymph is collected in the lymphatic cistern, located transversely in the region of the I-II lumbar vertebrae. From the cistern, lymph flows through the thoracic lymphatic duct into venous system in the region of the left venous angle - the confluence of the subclavian vein with the internal jugular. In the same place, supraclavicular metastases are usually determined.

Hematogenous way Metastasis is associated with the germination of the tumor in the venous network with subsequent spread with the blood flow - primarily to the liver, lungs, bones and other organs.

Implantation way metastasis, or contact, is associated with the germination of the tumor of all layers intestinal wall, detachment of cancer cells from the bulk of the tumor and their implantation along the peritoneum. These cancer cells give rise to a small, bumpy rash called peritoneal carcinomatosis. The latter is usually accompanied by cancerous ascites. The manifestation of carcinomatosis are metastases in the navel and in the peritoneum of the small pelvis. These metastases can be identified during the initial examination of the patient using digital rectal and vaginal examination methods. Their detection indicates a running process.

Division by stage

The stage of colon cancer or the extent of the tumor process is determined by the following 3 components:

Size and depth of invasion of the primary tumor;

Metastasis to regional lymph nodes;

Metastasis to distant organs.

I stage- a tumor up to 1.5 cm in greatest dimension, localized within the mucous membrane and submucosal layer of the intestinal wall. There are no regional metastases at this stage.

II stage:

a) a tumor of large size, but occupying no more than a semicircle of the intestine and not germinating the serous cover; there are no regional metastases;

b) a tumor of the same or smaller size, but there are single metastases in the nearest regional lymph nodes.

III stage:

a) a tumor that occupies more than half of the circumference of the intestine, germinating all layers of its wall and serous cover; no metastases;

b) a tumor of any size, but in the presence of multiple metastases in the regional lymph nodes.

IV stage- an extensive tumor that grows into neighboring organs, the presence of multiple lymphogenous metastases or a tumor of any size with the presence of distant metastases.

It should be noted that the stage of the disease should be reliably established after a comprehensive examination of the patient - clarification of the local status, possible metastases, morphological examination of the surgical material. Lack of relevant

information often leads to an unreasonable overestimation of the stage of the process, which, of course, is reflected in the indicators of neglect.

To unify the staging of ROK, the International Clinical Classification according to the TNM system (2002) is used.

INTERNATIONAL TNM CLASSIFICATION (2002)

Classification rules

The classification below applies only to cancer. In each case, histological confirmation of the diagnosis is necessary.

Anatomical regions

Colon

1. Vermiform appendix.

2. The caecum.

3. Ascending colon.

4. Hepatic flexure of the colon.

5. Transverse colon.

6. Splenic flexure of the colon.

7. Descending colon.

8. Sigmoid colon. Rectosigmoid junction

Regional lymph nodes

Below are the main groups of lymph nodes for each anatomical region.

Vermiform appendix: iliocolic lymphatic

cal nodes.

Cecum: ileocolic and right

colonic lymph nodes.

Ascending colon: ileocolic, right

colon, middle colon lymph nodes.

Hepatic flexure: right colic and middle

fetal lymph nodes.

Metastases to other lymph nodes are considered distant. The exception is a primary tumor that spreads to other segments of the colon and rectum or to the small intestine.

Clinical classification of TNM

T - primary tumor

Tx - assessment of the primary tumor is not possible. T0 - primary tumor was not detected.

Tis - cancer in situ: cancer cells are found within the basement membrane of the glands or in the lamina propria*.

T1 - the tumor affects the submucosal layer.

T2 - the tumor penetrates the muscle layer.

Note!

* To cancer in situ do not include tumors that penetrate the submucosal layer or the muscularis mucosa.

T3 - the tumor penetrates into the subserous layer or the pericolitis and pararectal tissue not covered by the peritoneum.

T4 - the tumor affects neighboring organs and tissues * , ** and (or) penetrates through the visceral peritoneum.

Note!

* Damage to neighboring organs and tissues includes the spread of the tumor to other parts of the colon through the serosa (for example, the spread of a tumor of the caecum to the sigmoid colon).

** Macroscopic spread of the tumor to neighboring organs is regarded as stage T4. Organ damage, according to microscopic examination, is regarded as stage pT3.

N - regional lymph nodes

The state of regional lymph nodes cannot be assessed.

N0 - no metastases in regional lymph nodes. N1 - affected from 1 to 3 regional lymph nodes. N2 - 4 or more regional lymph nodes are affected.

Note!

Detection of the affected lymph nodes of the usual form in the pericolitis or pararectal adipose tissue in the absence of residual lymph nodes without histological confirmation is described by pN and regarded as metastases to regional lymph nodes. In turn, the detection of irregularly shaped metastatic nodes is defined as pT and indicates vascular damage. In the case of microscopic germination of the vein wall, the tumor is described as V1, with macroscopic germination - as V2.

M - distant metastases

Mx - insufficient data to determine distant metastases.

M0 - no distant metastases. M1 - there are distant metastases.

Pathological classification of pTNM

For the purpose of pathomorphological assessment of the N index, 12 or more regional lymph nodes are removed. It is now accepted that the absence of characteristic tissue changes

pathological examination of biopsy specimens of a smaller number of lymph nodes allows confirming the pN0 stage.

Grouping by stages

Complications

Complications of ROK include:

Obstructive intestinal obstruction;

Perforation of the colon tumor with the development of peritonitis;

Perifocal inflammatory-purulent processes (purulent paracolitis, paranephritis, phlegmon of the abdominal wall, retroperitoneal space);

Bleeding from the tumor (rarely profuse);

Germination of the tumor in neighboring organs and the development of interorgan fistulas.

CLINICAL PICTURE

Symptoms of cancer of the right and left half of the colon

Clinical manifestations of ROK are very diverse and are determined by the localization of the tumor, the anatomical type of neoplasm growth, the histological structure of cancer, the stage and extent of the tumor process, complications and individual reactivity of the organism.

The clinical picture of ROK is characterized by the following groups of symptoms.

1. Pain in the abdomen. As an initial symptom, they are 2-3 times more common when the tumor is located in the right half of the colon. By the nature of the pain sensations can be very diverse - from dull, aching minor pains to severe, paroxysmal, forcing patients to be hospitalized in surgical hospitals as an emergency. The appearance of such pain indicates a violation of the passage of intestinal contents, the development of intestinal obstruction, which is observed most often with left-sided localization of the tumor.

2. Intestinal discomfort (loss of appetite, belching, sometimes vomiting, feeling of heaviness in the upper abdomen). These symptoms are more often observed with damage to the transverse colon, its right half, less often - with left-sided localization of the tumor.

3. Intestinal disorders (constipation, diarrhea, alternating constipation with diarrhea, rumbling and bloating). These symptoms of an intestinal passage disorder are most often observed with left-sided localization of the tumor, which is explained, firstly, by the predominantly circular growth of the tumor in the left half of the colon, and secondly, by the dense consistency of already formed feces. The final stage of violation of the intestinal passage is the development of partial, and then complete obstructive colonic obstruction.

4. Pathological discharge in the form of blood, mucus, pus during the act of defecation is a frequent manifestation of cancer of the distal sigmoid colon.

5. Violation of the general condition of patients is expressed by malaise, increased fatigue, weakness, weight loss, fever, pallor of the skin and increasing hypochromic anemia. All these general symptoms diseases are associated with intoxication of the body, caused by a decaying cancerous tumor and infected intestinal discharge, characteristic of cancer of the right half of the colon. It is associated with a functional feature (absorption capacity) of the mucous membrane of this section of the colon.

The presence of a palpable tumor is rarely the first symptom of the disease and is usually preceded by other symptoms. Tem

no less palpatory definition of the tumor often serves as the basis for making the correct diagnosis.

Main clinical forms

Currently, according to most researchers, it is advisable to distinguish 6 forms clinical course ROCK.

1. Toxico-anemic form - most often observed in cancer of the right half of the colon, in which the signs of a violation of the general condition of patients against the background of progressive hypochromic anemia and fever come to the fore. Such patients are examined for a considerable time in various medical institutions for anemia of unknown origin, until intestinal disorders appear. This contingent of patients needs careful special research of all large intestine.

2. Enterocolitic form - the clinical picture of the disease begins with intestinal disorders. Such patients are often diagnosed with various diagnoses: colitis, enteritis, enterocolitis, and in the presence of blood in the feces or with liquid feces, the diagnosis of dysentery. Therefore, in the presence of these symptoms, a thorough examination of the entire colon is always required.

3. Dyspeptic form - the presence of signs of gastrointestinal discomfort is characteristic. With this form of the course of ROK, a diagnosis is often made: gastritis, peptic ulcer, cholecystitis, etc., therefore, only the upper gastrointestinal tract is examined. With further progression of the disease, intestinal disorders join, and correct diagnosis set only after a complete X-ray endoscopic examination of the colon.

4. Obstructive form - most often serves as a manifestation of cancer of the left half of the colon with symptoms of progressive intestinal obstruction (partial and complete obstructive colonic obstruction).

5. Pseudo-inflammatory form - in the clinical picture of the disease, signs of an inflammatory process in the abdominal cavity take the 1st place (abdominal pain, fever, signs of peritoneal irritation, leukocytosis in a blood test). This symptom complex is often a manifestation of the course of ROK, complicated by a purulent-inflammatory process like paracolitis. This form of cancer is difficult to diagnose, because, depending on the localization of the tumor, the clinical picture

can simulate acute appendicitis, cholecystitis, adnexitis, pyelonephritis and other inflammatory diseases of the abdominal cavity and small pelvis.

6. Tumor (atypical) form - with this form of colon cancer, the disease begins with the fact that the patient himself or the doctor during a preventive examination against the background of complete well-being palpably finds a tumor in the abdominal cavity. Palpation of a tumor in the abdomen is a frequent occurrence in patients with ROK. However, the tumor form of the course of cancer should include only those cases where the palpation definition of the tumor clinically dominates, and other signs are not expressed or are so insignificant that they do not capture the attention of the patient.

DIFFERENTIAL DIAGNOSIS

Taking into account the close relationship of the colon with the organs of the abdominal cavity, retroperitoneal space, anterior abdominal wall, ROK must be differentiated from many diseases of both the intestine itself and adjacent organs and tissues. Most often it is:

1) inflammatory diseases of the colon - chronic colitis, chronic ulcerative colitis, Crohn's disease, appendicular infiltrate, etc.;

2) specific inflammatory processes - tuberculosis, actinomycosis;

3) extraintestinal diseases of the abdominal cavity and small pelvis;

4) non-epithelial benign (leiomyoma, fibromyoma) and malignant (sarcoma) tumors of the colon;

5) other types of intestinal obstruction - adhesive, strangulation, volvulus, invagination, coprostasis, dynamic intestinal obstruction;

6) polyposis of the colon;

7) diverticulosis (diverticulitis) of the colon;

8) tumors and cysts of the kidneys, nephroptosis;

9) extraorganic retroperitoneal tumors;

10) tumors and ovarian cysts.

The scheme of differential diagnosis of diseases of the colon is presented in Table. 21.1.

Table 21.1. Differential diagnosis of some diseases of the colon

Chronic colitis is more often the result of a previous dysentery or amoebic colitis. Frequent exacerbations, bacterial carriage are possible.

Chronic ulcerative colitis is characterized by an autoallergy to the colon's own mucosa, which is torn away, exposing the wound surface; erythrocytes, plasma, plasma proteins, etc. are released through it. During the day, patients can lose up to 500 ml of blood. Frequent, loose stools are observed - several dozen times a day. Due to the chronic inflammatory process, the intestine becomes short (up to 60-80 cm), the lumen narrows; endoscopic examination reveals ulcers that are subject to biopsy and morphological examination.

Crohn's disease is a terminal ileitis, but the pathological process can also be localized in the colon and rectum. This nonspecific inflammatory infiltrate can proceed as a cancer of the caecum. X-ray shows an alternation of narrowed and expanded areas. The bowel is deformed. The endoscopic picture resembles a "cobblestone pavement".

Periappendicular infiltrate is a consequence of acute appendicitis. It includes the caecum, appendix, greater omentum, loop of the small intestine, anterior abdominal wall. As a rule, in its center there is a molten appendix, an abscess, which, under certain conditions, can break into the free abdominal cavity. Usually, the infiltrate appears on the 3rd and subsequent days after an attack of acute appendicitis, which was not diagnosed in a timely manner. The infiltrate, as a rule, is palpable in the right iliac region, at first it is painful. Such patients are subject to conservative treatment - they are prescribed local cold, antibacterial, anti-inflammatory, detoxification therapy. With abscess formation and breakthrough of the abscess into the free abdominal cavity, an emergency surgical intervention is indicated - laparotomy, appendectomy and drainage of the abdominal cavity.

After conservative treatment and resorption of the infiltrate, appendectomy is indicated after 4-6 months.

Tuberculosis of the colon is more often localized in the caecum, develops in young people and those suffering from pulmonary tuberculosis. In these patients, a smooth tumor is found in the projection of the caecum, which is characterized by dense elastic

consistency, soreness, immobility. Patients have subfebrile temperature, leukopenia, lymphocytosis. Tuberculosis bacilli may be found in the feces. Diagnosis is aided by colonoscopy with biopsy.

Actinomycosis is rare. With this disease, a woody infiltrate is formed, often with fistulas in the region of the caecum. Facilitates the differential diagnosis of the detection of drusen isolated from the fistula of the radiant fungus - actinomycete.

Non-epithelial tumors of the colon are rare. Their malignant variants are characterized by infiltrating growth, decay. The sarcoma can reach a large size.

Tumors of the sigmoid colon due to the high mobility of its mesentery often have to be differentiated from tumors and ovarian cysts. Therefore, in case of ovarian pathology, an examination of the colon is necessary.

A large group of tumors of the retroperitoneal space, adjacent organs also require differential diagnosis between them and ROK - ranging from nephroptosis, kidney cysts, primary or secondary liver cancer, liver echinococcus, stomach cancer, pancreas, etc.

DIAGNOSTICS

Diagnosis of ROK should be comprehensive, include a clinical study, x-ray, endoscopic laboratory methods, as well as special additional methods, incl. exploratory laparotomy.

1. Clinical methods:

Patient's complaints. Symptoms associated with insufficiency of digestion, absorption, exudative enteropathy, intestinal discomfort, pathological discharge;

Collecting an anamnesis, in which indications of the presence of familial polyposis, colitis and other previous diseases can be found;

Objective examination data - all methods of objective examination are used: examination, palpation, percussion of the abdominal cavity with mandatory change position of the patient;

Finger examination of the rectum - it is also necessary to carry out in various positions of the patient.

2. X-ray diagnostics- irrigoscopy, irrigography, survey radiography of the abdominal cavity. These methods have their own resolution capabilities and are constantly being improved.

The study of the colon is carried out using contrast medium- a solution of barium sulphate, which is injected into the colon with an enema. Tight filling of the intestine with a solution of barium is not always carried out, but according to indications.

The following technique is more often used: 300-400 ml of a solution of barium sulfate is injected into the intestine in the position of the patient on the back or left side and the 1st x-ray is taken. In this case, the rectum and sigmoid colon are contrasted. Then lift the foot end of the couch on which the patient lies; in this position, the splenic (left) flexure and the distal segment of the transverse colon are filled. Make the 2nd x-ray. Then the patient turns on the right side; this fills the right bend. The patient stands upright - the caecum and the ascending colon are filled. For double contrasting, air is introduced into the intestinal lumen using a gas outlet tube.

Most often, with tumors, a defect in the filling of the colon, a depot of barium is detected, there is a lack of haustrations, narrowing of the intestinal lumen, rigidity of the contour, non-expansion of the intestine, impaired displacement and peristalsis, as well as leakage of a contrast agent outside the contour of the intestine when a fistulous tract appears.

Plain radiography of the abdominal cavity allows you to determine the symptom of the bowl of Cloiber. They indicate a violation of the passage through the intestine, but can be both with obstructive obstruction and paralytic.

The state of the passage through the gastrointestinal tract can be judged by taking 2-3 sips of thick barium, which should normally leave the lumen of the stomach after 2 hours, the small intestine after 6-8 hours, and reach the rectum after 15-20 hours. Deviations from the indicated time indicators indicate a violation of the passage, which may serve as the basis for making a decision on an emergency operation.

3. Endoscopic diagnostics- sigmoidoscopy, fibrocolonoscopy, laparoscopy (with biopsy, taking smears for cytological and histological examination).

Fibrocolonoscopy allows you to examine the lumen of the colon to the dome of the caecum. The study includes a mandatory

taking material for cytological and histological examination (Fig. 21.1).

4. Laboratory diagnostics:

Complete blood count (colon tumors are characterized by hypochromic anemia, increased ESR, leukocytosis);

Fecal occult blood test (positive Gregersen reaction, cryptogemtest);

Coagulogram (there are signs of hypercoagulability);

A blood test for cancer-embryonic antigen (CEA) is a glycoprotein that is found in the plasma, intestines, pancreas and liver of embryos and newborns. In small concentrations, CEA is found both in healthy people and in some forms of malignant neoplasms, in particular, in RCC and rectal cancer.

5. Special additional methods studies to clarify the prevalence of the tumor process:

Liver scan - to diagnose hematogenous metastases;

Ultrasound and CT - for the diagnosis of metastases in the liver and retroperitoneal lymph nodes and collectors (Fig. 21.2).

6. Exploratory (diagnostic) laparotomy.

TREATMENT

The main method of ROK treatment is surgical, including 2 types of surgical interventions.

1. Radical operations:

a) simultaneous: right-sided hemicolectomy (Fig. 21.3), resection of the transverse colon, left-sided hemicolectomy, intra-abdominal resection of the sigmoid colon, anterior resection of the rectosigmoid colon with restoration of intestinal continuity or resection of the rectosigmoid according to Hartmann;

b) 2- and 3-stage operations: Zeidler-Schloffer operation (colostomy + bowel resection + intestinal stoma closure), operation of obstructive colon resection according to Mikulich or Grekov, etc.;

c) combined operations with resection of adjacent organs and surrounding tissues in case of locally advanced forms of ROC.

2. Palliative operations:

a) bypass anastomosis;

b) the imposition of an intestinal stoma - ileostomy, cecostomy, transversostomy, sigmostomy.

Surgical interventions on the colon should be ended with digital stretching (devulsion, redressing) of the anus. According to the indications, intubation is carried out with a probe or a double-lumen tube of the leading intestine.

Tactics in cancer complicated by acute intestinal obstruction

Obstructive intestinal obstruction is one of the frequent complications during ROK. Its development is influenced by a number of factors; the dominant ones are localization, anatomical shape and tumor stage. Intestinal obstruction in cancer of the sigmoid or descending colon develops 2-3 times more often than with damage to the right half of the colon, for the following reasons:

1) the diameter of the sigmoid and descending colon is almost half the diameter of the blind and ascending colon;

2) endophytic stenosing tumors develop more often in the left half;

3) the formed dense feces more often obturate the stenotic area than the liquid or mushy contents of the oral sections of the colon.

In the treatment of patients with acute intestinal obstruction caused by a tumor, a very crucial moment is the choice of tactics and nature of surgical intervention. As a rule, such operations are carried out in unfavorable conditions in seriously ill patients, weakened by the main and concomitant disease, which undoubtedly affects the outcome of treatment.

The main task of surgical intervention for obstructive colonic obstruction at the 1st stage is to empty the intestine from the contents and eliminate its obstruction. This problem can be solved in 2 ways: by imposing a fistula (colostomy) to divert intestinal contents to the outside or by creating a bypass anastomosis to divert it into the intestine. Each of these interventions can be definitive (usually for stage IV cancer) or temporary, performed to prepare the patient for subsequent stages. These surgical interventions are palliative in nature and are aimed primarily at eliminating the immediate threat to the life of the patient resulting from obstruction of the colon.

In some cases, with complicated forms of colon cancer, radical surgical interventions can be performed according to the type of primary obstructive resection, including with the imposition of a proximal colostomy. The subsequent stages are performed after a few months, after additional preparation of the patient. However, primary radical operations in patients with obstructive intestinal obstruction of tumor genesis are indicated only in their general satisfactory condition, the absence of peritonitis and ascites. Under the same conditions, but with an unremovable tumor, a bypass interintestinal anastomosis can be applied.

In acute intestinal obstruction caused by a tumor of the right half of the colon, as well as the right and middle third of the transverse colon, the following surgical interventions can be performed:

1) right-sided hemicolectomy with the removal of the ends of the ileum and transverse colon to the anterior abdominal wall;

2) imposition of a bypass ileotransverse anastomosis, the imposition of a bypass or ileotransversoanastomosis with unilateral exclusion of the right half of the colon and the removal of the aboral end of the ileum to the anterior abdominal wall, the imposition of a double-barreled ileostomy and cecostomy.

Right-sided hemicolectomy for acute obstructive colonic obstruction, which is a radical operation, is carried out only in the general satisfactory condition of the patient and the absence of signs of peritonitis or ascites.

In the period of acute intestinal obstruction caused by cancer of the left half of the colon, 2 types of surgical interventions are mainly used: obstructive resection of the tumor-affected area of ​​the colon with the imposition of a proximal colostomy or only a colostomy. Primary resection is carried out only with the general satisfactory condition of the patient and the absence of signs of peritonitis or ascites. However, the main type of surgical interventions for acute obstructive obstruction of the left half of the colon is the imposition of a fistula proximal to the tumor on the colon (transversostomy, sigmostomy).

In acute intestinal obstruction caused by a cancerous tumor of the left half of the colon, it is widely used

3-stage Zeidler-Schloffer type operation. This operation is performed in cases where there are phenomena of peritonitis. At its 1st stage, an unloading colostomy is placed proximal to the tumor (like a cecostomy, transversostomy, or sigmostoma); the 2nd stage consists in resection of the tumor-affected area of ​​the left half of the colon and the imposition of an interintestinal anastomosis to restore intestinal continuity; this stage is performed after the complete elimination of signs of intestinal obstruction and improvement of the general condition of the patient. At the 3rd stage, usually 2-3 weeks after the healing of the anastomosis performed at the 2nd stage, the colostomy is closed.

One of the surgical interventions used in acute colonic obstruction due to cancer is the Hartmann operation, proposed for the treatment of cancer of the sigmoid and rectosigmoid colon, as well as tumor lesion upper ampulla of the rectum. The essence of the operation is the resection of the colon affected by the tumor and the imposition of a proximal single-barrel colostomy. The advantage of the operation lies in the possibility of a subsequent delayed restoration of the continuity of the intestinal tract.

Common ROK remains a significant cause of cancer-related death worldwide. In most patients, chemotherapy can improve survival. For many decades, 5-fluorouracil has been used for this purpose. As monochemotherapy, the drug is used in a total dose of 2600 mg/m 2 as a 24-hour infusion weekly until toxicity occurs. The combination of 5-fluorouracil with folic acid- fluorouracil at a dose of 500 mg / m 2 intravenously on days 1, 8, 15, 22, 29, 36 and leucovorin (calcium folinate) at a dose of 500 mg / m 2 intravenously as a 2-hour infusion 1 hour before administration 5-fluorouracil on the same days.

In the last 10 years, there has been an evolution in the treatment of ROK with the transition from 5FU / LV treatment to PCT: fluoropyrimidines with oxaliplatin (FOLFOX, XELOX) or irinotecan (FOLFIRI, R-IFL) with their integration into therapeutic strategies, when surgical treatment is given more and more importance. place in the treatment of patients with metastases. Oxaliplatin with 5FU/LV (FOLFOX) is the first combination to demonstrate superiority over 5FU/LV in the adjuvant treatment of colorectal cancer. Correlating with this, the median

The survival rate for patients with metastatic colon cancer is between 17 and 22 months. The combination of 5-fluorouracil/folic acid + capecitabine or oxaliplatin is considered as the regimen of choice in the 1st line of therapy for metastatic colorectal cancer. When high-dose oxaliplatin chemotherapy was added to the simple regimen (5-FU/LV once every 2 months) as the 2nd line chemotherapy for metastatic colorectal cancer, the median survival was extended from 6.8 to 8.8 months and the survival increased to 4.5 months

Current trends in the treatment of ROK are associated with the use of treatment methods specific for each patient, which is facilitated by the identification of the genetic and molecular profile of tumors and an increase in the number of targeted agents. Molecular prognostic factors are best studied in colorectal cancer due to its greater prevalence and availability for research and diagnosis among all solid tumors- these are tumor suppressors of oncogenesis p53, k-ras, DCC, biochemical determinants of 5-fluorouracil metabolism and DNA repair defects. Improving treatment outcomes in advanced cancers can be continued due to the development of multimodal approaches and the introduction of new targeted agents with innovative combinations of chemotherapy drugs.

Two of the most promising targets in the treatment of colorectal cancer are epithelial growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF). Angiogenesis is a prerequisite for tumor growth greater than 2 mm, since simple diffusion of oxygen can no longer support the rapid proliferation of malignant cells. The process of angiogenesis is a precise balance between inhibitory and stimulating factors, the knowledge of which helps to identify targets for the treatment of colorectal cancer. Angiogenesis in primary tumors sequentially triggers a cascade of molecular events leading to rapid exponential tumor growth. In primary tumors, liver metastases can develop without traditional angiogenesis pathways, co-opting into the existing hepatic vasculature. The study of angiogenesis has revealed many different targets that can be attacked by agents such as tyrosine kinase inhibitors. A variety of anti-angiogenic agents are currently undergoing preclinical evaluation, of which

several are going through phases I and II clinical trials. However, preliminary results already suggest that anti-angiogenic therapy may be an important adjunct to conventional cancer chemotherapy.

Components that inactivate EGFR or bind VEGF have demonstrated clinical activity both alone and in combination with chemotherapy in Phase II and III clinical trials. The most promising of these components are cetuximab, which blocks the binding of EGF and FCF-α to EGFR, and bevacizumab, which binds free VEGF. Cetuximab and irinotecan were evaluated in two US clinical trials. We studied the results of the use of cetuximab in patients refractory to irinotecan with EGFR-positive colorectal metastases. Partial regression was noted in 10.5% of cases, and objective regression was achieved in 22.5% of patients using cetuximab and irinotecan. Another promising agent, bevacizumab, is a variant of the anti-VEGF monoclonal antibody. VEGF is produced by healthy and tumor cells. Its activity to two tyrosine kinase receptors has been established. VEGF signaling is a manifestation of physiological and pathological angiogenesis. Bevacizumab has been studied as an anti-angiogenic therapeutic agent alone and in combination with chemotherapy in patients with stage III and IV ROK. In addition to a direct anti-angiogenic effect, bevacizumab may promote more efficient delivery of chemotherapy drugs by damaging the tumor vasculature and reducing elevated tissue pressure in the tumor. The addition of bevacizumab 5 mg/kg to chemotherapy (5FU/LV) resulted in a higher objective response rate (40 vs. 17%), increased time to tumor progression (9 vs. 5.2 months), and longer median survival (21.5 versus 13.8 months). Studies aimed at identifying marker genes make it possible to predict the response of a tumor to chemotherapy. The purpose of these studies is to identify patients who require chemotherapy and to provide treatment according to the molecular profile of the tumor and the patient.

Radiation treatment of ROC is currently used to a limited extent (Vazhenin A.V. et al., 2003), due to factors such as colon mobility, small wall thickness, risk of perforation, and radioresistance of colon adenocarcinoma.

LONG-TERM RESULTS

Long-term results of treatment of patients with early stages of colon cancer are satisfactory. For tumors limited to the mucosa, the 5-year survival rate reaches 90-100%. In stage II, this figure is reduced to 70%. In stage III with metastases to the lymph nodes, the 5-year survival rate is about 30%.

Questions for self-control

1. Name the morbidity rates in ROK.

2. List precancerous diseases colon.

3. Give the pathological and anatomical characteristics of ROC.

4. Describe the features of RTC metastasis.

5. How is division into stages carried out?

6. List the main clinical manifestations of ROK.

7. What are the features of the course of ROK depending on localization?

8. List the main clinical variants of ROK.

9. With what diseases is the differential diagnosis of ROK performed?

10. Describe the principles and methods for diagnosing ROCK.

11. What diagnostic value have radiological and endoscopic methods research?

12. Explain the principles of ROC treatment.

13. What volumes of operations are performed depending on the location of the cancer?

14. What is the essence of palliative operations?

15. List the indications for drug and combined treatment.

Diagnosis of the disease

To diagnose tumors of the colon, X-ray examination (irrigoscopy), endoscopic examination (colonoscopy), digital and endoscopic examination of the rectum (sigmoidoscopy) are used.

Clinical manifestations of colon cancer

Clinical manifestations of colon cancer largely depend on the location malignant neoplasm, degree of distribution tumor process and availability complications aggravating the course of the underlying disease.

The most common symptoms: pain in the abdomen, a violation of the motor-evacuation function of the intestine, clinically manifested by alternating constipation and diarrhea, pathological discharge with feces, a change in the general condition of the patient, and, finally, a tumor palpable through the anterior abdominal wall.

Stomach ache- the most common symptom of colon cancer and are observed in almost 80% of patients. In clinical observations with right-sided localization of the tumor, pain, as one of the first symptoms of cancer, occurred 2-3 times more often than with cancer of the left half. This fact is explained by the violation motor function: pendulum movement of intestinal contents from the small intestine to the blind and vice versa.

Spasmodic contractions of the intestine, pushing the feces through the lumen of the intestine partially blocked by the tumor, cause pain. Intratumoral and perifocal inflammation of the intestinal wall, often associated with decaying infected tumors, exacerbates pain.

Tumors of the colon can proceed without pain for a long time, and only when the neoplasm spreads beyond the intestinal wall, when moving to the peritoneum and surrounding organs, pain appears, the intensity and frequency of which may be different. depending on the location of the tumor pain syndrome may simulate chronic appendicitis, cholecystitis, peptic ulcer stomach and duodenum, chronic adnexitis.

For malignant neoplasms of the right half of the colon, a combination of pain syndrome, hyperthermic reaction (fever), leukocytosis and rigidity (tension) of the muscles of the anterior abdominal wall is characteristic. The clinical manifestations of the disease resemble destructive appendicitis, and the correct diagnosis can only be established during the revision of the abdominal organs during surgery. Analysis of the clinical course of cancer of the right half of the colon showed that in almost 60% of cases the presence of a tumor is accompanied by pain in the right abdomen, intestinal disorders, hyperthermia, symptoms of intoxication and anemia.

This combination clinical symptoms is characteristic of the toxic-anemic form of colon cancer.

Violations of the motor-evacuation function of the colon lead to stagnation of intestinal contents and cause such symptoms of discomfort as a feeling of heaviness in the abdomen, loss of appetite, and nausea. An important role in the development of intestinal discomfort is played by reflex functional disorders of other organs of the digestive system. Absorption of decay products by the inflamed mucosa, a change in the normal composition of the intestinal microflora, accompanied by the appearance of pathogenic strains that secrete exo- and endotoxins, leads to the development of endogenous intoxication syndrome. Functional Disorders gastrointestinal tract in patients with colon cancer, they are manifested by a violation of the passage of contents, constipation, bloating, paroxysmal pain.

The accumulation of feces above the tumor is accompanied by an increase in the processes of putrefaction and fermentation, leading to bloating with retention of stool and gases.

In cases where the course of the tumor process is complicated by the development of intestinal obstruction, the clinical picture of patients with colon cancer is dominated by symptoms such as bloating with difficulty in passing feces and gases, nausea, belching, and vomiting. The pains are paroxysmal in nature. According to some authors, when a malignant tumor is localized in the left half of the colon, the stenosing nature of the tumor growth leads to a narrowing of the intestinal lumen, as a result of which the feces, accumulating above the tumor, can be palpated through the abdominal wall and are sometimes mistaken for a tumor.

One of the fairly frequent and relatively early clinical manifestations of colon cancer are pathological discharge from the rectum. These include mucus, blood, pus, tumor masses, etc. Most often, pathological impurities in the feces were noted with the left-sided localization of the colon tumor than with the location of the tumor in the right half (62.4% and 18.5%, respectively). Much less marked discharge of pus, fragments of tumor masses, indicating the addition of the inflammatory process, leading to the disintegration of the tumor, infection and the formation of perifocal and intratumoral abscesses. In any case, the presence of such secretions quite often indicates a widespread tumor process.

One of the symptoms indicating a far advanced tumor process is a tumor palpated through the abdominal wall. The frequency of this symptom ranges from 40 to 60%.

Any of the symptoms listed above (pain, intestinal disorders, the presence of pathological impurities in the stool) can be present in any bowel disease, not just tumors. Analysis of the clinical course of colon cancer indicates a significant percentage of diagnostic errors (up to 35%), leading to hospitalization in general therapeutic and infectious disease clinics for the treatment of anemia of unknown etiology, dysentery, etc. The percentage of patients hospitalized in general surgical hospitals for emergency indications at the height of obstructive intestinal obstruction remains high.

The following clinical forms of colon cancer are distinguished:

• toxic-anemic, characterized by varying degrees of severity of anemia, general symptoms, intoxication;
• obstructive- characterized by the appearance of signs of impaired intestinal patency and accompanied by paroxysmal abdominal pain, rumbling and increased peristalsis, stool retention and poor gas passage;
• enterocolitic form accompanied by bloating, alternating diarrhea with constipation, the presence of pathological impurities in the feces, dull, aching pain in the abdomen;
• pseudo-inflammatory form, characterized by low intensity intestinal disorders against the background of signs of an inflammatory process in the abdominal cavity;
• tumor (atypical) form, for which general symptoms are uncharacteristic, impaired intestinal patency, with a palpable tumor in the abdominal cavity;
• dyspeptic form, the characteristic features of which are symptoms of gastric discomfort (nausea, belching, feeling of heaviness in the epigastric region), accompanied by pain, localized mainly in the upper floor of the abdominal cavity.

It must be emphasized that selection clinical forms, to a certain extent, conditionally and mainly characterizes the leading symptom complex. However, knowledge of the manifestations of colon cancer makes it possible to suspect the presence of a tumor even in cases where the disease proceeds with mild intestinal disorders.

Complicated forms of colon cancer

Complications quite often associated with colon cancer that have a direct impact on the course of the disease and the prognosis of the tumor process include intestinal obstruction of varying severity, perifocal inflammatory process, perforation of the tumor, intestinal bleeding, as well as the spread of the tumor to surrounding organs and tissues.

According to the literature, the incidence of intestinal obstruction in patients with colon cancer ranges from 10 to 60%. Such pronounced differences in the frequency of this complication are largely due to the fact that the vast majority of patients with a complicated course of the tumor process end up in emergency surgical hospitals, and not in specialized medical institutions.

The clinical course of the disease largely depends on the severity of intestinal obstruction. With a decompensated form of intestinal obstruction (sharp abdominal distension with retention of stools and gases, vomiting, cramping pains throughout the abdomen against the background of severe metabolic disorders), an emergency surgical intervention is indicated, the volume and nature of which depends not only on the localization of the tumor, but also on the severity of the developed complication. In cases of a compensated form of obstructive intestinal obstruction, conservative measures are often effective, allowing the patient to be prepared for a planned operation.

The passage of liquid intestinal contents is preserved when the intestinal lumen is narrowed to 0.8-1 cm; in cancer of the right half of the colon, ileus phenomena (intestinal obstruction) usually occur with large tumor sizes. As the stenosis progresses, an expansion of the intestine above the tumor is formed, leading to the accumulation of feces and the appearance of aching pains in the abdomen, sometimes cramping and spastic in nature.

When the tumor is localized in the left colon, the development of intestinal obstruction is often preceded by constipation, alternating with profuse, fetid loose stools. In cases of decompensated intestinal obstruction, the disorder of the function of the organs of the gastrointestinal tract is quickly joined by metabolic disorders, leading to a violation of the vital functions of organs and systems.

Intratumoral and perifocal inflammatory processes are of great danger in colon cancer. The frequency of such complications is quite high: from 12 to 35%.

Inflammatory changes in the tumor, caused by the presence in the intestinal contents of a large number of virulent microorganisms, the qualitative and quantitative composition of which changes with the decay of the tumor tissue, lead to infection and the formation of inflammatory infiltrates and abscesses.

In most clinical cases, histological examination of removed preparations in patients with a perifocal inflammatory process showed ulceration of the tumor and signs of acute purulent inflammation with the formation of abscesses, necrosis and fistulas in the thickness of adipose tissue, tumor stroma or in the lymph nodes.

Perforation of the intestinal wall and bleeding from a decaying tumor are the most formidable complications of this disease. Prolonged stasis of intestinal contents against the background of chronic intestinal obstruction in combination with trophic disorders of the intestinal wall lead to the formation of bedsores and perforation.

The most unfavorable for the prognosis is perforation of the tumor into the free abdominal cavity, leading to diffuse fecal peritonitis. With perforation of a segment of the intestine, devoid of peritoneal cover, an acute purulent focus is formed in the retroperitoneal space. In a number of patients, a pinpoint perforation is covered by an omentum or a nearby organ, leading to the formation of a perifocal inflammatory process that spreads to nearby organs and tissues. Perifocal and intratumoral inflammation, which complicates the course of the underlying disease, on the one hand, and perforation of the colon tumor, on the other hand, are links in the same pathological process, which is based on the infection of the affected section of the colon with conditionally pathogenic strains of microorganisms penetrating through the pathologically altered intestinal wall. .

Diagnostics

Improving the methods of clinical examination of the patient with the use of modern X-ray and endoscopic techniques, the use of a wide arsenal of screening diagnostic methods, until recently, did not significantly improve the early detection of colon cancer. More than 70% of patients with colon cancer at the time of hospitalization had III and IV stages of the disease. Only 15% of them turned to a specialist within 2 months from the moment the first symptoms of the disease appeared. In less than half of the examined patients, the diagnosis was established within 2 months from the onset of the disease, and in every fourth it took more than six months to determine the nature of the disease. Quite often occurring diagnostic errors led to the performance of unreasonable surgical interventions, physiotherapy procedures, leading to the dissemination of the tumor process.

The diagnosis of colon cancer is established on the basis of X-ray and endoscopic studies. Not less than important method The physical examination of the patient is palpation of the abdomen, which allows not only to identify a tumor in the abdominal cavity, but also to assess its consistency, size, mobility.

Research types

• X-ray examination, along with colonoscopy, is leading in the diagnosis of colon cancer.
• Irrigoscopy allows you to get information about the localization of the neoplasm, determine the extent of the lesion, determine the form of tumor growth, assess its mobility, and sometimes judge the relationship with other organs. When performing barium enema, it is also possible to detect synchronous tumors of the colon. The latter circumstance is also important because with the stenosing nature of the growth of the neoplasm, endoscopic examination does not allow assessing the state of the overlying sections of the colon before surgery.
• Endoscopy, along with the visualization of a malignant tumor, allows obtaining material for histological examination, which is a necessary attribute of the preoperative diagnosis of a malignant neoplasm.
• The simplest and most widely used method of endoscopic examination of the colon is sigmoidoscopy, at which it is possible to assess the condition of the lower part of the intestinal tube. When performing sigmoidoscopy, the researcher assesses the condition of the colon mucosa, vascular pattern, the presence of pathological impurities in the intestinal lumen, elasticity and mobility of the intestinal wall. When a colon tumor is detected, its size, appearance, consistency, mobility during instrumental palpation are studied, and a biopsy is performed.

Determination of the degree of spread of the tumor process

The program for examining a patient before surgery, in addition to the already listed traditional methods, includes special X-ray and radioisotope studies.

Hematogenous metastasis is based on the process of embolization by cancer cells of the venous outflow tracts from the organ affected by the tumor process. The penetration of tumor cells into venous vessels occurs as a result of invasion and destruction of the vessel wall by the tumor. The bulk venous blood in patients with colorectal cancer through the system of the inferior and superior mesenteric veins enters the portal vein, which explains the fact of the main localization of distant metastases in the liver.

Ultrasound procedure has found wide distribution for assessing the degree of spread of the tumor process. It is based on the principle of registering the reflected ultrasonic wave from the interface between tissues that differ in density and structure. With high resolution and information content, ultrasound procedure a practically harmless diagnostic method that allows visualizing tumor nodes with sizes
0.5-2.0 cm.

The anatomical and topographic structure of the liver, the good distribution of ultrasound in it determines the high information content of the study. It is important that ultrasound helps to determine not only the nature of pathological changes in the liver, but also to establish the localization and depth focal changes. When performing ultrasound tomography, a layered image of the internal structure of the liver is obtained and pathological volumetric formations or diffuse changes. Ultrasound of the liver can be repeated quite often without harm to the patient's body, which allows you to evaluate the results of the treatment.

Application of X-ray computed tomography(CT) in medicine has contributed to a significant improvement in the diagnosis of various pathological conditions.

Computed tomography has the following important advantages over other examination methods:

• represents the image of anatomical structures in the form of a cross section, excluding the combination of their images;
• causes a clear image of structures that slightly differ in density from each other, which is extremely important for diagnosis;
• provides an opportunity for quantitative determination of tissue density in each area of ​​the image of the studied organ for differential diagnosis of pathological changes;
• has a non-invasive nature of the diagnostic method, safety and low radiation exposure to the patient's body.

According to researchers, in the analysis of CT images of metastatic tumors of colorectal cancer, in 48% of cases, tumor nodes contained calcifications, and sometimes total calcification of metastatic tumors was detected.

Radionuclide (isotope) methods diagnosis and assessment of the spread of colorectal cancer in the daily practical work of medical institutions are used quite rarely. One of these methods is positive scintigraphy, based on the use of such specific preparations as gallium in the form of a citrate complex, as well as bleomycin labeled with an indium isotope.

COLON CANCER TREATMENT

The choice of the type of surgical intervention and the rationale for its scope

The history of surgical treatment of colon cancer has more than 150 years. Reybard in 1833 performed the first resection of the colon for a malignant tumor with the formation of an interintestinal anastomosis. In Russia in 1886 E.V. Pavlov performed the first resection of the caecum for its malignant tumor with an anastomosis between the ascending colon and the ileum. Unlike manipulations on the small intestine, resection of the large intestine, according to V. Schmiden (1910), is one of the most important surgical interventions associated with the existence of such features as the presence of pathogenic microflora in the contents hollow organ, lack of mesentery in fixed areas of the colon, over a thin layer of muscularis. These features of the colon predetermine increased demands on the reliability of the formation of interintestinal anastomoses, taking into account anatomical features various sections of the colon and the adequacy of the blood supply to the anastomosed segments.

The main disadvantage of these surgical interventions is the presence of albeit a temporary colostomy - the output of the intestine to the anterior abdominal wall. Therefore, in specialized oncoproctological clinics, there is a rethinking of the indications for performing two-stage surgical interventions, considering them justified only in debilitated patients with symptoms of decompensated intestinal obstruction.

The volume and nature of surgical intervention for colon cancer depends on a number of factors, among which the most important are the localization, the degree of spread of the tumor, the presence of complications of the underlying disease, as well as the general condition of the patient.

The choice of the type of surgical intervention in the complicated course of colon cancer

Most patients with colorectal cancer are admitted to specialized medical institutions in stages III and IV of the tumor process. Many of them have various complications (obstructive form of intestinal obstruction, perforation of the tumor, bleeding and perifocal inflammation), often requiring emergency surgical intervention.

The results of surgical interventions in patients with complicated colorectal cancer to a certain extent depend on the qualifications of the operating surgeon, his ability to assess the degree and severity of the pathological process complicating the course of the underlying disease, and taking into account the general condition of the patient.

When choosing the type of surgical intervention, they seek not only to save the patient from acute surgical complication, but also, if possible, to perform a radical operation.

One of the most dangerous complications of colon cancer is perifocal and intratumoral inflammation, often spreading to surrounding tissues. The frequency of such complications is quite high and ranges from 6% to 18%. This complication is clinically acute inflammation and intoxication, and the spread of the process to neighboring organs and surrounding tissues contributes to the formation of infiltrates, abscesses, phlegmon. Often, a pronounced inflammatory process in the tumor and its surrounding organs is interpreted as tumor infiltration, which is the reason for the inadequate volume of surgical intervention.

The presence of perifocal and intratumoral inflammation in colon cancer has a significant impact on the choice of the volume and nature of surgical intervention only in cases where the inflammatory process spreads to the surrounding organs and tissues, and forces one to resort to combined surgical interventions.

Combined operations for colon cancer

Expansion of the volume of surgical intervention due to the spread of a malignant tumor to nearby organs and tissues increases the duration of the operation, trauma and blood loss. The exit of the tumor beyond the intestinal wall indicates a far advanced neoplastic process, but the absence of distant metastases allows performing a combined operation, which, improving the quality of life of patients, eliminates severe complications tumor process and creates real prerequisites for the use specific methods anticancer treatment.

Palliative surgery in patients with colon cancer

Almost 70% of patients with colon cancer at the time of surgical intervention are diagnosed with stages III and IV of the disease, and in every third patient, among those operated, distant metastases are diagnosed, mainly in the liver and lungs. The development of intestinal obstruction forces resorting to symptomatic surgical interventions - colostomy, the formation of a bypass anastomosis in patients with stage IV of the disease. However, an increasing number of surgeons for advanced colorectal cancer are opting for palliative resection or hemicolectomy.

Palliative resection of the colon or hemicolectomy significantly improves the quality of life, saving the patient from such complications of the tumor process as purulent-septic complications, bleeding, tumor decay with the formation of a fecal fistula.

A comparative analysis of the immediate and long-term results of treatment of patients with colon cancer who underwent resection or hemicolectomy, regardless of whether the operation was radical or palliative, showed that the frequency and nature postoperative complications were about the same.

Palliative surgical interventions in the amount of resection or hemicolectomy are finding more and more supporters and are increasingly being the operation of choice for metastatic cancer colon. This was facilitated by a decrease in the frequency of postoperative complications and mortality, the expansion of indications for resection of organs affected by metastases (liver, lungs). When determining the indications for palliative surgical interventions in the scope of colon resection or hemicolectomy, both the general condition of the patient and the degree of tumor dissemination are taken into account.

One of the important factors affecting the prognosis for the course of the disease in patients undergoing liver resection for metastases is the time interval between treatment for the primary tumor and the detection of liver metastases. It has been established that the longer the duration of the relapse-free course of the tumor process, the more favorable the prognosis of surgical treatment of liver metastases.

When determining the scope of surgical intervention for metastatic colorectal cancer, an important role is played by the study of the functional state of the liver. Liver failure in itself is one of the main causes of postoperative mortality in extensive liver resections. The liver is an organ with great compensatory capabilities. Enough 10-15% of its healthy parenchyma for the full functioning of the body.

An important issue for determining surgical tactics is the number of metastatic nodes in the liver. Multiple nodes significantly worsen the prognosis and are one of the main reasons for the refusal of active surgical tactics. However, the presence of multiple nodes localized in one anatomical half of the liver is not a contraindication to surgical treatment, although, of course, the prognosis in such patients is much worse than with a single and single (2-3 nodes) metastases.

Combined treatment of colon cancer

The reasons for the failure of surgical treatment of patients with colon adenocarcinoma are local recurrences and distant metastases. Unlike rectal cancer, in this disease, local recurrences are relatively rare, and liver metastases predominate. In patients with stage III colon cancer, local recurrences occur in 7% of cases, and distant metastases - in 20%. The occurrence of these unfavorable secondary tumor formations is due to the dissemination of tumor cells during surgery. To increase the ablasticity of surgical interventions, preoperative radiation therapy, which has recently begun to be introduced into the practice of oncoproctological clinics, allows.

Depending on the sequence of application of ionizing radiation and surgical intervention, pre-, post- and intraoperative radiation therapy is distinguished.

Preoperative radiotherapy

Depending on the goals for which preoperative radiation therapy is prescribed, two main forms can be distinguished:

1. irradiation of operable forms of colon cancer;
2. irradiation of inoperable (locally advanced) or doubtfully operable forms of tumors.

The death of tumor cells as a result of radiation exposure leads to a decrease in the size of the tumor, delimitation from the surrounding normal tissues due to the growth of connective tissue elements (in cases of prolonged preoperative irradiation and delayed operations). Implementation positive effect preoperative radiation therapy is determined by the magnitude of the radiation dose.

In clinical studies, it has been shown that a dose of 40-45 Gy leads to the death of 90-95% of subclinical growth foci. A focal dose of not more than 40 Gy, administered at 2 Gy daily for 4 weeks, does not cause difficulties in performing the subsequent operation and does not have a noticeable effect on the healing of the postoperative wound.

Postoperative radiotherapy

Certain advantages of postoperative radiotherapy are:

• planning of the volume and method of irradiation is carried out on the basis of data obtained during the operation and after a thorough morphological study of the removed tissues;
• there are no factors that have a negative impact on the healing of postoperative wounds;
• surgery is performed as quickly as possible from the moment of clarifying the diagnosis of the disease.

For achievement therapeutic effect postoperative radiation therapy requires high doses - at least 50-60 Gy.

The presence of inflammation in the area of ​​surgical intervention, impaired blood and lymph supply leads to a delay in the supply of oxygen to tumor cells and their complexes, which makes them radioresistant. At the same time, normal tissues in the state of regeneration become more radiosensitive, namely, they must be included in a larger volume in the target for postoperative irradiation, because. it is necessary to act on the tumor bed, the whole postoperative scar and areas of regional metastasis.

The colon is the largest section of the large intestine in terms of length and area. Digestion, absorption of dietary fibers and elements takes place in it. What could not be digested is formed into feces and comes out.

Colon cancer is a malignant lesion of one or more of its departments with a progressive course, metastasis, dysfunction and various complications.

In the anatomy of the intestine, independent sections and bends are distinguished.

The departments include:

• Ascending part.

Located in the right side of the abdomen. It is a continuation of the caecum.

• Cross section.

Occupies top floor abdominal cavity. It is projected in the supra-umbilical region, follows the ascending section.

• descending part.

Lies in the left half of the abdomen, serves as a continuation of the transverse segment, is the final section of the colon. It ends with a transition to the sigmoid colon.

Between the parts there are bends:

• Hepatic flexure of the colon.

It is located under the liver, on the right, in the upper right quadrant of the abdominal wall. Lies between the end of the ascending part and the beginning of the transverse. There the organ has a certain extension.

• Splenic flexure.

Located on the left, in the upper left quadrant. Extends between the end of the transverse section and the beginning of the descending section, borders on the spleen.

Classification

There are several classification criteria. Depending on the type of tissues and cells from which the tumor is formed, there are:

• epithelial cancer.

Formed from epithelial type tissues. It is the most common form. Responds well to chemotherapy treatment.

• Adenocarcinoma.

It is dominated by mutation and degeneration of glandular elements. It is in second place in terms of prevalence. Tends to progress rapidly. Not always treatable with chemotherapy.

• Mucous cancer.

Formed from mucus-producing cells and mucous membranes. It is not so common, about 10% of all types.

• Ring cell carcinoma.

It is put only on the basis of a study of biopsy specimens under a microscope. In cells, the nuclei are of huge size, they resemble a ring in shape, hence the name. Aggressive tumor, has a severe course.

• undifferentiated carcinoma.

It is almost impossible to determine the neglected form, the type of cells. Poorly treatable, has a poor prognosis.

Depending on the form, progression and extent of the lesion, the stages are distinguished:

• Stage 0 is precancerous.

The first atypical cells begin to form, there are no complaints or symptoms yet. May be manifested by mucosal hyperemia. It responds well to treatment, the prognosis of recovery is close to 100%.

• Stage 1

True cancer, the most initial and light in the flow. It is characterized by a small tumor, on the mucous layer, without germination in depth, does not give metastases.

It may not manifest itself clinically, so it is not often diagnosed. With timely detection and treatment, the prognosis is good, the cure rate is 90%.

• Stage 2

The tumor takes on a larger size, the submucosal layer is affected, without metastasis, appear early symptoms. Pain syndrome, dyspeptic symptoms may disturb, it is well treated. The survival rate for stage 2 cancer is 70-90%.

• Stage 3

The tumor is large, grows into the deep layers. Blocks more than half of the intestinal lumen. It has metastases and lesions of the lymph nodes.

Symptoms are expressed: pain at the site of localization, obstruction, constipation, asthenovegetative syndrome. It is not always treatable, the prognosis is moderately favorable. The five-year survival rate is 30-50%.

• Stage 4

The heaviest and most neglected. Extensive damage to the organ, obturation of the lumen. Multiple distant metastases and lesions of the lymph nodes.

Expressed complications in the form of intestinal obstruction, bleeding, infectious processes. The prognosis is not favorable, it is practically not amenable to treatment. The three-year survival rate is up to 20%.

The first symptoms of colon cancer

Symptoms do not always occur in the early stages. They usually develop in the later stages. This complicates the tactics of treatment and prognosis.

• Feeling of discomfort at the site of the tumor or pain syndrome.

It can form in the left or right side of the abdomen. All envy from the localization of the malignant focus. At first, the pain is periodic, muffled. Then it becomes a nagging constant. Not related to eating.

• Constipation is a common symptom.

A person cannot empty his intestines for 3-4 days, sometimes for weeks. At the same time, the stomach is greatly swollen.

• Flatulence.

The phenomenon of abundant gas formation and swelling of intestinal loops. It may be the only sign of pathology.

• Feces with pathological impurities.

First mucus joins, then pus. At extreme degrees, streaks of blood or obvious bleeding appear, this is a formidable sign, if it appears, immediately consult a doctor.

• Loss of appetite.

associated with violation digestive functions intestines.

• Rapid weight loss.

Caused by tumor blockage of the lumen of the colon:

• Paleness of the skin, followed by increasing jaundice.
• General weakness, malaise, chronic fatigue.
• Dyspeptic phenomena: nausea, vomiting, diarrheal syndrome.
• Persistent and prolonged increase in body temperature.

When joining complications, the following symptoms may appear:

• Suppuration of the tumor, purulent fusion. Comes with sharp pains.
• Accession secondary infection. Clinic of septic lesions.
• Bleeding internal hidden and external explicit.
• Rupture of the intestinal wall. Causes a state of shock, loss of consciousness, to whom.
• Wall perforation.

Symptoms of liver damage

In colon cancer, the first organ that suffers from metastatic lesions is the liver. Most often this happens when primary focus localized in the hepatic flexure.

The tumor itself can grow into the capsule and parenchyma of the liver. What characterizes this phenomenon:

• The patient will report general malaise.

Suffering from insomnia, anxiety, decreased performance.

• An important syndrome is jaundice.

The sclera are stained bright yellow, the mucous membranes are visible, and then the whole skin. The jaundice is constant and does not go away.

• Skin itching.

A sign of cholestatic lesions and congestion of bile, joins at stages 3-4:

• Dull pain in right hypochondrium.
• Discoloration of feces. It becomes almost white.
• Urine acquires a dark color, becomes the color of beer.
• Skin rashes, hemorrhages.
• Edema syndrome.

First, edema appears on the limbs, then in the abdominal cavity. ascites is formed.

• Portal hypertension syndrome is a persistent increase in blood pressure numbers.
• Varicose veins of the esophagus with subsequent bleeding from them.

Symptoms in women

Due to the peculiarities of the reproductive system and anatomical and physiological nuances, the symptoms of colon cancer in women may differ.

Due to a different innervation, pain can spread not only at the site of the focus, but also in the lower abdomen, inguinal zones.

With menstrual irregularities that are not associated with hormonal disruptions or pregnancy, in some women, menstruation becomes profuse, resembling uterine bleeding.

The main signs in women:

• An increase in the size of the abdomen as during pregnancy.
• Soreness and hardening of the inguinal lymph nodes.
• Hormonal failures, endocrinopathy.
• Sudden mood swings, brittle nails, strong fallout hair.

Cancer of the hepatic flexure of the colon

Occurs relatively infrequently, localized in the upper right half of the abdomen. The tumor progresses moderately, the liver is often involved in the process, as it borders on the department.

What are the symptoms of cancer:

• Pain of diffuse dull nature.

It spreads in the right hypochondrium, in the umbilical region on the right. It can give to the navel, epigastrium, back, lower back.

• Jaundice.

Early development of icterus of the sclera, skin, visible mucous membranes. Jaundice is not eliminated by drugs.

• The presence of hemorrhages on the skin of the extremities.
• Obstructive intestinal obstruction. The patient is unable to empty the bowels.
• The presence of ascites, edematous syndrome.
• At grade 4, an expansion of the veins is formed on the skin of the abdominal wall.
• In extreme cases, a coma, hepatic encephalopathy is formed.

Pathology is treated in a combined way: a combination operational methods and chemotherapy. The prognosis for cancer of the hepatic flexure depends on the stage. At 1-2 degrees, it is treated well, not for a long time.

Survival after surgery is 80-90%. At 3-4 degrees, the prognosis is doubtful, more in an unfavorable direction.

Cancer of the splenic flexure of the colon

The percentage of its prevalence is not high. It rarely appears as an independent focus, it is a metastatic lesion from other parts of the intestine, while the spleen is involved in the process.

Symptoms:

• Dull pain in the left hypochondrium, to the left of the umbilicus. Irradiation in left shoulder blade, collarbone, epigastric region
• Severe nausea, frequent vomiting.
• Nose, gum bleeding.
• The appearance of multiple bruises on the skin of the body.
• Frequent diarrhea.
• Intestinal obstruction may be associated.
• Lemon jaundice.

Treatment requires special attention, as a delicate organ is involved - the spleen. At the first stage, courses of chemotherapy drugs are prescribed, followed by operational access, the entire area with the affected lymph nodes is removed.

The prognosis for cancer of the splenic flexure of the colon is uncertain. If there is no germination in the spleen, then the survival rate is high, in other cases there is a high risk of death.

Symptoms of cancer of the ascending colon

For cancer of this department of the organ, all the general symptoms are characteristic. Highlight individual points:

• The pain of a aching character is distributed throughout the right half of the abdomen, from the very bottom to chest. It intensifies a couple of hours after eating, when the intestinal loops are stretched.
• Intestinal obstruction appears early. Such patients with an acute attack get to the hospital as a matter of urgency.
• Loss of appetite, sudden weight loss.
• Prolonged constipation.
• Weakness, dizziness, nausea.

Prognosis of Survival in Ascending Colon Cancer

The prognosis for this form is related to the degree. The early stages are actively amenable to chemotherapy. Then the affected area is removed by performing an anastomosis. The survival rate is high, over five years 70%, 3-5 years - 90%.

In the later stages, due to metastatic spread and complications, treatment is complicated. Five-year survival is up to 40%, 3-year - up to 50%. This is why early diagnosis is so important.

Symptoms and prognosis in transverse colon cancer

Pathology is common among all oncological lesions of the intestine. It has symptoms characteristic of the entire colon.

• Pain in the injured area. Patients note soreness of a dull or acute nature from above the navel, it increases a couple of hours after eating.
• Asthenovegetative manifestations.
• Alternating constipation and diarrhea.
• Vomiting of food eaten the day before.
• Nausea.
• Formation of difficulty in the passage of the food bolus through the intestines.
• Heartburn.
• Persistent fever.

The prognosis for the disease is associated with early diagnosis. The earlier the disease is detected, the greater the chance of a favorable outcome. At complete resection transverse section survival rate is 75%.

If there are metastases, then the percentage drops to 50. At grade 4, the outcome is not favorable. Doctors give a life span of 3-5 years, subject to all recommendations.

Symptoms of cancer of the descending colon

The disease is characterized by:

• Heaviness in the left abdomen and lower back.
• Intestinal obstruction. Profuse diarrhea.
• An admixture of mucus, pus, blood in the feces.
• Weight loss of a person for a month by 10-15 kg.
• Dryness and pallor of the skin.
• Absence of vomiting.
• Rapid progression of the disease.

Surgical treatment of cancer

For the treatment of colon cancer, a combination of methods is used: chemotherapy, radiation therapy and surgery. Operational tactics play a leading role.

What do they do with online access. It all depends on the prevalence of localization, the volume of the lesion. If the focus is located in the right sections, then they resort to a hemicolonectomy operation, remove the entire cecum, the ascending colon, and a section of the transverse colon.

The lymphatic regional apparatus is completely excised. The remaining sections of the intestine are connected by making an anastomosis between the loops. If necessary, a stoma is applied - the loop section is brought out onto the abdominal wall.

If the left sections are affected, a left-sided ectomy is performed. The left sections of the intestine are excised with the imposition of anastomoses and stoma, if necessary.

If the tumor is small early stage, the gut is not completely removed. Produce its resection - excision of a site or several loops. Be sure to remove the mesenteric lymph nodes.

In the later stages, palliative operations are performed aimed at preserving and prolonging the life of the patient, alleviating his suffering and providing comfort.

Cancer Survival

It depends directly on the duration of the course, the volume of the lesion, the stage of the pathology. If the tumor is small, without metastases and complications, then the prognosis is favorable. People are cured completely without relapses, the survival rate is close to 90%.

If there are metastases, then the percentage is significantly reduced, they look at the shape and volume of the operation.

Survival rates range from 50 to 70%. In the later stages, survival is low. With palliative tactics, people live 5 or more years - 15%, 2-3 years up to 30%.

Differential Diagnosis

Colon cancer should be distinguished from other pathologies with similar symptoms.

• inflammatory processes.

They are characterized by an acute course, the pain is more pronounced. Feature - liquid stools and profuse vomiting. High fever, pronounced intoxication syndrome. Amenable to antibacterial and anti-inflammatory treatment, does not have a long-term character.

• Acute appendicitis.

Severe pain in right iliac region, high fever. At the same time, appendicular symptoms are positive. On palpation of the area, the pain increases.

In the general blood test, inflammatory changes are noted, there is no intestinal obstruction, jaundice. An inflamed appendicular process is determined by ultrasound.

• Nonspecific ulcerative colitis.

Pain is localized in lower sections abdomen without obstruction. Mucus impurities in the feces, diarrheal syndrome is characteristic, confirmed endoscopically. Actively treated with antibiotic therapy.

• Worm infestations.

They proceed without intoxication and temperature, without pain. Often there is itching in the anal area. In the general analysis of blood, eosinophilia is detected. Amenable to therapy with antihelminthic drugs.

Colon cancer is a malignant neoplasm that has an epithelial origin (a tumor originating in the cellular composition from the mucous layer of the large intestine).

It is important to know the anatomical location as well as functional features of the affected organ: the colon continues with a transition to the caecum and then articulates into the rectum, belongs to one of the main sections of the large intestine. The colon has its own properties, but does not take part in the process of digestion of food substances, it performs the function of absorbing water and all electrolytes through its walls. Colon cancer can form throughout all its departments: cancer of the transverse colon; sigmoid part; cancer of the ascending colon; descending colon cancer. Malignant neoplasms that have arisen are located on the surface of the walls of the mucous membranes and, with growth, tend to slightly or completely overlap the entire space of the intestine (diameter is up to 7 cm).

The characteristic signs of the pathology are: asymptomatic onset, prolonged local growth, later with progression pain syndrome, constipation, slight discomfort with going to the toilet, an admixture of mucous and blood inclusions in the fecal masses, the general condition worsens, signs of tumor intoxication appear. With further progression, intestinal obstruction, perforation, bleeding, infection and metastasis are formed (late lesion lymphatic systems located regionally, distant metastasis is also possible).

Colon cancer in the total number of oncological diseases of the digestive tract, according to various sources, ranks second in incidence, after esophageal cancer and. According to statistics, it makes up to 15% of the number of malignant tumors diagnosed in the gastrointestinal tract.

As a rule, colon cancer is diagnosed in the age range of 51-76 years, it is equally often possible to detect both male and female patients examined.

The most widely given malignant disease recorded in more economically developed countries, where the population prefers to eat animal fats and refined foods, and there are problems of overeating and obesity. The most striking rates of the incidence of the disease, to date, are recorded in the United States, Canada and distant Australia, in the European part of the mainland, the level of damage is lower, and in the Asian part and among the African population, pathology is much less common. But, nevertheless, in the time span of the last few years, the witnessed increase in the number of diseases still has a significant tendency to progress, spreading even to the populations of Asian countries, for which it was completely uncharacteristic before. According to world statistics regarding mortality - within 2 years, colon cancer takes the lives of 85% of patients if they did not have proper treatment and timely diagnosis of this pathology.

Treatment is carried out by specialists in the field of oncology, proctology. The very principle of treatment includes surgical radical intervention or palliative surgery - surgical removal by resection of the part of the intestine affected by the tumor, in addition to radiation or chemotherapy.

Causes of Colon Cancer

The main causal factors in the development of colon cancer are due to a number of pathogenetic and etiological provocateurs, oncologists identify the following important reasons:

Hereditary-familial factor in the development of colon cancer. The risk of occurrence increases significantly if there is a burdened family history. This is especially true of the most genealogically close relatives - parents, brothers, sisters.

Irrational nutrition, overeating, unbalanced diets, eating a huge amount of animal fats, a lack of coarse vegetable fiber and vitamins (the prevalence of refined foods) is especially detrimental. Animal fats stimulate the production of bile, which changes the microflora of the large intestine (there is a process of splitting animal fat and the formation of carcinogenic peroxidase substances that provoke colon cancer).

Insufficient fiber intake leads to a slowdown in intestinal motility and already formed carcinogens have contact with the intestinal wall for a long time, stimulating the malignant degeneration of the mucosal cell structures, and cannot be eliminated from the intestine.

The lack of vitamins and mineral complexes in the food consumed, and these are natural inhibitors of carcinogenesis, deepen the adverse effect.

An inactive lifestyle is hypodynamia, and as a result.

Systematic chronic constipation, in which the risk of injuring the natural physiological curves of the intestine with solid feces increases significantly.

Atony or hypotension of the intestine, characteristic of a more advanced age.

Precancerous diseases, which include: non-specifically developing ulcerative colitis, Peutz-Jeghers syndrome, colonic diverticulosis, solitary adenomatous polyps, familial hereditary polyposis, Türk's syndrome.

age factor. After age 50, the risk factor increases in direct proportion to age.

Work with harmful working conditions: contact with chemicals, specialties related to the processing of asbestos, mountain dust, work in sawmills.

In the formation of colon cancer, a certain role is assigned to sex hormones, in particular, progesterone, under its influence, the release of bile acids into the intestine decreases.

The risk of development increases in nulliparous women, they have it twice as high as those who have already given birth to three or more children.

Colon Cancer Symptoms

The symptomatology of this pathology directly depends on the location and type of malignant tumor, its size and staging of development.

At the very beginning of the onset, colon cancer is completely asymptomatic and can be accidentally diagnosed during a planned dispensary examination. If certain symptoms are already beginning to appear, then most likely the patient will complain about: sudden onset constipation, progressive pain and intestinal discomfort, decreased ability to work, defecation disorders, mucus and bloody impurities in the feces.

Pain syndrome and malaise indicates damage to the right parts of the intestine (pain of low intensity, aching). With the defeat of the left departments - flatulence, rumbling of the abdomen, frequent urges on defecation without result, feces in appearance like “sheep feces”, with traces of bloody and mucous masses, the appearance of sharp contractions-attacks, indicating the occurrence of intestinal obstruction, which is due to the peculiarities of the spread of neoplasia with the further formation of a formed narrowing that prevents the advancement of fecal masses.

Many patients complain of dysphagia, lack of urge to eat and discomfort in the abdominal area, general weakness and systematic malaise, weight loss, excessive pallor of the skin, hyperthermic manifestations and - this is more common in cancer of the transverse colon, less often in lesions of the descending colon and sigmoid.

Also, the symptomatology depends on the subspecies of colon cancer, their oncologists distinguish six main forms:

one). Obstructive with the main symptom - intestinal blockage. With partially manifested obstruction, the rumbling of gases and bloating, attacks of a cramping nature, and difficult discharge of feces are characteristic. With a complete variant of obstruction, immediate surgical intervention is required.

2). Toxico-anemic. Inherent in this form is anemia, malaise, painful pallor.

3). Dyspeptic. Symptoms of nausea and further vomiting, belching, pain in the upper abdominal area, bloating.

four). Enterocolitic. Characteristic disorder of the stool, rumbling, blood impurities and mucus in the feces.

5). Pseudo-inflammatory. There is hyperthermia, minor pain and intestinal disorders, an increase in the erythrocyte sedimentation rate and.

6). Tumor-like. This is an atypical subspecies - asymptomatic.

Colon cancer stages

Classify the main four stages of colon cancer development:

0 stage. When only the mucous layer is affected, signs of malignant infiltrative growth are not determined, there are no metastases and the lymph nodes are not affected.

1 stage. A small primary tumor is determined, not exceeding one and a half centimeters in size, which is formed in the submucosal and mucous layers. Metastases are not typical.

Stage 2. The lesion is over 1.5 cm, but extends to less than half of the semicircle of the outer wall of the intestine, does not penetrate nearby organs. Single recorded metastases are possible.

3 stage. The size of the tumor exceeds the semicircle of the intestine, it is already growing into the intestinal wall, growing into adjacent organ cavities. Numerous foci in regional lymph nodes, but there are no distant metastases yet.

Stage 4. A large tumor, with penetration into nearby tissue structures and multiple metastases.

Colon cancer treatment

The leading prevailing method for the treatment tactics of colon cancer is surgical intervention. The treatment and choice of tactics for the surgical intervention is determined by the attending surgeon, based on a whole list of factors - this is the type of malignancy, the presence of distant foci and concomitant diseases in humans, the presence of complications, the localization of the pathologically occurring process, the stage of the process, the general condition at the time of the operation , age of the patient.

Depending on the extent of the coverage of the pathological process, a radical approach is performed (almost all subtypes of colon cancer) or palliatively oriented intervention (for severely neglected forms that cannot be operated on), combined operations (when spread to nearby organs and tissue structures).

Radical operations are performed in the absence of distant foci and any related complications. Their essence is that the affected malignant neoplasm portions of the intestines, together with those adjacent to them lymph nodes and part of the mesentery. The operation can be performed in one approach with the restoration of the passage of the intestinal chyme or in several stages with the removal of the colostomy (used for intestinal obstruction, the presence of bleeding and perforation of the malignant neoplasm itself).

The goal of palliative surgery is to prevent the development of obstruction in the intestine with the imposition of a bypass joint or removal of the colostomy. To completely exclude the participation of loops in the process, they are stitched, leading and abducting, between the connection itself and the fistula, and then the fistula, together with the part of the intestine isolated during stitching, is resected. Such an operation is most relevant for carrying out in the presence of a large number of fistulas and with a fleeting deterioration in the patient's body condition.

Surgical interventions according to localization:

one). If colon cancer is localized zonal with right side, then an operation called right-sided hemicolectomy is performed: the caecum, one third of the transverse colon, the ascending part and about ten centimeters of the ileum in the terminal section are to be removed. Excision is carried out in one approach and regionally determined lymphatic growths and the formation of the articulation of the small intestine with the large intestine.

2). In left-sided lesions, a left-sided hemicolectomy is performed, respectively. Create a joint and delete following departments: part of the sigmoid colon, mesenteric part, one third of the transverse section, descending colon, regional lymph nodes.

3). A small neoplasia in the center of the transverse intestine is removed, as is the omentum itself with overgrowths of lymphatic tissues.

four). The tumor in the underlying part of the sigmoid colon or its central part is resected by the lymph nodes and the mesenteric part, and then a part of the large intestine is connected to the end of the small intestine.

5). When neoplasia spreads to nearby tissue and organ structures, malignantly altered areas are removed using a combined operation.

Radical operations for colon cancer can be both one-stage and carried out in several stages:

one). When performing a one-stage surgical intervention, a hemicolectomy is performed, the essence of which is to remove a part of the colon with the creation of an articulation between the remaining sections of the resected intestine.

2). When carrying out multi-stage interventions for colon cancer, a colostomy is first performed, and only after that a malignantly altered intestine is excised (sometimes at the same time), and after a period of time, after recovery, an operation is performed to restore intestinal continuity by forming a direct articulation.

3). With widespread colon cancer in the body, volumetric surgical interventions are performed, its volume is calculated taking into account the damage to both the lymph nodes and nearby organs. If extensive radical excision of the neoplasm is not possible, palliative measures are performed.

If there is the slightest chance that the patient will survive reoperation and he has high percent predicted survival, it is more desirable to perform staged operations. If a person's condition does not allow for advanced cases to do this and the body is so weakened that the risk of mortality from surgical interventions is quite high, then one-stage resection of the affected areas of the body is chosen.

Surgical treatment of colon cancer is always additionally combined with subsequent radiation exposure and chemotherapy.

Radiation therapy in the treatment of colon cancer is rather complementary auxiliary character. Procedures begin at least a couple of weeks after the last surgical intervention. The zone of direct growth and progression of neoplasia (local irradiation) is often exposed to irradiation. Radiation therapy has adverse effects in the form of side effects that tend to occur as a result of damage to the mucous layer of the intestine by the rays - this is vomiting and persistent nausea refusing to eat. The purpose of its use in the preoperative period is to inhibit biological activity malignant cancer cells, lowering their malignant potential and the possibility postoperative appearance relapses.

Chemotherapy for colon cancer is used only in a complex form, very rarely as independent course therapy (usually after symptomatic surgery). For the treatment of poorly differentiated malignant tumors, it is carried out in the adjuvant mode. Reception of a number of cytostatic modern safe drugs(Levamisole, Fluorouracil, Leucovorin) does not stop for at least one calendar year. The drugs are as safe as possible and devoid of side effects, so they are much easier to carry. But, nevertheless, in some recorded cases, the following undesirable consequences can be observed: allergic rashes - and erythematous rash, vomiting, nausea, leukopenic manifestations in the analyzes (decrease in the concentration value of leukocyte mass).

Colon cancer prognosis

The prognosis for colon cancer can be characterized as moderately favorable, it is determined by the staging at which the patient was identified and taken into account and when the appropriate treatment of the oncological process began.

When colon cancer is diagnosed, the predicted further development worsens with all the ensuing consequences and complications and possibly developing side effects. Lethal outcomes registered after operations vary within 8%.

The average five-year survival rate for the first stage of cancer is about 90 to a maximum of 100%, for the second stage - 70%, and already in the third - 30%, after radical excision - 50%. In the presence of a tumor that does not grow through the submucosa, survival reaches a maximum - all 100%. In the absence of distant lesions in lymphatic growths - 80%, but in the presence of metastasis, and especially in the liver, this figure decreases to 40%.

With early detection of cancer of the ascending colon and cancer of the transverse colon, the prognosis is still favorable: the treatment finishes with a complete recovery in 95% of treated patients. Cancer of the descending colon in the total number of morbidity does not reach 5% of all registered cases, and timely treatment also brings successful results in curing patients.

All patients who underwent surgery to excise neoplasia should be under the active supervision of an oncologist, regularly undergo examinations, both radiological and endoscopic, for early detection and prevention of local recurrences or possible distant metastases.

The earlier a malignant lesion is initially diagnosed and resection is performed, the greater the chances of a favorable outcome. In advanced situations and incorrect therapeutic cancer treatment mortality reaches 100%.