in section Oncology
Stomach cancer Morbidity and mortality rate ranks first among all malignancies (30-38% of malignant tumors of men, 22-29% - women). The indicator of gastric cancer in the 100 000 per year in various countries ranges from 20-30 (Indonesia, Thailand, the United States) to 40-60 (Germany, Italy, Russia), and even up to 70-85 (Japan, Finland, Iceland).
В etiology of gastric cancer a role playing features of life and the power (the nature of the food, its preparation method, temperature, diet). Smoking and consumption of alcohol, especially in its pure form, also increase the risk of stomach cancer. By precancerous diseases include chronic gastritis, polyps, ulcers, and pernicious anemia, which is usually accompanied by chronic atrophic gastritis. However, the majority of gastric tumors occur in relatively healthy people who do not have the listed diseases.
The clinical picture of gastric cancer It is very varied. Depending on the previous state of the stomach to distinguish between three types of clinical disease: 1) cancer, which developed without previous symptoms of diseases of the stomach; 2) cancer in the background gastric ulcer; 3) cancer with chronic gastritis and polyposis.
In the early stage stomach cancer Does not have typical symptoms and most often manifests itself as a "syndrome of small signs": 1) a change in the general well-being of the patient, the emergence of causeless weakness, disability; 2) a persistent decrease in appetite, sometimes complete loss of it up to aversion to food; 3) phenomena of "gastric discomfort" (feeling of heaviness after eating, gasping, sometimes nausea); 4) causeless progressive weight loss; 5) mental depression, expressed in the loss of interest in life, apathy. The syndrome of small signs in stomach cancer is more than in 80% of patients. In 2-3% of observations there are asymptomatic, "silent" forms of stomach cancer. Vomiting, dysphagia associated with food delay, hiccough, pain, bleeding, jaundice, ascites are usually symptoms of a neglected tumor.
Diagnosis of gastric cancer
RџSЂRё the diagnosis of gastric cancer The examination (the color of the skin, the turgor of tissues, the severity of the subcutaneous tissue) and palpation (a tumor in the epigastric region, enlargement of the liver, the appearance of metastases in the supraclavicular area, in the ovaries, the Douglas space) are important. However, the main methods for diagnosing gastric tumors are X-ray examination with barium suspension (the main radiographic signs of stomach cancer - the presence of an additional shadow or filling defect, loss of elasticity and a change in the relief of the stomach wall in the tumor zone), and fibrogastroscopy, in which the material is sampled for morphological examination . Radioisotope and ultrasound studies are conducted to identify possible metastases in the liver and lymph nodes. Laparoscopy allows you to "see" the transition of the tumor to neighboring organs, metastases to the liver, colonization of the peritoneum and thus prevent in vain operation. Diagnostic laparotomy is indicated for patients with suspected gastric cancer, which can not be confirmed or rejected by other methods.
The only radical method of treatment of patients with gastric cancer is timely surgical intervention. In gastric cancer used three main types of radical operations:
- Distal subtotal resection of the stomach, which is performed with exophytic tumors of the distal third of the stomach;
- Proximal subtotal gastrectomy performed with exophytic tumors of the upper third of the organ, which extend to the cardia outlet or esophagus;
- Total gastrectomy, shown in most cases (infiltrative or mixed forms of the tumor, exophytic neoplasms with localization in the middle or upper third of the stomach in the absence of damage to the cardia outlet).
In the transition to the esophagus tumor is of particular importance level of resection, because microscopic tumor borders are visible exceed a few centimeters. In the transition of the tumor to adjacent organs can be performed combined operations (with splenectomy, rezektsitey pancreatic lobe of the liver, transverse colon).
Stomach Cancer Treatment
In the radical surgical treatment of stomach cancer, it is mandatory to remove the large and small omentum, the intersection of the left gastric artery at the point of its deviation from the celiac, the intersection of the duodenum, retreating from the doorkeeper downwards to 2-3. As a result, not only the affected part of the stomach but Regional lymph nodes. In general, radical surgical operations are feasible in less than half of patients with stomach cancer. Only in Japan, where early detection of gastric cancer for many years is carried out under the state program, this percentage reaches 80. Five-year survival of radically operated patients with stomach cancer is 30-40%. The prognosis worsens in the presence of metastases, especially multiple, in the regional lymph nodes *; When invading the muscles of the stomach; In cases of cancer spread beyond the body.
Palliative surgery is performed in cases where radical intervention is not feasible because of the prevalence of the tumor, or due to severe concomitant pathology. Palliative resection of 2 / 3 of the stomach is performed to eliminate stenosis or prevent bleeding from a decaying tumor. Very often, with inoperable gastric cancer, gastroenteroanastomosis, esophagogo-ananastomosis, esophagoduodenoanastomosis, gastrostomy, and the like are superimposed. Palliative resection of the stomach is considered preferable to bypass surgery, as it not only prolongs the life of patients, but also allows additional chemotherapy or immunotherapy, radiation, prevent or delay complications such as stenosis, bleeding, perforation.
Radiation therapy as a component of radical combination treatment is most often used in the form of preoperative irradiation (15-20 fractions according to 2 Gy, operation through 10-20 days). The area of the irradiation includes the area of the stomach in such a way that the boundaries of the fields are not less than 5 cm away from the visible infiltration boundaries. For example, in the case of lesions of the cardia, only the antral section is screened. In addition to the stomach, regions of regional metastasis are irradiated. When radiation treatment of stomach cancer is most often used opposing direct curly fields, sometimes using a three-field technique with the connection of the side field. Such irradiation at 10-20% increases the resectability of tumors and approximately the same extent increases the long-term survival of patients.
Promising is the use of intraoperative irradiation (single remote impact on the tumor bed in a dose 15-30 Gy), which reduces the incidence of local recurrence of the tumor and 5-15% increase long-term survival rates. In the postoperative period using the contact radiotherapy (intravenous or intraperitoneal injection of radioactive colloidal gold - 98Ai).
As a separate type of treatment is radiation therapy for cancer of the stomach can be displayed in the following cases:
- the impossibility of carrying out a radical operation due to local distribution established during laparotomy;
- relapse in the cult of the stomach when it is impossible to quickly remove it;
- inoperable cancer of the cardiac section of the stomach with symptoms of severe dysphagia;
- the presence of distant or unredeemed regional metastases
- the presence of general contraindications to surgical treatment for resectable tumors of the stomach.
In all these cases, radiation therapy is undertaken with purely palliative, and more - with symptomatic purpose, carried out on high-energy systems to the total dose of up to 30 45 Gy and is usually combined with chemotherapy and immunotherapy.
Contraindications to irradiate patients with gastric cancer are severe stenosis of target department, the disintegration of the tumor, accompanied by bleeding, or actual threat thereof, as well as asthma comorbidity.
In recent years, intensive development of methods of radiation therapy on the background of the use radiomodifiers (electron-acceptor compounds, hypoxic gas mixtures, hyperthermia, hyperglycemia). These methods enhance the antitumor effect of the irradiation beam while reducing damage to surrounding normal tissues.
Chemotherapy is used when inoperable stomach cancer, as well as the generalization of cancer. The most common 5-fluorouracil and ftorafur used as mitomycin C, adriablastin and others. The objective positive effect in this case is recorded in 30-50% of patients, and is expressed in reducing tumors and improving the passage of food.
When unresectable gastric cancer using chemoradiotherapy: irradiation in total doses 30-40 Gy with concurrent administration of 5-fluorouracil to 3-6 of Such treatment may be supplemented with immunotherapy, which uses levamisole; polymerized autologous tissue cancer of the stomach, mixed with tuberculin; interleukin-2; Interferons and their inducers; tumor necrosis factor and others.
Overall five-year survival of patients with gastric cancer stage I-II reaches 40-50 even 60%, stage III - 20-33%, while stage IV not more than 5-10% of patients undergoing this period is much rarer, accounting 0,5-3 % of all forms of malignancies.
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