Tumors

Tumors - excess, uncoordinated with the body, pathological growth of tissues, continuing after the cessation of the causes that caused it.

Tumors are divided into benign and malignant, although benign tumors can be malignant. The main difference is the maturity of the tumor cells. If benign cells are completely ripe, with normal structure and metabolism differ only in randomness of location, then malignant cells begin the process of division with incomplete maturation (atypism), and this property is transmitted genetically to the offspring. The earlier the tumor cell begins its division, i.e. The less it is differentiated; the tumor is malignant, which is important for its verification.

How does the tumor develop?

A distinctive feature of malignant cells is their autonomy - they can live apart from the tissue from which they originated; moreover, these cells loosely associated with the tumor easily come off, so they can penetrate the blood and spread throughout the body. In other tissues, they easily settle down, forming a metastasis, and retain the properties of the maternal tissue from which they occurred (for example, metastatic cells of the cancer of the gastric mucosa in the lungs release hydrochloric acid, etc.). This is also important for their verification; because often the primary tumor is latent, and metastasis gives a vivid clinical picture. Rapid and early division of malignant cells, provides rapid growth of the tumor. Cells, because of their weak differentiation, easily penetrate the intercellular spaces into other tissues, replacing their healthy cells. This provides invasive growth of the tumor with germination in other tissues, including in the nervous tissue, which determines the painlessness of the tumor, as the nerve endings die.

Energy exchange of malignant cells is extremely high, energy and nutrient intake is 10-15 times higher than that of normal cells. They literally capture all the nutrients that enter the body, violate the neurohumoral regulation and homeostasis. As a result, fast weight loss occurs, and then exhaustion of the patient, up to cachexia. The energy reserves of the body are rapidly depleted, because of the cancerous intoxication with metabolic products, the appetite disappears in patients, nutrient absorption by tissues is disrupted, catabolism is formed. Squeezing and germinating through the vessels, tumors turn off the parts of the body from the circulation with the development of their own decay, starting from the center. Often associated pyogenic microflora, which gives additional intoxication and forms a pain syndrome.

With external examination and palpation benign tumors: rounded, elastic, soft consistency, mobile, can be moderately painful, the skin above them and surrounding tissues, if they are not squashed by the tumor, are not changed, the tumors are encapsulated. Another picture with malignant tumors: they are very dense, "stony" consistency, absolutely immobile, painless on palpation, closely connected with the skin in the outer position, the color differs from the surrounding tissues - they are whitish or, on the contrary, dark, can ulcerate. When malignancy of benign tumors, for example, melanoma is noted: its darkening, compaction, rapid growth of strands from the underlying tumor, adhesion to the skin, i.e. Obvious 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, on the basis of their histological differences. In clinical practice, the nomenclature of tumors is used, which is defined as a clinical classification.

Diagnosis of a benign tumor

The diagnosis of a benign tumor is formed according to the following principle. Indicate: the source of tumor development (cell, tissue, organ); its belonging to a segment or anatomical area of the body. At one site, the suffix "ohm" is attached to the name of the tissue, at multiple sites - "oz". For example, hip lipoma, shoulder osteoma, brush ganglion, breast fibromatosis, and the like. Either the diagnosis is formed indicating the relationship with a particular organ: for tumors of the thymus gland - thymoma, meningioma, etc. -

The nomenclature of malignant tumors is considerably more complicated due to the diversity of localization, histological species, prevalence. If morphologists manage to verify the tumor, then the diagnosis is made by its histological accessory, for example, adenoblastoma of the stomach, etc. If verification fails, take into account the tissue from which the tumor occurred. Tumors that develop from epithelial tissue are called "cancer" or "cancer", for example, stomach cancer, lung cancer, etc. If the growth of the tumor comes from the glandular tissue, they are called "scirrus." Tumors from the connective, bone, muscle, nerve tissues are called "sarcomas", for example, sarcoma of the thigh, sarcoma of the spine, etc. Some classifications indicate tumor growth relative to the lumen of the hollow organ: endophytic growth is directed deep into the wall of the organ with subsequent germination into neighboring organs; exophytic growth is directed into the cavity of the organ - the stomach, bladder, pharynx, bronchus, intestine; growth with capture of 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 suggest additionally to introduce into the international classification histopathological gradation (G-gradus - determined by the degree of cell differentiation, pT - by the state of the primary tumor, P - by the degree of germination walls of a hollow organ), but it has not yet been fully developed and accepted at the international level by a conciliation commission. On the development and prevalence of tumors are divided into four stages of development.

• The first stage of development - the tumor does not go beyond the limits of the organ wall, organ lymph nodes can be involved in the process, there are no metastases. According to the international classification - T1, N1, M0.
• 2 nd stage 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.
• The third stage of development - the tumor goes 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. Lymphonoduses are affected only regional, distant are free (for example, axillary lymphonoduses at a tumor of a mammary gland). There are no metastases.

According to the international classification - T3, N2-3, M0: This stage is still operable, but the operation by volume is huge, often it is possible to perform only a conditional-radical operation with removal of the main focus, but not all surrounding tissues and regional lymph nodes. Survival, as a rule, is not more than five years.

• The fourth stage of development of the tumor sprouts into neighboring organs, metastasizes to other organs, the process involves distant lymph nodes. Such tumors are already inoperable. According to the international classification, they are determined by T4, N2-3, M1.

For statistical processing and determining the tactics of managing patients with malignant tumors, patients are divided into four clinical groups.

• I clinical group - patients with precancerous diseases. This conditionally isolated group of chronic diseases, accompanied by increased metaplasia of cells (ulcers, polyps, chronic inflammatory diseases accompanied by proliferation, fibromatosis, adenomatosis, etc.), in which the most frequent malignant transformation of the main benign process into a malignant tumor. There are a lot of such diseases, they all make up a dispensary group of records, 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 techniques, including a biopsy for histological examination.
• II clinical group - patients with malignant tumors, subject to radical operational removal. Basically, 1-2 stages of development. Conventionally, tumors of the third stage of development are also included here, before the conclusion of oncologists about its operability;
• III clinical group - patients operated radically. Are on dispensary account with a specialist of the appropriate profile. Must be examined and consulted by an oncologist at least 2 times a year to avoid relapse.
• IV clinical group - is inoperable patients with a 3-4 stage of malignant tumor development or with its relapse. Such patients require only conservative symptomatic treatment.

To determine the stage of development of the tumor and the relation to the clinical group are differentiated. This issue is solved after a full and comprehensive examination, including a biopsy, by a consultation of specialists from the oblast or city oncology dispensaries.

[1], [2], [3], [4]

The principle of oncological alertness

Examination of the patient: in case of treatment, preventive medical examination, during clinical examinations - it should be aimed at revealing the early stages of development of malignant tumors, when their radical removal is possible, which gives the clinical effect. But the difficulty of diagnosing the early stages is not the severity of the clinical picture: they are painless, small in size, so do not cause functional disorders of the organ in which they are located. Therefore, any specialist should be wary of oncological diseases.

In the plan of oncological alertness, as an obligatory component, annual fluorography is included; when visiting polyclinics by women, they conduct their examination in the preventive room - examination of the mammary glands, vaginal examination. But the main burden, of course, falls on general practitioners, who are more likely to work with patients. Here the principle of oncological alertness must be carried out rigorously;

The fact is that the primary tumor from a clonal cell to 1 cm in diameter grows for five years, and in the last three years it gives manifestations in the form of symptoms of "small signs" caused by cancer intoxication. This, first of all, manifests itself in the atypism of the course of a chronic disease: it becomes stubborn, does not lend itself to schematic treatment, constantly recurs. For example, gastritis - with the appointment of antispasmodics and drugs blocking H-secretion, it stops in 1-3 days completely - with malignancy, there is some improvement, but the discomfort remains, and after a few days the patient again comes with complaints of exacerbation. There are many examples to give, since the primary tumor has many "masks", but the main thing for suspicion is the persistence and atypicality of the disease. Against this backdrop, unobtrusive symptoms of "small signs" are superimposed: fatigue of the patient, drowsiness, a small weight loss with normal nutrition, social apathy, lack of appetite and a change in attitude towards food and odors (for example, in patients with lung cancer there is aversion to tobacco and it is easy quit smoking, women do not like the smells of perfume, children dislike the sweet, which used to be loved, etc.). These symptoms can also be caused by other social factors, but should disturb the doctor, how not to recall the principle of "sensitive and attentive attitude toward the patient."

The essence of oncological alertness is as follows: "When a patient with an atypical course of a chronic illness is treated, the cancer is excluded, and then look for another reason." For this you need only the desire of a doctor.

The modern complex of diagnostics allows to reveal formations up to 0,5-1,0 cm. If in doubt, refer the patient to a consultation with an oncologist at the dispensary.

Particularly greater caution in regard to cancer should be in people over 40 years of age, in which the processes of anabolism are catabolic. But in recent years - "cancer is younger" - and the age principle has lost its leading importance. The group of "risk" comes to the fore: drug addicts, alcoholics, antisocial personalities, etc. Although the "safe" cancer incidence is not lower.

Diagnosis of malignant tumors

Diagnosis of tumors is divided into primary, conducted by general practitioners in polyclinics, and specifying which oncologists are conducting - outpatient or in hospitals, not necessarily in oncology dispensaries. In modern conditions, there are all possibilities to conduct a complete and highly informative examination complex, including histological verification of the tumor. Large hospitals themselves have powerful diagnostic equipment, if not, diagnostic centers are set up in each region to solve this problem.

Diagnosis of tumors, as well as of any surgical disease, is based on data of anamnesis, examination, physical and instrumental examination. Onkostorozhennost is an absolute indication for any instrumental research, but, of course, choose the most informative. The main objectives of the survey are to determine whether there is tumor development or malignancy of the chronic process, to reveal 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, perform tests - clinical and biochemical blood, urine, serological reactions; Fluorography of the lungs.

The initial data for diagnosis of early forms of cancer are few: atypism of the course of a chronic disease and the presence of symptoms of small symptoms, one really needs to be wary. Manifestations of malignancy are brighter: there is a change in the course of the underlying disease; for example, the stomach ulcer proceeds with severe heartburn, with malignancy, on the contrary, a hypoacidic condition develops; when the fibroadenomatosis of the milk gland is malignant, there are discharge from the nipple, etc.

A more pronounced clinical picture is formed at the 2-3 rd or already 4 th stage of tumor development. In patients, progressive and intensive weight loss is noted, resulting in a tired and emaciated appearance. The skin becomes dry, acquires a yellowish or grayish hue. There is a marked change in taste (for example, with stomach tumors, patients do not tolerate even the smell of meat), apathy, fatigue, indifference to one's own condition and illness. Against this background, depending on the location of the tumor, there are specific signs of the already started process.

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

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

Tumors of the larynx and pharynx are accompanied by persistent hoarseness or hoarseness of the voice, until the development of aphonia, difficult swallowing and choking and coughing, especially when eating. In deep-seated cases, there is difficulty breathing, especially inhaling, coughing with an admixture of veins of dark blood, unpleasant tasks of the mouth, due to the disintegration of the tumor and the infection, the patient should be consulted by an ENT doctor and an ENT oncologist, since the main examination will be carried out by them . The tumor is well / visible in laryngoscopy, while also performing a scarification or puncture biopsy.

If the tumor is black, which is suspicious of Kaloshi's sarcoma, tests are performed for the presence of AIDS. To determine the prevalence of the tumor, laryngography, magnetic resonance tomography of the pharynx, bronchoscopy and esophagoscopy are performed.

Tumors of the esophagus are accompanied by dysphagia; unpleasant sensations behind the breastbone, regurgitation, vomiting, drooling, but the main symptom is difficulty in passing food. At first, the patient experiences difficulty in swallowing dry solids, then soft food and, finally, liquids. After swallowing behind the sternum there is a persistent feeling of a lump, after a few hours there may be vomiting of undigested foods eaten. Due to the involvement of the laryngeal, vagus, sympathetic nerves in the process, the tumors of the esophagus can give "mask symptoms". In this case, there are reflected pain in the neck, chest, spine, heart, abdomen, dysphagia is formed, nausea, regurgitation, heartburn, etc.

Given that the same clinical picture is given by esophagitis, esophageal diverticula, esophageal hernia, etc., some therapists without examination prescribe antispasmodics, which for a while remove symptoms, but this is a gross mistake. For differential diagnosis of these diseases and detection of a tumor of the esophagus, it is enough to conduct two available studies: fibroesophagoscopy with biopsy and fluoroscopy of the esophagus with contrasting barium suspension. It is easy to detect a tumor of the esophagus, but to determine its prevalence and operability is difficult, due to the complexity of the anatomy and close connection of the organs of the posterior mediastinum. A small tumor, revealed during the primary examination, does not yet indicate its operability, especially when endophytic growth, it can germinate into the aorta, bronchi, spine. This is possible only in specialized offices. The examination complex is quite large and technically complex: a two-contrast mediastinography, a mediastinum tomography of the mediastinum, bronchoscopy with puncture of bifurcation lymph nodes, bronchography, aortography, which can be performed only in a hospital.

Diagnosis of stomach tumors is complicated by the fact that they often develop against the background of already existing chronic diseases: gastritis, polyps, ulcers, etc. Therefore, in diagnostics, it is very cautious to treat the course of the disease. Such patients are put on dispensary records, classified as "risk" and examined at least 4 times a year: FGS, analysis of gastric juice, analysis of feces for latent blood (Grigersen reaction).

Symptoms of "small signs" accompany the development of cancer or malignancy in 80% of cases. As the tumor grows, there are clear signs: a feeling of heaviness in the epigastrium, raspiraniya, discomfort, regurgitation, and occasionally nausea and vomiting. As the tumor grows, this symptomatology grows: nausea and vomiting become daily, then persistent, more often in the evening, eaten on the eve of food, often fetid, has the appearance of meat slops, often indomitable hiccups, drooling. The patient sharply grows thin, the skin acquires an earthy shade, the features are sharpened. When the tumor is located in the pyloric part of the stomach, signs of obstruction develop. In general, the clinic of stomach tumors largely depends on their location: the lower from the output department the tumor forms and the picture of high obstruction develops, the earlier can be diagnosed with cancer; Cardiac tumors in most cases are detected very late. The problem is very serious, and now the question is raised about the mandatory endoscopic examination of the stomach at least once a year, with preventive medical examinations, along with lung fluorography. Preference for endoscopy is given due to the high informativeness and the ability to immediately take a biopsy specimen from the mucosa. Of course, to determine the prevalence of the tumor perform gastroscopy with contrasting barium suspension, two-contrast laparography, laparoscopy. Clinic of lung tumors depends on the location: in bronchi - central lung cancer; in the parenchyma - peripheral lung cancer; In the alveolar part of the lung, alveolar carcinoma, in the pleura - mesoepithelioma.

Clinical manifestations of the initial stages of development of a malignant tumor are minimal, except for the persistent and recurrent nature of the course of some chronic inflammatory disease - pneumonia or bronchitis, which actually occur, covering the tumor with perifocal inflammation. Even in the period of disintegration, the peripheral tumor manifests itself as a lung abscess. Therefore, for differential diagnostics, a course of anti-inflammatory treatment is first conducted. Already developed tumors are accompanied by: dyspnea, persistent cough, sputum with blood veins; or abundant, foamy, pink in the case of alveolar cancer. Mesoepithelioma is accompanied by the development of persistent pleurisy or hemoplethritis, which is not amenable to usual treatment.

Most often, these patients are referred to tuberculosis clinics with suspicion of tuberculosis, on which the entire burden of differential diagnosis lies. The main methods of diagnosis and differential diagnosis are: X-ray - X-ray and tomography; and endoscopic - bronchoscopy and thoracoscopy. A clear diagnostic picture is provided by magnetic resonance imaging.

On X-rays: peripheral tumors are manifested by a homogeneous intense darkening of the pulmonary parenchyma, of round or irregular shape, with a pronounced peribronchial lining-sealing of peribronhial tissue; in central carcinoma - pronounced compaction of bifurcation lymph nodes, compaction and deformation of the bronchus and surrounding tissue, rapid development of atelectasis of the segment or lobe of the lung; in alveolar cancers, the modified pulmonary tissue acquires a densified cellular pattern, the bifurcation lymph nodes are enlarged and compacted (the tumor is hormonally active, therefore it does not give an intensive darkening, which makes it difficult to diagnose; mesoepitheliomas are clinically accompanied by the development of pleural syndrome.

Endoscopic diagnosis is very important, as fibrobronchoscopy allows you to view the bronchi up to the fourth order, take rinsing water for cytosis, and bronchoscopy with a hard endoscope to perform more complex biopsies - pinch, scarification; to puncture the bifurcation lymph nodes with the fence of the material on the histology, which allows verifying the lung tumors. Thoracoscopy is indispensable for mesoepithelioma and alveolar cancer, since it allows a qualitative examination of the pleural cavity and lung, and a biopsy; and for the relief of exudation, a chemical pleurodesis is produced by talc or aureomycin.

Tumors of the liver and hepatobiliary zone are manifested: a feeling of heaviness in the right hypochondrium; itching of the skin; jaundice, which has a greenish tinge, can be transient, depending on the level of organ damage, can be parenchymal or mechanical; early development of dyspepsia. In all cases, the liver increases in size, becomes dense, tuberous. Liver tumors are often combined with cirrhosis, with rapid development of hepatic insufficiency (ascites, esophageal bleeding, hepatic coma). The initial research should be ultrasound - sonography. The subsequent complex is multifaceted, it is appointed together with the oncologist.

Tumors of the large intestine are often detected late, already with the development of obturation intestinal obstruction, in connection with which patients are operated. This is due to the lack of clinical manifestations, except: clinics of chronic colitis, the presence of blood veins in the stool, the positive reaction of Grigersen. The same manifestations occur with ulcerative colitis (NNC), polypus of the intestine. Differential diagnosis and diagnosis of tumors are based on colonoscopy and irrigoscopy data. To clarify the prevalence of the tumor, especially with endophytic growth, laparoscopy is indicated.

Tumors of the rectum are accompanied by nevolnymi bleeding during the stool, difficulties in defecation, especially hard stool. Patients do not seek the help of surgeons because of the absence of pain, and the use of laxatives allows to achieve improvement of defecation and relief of bleeding. They are more often detected with concomitant hemorrhoids, prostatitis, which give pain, which makes it necessary to consult a doctor. For diagnosis, finger examination, rectal examination with a rectal mirror, sigmoidoscopy and colonoscopy are performed.

Tumors of the bones are usually detected late, more often with the formation of pathological fractures or germination of the blood and lymph vessels, nerves. Tumors are painless, even with a fracture, characterized by rapid growth and metastasis. Sarcomas are located in the area of metaphyses of bones, osteoblastoklastomy in the diaphysis zone. Often palpable through soft tissue; With the growth of the vessels there is an increase in the limb in the volume, sometimes there may be an arrosive bleeding with the formation of a hematoma. With the germination of the nerve, the sensitivity and limb tolerance is impaired. The diagnosis is roentgenologically: with sarcoma - a non-uniform expansion of the metaphysis of the bone with the formation of a cellular pattern, detachment of the periosteum in the form of visors; with osteoblastoklastomoe - in the area of the diaphysis of bone there is a defect of bone tissue in the form of "eaten sugar." The biopsy material is taken by bone puncture or by operating biopsy of the bone tissue itself and regional lymph nodes.

Tumors of the breast must be differentiated with fibroadenomas, mytopathies, galactocele, cysts, specific infectious processes (syphilis, tuberculosis, actinomycosis). In this case, fibroadenomas and mastopathy can be malignant. Malignant tumors from benign processes differ: absence of pain during palpation, high density of formation, tuberosity, fuzzy contours, lack of connection of increase and soreness with menstrual processes, can be peeling and wetting of the nipple, discharge from it, obligatory association of education with skin or its seeding with small nodes with carapaceous cancer.

The patient is given: primary examination, breast x-ray (mammography), ultrasound examination (sonography of mammary glands), mandatory full examination with a gynecologist. After that, in any case, send to oncodispenser to the oncologist-mammologist. Which will conduct further examination and dispensary observation, even in a benign process.

[5], [6],

Methods of biopsy and verification of tumors

The detected tumor should be verified: its initial tissue and structure was determined, differential diagnosis between the primary focus and metastasis was made, the tumor shape was determined according to the international histological classification. Intravital excision of the tumor for histological examination is achieved by biopsy. Several methods are used for this purpose.

The most commonly performed surgical biopsy. Tissue removal: the removed part of the organ, tumors, lymph nodes, in some cases, for the reliability of radical removal of the tumor and surrounding tissues, before the application of anastomosis, pieces of tissue are taken from the edges. Histological examination is carried out with complete staining of the tissues, sometimes using several species, down to histochemical and luminescent methods - it is long-lasting. The surgeon often needs immediate results while the patient is on the operating table. In this case, an express biopsy is performed with a histological examination of frozen tissues. It is not absolutely accurate, but it gives all the necessary answers.

Puncture biopsy is achieved with the help of special or conventional needles, which are injected into a tumor or lymph node with a material fence. Special needles: Silverman, Bigleysen, Tishchenko, Palinka, etc., make it possible to obtain a column of tissue sufficient for histological examination - the method is called trepanobiopsy. When using conventional needles, when tissue suction is produced using 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. More often it is used in endoscopy.

Aspiration biopsy consists in taking the material by suctioning exudate, transudate, washing water for cytological examination from serous cavities, lumen of hollow organs, for example, bronchi.

Scarification biopsy is more often performed with endoscopic examinations or with cavitary manipulations. The material is obtained by scraping the tissues with curettes (for example, from the uterine cavity), bristle tools, the sampling of the material can be performed by biting a piece of tumor with a cutting tool or cutting a protruding part of the tissue with loops (eg a polyp) followed by electrocoating. You can take a smear-imprint directly from the surface tumor on the glass.