Tangshan People's Hospital Radiochemotherapy Department
Gastrointestinal cancer is the most common and major malignant tumor, including gastric cancer, colon cancer and rectal cancer.There are obvious regional differences in the incidence of gastric cancer. The incidence of gastric cancer in the northwest and eastern coastal areas of China is significantly higher than that in the south.The most common age is over 50 years old, and the ratio of male to female incidence is 2:1.Colorectal cancer is a common malignant tumor, including colon cancer and rectal cancer. In recent years, it has a tendency to develop to the proximal (right colon).Its pathogenesis is closely related to lifestyle, heredity and colorectal adenoma.
Visiting department
Surgery
Multiple population
Over 50 years old, the ratio of male to female morbidity is 2:1
Common location
Stomach and large intestine
Common causes
Regional environment, diet and life factors, Helicobacter pylori infection;Precancerous lesions;Genetics and Genes
common symptom
Abdominal pain, weight loss, change of stool habits, blood in stool, abdominal mass, intestinal obstruction, etc
(1) Regional environment and food life factorsThere are obvious regional differences in the incidence of gastric cancer. The incidence of gastric cancer in the northwest and eastern coastal areas of China is significantly higher than that in the south.The high incidence of distal gastric cancer among people who eat smoked and salted food for a long time is related to the high content of carcinogens or pre carcinogens such as nitrite, mycotoxins, polycyclic aromatic hydrocarbons in food;The risk of gastric cancer in smokers is 50% higher than that in non-smokers.
(2) Helicobacter pylori（Hp）InfectionAdults in high incidence areas of gastric cancer in ChinaHpThe infection rate is more than 60%.Helicobacter pylori can promote the transformation of nitrate into nitrite and nitrosamines to cause cancer;HpInfection causes chronic inflammation of gastric mucosa and environmental pathogenic factors accelerate the excessive proliferation of mucosal epithelial cells, leading to distortion and carcinogenesis;The toxic products of Helicobacter pylori, CagA and VacA, may have cancer promoting effects. The detection rate of anti CagA antibody in gastric cancer patients is significantly higher than that in the general population.
(3) Precancerous lesionGastric diseases include gastric polyps, chronic atrophic gastritis and remnant stomach after partial gastrectomy. These diseases may be accompanied by chronic inflammatory processes of varying degrees, intestinal metaplasia or atypical hyperplasia of gastric mucosa, and may turn into cancer.Precancerous lesions refer to the pathological changes of gastric mucosa that are prone to canceration. They are borderline pathological changes in the process of transforming from benign epithelial tissue to cancer.
(4) Genetics and GenesGenetic and molecular biological studies showed that the incidence of gastric cancer in relatives of gastric cancer patients with blood relationship was 4 times higher than that in the control group.The canceration of gastric cancer is a multifactorial, multi-step and multi-stage development process, involving changes in oncogenes, tumor suppressor genes, apoptosis related genes and metastasis related genes, and the forms of gene changes are also diverse.
2. Colorectal cancer
The occurrence of colorectal cancer is related to high-fat and low fiber diet, chronic inflammation of the large intestine, adenoma of the large intestine, genetic factors and other factors such as schistosomiasis, pelvic radiation, environmental factors, smoking, etc.
clinical manifestation
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1. Gastric cancer
Most patients with early gastric cancer have no obvious symptoms, and a few have nausea, vomiting or upper gastrointestinal symptoms similar to ulcer disease.Pain and weight loss are the most common clinical symptoms of advanced gastric cancer.Patients often have clear upper gastrointestinal symptoms, such as abdominal discomfort and fullness after eating. As the disease progresses, upper abdominal pain increases, appetite decreases, and fatigue.Depending on the location of the tumor, it also has its special manifestations.Cardiac and gastric fundus cancer may have retrosternal pain and progressive dysphagia;Gastric cancer near pylorus has pyloric obstruction;After the tumor destroys the blood vessels, there may be hematemesis, melena and other gastrointestinal bleeding symptoms.Persistent abdominal pain often indicates that the tumor extends beyond the stomach wall, such as supraclavicular lymph node enlargement, ascites, jaundice, abdominal mass, rectal depression and mass.
2. Colorectal cancer
Colorectal cancer has no symptoms at the early stage, or the symptoms are not obvious, only feeling unwell, dyspepsia, fecal occult blood, etc.With the development of cancer, symptoms gradually appear, which are manifested as changes in stool habits, abdominal pain, blood in the stool, abdominal mass, intestinal obstruction, etc., with or without anemia, fever, emaciation and other systemic symptoms.Tumor metastasis and invasion can cause changes in the affected organs.
(1) Right colon cancerThe right colon cancer leads to iron deficiency anemia, which shows fatigue, fatigue, shortness of breath and other symptoms.Because the right colon has a large intestinal cavity, abdominal symptoms will not appear until the tumor grows to a certain size, which is also one of the main reasons for the late staging when the tumor is diagnosed.
(2) Left colon cancerThe left colon cavity is narrower than the right colon cavity, and the left colon cancer is more likely to cause complete or partial intestinal obstruction.Intestinal obstruction leads to changes in stool habits, including constipation, bloody stool, diarrhea, abdominal pain, abdominal cramps, abdominal distension, etc.Stool with fresh bleeding indicates that the tumor is located at the end of the left colon or rectum.
(3) Rectal cancerThe main clinical symptoms of rectal cancer are bloody stool, change of bowel habits and obstruction.Those with low tumor position and hard fecal mass are prone to bleeding due to friction of fecal mass, which is mostly bright red or dark red. They are not mixed with formed feces or attached to the surface of fecal column, and are misdiagnosed as "hemorrhoid" bleeding.
(4) Tumor invasion and metastasisThe most common form of invasion of colorectal cancer is local invasion. The tumor invades surrounding tissues or organs, causing corresponding clinical symptoms.Anal incontinence, persistent pain in the lower abdomen and lumbosacral region are caused by rectal cancer invading the sacral plexus.
There are two main ways of distant metastasis of colorectal cancer: lymphatic metastasis and hematogenous metastasis.Tumor cells can be transferred to lymph nodes through lymphatic vessels, or to liver, lung, bone and other parts through blood.
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1. Gastric cancer
(1) X-ray barium meal examinationThe application of digital X-ray gastroenterography is still a common method for the diagnosis of gastric cancer.Air barium double contrast examination is often used to make diagnosis through observation of mucosa phase and filling phase.
(2) Fiber gastroscopyIt is the most effective method for diagnosis of gastric cancer to directly observe the location and scope of gastric mucosal lesions, and obtain pathological examination of pathological tissues.
(3) Abdominal ultrasoundIn the diagnosis of gastric cancer, abdominal ultrasound is mainly used to observe the infiltration of adjacent organs of the stomach and lymph node metastasis.
(4) Spiral CT and positron emission imagingMulti slice spiral CT scanning combined with three-dimensional reconstruction and virtual endoscopy is a new non-invasive examination method, which is helpful to the diagnosis and preoperative clinical staging of gastric cancer.Using the affinity of gastric cancer tissue for fluoride and deoxy-D-glucose (FDG), positron emission tomography (PET) can be used to determine lymph nodes and distant metastatic lesions with high accuracy.
2. Colorectal cancer
(1) Laboratory inspectionRoutine blood tests, biochemical tests (liver and kidney function+serum iron), stool routine tests+fecal occult blood tests and other laboratory tests are helpful to understand whether the patient has iron deficiency anemia, liver and kidney functions and other basic conditions.The detection of carcinoembryonic antigen (CEA), a blood tumor marker, is helpful to the diagnosis of tumors.In patients with colorectal cancer, a high level of CEA does not mean that all patients have distant metastasis;In a few patients with metastatic tumor, CEA is not increased.
(2) EndoscopyColonoscopy is to extend a fiber colonoscope into the ileocecal region at the beginning of the colon, examine the colon and rectal cavity, and conduct biopsy and treatment during the examination.Colonoscopy is more accurate than barium enema X-ray, especially for small colonic polyps, which are confirmed by colonoscopy and pathology.
(3) Biopsy and exfoliative cytologyLiving tissue examination has decisive significance in the diagnosis of colorectal cancer, especially early cancer and polyp canceration, as well as in the differential diagnosis of lesions. It can clarify the nature, histological type and malignant degree of tumors, judge the prognosis and guide clinical treatment.Abscission cytology has high accuracy, complicated sampling, difficult to obtain satisfactory specimens, and few clinical applications.
diagnosis
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Diagnosis can be made according to clinical manifestations, relevant examinations and histopathological characteristics.
treatment
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1. Gastric cancer
(1) Surgical treatment
1) Radical operationThe principle is to remove part or all of the stomach, including cancer and possibly invaded gastric wall, and remove lymph nodes around the stomach as a whole according to clinical staging standards to reconstruct the digestive tract.
2) Palliative operationIf the primary focus cannot be removed, the operation is performed to alleviate the symptoms caused by obstruction, perforation, bleeding and other complications, such as gastrojejunostomy, jejunostomy, perforation repair, etc.
(2) Chemotherapy
It is used to prolong the survival period before, during and after radical surgery.Appropriate chemotherapy for patients with advanced gastric cancer can slow down the development of tumor, improve symptoms, and have a certain short-term effect.In principle, adjuvant chemotherapy is not necessary after radical resection of early gastric cancer. The commonly used routes of chemotherapy for gastric cancer include oral administration, intravenous administration, peritoneal cavity administration, arterial intubation area perfusion administration, etc.The commonly used oral chemotherapeutic drugs include tegafur, eufdine, and fluoroferron.Common intravenous chemotherapy drugs include fluorouracil, mitomycin, cisplatin, amycin, etoposide, calcium formyltetrahydrofolate, etc.In recent years, new chemotherapeutic drugs such as paclitaxel, oxaliplatin, topoenzyme inhibitor and Xeloda have been used for gastric cancer,
(3) Other treatments
Including radiotherapy, hyperthermia, immunotherapy, traditional Chinese medicine treatment, etc.Immunotherapy for gastric cancer includes nonspecific biological response regulators such as BCG vaccine, lentinan, etc;Cytokines such as interleukin, interferon, tumor necrosis factor, etc;And the clinical application of adoptive immunotherapy such as lymphocyte activated killer cells (LAK), tumor infiltrating lymphocytes (TIL), etc.Anti angiogenic gene is a gene therapy method that has been studied extensively and may play a role in the treatment of gastric cancer.
2. Colorectal cancer
(1) Surgical treatment
1) Colon cancerThe treatment plan for colon cancer is a comprehensive treatment plan based on surgical resection.I、Stage II and III patients often adopt radical resection+regional lymph node dissection, and determine the scope of radical resection and surgical method according to the location of the cancer.In case of intestinal obstruction and severe intestinal bleeding in stage IV patients, palliative resection is feasible instead of radical surgery.
2) Rectal cancerRadical treatment of rectal cancer is based on surgery.Rectal surgery is more difficult than colon surgery.The common surgical methods are: transanal resection (near the anal margin at a very early stage), total mesorectal resection, low anterior resection, and transabdominal anal sphincter abdominal perineum resection.For stage II and III rectal cancer, preoperative radiotherapy and chemotherapy are recommended to reduce the tumor size and local tumor stage, and then radical surgery is recommended.
(2) Comprehensive treatment
1) Adjuvant chemotherapyOxaliplatin combined with fluorouracil (5-fluorouracil) is currently the standard treatment scheme for patients with stage III colorectal cancer and some colorectal cancer with high-risk factors, and the treatment time is 6 months.It is applicable to rectal cancer patients who do not receive neoadjuvant radiotherapy before operation and who need adjuvant radiotherapy after operation.
2) Treatment of colorectal cancerIt is mainly a comprehensive treatment scheme based on chemotherapy. Chemotherapy drugs include 5-fluorouracil, capecitabine, oxaliplatin, irinotecan, bevacizumab, cetuximab, paniximab and other drugs. Common chemotherapy schemes include: FOLFOXXELOX, FOLFIRI, etc., on the basis of chemotherapy, combine targeted drug therapy (bevacizumab, cetuximab, paniximab) as appropriate.
(3) Radiotherapy
At present, the comprehensive treatment of surgery and radiotherapy, including preoperative radiotherapy, intraoperative radiotherapy, postoperative radiotherapy, and "sandwich" radiotherapy, has better effect and more research. Each has its own characteristics.Palliative radiotherapy is used for patients with advanced rectal cancer, patients with local tumor infiltration, and patients with surgical contraindications.
