《外科学总论》课件：肿瘤学概论

1、肿瘤学概论,恶性肿瘤发病率（北美）,Cancer Statistics, 2011. CA CANCER J CLIN 2012.,恶性肿瘤死亡率（北美）,恶性肿瘤发病率（中国）,2014年4月14日中国肿瘤登记中心,恶性肿瘤死亡率（中国）,2014年4月14日中国肿瘤登记中心,肿瘤定义,肿瘤（tumour）是机体细胞在不同致癌因素长期作用下，在基因水平上失去了对其生长的正常调控而致的克隆性异常，所形成的新生物叫肿瘤。,肿瘤分类,良性肿瘤 恶性肿瘤 癌（Carcinoma） 肉瘤（Sarcoma） 交界性肿瘤,良性肿瘤与恶性肿瘤的区别,肿瘤病因,病毒Viruses (DNA and RNA V

2、iruses) 化学性因素Chemical Factors 物理因素Physical Factors 激素Hormonal Factors 饮食因素Diet and Energy Intake 遗传因素Cancer Genetics (Hereditary factors),癌前病变（Pre-malignant Lesion）,癌前病变 恶性肿瘤 隐睾(cryptorchidism) 睾丸癌 家族性结肠息肉病(HNPCC) 结肠癌 溃疡性结肠炎(UC) 结肠癌 恶变倾向黑痣(Nevus) 黑色素瘤 粘膜白斑病（leukoceratosis） 鳞状细胞癌 多发性内分泌瘤（MEN） 甲状腺髓样癌,

3、恶性肿瘤的侵袭和转移,Invasion and Metastasis The important factors Loss of cell-cell adhesion Fibronectin（纤连蛋白） laminin(层粘连蛋白) Production of proteolytic enzymes Metalloproteinases family,肿瘤转移途径,Direct Extension Lymphatic Spread Vascular Spread Spread through Serous Cavities,常见恶性肿瘤的转移器官,肿瘤的三级预防,1/3 patients ar

4、e preventable 1/3 patients are curable 1/3 patients are prolonged their life and decreased their pain Three grade of Cancer Prevention Grade I: Etiological Prevention Grade II: Early Detect, Early Diagnose, Early Treat Grade III: Improve patients life quality,肿瘤一级预防,Preventing Tobacco-Related Cancer

5、s Diet and Chemopreventive Agents: Fat: Breast Cancer, Colon Cancer, Prostate Cancer and other Cancer Aspirin and Other Nonsteroidal Antiinflammatory Drugs and the Risk of Cancer Development Physical Activity and Body Weight Immunological prevention,肿瘤筛查,大肠癌 胃癌 宫颈癌. 手段 内镜，血液学，影像学，基因学.,肿瘤常见临床表现-局部表现,

6、肿块 疼痛 溃疡 出血 梗阻 其他,肿瘤常见临床表现-全身表现,贫血 低热 消瘦 恶液质 系统功能紊乱,肿瘤诊断,病史 体格检查 视诊 触诊 叩诊 听诊,举例：乳房的体格检查,橘皮症,举例：乳房的体格检查,肿瘤诊断,实验室诊断 血常规 ，尿常规，粪便常规 痰液 胸腹水 胃液，肠液，胰液 血清学检查：激素，碱性磷酸酶.,肿瘤诊断,实验室诊断 免疫学检查 AFP CEA CA199 CA125 PSA 铁蛋白. 流式细胞仪 基因诊断(BRCA1与BRCA2),肿瘤标志物分布图,BRCA1与BRCA2(乳腺癌70%，卵巢癌45%),肿瘤诊断的影像学检查Ultrasonography,Ultrason

7、ography is particularly suitable for the following patient groups: Liver, gallbladder, spleen and pancrease Retro-peritoneal Kidney and adrenal gland Breast and thyroid Ultrasound observations Boundaries and shape Internal echoes Posterior shadowing,肿瘤诊断的影像学检查Computed Tomography,Liver and gallbladde

8、r Pancreas and spleen Kidney and Adrenal Gland Small Bowel and Colon Esophagus and Stomach Lungs and Mediastinum Musculoskeletal System Central Nervous System,肿瘤诊断的影像学检查Magnetic Resonance Imaging,Brain, Spine Head and Neck Breast Liver Adrenal Glands, Kidney Uterus, Ovary Prostate, Bladder Musculosk

9、eletal System,其他影像学检查,Functional and Metabolic ImagingPositron Emission Tomography (PET) Interventional Radiology Radionuclide Imaging,内镜检查: Endoscopy,Upper Gastrointestinal Endoscopy Endoscopic Ultrasonography Signoidoscopy, Colonoscopy Laparoscopy Endoscopic Retrograde Cholangiopancreatography Sma

10、ll Intestinal Endoscopy: Enteroscopy Percutaneois Endoscopic Gastrostomy Bronchoscopy Mediastinoscopy Thoracoscopy,肿瘤诊断金标准病理学,细胞学 印片，毛刷，细针穿刺（FNA）. 组织学 粗针穿刺 切除活检 切取活检,肿瘤分期（UICC TNM分期）,肿瘤治疗,肿瘤治疗原则 根治性切除肿瘤 延长生存期 改善生活质量,肿瘤治疗手段,Surgery Radiotherapy Chemotherapy Hormonal therapy Immunotherapy Gene therapy

11、 Biological modifiers,肿瘤外科治疗的目的分类,Diagnosis and staging Curative Removal of metastatic disease Palliation Prevention Reconstruction,肿瘤根治性手术,Cancer surgery has been based upon the concept that cancer begins as a local disease and spreads in an orderly fashion from the primary site to adjacent tissues

12、 by direct extension to the regional lymph nodes by lymphatics and through the blood vessels. The surgical procedure was designed to remove the primary neoplasms and the usual contiguous routes of spread with aim of removing every cancer cell from the body.,根治性手术的基本原则,去除全部肿瘤组织 避免脱落肿瘤细胞的种植，把医源性的、淋巴管和

13、血管的播散，减到最小程度 使切除的原发瘤周围保持一个完整的正常组织缘,原发瘤周围的全部切缘应保持有正常组织 切缘情况不能确定时应采用冰冻切片检查 切除全部累及的区域淋巴结 切除累及的邻接器官 整块切除活检区域和肿瘤窦道,肿瘤外科治疗原则,不切割原则：手术中不直接切割癌肿组织，由四周向中央解剖，一切操作均应远离癌肿的正常组织中进行 整块切除原则：将原发病灶和所属区域淋巴结作连续性的整块切除，而不应将其分别切除 无瘤技术原则： 无瘤技术的目的是防止手术过程中肿瘤的种植和转移。其主要内容为手术中的任何操作均不接触肿瘤本身，包括局部的转移病灶,肿瘤外科治疗优点,肿瘤对外科切除没有生物抵抗性（0级动力学

14、） 外科手术没有潜在的致癌作用 治疗效果不受肿瘤异质性的影响 外科能治疗很大一部分没有扩散的实体瘤 提供准确的肿瘤病理分期和组织学特征,缺点,切除术对肿瘤组织并无特异性，即正常组织和肿瘤组织同样受到破坏 外科治疗可能出现威及生命的并发症，并可造成畸形和功能丧失 肿瘤如果超越局部及区域淋巴结时不能用手术治愈,肿瘤外科治疗原则,不切割原则：手术中不直接切割癌肿组织，由四周向中央解剖，一切操作均应远离癌肿的正常组织中进行 整块切除原则：将原发病灶和所属区域淋巴结作连续性的整块切除，而不应将其分别切除 无瘤技术原则： 无瘤技术的目的是防止手术过程中肿瘤的种植和转移。其主要内容为手术中的任何操作均不接触

15、肿瘤本身，包括局部的转移病灶,术前准备,根治性手术前必须确诊，必要时在术中行快速冰冻切片争取病理学诊断 估计肿瘤的范围和分期，充分估计手术切除的可能性，是根治性切除还是姑息性切除 正确选择手术适应证和禁忌证 正确估计机体的状况和手术可能造成的影响,掌握适应症,良性肿瘤和交界性肿瘤 实体瘤尚局限于原发病灶及区域淋巴结，或邻近器官虽受侵犯但可一并切除者 肿瘤固定无法局部切除，但可连同受累肢体一并切除 原发病灶已控制的单发转移瘤，如肺、脑、肝转移瘤 晚期肿瘤已无法根治，但因并发出血、梗阻、穿孔、顽固性疼痛等可用手术姑息性治疗,排除禁忌症,机体一般情况差，恶病质，严重贫血，严重营养代谢紊乱，不能耐受大

16、手术者 年老体弱不能耐受大手术 重要脏器功能障碍 肿瘤浸润固定，不能连同受累器官或肢体一并切除者 肿瘤广泛转移者,术中防止肿瘤种植和转移的措施,活检后重新消毒铺巾，更换器械 切口暴露充分，便于操作 用厚纱布巾保护切口和创面，以防肿瘤细胞种植 术中探查应先远后近，最后探查肿瘤 术中尽量用锐性分离，少用钝性分离 先结扎输出静脉，后处理供应动脉，防止术中癌细胞进入循环血流 术中动作轻巧，避免挤压肿瘤,肿瘤放疗,Definition The treatment of disease with ionizing radiation produced by linear accelerators or b

17、y cobalt-60 teletherapy units /brachytherapy uses high-energy x-rays or gamma rays with peak photon energies above 1 MeV Objection damage cancer cells and stop them from growing and dividing A local treatment,放疗,External radiation Internal radiation,肿瘤放疗计划实施,Obtain CT Scans Define Target Area Establ

18、ish Irradiation Field Construct 3D Image Create Blocks Confirm Dose Distribution,放疗治疗疗效影响因素,Radiosentivity of the primary tumor Volume of the tumor Site of the tumor,肿瘤化疗,The role of chemotherapy Adjuvant chemotherapy Neo-adjuvant chemotherapy Palliative chemotherapy High-dose chemotherapy,Adjuvant

19、chemotherapy辅助化疗,Rational for adjuvant therapy Subclinical metastases, therapy directed at the primary tumor is not helpful, Systemic therapy after surgery, at a time when patients are clinically free of disease but are at high risk of having residual micrometastases. Two types of systemic approache

20、s are effective, chemotherapy (cytotoxic agents) and hormone therapy.,Palliative chemotherapy姑息化疗,Benefits: Metastatic breast cancer is very treatable and is one of the solid tumor most responsive to cytotoxic chemotherapy. Patients will survive logner and enjoy better quality of life,化疗药物,Alkylatin

21、g agents (CTX) Intercalators (Anthracyclines) (ADM, Epi-ADM, MMC) Antimetabolites (MTX, 5-FU) Antitubulins (Taxol, docetaxel, VCR, VBL) Others,化疗药物毒性反应,Common: Myelosuppression Alopecia NauseaPremature ovarian failure VomitingWeight loss Less Common: Systemic infections Thrombosis Neurological problems,Hormonal Therapies内分泌治疗,Antiestrogens Tamoxifen, Toremifene, Megestrol Aromatase Inhibitors Gonadotropin-Releasing Hormone Analogues Antiandrogens Other Hormonal Therapies,肿瘤靶向