Tumors

Tumors are excessive, uncoordinated pathological tissue growths that continue after the causes that caused them have ceased to act.

Tumors are divided into benign and malignant, although benign tumors can become malignant. The main difference is in the maturity of tumor cells. If benign cells are fully mature, with a normal structure and metabolism, they differ only in the chaotic arrangement, then malignant cells begin the process of division at incomplete maturation (atypism), and this property is transmitted genetically to descendant cells. The earlier the tumor cell begins its division, i.e. the less differentiated it is; the more malignant the tumor is, which is important for its verification.

How do tumors develop?

A distinctive feature of malignant cells is their autonomy - they can live separately from the tissue from which they originated, moreover, these cells are loosely connected to the tumor and easily break away, so they can penetrate into the blood and spread throughout the body. In other tissues, they easily take root, forming a metastasis, and retain the properties of the maternal tissue from which they originated (for example, metastatic cells of gastric mucosa cancer in the lungs secrete hydrochloric acid, etc.). This is also important for their verification; since the primary tumor often proceeds latently, and metastasis gives a vivid clinical picture. Rapid and early division of malignant cells ensures rapid tumor growth. Due to their weak differentiation, cells easily penetrate through the intercellular spaces into other tissues, replacing their healthy cells. This ensures invasive tumor growth with germination into other tissues, including the nervous tissue, which determines the painlessness of the tumor, since the nerve endings die.

The energy exchange of malignant cells is extremely high, the consumption of energy and nutrients is 10-15 times higher than that of normal cells. They literally capture all the nutrients entering the body, disrupt neurohumoral regulation and homeostasis. As a result, rapid weight loss occurs, and then the patient becomes exhausted, up to cachexia. The body's energy reserves are quickly depleted, since due to cancer intoxication with metabolic products, patients lose their appetite, the absorption of nutrients by tissues is disrupted, and catabolism is formed. Squeezing and growing through blood vessels, tumors turn off areas of the body from blood circulation with the development of their own decay, starting from the center. Pyogenic microflora often joins, which gives additional intoxication and forms a pain syndrome.

On external examination and palpation, benign tumors are round, elastic, soft in consistency, mobile, can be moderately painful, the skin above them and surrounding tissues, if they are not compressed by the tumor, are unchanged, the tumors are covered with a membrane (encapsulated). Another picture is with malignant tumors: they are very dense, of a "stony" consistency, absolutely immobile, painless on palpation, closely connected to the skin when located externally, the color differs from the surrounding tissues - they are whitish or, conversely, dark, can ulcerate. With malignancy of benign tumors, for example, melanoma, the following is noted: its darkening, compaction, rapid growth in strands from the main tumor, fusion with the skin, i.e. clear signs of melanoblastoma are formed.

Nomenclature and classification of tumors

There is no single comprehensive classification of tumors. But more than 25 morphological classifications have been created based on their histological differences. In clinical practice, tumor nomenclature is used, which is defined as a clinical classification.

Diagnosis of benign tumor

The diagnosis of a benign tumor is formed according to the following principle. The following is indicated: the source of tumor development (cell, tissue, organ); its belonging to a segment or anatomical region of the body. In the case of one node, the suffix "oma" is added to the name of the tissue, in the case of multiple nodes - "oz". For example, lipoma of the hip, osteoma of the shoulder, ganglioma of the hand, fibromatosis of the mammary gland, etc. Or the diagnosis is formed indicating the connection with a certain organ: in the case of tumors of the thymus gland - thymoma, meninges - meningioma, etc.

The nomenclature of malignant tumors is much more complex due to the variety of localization, histological type, prevalence. If morphologists manage to verify the tumor, then its histological affiliation is included in the diagnosis, for example, gastric adenoblastoma, etc. If verification is not possible, the tissue from which the tumor originated is taken into account. Tumors developing from epithelial tissue are called "cancer" or "cancer", for example, stomach cancer, lung cancer, etc. If the tumor grows from glandular tissue, they are called "scirrhus". Tumors from connective, bone, muscle, nervous tissues are called "sarcomas", for example, hip sarcoma, spinal sarcoma, etc. Some classifications indicate tumor growth relative to the lumen of a hollow organ: endophytic growth is directed deep into the organ wall with subsequent germination into neighboring organs; exophytic growth is directed into the cavity of an organ - stomach, bladder, pharynx, bronchus, intestine; growth that involves the entire organ is defined as diffuse.

The prevalence of the tumor is determined by two classifications: domestic and international - T, N, M. Many oncologists propose to additionally introduce histopathological gradation into the international classification (G-gradus - determined by the degree of cell differentiation; pT - by the state of the primary tumor; P - by the degree of penetration of the wall of the hollow organ), but it has not yet been fully developed and has not been accepted at the international level by the conciliation committee. According to the development and prevalence of the tumor, they are divided into four stages of development.

• Stage 1 of development - the tumor does not extend beyond the organ wall, organ lymph nodes may be involved in the process, there are no metastases. According to the international classification - T1, N1, M0.
• Stage 2 of development - the tumor extends beyond the organ wall, but does not grow into surrounding tissues, organ and nearby regional lymph nodes are affected, there are no metastases. According to the international classification - T2, N1-2, M0.
• Stage 3 of development - the tumor extends beyond the organs, grows into the surrounding tissues, but does not grow into neighboring organs, i.e. those cases when the tumor can be separated from the surrounding tissues. Only regional lymph nodes are affected, distant ones are free (for example, axillary lymph nodes in breast tumors). There are no metastases.

According to the international classification - T3, N2-3, M0: This stage is still operable, but the operation is huge in scope, often it is possible to perform only a conditionally radical operation with removal of the main focus, but not all surrounding tissues and regional lymph nodes. Survival, as a rule, is no more than five years.

• Stage 4 of development: the tumor grows into neighboring organs, metastasizes to other organs, and distant lymph nodes are involved in the process. Such tumors are no longer operable. According to the international classification, they are defined as T4, N2-3, M1.

For statistical processing and determination of treatment tactics for patients with malignant tumors, patients are divided into four clinical groups.

• Clinical group I - patients with precancerous diseases. This is a conditionally distinguished group of chronic diseases accompanied by increased cell metaplasia (ulcers, polyps, chronic inflammatory diseases accompanied by proliferation, fibromatosis, adenomatosis, etc.), in which the degeneration (malignancy) of the main benign process into a malignant tumor is most often observed. There are a large number of such diseases, all of them make up a dispensary registration group, according to which the patient is regularly observed and examined by specialists of various profiles. Suspicion of malignancy in these diseases requires a thorough examination using the most informative methods, including biopsy for histological examination.
• Clinical group II - patients with malignant tumors subject to radical surgical removal. Mainly, stages 1-2 of development. Conventionally, stage 3 tumors are also included here, before the oncologists' conclusion on its operability;
• Clinical group III - patients who have undergone radical surgery. They are registered with a specialist in the relevant field. They are required to undergo examination and consult an oncologist at least twice a year to rule out relapses.
• Clinical group IV - these are inoperable patients with stage 3-4 malignant tumor development or its recurrence. Such patients require only conservative symptomatic treatment.

The determination of the stage of tumor development and the relation to the clinical group are treated differentially. This issue is decided after a full and comprehensive examination, including a biopsy, by a council of specialists from the regional or city oncology dispensaries.

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The principle of oncological alertness

Examination of the patient: upon referral, preventive medical examination, during medical examinations - should be aimed at identifying the early stages of malignant tumors, when their radical removal is possible, which gives a clinical effect. But the difficulty of diagnosing early stages lies in the lack of clinical expression: they are painless, small in size, and therefore do not cause functional disorders of the organ in which they are located. Therefore, any specialist should be wary of oncological diseases.

In terms of oncological alertness, annual fluorography is included as a mandatory component; when women visit polyclinics, they are examined in a preventive room - examination of the mammary glands, vaginal examination. But the main burden, of course, falls on general practitioners, who work with patients to a greater extent. Here, the principle of oncological alertness must be strictly followed;

The fact is that the primary tumor from a clonal cell up to 1 cm in diameter grows for five years, and in the last three years it manifests itself in the form of symptoms of "minor signs" caused by cancer intoxication. This, first of all, manifests itself in the atypism of the course of some chronic disease: it becomes persistent, does not respond to schematic treatment, constantly recurs. For example, gastritis - with the appointment of antispasmodics and drugs blocking H-secretion, is completely stopped in 1-3 days - with malignancy, some improvement is noted, but discomfort remains, and after a few days the patient again comes with complaints of exacerbation. Many examples can be given, since the primary tumor has many "masks", but the main thing for suspicion is the persistence and atypicality of the disease. Against this background, there are also subtle symptoms of "minor signs": increased fatigue of the patient, drowsiness, slight weight loss with normal nutrition, social apathy, lack of appetite and a change in attitude to food and smells (for example, patients with lung cancer develop an aversion to tobacco and easily quit smoking, women stop liking the smell of perfume, children are disgusted by sweets that they used to love, etc.). These symptoms can also be caused by other social factors, but they should worry the doctor, how can one not remember the principle of "sensitive and attentive attitude to the patient."

The essence of oncological alertness is as follows: "When a patient with an atypical course of a chronic disease comes to you, exclude cancer, and then look for another cause." All that is needed for this is the doctor's desire.

Modern diagnostic complex allows to detect formations up to 0.5-1.0 cm. If you doubt yourself, refer the patient to an oncologist at the dispensary for consultation.

People over 40 years of age, in whom the processes of anabolism turn into catabolism, should be especially wary of oncological diseases. But in recent years, "cancer is getting younger" - and the age principle has lost its leading significance. The "risk" group comes to the fore: drug addicts, alcoholics, antisocial personalities, etc. Although the "prosperous" have no lower oncological morbidity.

Diagnosis of malignant tumors

Tumor diagnostics are divided into primary, conducted in polyclinics by general practitioners, and clarifying, which is conducted by oncologists - on an outpatient or inpatient basis, not necessarily in oncology dispensaries. In modern conditions, there are all the possibilities to conduct a full and highly informative examination complex, including histological verification of the tumor. Large hospitals themselves have powerful diagnostic equipment, if they do not have it, diagnostic centers have been organized in each region, which allow solving this problem.

Tumor diagnostics, like any surgical disease, is based on anamnesis, examination, physical and instrumental examination. Oncoalergy is an absolute indication for any instrumental examination, but, of course, the most informative ones are chosen. The main objectives of the examination: to determine whether a tumor is developing or a chronic process is malignant, to identify the localization and prevalence of the process, to conduct histological verification of the tumor and differential diagnostics of the primary focus and metastasis, to determine the operability of the tumor and to develop the best option for general treatment. In all cases, of course, tests are performed - clinical and biochemical blood, urine, serological reactions; fluorography of the lungs.

There are few initial data for diagnosing early forms of cancer: atypism of the course of a chronic disease and the presence of symptoms of minor signs, one really needs to be wary. Manifestations of malignancy are brighter: a change in the course of the underlying disease is noted; for example, a stomach ulcer occurs with severe heartburn, while with malignancy, on the contrary, a hypoacid state develops; with malignancy of fibroadenomatosis.of the mammary gland, discharge from the nipple appears, etc.

A more pronounced clinical picture is formed at the 2nd-3rd or already the 4th stage of tumor development. Patients experience progressive and intense weight loss, resulting in a tired and emaciated appearance. The skin becomes dry, acquires a yellowish or grayish tint. There is a pronounced change in taste (for example, with stomach tumors, patients cannot stand even the smell of meat), apathy, fatigue, indifference to their own condition and illness. Against this background, depending on the localization of the tumor, specific signs of an already advanced process appear.

Brain tumors are accompanied by: persistent paroxysmal headaches, frequent short-term loss of consciousness, dizziness, ataxia, vomiting of central genesis (without precursors, not bringing relief), focal symptoms in the form of loss of brain function or cranial nerves. Primary instrumental examination includes: skull radiography, consultative examination by a neurologist, ophthalmologist, ENT doctor, ultrasound echolocation of the brain to detect displacement of midline structures, rheography and electroencephalography of the brain.

A clarifying examination includes: ultrasound Dopplerography of the brachiocephalic vessels and intracranial magnetic resonance imaging - without or with contrast. This method is the most informative of all available. After this, the patient should be consulted by a neurosurgeon or neuro-oncologist, who, usually in a hospital setting, conduct additional studies to verify and determine the operability of the tumor, up to and including diagnostic or decompressive craniotomy.

Tumors of the larynx and pharynx are accompanied by persistent hoarseness or hoarseness of the voice, up to the development of aphonia, difficulty swallowing and choking and coughing, especially when eating. In advanced cases, difficulty breathing appears, especially inhalation, cough with streaks of dark blood, unpleasant smell from the mouth, due to the disintegration of the tumor and the addition of infection, the patient should be consulted by an ENT doctor and ENT oncologist, since the main examination will be carried out by them. The tumor is well / visible during laryngoscopy, at the same time, scarification or puncture biopsy is performed.

If the tumor is black, which is suspicious for Kaposi's sarcoma, tests are performed for AIDS. To determine the spread of the tumor, laryngography, magnetic resonance imaging of the pharynx, bronchoscopy and esophagoscopy are performed.

Esophageal tumors are accompanied by dysphagia; discomfort behind the breastbone, regurgitation, vomiting, salivation, but the main symptom is difficulty in passing food. At first, the patient experiences difficulty in swallowing dry solid foods, then soft foods and, finally, liquids. After swallowing, a persistent feeling of a lump appears behind the breastbone, and after a few hours, vomiting of undigested food may occur. Due to the involvement of the laryngeal, vagus, and sympathetic nerves, esophageal tumors can give "mask symptoms". In this case, reflected pain appears in the neck, chest, spine, heart, abdomen, dysphagia, nausea, regurgitation, heartburn, etc.

Considering that the same clinical picture is given by esophagitis, esophageal diverticula, hernias of the esophageal opening, etc., some therapists prescribe antispasmodics without examination, which relieve symptoms for some time, but this is a gross mistake. For differential diagnosis of these diseases and detection of esophageal tumors, it is enough to conduct two available studies: fibroesophagoscopy with biopsy and esophageal X-ray with contrasting with barium suspension. It is easy to detect an esophageal tumor, but it is difficult to determine its prevalence and operability, due to the complexity of the anatomy and the close connection of the organs of the posterior mediastinum. A small tumor detected during the initial examination does not yet indicate its operability, especially with endophytic growth, it can grow into the aorta, bronchi, spine. This is possible only in specialized departments. The examination complex is quite large and technically complex: double-contrast mediastinography, computed tomography of the mediastinum, bronchoscopy with puncture of the bifurcation lymph nodes, bronchography, aortography, which can only be performed in a hospital setting.

Diagnosis of stomach tumors is complicated by the fact that they most often develop against the background of existing chronic diseases: gastritis, polyps, ulcers, etc. Therefore, in diagnostics, one must be very wary of changes in the course of the disease. Such patients are registered with a dispensary, are included in the "risk" group and are examined at least 4 times a year: FGDS, gastric juice analysis, stool analysis for occult blood (Grigersen reaction).

Symptoms of "minor signs" accompany the development of cancer or malignancy in 80% of cases. As the tumor grows, clear signs appear: a feeling of heaviness in the epigastrium, distension, discomfort, regurgitation, occasionally nausea and vomiting. As the tumor grows, these symptoms increase: nausea and vomiting become daily, then constant, more often in the evening, of food eaten the day before, often foul-smelling, looking like meat slops, often uncontrollable hiccups, salivation. The patient loses weight sharply, the skin acquires an earthy tint, facial features become sharper. If the tumor is located in the pyloric section of the stomach, signs of obstruction develop. In general, the clinical picture of gastric tumors largely depends on their location: the lower from the outlet section the tumor forms and the picture of high obstruction develops, the earlier a diagnosis of cancer can be made; tumors of the cardia are detected very late in most cases. The problem is very serious, and now the question is being raised about mandatory endoscopic examination of the stomach at least once a year, during preventive medical examinations, along with fluorography of the lungs. Preference is given to endoscopy due to its high information content and the ability to immediately take a biopsy of the mucosa during the examination. Of course, to determine the prevalence of the tumor, gastroscopy with contrasting barium suspension, double-contrast laparography, laparoscopy are performed. The clinical picture of lung tumors depends on the localization: in the bronchi - central lung cancer; in the parenchyma - peripheral lung cancer; in the alveolar part of the lung - alveolar cancer, in the pleura - mesoepithelioma.

Clinical manifestations of the initial stages of malignant tumor development are minimal, with the exception of the persistent and recurrent nature of some chronic inflammatory disease - pneumonia or bronchitis, which do occur, covering the tumor with perifocal inflammation. Even during the period of decay, a peripheral tumor manifests itself as a lung abscess. Therefore, for differential diagnosis, a course of anti-inflammatory treatment is initially carried out. Already developed tumors are accompanied by: shortness of breath, persistent cough, sputum with blood streaks; or abundant, foamy, pink in alveolar cancer. Mesoepitheliomas are accompanied by the development of persistent pleurisy or hemopleurisy, which is not amenable to conventional treatment.

Most often, such patients are referred to phthisiologists with suspected tuberculosis, who bear the entire burden of differential diagnostics. The main methods of diagnostics and differential diagnostics are: radiological - radiography and tomography; and endoscopic - bronchoscopy and thoracoscopy. Magnetic resonance imaging provides a clear diagnostic picture.

On radiographs: peripheral tumors are manifested by homogeneous intense darkening of the lung parenchyma, round or irregular in shape, with a clearly defined peribronchial track - compaction of the peribronchial tissue; in central cancer - pronounced compaction of the bifurcation lymph nodes, compaction and deformation of the bronchus and surrounding tissue are determined, atelectasis of the segment or lobe of the lung quickly develops; in alveolar cancers, the altered lung tissue acquires a compacted cellular pattern, the bifurcation lymph nodes are enlarged and compacted (the tumor is hormonally active, therefore it does not give intense darkening, which complicates its diagnosis; mesoepitheliomas are clinically accompanied by the development of pleural syndrome.

Endoscopic diagnostics is very important, since fibrobronchoscopy allows to view the bronchi up to the fourth order, take washing waters for cytosis, and bronchoscopy with a rigid endoscope to perform more complex biopsies - pinching, scarification; to perform a puncture of bifurcation lymph nodes with the collection of material for histology, which allows to verify lung tumors. Thoracoscopy is indispensable for mesoepithelioma and alveolar cancer, since it allows to perform a high-quality examination of the pleural cavity and lung, take a biopsy; and to stop exudation, to perform chemical pleurodesis with talc or aureomycin.

Liver and hepatobiliary tumors are manifested by: a feeling of heaviness in the right hypochondrium; itching of the skin; jaundice, which has a greenish tint, can be transient, depending on the level of organ damage, can have a parenchymatous or mechanical character; early development of dyspeptic phenomena. In all cases, the liver increases in size, becomes dense, lumpy. Liver tumors are often combined with cirrhosis, with the rapid development of liver failure (ascites, esophageal bleeding, hepatic coma). The initial examination should be ultrasound - sonography. The subsequent complex is multifaceted, it is prescribed together with an oncologist.

Colon tumors are most often detected late, when obstructive intestinal obstruction has already developed, for which patients are operated. This is due to the absence of clinical manifestations, except for: clinical features of chronic colitis, the presence of blood streaks in the stool, a positive Grigersen reaction. The same manifestations occur in nonspecific ulcerative colitis (NUC), intestinal polyps. Differential diagnostics and diagnostics of the tumor are based on colonoscopy and irrigoscopy data. Laparoscopy is indicated to clarify the prevalence of the tumor, especially in case of endophytic growth.

Rectal tumors are accompanied by slight bleeding during stool, difficulties with defecation, especially hard stool. Patients do not seek help from surgeons due to the lack of pain, and the use of laxatives allows for improved defecation and stopping bleeding. They are most often detected with concomitant hemorrhoids, prostatitis, which cause pain, which makes you see a doctor. For diagnosis, a digital examination, examination of the rectum with a rectal mirror, rectoscopy and colonoscopy are performed.

Bone tumors are usually detected late, more often with the formation of pathological fractures or the ingrowth of blood and lymphatic vessels, nerves. Tumors are painless, even with a fracture, are characterized by rapid growth and metastasis. Sarcomas are located in the area of bone metaphysis, osteoblastoclastomas in the diaphysis zone. They are often palpated through soft tissues; With vascular ingrowth, an increase in the volume of the limb is noted, sometimes arrosive bleeding with the formation of a hematoma can develop. With nerve ingrowth, sensitivity and weight-bearing ability of the limb are impaired. The diagnosis is made radiologically: with sarcoma - heterogeneous proliferation of the bone metaphysis with the formation of a cellular pattern, detachment of the periosteum in the form of canopies; with osteoblastoclastoma - a defect in bone tissue in the diaphysis of the bone is noted in the area of the bone. Biopsy material is collected by bone puncture or surgical biopsy of the bone tissue itself and regional lymph nodes.

Breast tumors must be differentiated from fibroadenomas, mastopathy, galactocele, cysts, specific infectious processes (syphilis, tuberculosis, actinomycosis). Fibroadenomas and mastopathy can become malignant. Malignant tumors are distinguished from benign processes by: absence of pain during palpation, high density of the formation, tuberculosis, unclear contours, no connection between enlargement and pain and menstruation, there may be peeling and oozing of the nipple, discharge from it, mandatory connection of the formation with the skin or its seeding with small nodes in case of shell cancer.

The patient undergoes: primary examination, X-ray of the mammary gland (mammography), ultrasound examination (sonography of the mammary glands), mandatory full examination by a gynecologist. After this, in any case, they are sent to the oncology dispensary to an oncologist-mammologist. Who will conduct further examination and dispensary observation, even in the case of a benign process.

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Methods of biopsy and verification of tumors

The detected tumor must be verified: its original tissue and structure must be determined, differential diagnostics between the primary focus and metastasis must be performed, and the tumor form must be determined according to the international histological classification. Intravital excision of the tumor for histological examination is achieved using a biopsy. Several methods are used for this purpose.

The most common type of biopsy is surgical biopsy. Tissue sampling: a removed part of an organ, tumor, lymph nodes, in some cases, to ensure the radical removal of the tumor and surrounding tissues, pieces of tissue are taken from the edges before anastomosis is applied. Histological examination is performed with full tissue staining, sometimes using several types, including histochemical and luminescent methods - it is lengthy. The surgeon often requires an immediate result while the patient is on the operating table. In this case, an express biopsy is performed with histological examination of frozen tissues. Although it is not absolutely accurate, it gives all the necessary answers.

Puncture biopsy is achieved using special or regular needles that are inserted into a tumor or lymph node to collect material. Special needles: Silverman, Bigleysen, Tishchenko, Palinka, etc. allow you to get a tissue column sufficient for histological examination - the method is called trepan biopsy. When using regular needles, when tissue is sucked in with a syringe, a very small amount of material is obtained, sufficient only for cytological examination. The method is widely used for tumors of the lungs, liver, bronchi, bones. It is most often used in endoscopies.

Aspiration biopsy involves collecting material by suction of exudate, transudate, and washings for cytological examination from serous cavities and the lumen of hollow organs, such as the bronchi.

Scarification biopsy is often performed during endoscopic examinations or cavity manipulations. The material is obtained by scraping tissue with curettes (for example, from the uterine cavity), brush instruments; the material can be collected by biting off a piece of the tumor with nipper instruments or cutting off the protruding part of the tissue with a loop (for example, a polyp) followed by electrocoagulation. A smear-imprint can be taken directly from the superficial tumor onto glass.