Surgical treatments in oncology
Oncology / / August 12, 2017
Contraindications to surgical treatment of cancer
Indications for surgical treatment
cancer Mistakes during surgery
Survival after cancer surgery
diagnostic operations at
cancer Electrosurgical and cryosurgical treatment of cancer
Surgicalmethods - it's mostly local treatment methods, based mainly on the blade, or electrosurgical excision of the primary tumor malignancy.To surgical methods also include the freezing of tumor tissue, cryosurgery and laser beam to destroy the tumor.
Despite various kinds of mechanical and physical effects, all of these methods primarily pursue the goal of direct removal or destruction of the tumor based on the idea that initially it has a local character.In other words, the surgical techniques are most effective in the treatment of early stages of tumor development.
Currently, almost all tumor localizations may be subjected to surgical treatment.Widely used esophageal cancer surgery, lung, larynx, thyroid, trachea,
In discussing the plan of treatment for each cancer patient, which must necessarily be carried out group of specialists-oncologists (surgeon, radiologist, chemotherapist) determine the indications for use of the method of treatment that can be most effective in this case.It is necessary to take into account the age of the patient, presence of concomitant diseases, localization of cancer, the extent of its prevalence, growth and morphological structure of the tumor.Only an objective discussion of these data can be finally settled the question of the appropriateness of the surgical treatment.
Contraindications to surgical treatment of cancer
contraindication to radical surgical treatment is a generalization of the tumor process - development and dissemination of the appearance of distant metastases, be permanently during surgical intervention.Typically, such a generalization is observed in poorly differentiated cancers occurring biologically extremely aggressive.
contraindication for surgery may also be a general grave condition of the patient, due to the senile age and the presence of uncompensated related chronic diseases of the heart, lungs, liver and kidneys.However, after careful preparation of such patients in a hospital general condition and functional performance are significantly improved, suggesting the ensuing compensation.In such cases, especially for localized tumor process should be re-discuss the possibility of surgery.
Indications for surgical treatment
cancer Surgical treatment is indicated and, as evidenced by the experience, it is most effective under the following conditions.
1. Localization of cancer within a portion of the affected organ (the share segment, sector), when the tumor has not spread beyond the body covering serous membrane or capsule.Upon germination of the latter and the development of metastases in regional lymph nodes of the surgical method is also applicable, however, long-term results in such cases is significantly deteriorated.
2. Exophytic nature of the tumor, as well expressed its borders and tumor site is clearly limited by the surrounding tissue.If the tumor is infiltration without clear boundaries, it greatly reduces the possibility of radical resection, because it is very difficult to determine the true spread of the tumor on the body.In such cases, histological examination of the drug through the remote incision often detect tumor cells.
3. Preserving high tumor cell differentiation, t. E. The presence of a structural pattern of maturity of tumor tissue when compared with normal, although it is less sophisticated, but still retains a measure of its morphological and functional characteristics.In contrast, the prognosis worsens in the surgical treatment of malignant tumors of a low degree of maturity, with the loss of cell differentiation.
4. The slow rate of progression of the tumor, which is determined based on the study of anamnestic data, the results of follow-up, by comparing photofluorogram and radiographs made in previous years with preventive x-rays, design to a spa treatment, applying for a job, and so on. D.There is a certain relationship between the clinical course and morphological characteristics of the tumor.At long, torpid development of the disease, sometimes amounts to many months or even years, there is a high probability of a relatively high degree of maturity of a malignant tumor.For example, clinical course highly differentiated forms of papillary thyroid cancer and malignant intestinal carcinoids can amount to a few years, while the patients with poorly differentiated forms of thyroid cancer, stomach, colon, breast, tend to have a short history of clinically these tumorsproceed very aggressively.On the other hand, the clinical course of malignant tumors, not only due to the degree of maturity of tumor cell elements, but the reactivity, which is very important when choosing a surgical treatment.
Prerequisite surgery for malignant tumors is the observance of the principles of oncological radicalism, providing knowledge of the biological characteristics of the tumor has spread within the affected organ, opportunities to move to adjacent organs and tissues, as well as a clear understanding of the ways of metastasis through the lymphatic collectors.
errors in surgery
Experience shows that surgeons who do not have special training to operate patients with cancer and not having sufficient knowledge of the clinical and biological patterns of cancer development, allow a number of serious mistakes fatally detrimental to the future fate of the patient.
Quite often in skin melanoma produce outpatient, non-radical, cosmetic removal of the tumor, mistaken for "mole", "lentigo" and others. Sometimes, resorting to a biopsy of such education, which is absolutely unacceptable.In breast cancer, the soft tissue of the limbs and trunk are sometimes limited to enucleation of tumor sites, not realizing at the same time an urgent histological examination of tumor tissue removed, although in such cases, it must necessarily be carried out.A common mistake in stomach cancer, colon, larynx, thyroid, cervix, is to perform the operations do not meet fully the principles of oncologic surgery.In particular, it is not always widely removed the surrounding body tissue to the lymph nodes.Even in well-equipped surgical clinics often do not produce histological control via emergency biopsy with resection of the affected organ tumor.Meanwhile, in these cases, the tumor cells through the incision can be detected during a routine histological examination.This indicates that the volume of transactions was identified incorrectly and treatment was non-radical,
Surgery, produced in compliance with oncological radicalism necessarily provide a clear performance of the following principal units.
1. Wide excision of an organ or tissue, from which emanates a malignant tumor.Given the characteristics of the spread of the tumor, the most radical should be considered as total or subtotal removal of the affected organ, such as in breast cancer - its complete removal, gastric cancer - total or subtotal gastrectomy, in lung cancer - pneumonectomy.However, the presence of a limited number of cases, the process allows us to consider it possible to perform operations budget, which removes only the diseased share, sector or segment of the body.For example, if a small-sized lung cancer lobectomy can be performed at the initial thyroid cancer - hemithyroidectomy with the removal of the isthmus, at the circumscribed cancer of the larynx - horizontal or vertical organ resection.Performing such operations, sometimes in combination with radiotherapy or chemotherapy, does not reduce the degree of radical and at the same time is more beneficial functionally.
2. Removal of regional lymph node metastases is an area of potential or already affected by metastases.These regional lymph collectors for breast cancer is axillary and subclavian lymph nodes.The outflow of lymph from the stomach is carried out primarily in the lymph nodes of large and small gland.When the cervix and uterine body cancer lymphogenous metastasis at the first stage is limited and obstructive pool iliac pit.With a view to a more radical resection of lymph vessels and nodes are removed with the surrounding fatty tissue within the enclosing fascial sheath.
3. Removal of the affected organ, regional lymph collector and optionally tissue surrounding produce is usually a single unit, such as the nature of the surgery increases the radical due to the fact that it is not exposed at the surface of the tumor, lymph paths do not intersectand hence reduces the possibility of contamination of the surgical field tumor cells.In order to reduce the so-called handling equipment operating dissemination should be atraumatic, excluding direct contact of the hands of the operating surgeon and surgical instruments with the tumor.All this creates conditions for ablasticheskogo operating, just as aseptic provides preventive measures to avoid contamination of the surgical wound infection.
Survival after cancer surgery
Currently developed standard operation for cancer of various locations that provide the greatest degree of oncological radicalism and highly effective long-term results.So, radical mastectomy with localized forms of breast cancer provides a stable five-year recovery in 70-85% of patients.Extended hysterectomy for cancer of the body in combination with radiation therapy provides a five-year recovery in 74-82% of patients, extended laryngectomy for cancer of the larynx (in terms of the combined treatment) - 60-70%, total and subtotal thyroidectomy with highly differentiated and localized forms of cancerthyroid - at 80-84%.Somewhat worse than the results of surgical treatment of gastric cancer - a five-year survival rate is 35-40%.However, after radical resection of gastric cancer germinating only mucosa and muscle layer, five-year survival rate increases to 70%.Extirpation of the rectum with various forms of cancer as a whole provides a five-year survival rate of 35-40%.After pneumonectomy and lobectomy of all forms of lung cancer 5 years living 25-30% operated.There is no doubt that with the improvement of conditions for early detection of malignant tumors and timely implementation of radical surgery could significantly improve the results of surgical treatment.
Currently, however, surgery is often necessary to perform in less favorable conditions, when the tumor process already has a significant prevalence.Under these conditions, selection of particular importance is the optimal alternative surgical volume.In recent decades, it was an active discussion on this issue.Basically two views discussed.According to the first volume of surgery is determined by the formula: "a small tumor - a big operation, a large tumor - a small operation," ie,for large dissemination of the tumor is useless to rely on radicalism, even expanding the boundaries of surgery.The operation in such cases should be performed as a palliative or trial.According to another point of view, "small tumor requires major surgery, and the tumor is large - even more."Proponents of this view are for the expansion of surgical intervention even during the germination of the tumor to neighboring organs and tissues and the presence of distant, but to remove the oil metastases.They offer to carry out advanced or combined surgeries.Strong arguments in favor of such a large following data are in terms of operations.Past research has shown that a number of patients denied radical treatment due to falsely elevated incidence of cancer.Thus, it was found that 15% of patients after a previously made test thoracotomies about allegedly inoperable lung cancer managed with repeated interventions to perform radical surgery, more than 20% of patients with gastric cancer were also wrongly considered inoperable during laparotomy.These patients were more radically operated on by experienced surgeons-oncologists.
According to postmortem studies of dead late after typical by volume, the so-called radical surgery for lung cancer, nearly half of the cases reveal recurrences and metastases as a result of insufficient adequate level of operations.Thus, expanding the boundaries of reasonable surgical intervention, even with common forms of cancer, you can actually assist even more patients.The growing use of combined treatment, supplementing surgery using radiant energy or chemotherapy, allowing a permanent cure to improve performance.
extreme position occupied by surgeons performing the so-called superradical operations in far advanced forms of internal cancers.For example, when performing advanced cancer of the stomach total gastrectomy, resection of the colon, of the left lobe of the liver, pancreas, spleen and the percentage removal of the lung, where there is metastasis.In advanced cancer of the uterus produces a so-called pelvic evisceration - removal of the uterus, rectum, bladder, ureters with a change in the sigmoid colon.The same extensive surgery is performed while running Cancer language and floor of the mouth - the removal of the language, mandible resection, removal of muscle floor of the mouth, pharynx resection, excision of the larynx and metastases in the lymph nodes of the neck.
superradical Sometimes these operations are seriously debilitating and crippling the patient.Such, for example, half of the isolation of the shoulder girdle and lower limbs along with half the large bones of the pelvis.Physiological and psychological rehabilitation of patients after such surgery is very challenging.The study of long-term results after such operations superradical causes very reserved attitude to their performance.However, in some cases, they are justified and can be undertaken by well-trained surgeons with the necessary conditions (sophisticated equipment, specialists in anesthesiology and rehabilitation).
Along with the implementation of radical surgery for cancer produce so-called palliative surgery.Perhaps in no surgery is not performed so many palliative surgery, in oncology, in connection with still a large number of patients identified in the later stages of the disease.
Palliative operations can be divided into two categories.