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Tumors. Part 5. Tumor Treatment

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We have come to the last part of the cycle, devoted to the treatment of tumors. Today we will learn new medical words: palliative (relieving, auxiliary) and fascia (connective tissue septum, a term from anatomy), and we will also learn several new names for tumors. There is a lot of material, so it will be in the form of an abstract.

Treatment of benign and malignant tumors is different , because the latter have infiltrating growth, a tendency to metastasize and recur.

TREATMENT OF BENIGN TUMORS

The main method of treatment is surgical. Occasionally, in the treatment of tumors of hormone-dependent organs, instead of or together with the surgical method, hormone therapy.

Benign tumors that do not threaten the life of the patient, does not always have to be removed. If the tumor does not cause any harm to the patient, but at the same time there are contraindications for surgical treatment (severe concomitant diseases), then it is not advisable to operate on the patient.

Indications for surgery:

permanent trauma to the tumor (for example, on the scalp, on the collar area of ​​the neck, in the belt area in men)

organ dysfunction (closure of the lumen of a hollow organ, release of hormones into the blood)

not completely sure in benign tumor. During the operation, a biopsy is taken, and within 15 minutes, the pathologist must look at the biopsy under a microscope and give an answer. Surgeons are waiting at this time, the patient lies on the table under anesthesia.

cosmetic defects , especially in women.

Remove the tumor entirely (not in parts) , within healthy tissues, with a capsule (if any). The excised neoplasm is subject to mandatory histological examination. Relapses and metastases do not develop after removal of a benign tumor,

The operation completely cures the patient.

TREATMENT OF MALIGNANT TUMORS

This is a more difficult task. Apply 3 ways of treatment:

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surgery (also basic), radiotherapy (radiation) and chemotherapy (drugs).

Surgery

it most radical, and in some localizations, the only method of treatment. When removing the malignancy of the tumor, it is necessary to observe “ oncological principles“:

1. ablastics: non-proliferation measures tumor cells during surgery (particle a- means absence, blastoma means tumor). Ablastic measures:

incisions only within known healthy tissues

avoid mechanical injury to tumor tissues

ligate (ligate) the venous vessels from the tumor as soon as possible

a hollow organ with a tumor is tied with ribbons above and below the tumor so that tumor cells cannot move through the lumen

removal of the tumor as a single block with fiber and regional lymph nodes

before manipulations with the tumor, limit the wound with napkins

after removal of the tumor, change instruments and gloves, change the restrictive napkins

Antiblastics: measures to destroy during the operation of tumor cells that have come off the main mass of the tumor (particle anti means counteraction). Tumor cells can lie on the bottom and walls of the wound, enter the lymphatic and venous vessels and cause tumor recurrence and metastases. Ablastic happens:

1. physical: the use of an electric knife and a laser, irradiation of the tumor before surgery and in the early postoperative period.

2. chemical: wound treatment after removal of the tumor with 70% alcohol, intravenous administration of anticancer drugs on the operating table.

Zoning and sheathing

The purpose of the operation is to remove the entire area in which individual cancer cells can be located. That is why the tumor is removed in a block (one of the measures of ablastics). If the tumor grows outward (exophytic growth - into the cavity or lumen; exo - external), 5-6 cm recede from its visible border. If the tumor grows endophytically (in the wall of the organ; endo - internal), recede at least 8-10 cm .

Since the lymph nodes and lymphatic vessels, through which tumor cells can spread, are located in the fiber between the connective tissue septa ( fascia), then for a more radical operation, all fiber is removed, for example:

even with a small body tumors of the stomach,

growing endophytically (inside the wall), the stomach is removed as a whole block, and with it the large and small omentum.

at breast cancer the mammary gland, pectoralis major muscle, fiber with axillary, supraclavicular and subclavian lymph nodes are removed in a single block.

melanoma (the most malignant tumor) requires a wide excision of the skin, subcutaneous tissue, fascia, complete removal of regional lymph nodes, although the size of the primary tumor does not exceed 1-2 cm.

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Signs of melanoma. From left to right:

asymmetry - uneven borders - color - diameter (1/4 inch or 6 mm).

I have already written about melanoma in other parts of this series.

Melanoma on the face

Radical operations that cure a cancer patient can be performed only in stages 1-2 of a malignant tumor. In the advanced stages of malignant tumors,

palliative and symptomatic operations . They do not cure the sick, but only make it easier and

slightly prolong life. For example, with a decaying bleeding tumor of the stomach, a resection of the stomach is performed, eliminating the source of bleeding. Multiple metastases can no longer be removed, so this palliative operation will not cure the patient, but only prolong his life by stopping bleeding and reducing intoxication.

Radiation therapy

Rapidly multiplying cells are more sensitive to ionizing radiation, although they are sensitive in different ways:

the most sensitive: connective tissue tumors with round cell structures.

Lymphosarcoma: local tumor of lymphoid cells. If you remember, then a common (scientifically, generalized) tumor of lymphoid cells is called leukemia (leukemia).

Myeloma: a tumor of plasma cells

(a type of lymphocytes, which, in turn, belong to leukocytes), accumulate in the bone marrow, which leads to the destruction of bone tissue.

Endothelioma: A tumor of the endothelium that lines blood vessels.

highly sensitive: some epithelial tumors. When irradiated, these tumors quickly disappear, but often recur and are prone to metastasis.

Seminoma: a malignant tumor of the cells of the spermatogenic (sperm-forming) epithelium of the testicle.

- chorionepithelioma: a malignant tumor from areas of the germinal membrane of the fetus, occurs during pregnancy or after an abortion.

medium sensitive: tumors from the integumentary epithelium (skin cancer, cancer of the lip, larynx, bronchi, cancer

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esophagus). If the tumor is small, then the patient can be cured with radiation.

low sensitive:

1. tumors from the glandular epithelium (cancer of the stomach, kidney, pancreas, intestines),

2. highly differentiated sarcomas(if you remember, sarcomas are malignant tumors from the connective tissue):

Fibrosarcoma: a malignant tumor of soft connective tissue

Osteosarcoma: a malignant tumor of the bone

Myosarcoma: a malignant tumor of muscle tissue,

Chondrosarcoma: a malignant tumor of cartilage tissue.

3. - melanoblastoma (melanoma): from the name it is clear that the tumor develops from cells that form melanin (melanocytes). The pigment melanin makes our skin darker when we tan. Melanin protects against

adverse effects of solar radiation . Therefore, it is clear that for melanoma cells, irradiation is like a dead poultice. Surrounding healthy tissue will die sooner. Hence one more conclusion: you should not sunbathe a lot, so as not to stimulate melanocytes once again.

Sunburns are very harmful. (especially acquired in childhood), which greatly increase the risk of developing melanoma.

Melanoma on the arm.

Radiation therapy methods:

external exposure (installations for X-ray therapy and gamma therapy). Conducted courses for superficial tumors.

intracavitary irradiation : the radiation source is injected through a natural opening into the uterine cavity, bladder, oral cavity, etc.

interstitial: radioactive capsules are sewn in and

use radioactive isotopes, for example, I131 in thyroid cancer with metastases. Isotopes of iodine accumulate in the thyroid gland and its metastases, acting very selectively.

Complications of radiotherapy (you need to choose the right dose):

local: dermatitis (skin inflammation: redness, swelling, hair loss, pigmentation, expansion of small vessels), radiation ulcers (they are painful and practically do not heal).

general: acute or chronic radiation sickness (first of all, the bone marrow and hematopoiesis are affected).

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Chemotherapy

Impact on the tumor pharmacological agents. Used for systemic cancers (leukemia, lymphogranulomatosis) and hormone-dependent tumors (breast cancer, ovarian cancer, prostate cancer, etc.), and courses and for a long time - sometimes for many years.

Groups of chemotherapeutic agents:

cytostatics (inhibit the process of division of tumor cells)

antimetabolites (disrupt metabolism in tumor cells)

anticancer antibiotics (produced by microorganisms, kill tumor cells)

immunomodulators(stimulate certain parts of the immune system to fight the tumor)

hormonal preparations (for the treatment of hormone-sensitive tumors; both hormone analogues and drugs that block the action of hormones are used).

Complications: all drugs affect both healthy cells and , disrupting hematopoiesis, liver and kidney function, etc. Treatment is carried out under strict control of the blood picture.

Combined treatment - when 2 out of 3 are used

treatment methods. If 3 methods are used, then the treatment is called complex.

Treatment of stages of breast cancer:

cancer in situ and stage I: surgery.

Stage II: radical surgery + chemotherapy (combined treatment).

Stage III: first radiation, then radical surgery followed by chemotherapy (complex treatment).

IV stage: powerful radiation therapy. Operation according to indications.

Evaluation of the effectiveness of treatment:

the main indicator is 5-year survival (% of those patients who could live 5 years after diagnosis and treatment). If after 5 years the patients are alive and well, they are considered to have recovered from cancer.

And now let's look at advances in American medicine

(I did not find statistics for the CIS).

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Improved 5-year survival for the 13 most common cancers,

diagnosed in Ontario, in 1997-99. compared with

In the picture from top to bottom:

all types of cancer except non-melanoma skin cancer of the thyroid gland

prostate (prostate) skin melanoma

breast cancer (women only)*

body of uterus

kidney and urinary tract non-Hodgkin's lymphomas

intestines (colorectal)

oral cavity and pharynx leukemia (leukemia)

cancer of the stomach (stomach) cancer of the trachea, bronchi and lungs

pancreas (pancreas)

* - in men, by the way, it also happens, do not be surprised (my remark).

As you can see, progress in 10 years has been achieved in all directions although the greatest progress has been in the treatment prostate cancer. 5-year survival rate for thyroid cancer approaching 100%. Worst of all

with cancer of the pancreas, lung and stomach. this one good reason to quit smoking.

Let there be an example of Australian singer Kylie Minogue, who was diagnosed with breast cancer in May 2005. She was operated on, and now the singer is gradually

returns to normal.

This is the end of the cycle about tumors. You can’t cover everything here, and you don’t need to. I hope that now you have a more complete picture of neoplasms. And if something is unclear or missing, ask in the comments.

Hi all!

About myself...

About the site...

The site is not a resource only for healthcare professionals, but intended for a wide range of readers who are interested in the topics of health, disease, treatment, healthy lifestyle and medicine in general. On the other hand, this is not a textbook for medical students, since I deliberately simplify some things and formulations for a better understanding of readers.

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To contact me, leave a comment on any page of the site. I read all messages and reply if necessary.

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Write your comment:

Sometimes I go to LiveJournal and type in the word “ the medicine” in the search field. AT 85% bloggers scold all medicine in general and doctors in particular for indifference, inattention, unprofessionalism, rudeness, rudeness and much more. Of course, the bad is remembered more strongly than the good. But still the problem doctor - patient" and " doctor - relatives" exists.

Why is this happening? Why representatives of most noble profession“behave like this? For the sake of justice, everywhere they note that sometimes they still meet Doctors with a capital letter, similar to the ideal, but there are very few of them. I tried analyze the reasons not only from the standpoint of the patient, but also from the standpoint of the doctor. The reasoning refers to Belarus, but I think that in Russia the situation is similar.

1. Lack of time. According to the standards approved by the Ministry of Health, one patient is allowed to see a general practitioner in a polyclinic about 12-13 minutes(4.5 patients per hour). This rule was developed taking into account the fact that 3 primary patients(applied for the first time) on average it happens 2 “repeated”. Naturally, the “repeated” takes less time. In reality, it turns out that in 14-15 minutes the doctor often does not have time to properly talk with the “primary” patient, examine him, issue an outpatient card, prescribe treatment, explain to the patient about the treatment, regimen, diet. But even these standards are not met, especially in the winter-spring period, when there are many colds and up to 50-60 people per shift.



Add here doctor's house calls. In summer there are not very many of them, but in winter there are a lot of them on the site. about 10-20 calls. According to the standard, 1 home call is assigned 30 minutes. So think for yourself how the doctor should spin in order to be in time for everything, satisfy everyone and at the same time not spend the night at work.




There is not enough time, even if the doctor thinks and makes the correct (!) Diagnosis at the speed of a supercomputer. But this is a hypothetical. Everything is more difficult in life.




The population of the CIS countries is aging. This means that at the appointment with a particular doctor increasing proportion of elderly and senile people. Usually they have a lot of diseases, they move slowly and think, often they do not hear well. Standard 12 minutes here definitely not enough. For reflection: in private medical centers to receive a patient allotted 30 minutes.


2. Lots of paper work. The doctor and nurse have to do a lot of unnecessary, bureaucratic work. In recent years the number of papers is only growing. When you come to an appointment, the doctor has no time to look at you - he writes tensely in the card. And sometimes he doesn’t have time, he has to stay “after school”. I already wrote about this earlier in the revelations of the local doctor.



All in all, work on the conveyor and according to the template gives the same template result. There is no time to think and reason. In ancient times it was called Procrustean bed.


3. Overtime work. Due to such rather intense work (clinic + home calls), not everyone can survive in the place of a district doctor. It’s generally scary to go to some apartment calls at night and without security. That's why there are not enough doctors in Belarus.



According to the statistics of the Belarusian Ministry of Health, on average every Belarusian doctor works at 1.3 rates. That is a lot of work. The sick must be served. Doctors have to work for themselves and “for that guy”. AT November 2007 in Belarus, the average salary was Br736.4 thousand ($342), and the doctors - 1051.3 thousand rubles ($488.2). Doctors seem to make relatively good money, so why are they complaining? Let's divide $488 by 1.3 bets, we get $375, that is, slightly above the average level in Belarus. If all doctors worked for exactly 1 rate, as expected, then they would receive the average salary in the country.




And they work for 1.3 rates not only from "inborn greed", but also because Management asks for a job. The head is responsible for the entire institution and must think about how to fill the staffing gap. Are other patients to blame that there is no doctor in their area? And yes, you need money too. And here the doctor is promised different allowances for “ extended service area“, bonuses ... Everyone needs money, because the salary of a doctor is small in itself, especially for beginners.




old joke:

Why do doctors work for 1.5 rates?

Because there is nothing to eat for 1 bet, and there is no time for 2 bets.


4. Burnout Syndrome. Professions related to working with people are prone to burnout syndrome (BSE). This is when work and sick bored to death, I want to literally not see them, and if there is no such possibility, even “ shoot down” (I heard such an expression). According to some reports, about 50-60% of doctors have EBS in the initial stage, and about 5-10% - in expressed degree. And work in constant nervous tension due to lack of time, fear of complaints (about them another time) and 1.5 rates this is very helpful.




But who will the doctor help, who himself needs to be treated?


5. Lack of incentives. In the public health system, wages do not depend much on the number of patients. It doesn’t matter if the office doors are empty or there are constant queues, the salary will not differ much. Hence there is a temptation to make sure that there are fewer patients. Favorite excuses of such doctors:

• I would like to live to such years


• what do you want at your age?


• everyone is sick now


• You are so special, I don't know how else to treat you.

To reduce the flow of patients “used” inattention, rudeness, template treatment the simplest (ancient) drugs without proven effectiveness. As a result, patients no longer want to go to such a doctor again. Goal achieved: office has no queues. And patients turn to a paid medical center, where, by the way, the same doctor can receive part-time appointments.

This problem occurs because the doctor receives a salary not from patients, but from the state. In some ways, this system has its advantages (what exactly - think at your leisure), but there are also many disadvantages. One of the consequences: doctors of emergency departments subconsciously hate ambulance workers because they bring them work. After all, if the ambulance does not bring anyone, then you can do nothing for the whole shift, and the salary will not decrease from this in any way. And all the doctors are very fond of transfer work to a colleague, if there is any formal possibility. Less work means less responsibility, better sleep at night. So think what medicine do we need- paid or free?

BUT ancient equipment, which has not been updated for many years and regularly breaks down, also does not cause any desire to improve one's professional level. it psychological aspect which I personally noted.

In the West the problem of bad doctors expressed to a lesser extent. There is a doctor respected person in society with a very good salary. Working as an ordinary doctor “with us” can cause pity and sympathy those classmates who studied much worse, but now settled in the capital with a salary of 1.5-2 times more.

It is not easy to become a doctor abroad. Gotta endure big competition and be able to pay for studies. The key to the puzzle lies in technologies for selecting applicants. In the CIS and in the West, the selection of applicants for medical specialties of universities is significantly different. Take the selection of future doctors in Australia. Read this material yourself, and briefly I will say that our selection is based only on the amount of knowledge. In Australia and elsewhere, a key role is played by personal qualities: the ability to understand the interlocutor, feel him, empathize, support and much more. The selection is multi-stage, with several stages devoted to determining personal qualities of the future doctor:

The medical profession continues to dominate the top 25 of America's highest and lowest paid professions. The first 9 places are occupied by various medical specialties, led by anesthesiologists followed by surgeons and orthodontists.

Executive directors(“chief executives”, No. 10) and aircraft pilots(No. 11), who moved up 3 positions, are tearing apart this medical cartel, but only temporarily. The following 5 places are returned to the well-cleaned hands of doctors and dentists.

Even lawyers do not appear on the list before 17th place, down 1 position compared to last year.

At the other end of the scale are low and unskilled workers in restaurants, hotels and the leisure sector. Who has the lowest paying job? It's in people who cook and serve at fast food restaurants, followed by dishwashers, busboys, and people who wash your hair at hairdressers.

According to government data, the average salary of 31,030 anesthetists in the United States was $192,780 per year, an increase of 4.6% over the year. 2.6 million people with jobs that consist of cooking and serving earn $16,700 per year (+ 4.8%), which is 1/12 of the annual income of anesthesiologists. The average annual salary in the US for all occupations is $40,690 (+ 3.8% per year).

In general, the lowest paid professions provide jobs 15.6 million residents of America, and the highest paid - only for 3 million.

Our numbers were taken from U.S. government's National, State and Metropolitan Area Occupational Employment and Wage Estimates(“National, State and City Employment and Wage Estimates from the US Government”). The most recent figures use data from 2007 and are based on the national survey of employers of all types in all sectors of the economy. 801 professions were studied.

The survey covers full-time and part-time workers who receive salary or salary. It did not include self-employed people, owners and partners in unincorporated firms, household workers, and unpaid family workers.

During the study, questions were asked about basic salary (“basic pay”, standard salary, excluding overtime, bonuses or other additional payments), incentive payments and commissions, excluding overtime pay and non-monetary compensation (for example, stock options ).

This helps explain why average annual incomes seem less than one might imagine at the top of the list, and more at the bottom of the list, where accurate counts of unofficial workers are unlikely and accounting for all sources of cash, such as tips, is difficult.

However, it should be remembered that the mentioned figures are average for standardized specialties. They do not provide an answer to what may be the difference in wages for a particular specialty, nor the fluctuations in income for individual subgroups within the same specialty.

The total compensation (salary and bonuses, excluding stock options) for the highest paid CEO in our latest CEO compensation list was $192.92 million for Lawrence Ellison from Oracle, which is 1,274 times the compensation for the average CEO.

Likewise, there are many lawyers who earn much more than the average $118,280 for their profession, and we can say with certainty that there are dishwashers who receive much less than average $17,060 in year. At the same time there Warren Buffett, a Berkshire Hathaway CEO who pays himself below average at just $100,000 a year, despite being one of the richest people in the world.

Earnings can fluctuate greatly for the same specialty across industries and territories. Service station workers employed by the federal government earn nearly double the national average for that type of work. the same situation with the cashiers working in intermediary firms of telecommunication companies.

Typically, low-paying jobs offer low premiums in industries that generally earn high wages. A small number of service personnel and housewives employed by research organizations earn on average 2/3 of the national average.

There has been a slight change in the list of the 25 highest and lowest paid professions. No one fell out of the list, but the order has changed a bit. Numbers 1 and 2 remained intact, while numbers 3 and 4 were swapped. Petroleum engineers are up 5 places from 24th to 19th, while air traffic controllers are down 6 places from 17th to 23rd.

Among the lowest paid jobs, numbers 1-4 remained unchanged. It was not the best year for hair washers - they fell from 8th to 5th place in the list of the lowest paid. The bartenders get applause. Their incomes increased, and fate gave them + 7 positions: from 18 to 25.

———————————-

25 highest paying jobs in the US

It remains only to be glad for the American doctors and remember the well-known truth: it's good where we are not. I already wrote about the salaries of Belarusian doctors, including the income of a novice doctor soon. For several months now, newspapers have been talking about a significant increase in salaries in the Belarusian health care, but things are still there. This is a costly business - public medicine.

American doctor's car.

Belarusian doctor's car.

Recently, I needed to write a prescription for my grandmother, I had to call the local doctor at home. I am speaking absolutely seriously: the district police officer (she is about 45-50 years old) arrived in the same car as in the photo above, only older. She said that she was very glad that she decided to use her personal car today: the site is large (private sector), and house calls are accepted until 14-00 and therefore they can easily give the last call to the other end of the site, when in half an hour or an hour you have to be at admission at the clinic.

25 lowest paying jobs in the US