外科學課件：腫瘤（英語）

1、2021-6-151腫瘤Tumor ？Neoplasia？2021-6-152 Neoplasia (literally meaning “new growth”) is an abnormal growth of tissue resulting from the uncontrolled proliferation of transformed cells and serving no physiological function. The term tumor, which was originally used to describe the swelling caused by in

2、flammation, is now used interchangeably with neoplasm. Transformation is the multistep process whereby normal cells acquire malignant characteristics. Each step reflects a genetic alteration that confers a growth advantage over normal cells. Benign neoplasm: a neoplasm that tends to grow slowly, is

3、well differentiated, does not metastasize, and is usually non-life threatening Malignant neoplasm: a neoplasm that tends to grow rapidly, is poorly differentiated, often metastasizes, and frequently causes death of the host2021-6-154According to the impact on the human body2021-6-155These characteri

4、stics are shared by most, if not all, human tumors. World: Malignant tumor is the second most common cause of death in male, third in female. China: in the city, the most common are lung, gastric, liver, colorectal, and breast; in the rural area, the most common are gastric, liver, lung, esophagus a

5、nd colorectal. 2 million new cases occurred and 1.5 million died annually in China, .2021-6-156 A tumor can be benign or malignant, Benign: -oma (adenoma, fibroma) Malignant growths are broadly classified according to the type of cells they arise from as either carcinoma (epithelial origin), or sarc

6、oma (mesenchymal origin, from deeper tissue, e.g. bone or muscle), blastoma 母細胞瘤 (embryonal tumours ). 2021-6-157 Benign-sounding malignancies lymphoma, melanoma黑色素瘤, mesothelioma間皮瘤, seminoma精原細胞瘤 Malignant-sounding trivial lesions Hamartoma錯構(gòu)瘤(hamarto = to sin, miss the mark, error)develops and gr

7、ows at same rate as surrounding normally organized tissue without compression pulmonary chondroid hamartoma肺軟骨錯構(gòu)瘤island of disorganized, but histologically normal, cartilage軟骨, bronchi支氣管, and vessels Choristoma迷離瘤(chore = to disperse) mass of histologically normal tissue in an abnormal location (ar

8、e typically composed of normal tissue that develops and grows in an abnormal location).Papillary mucinous tumors乳頭狀粘液性腫瘤, Mixed tumor of salivary gland, Fibroma2021-6-159Environmental carcinogensGenetic factorsOver 80% of malignancy is related to environmental carcinogens.Environmental carcinogens:

9、Any agent contributing to tumor formation is referred to as a carcinogen:2021-6-1510 Chemical: direct-acting compounds, indirect-acting compounds, which require metabolic conversion. Physical: ionizing radiation, ultraviolet Biologic: Epstein-Barr virus, Hepatitis B, HIV, Helicobacter pylori, Schist

10、osoma haematobium埃及血吸蟲-膀胱癌，Clonorchis sinensis華支睪吸蟲-liver cancer，Schistosoma japonicum日本血吸蟲- Colorectal cancer 2021-6-1511Genetic factors: hereditary susceptibility, estrogen(breast Ca, endometrial Ca), immunodeficency (HIV, Immunoglobulin deficiency, organ transplantation)2021-6-1512 Malignant tran

11、sformation is the process whereby a clonal population of cells acquires alterations that confer a growth advantage over normal cells. Many of these alterations occur at the genetic level, involving the gain of function by oncogenes , the loss of function by tumor suppressor genes, loss function of r

12、epair genes, loss of apoptosis, over-expression of telomerase, adjustment disorder of signal transduction, and infiltrating and metastases. Malignant transformation, involving multigene, is a multistep process.2021-6-1513 Genetic mutations inherited from ones parents and present in all cells of the

13、body are called germline (or constitutional) mutations somatic mutations are acquired during an individuals lifetime and cannot be passed on to ones children. Somatic mutations, which account for most mutations in cancer, may be caused by exposure to carcinogens. A tumor may be classified as heredit

14、ary or sporadic. In hereditary cases, a germline mutation is responsible for the predisposition to neoplasia. If the tumors genetic mutations are somatic, the tumor is classified as sporadic. 2021-6-1514 Retinoblastoma: a pediatric retinal tumor , RB1 mutation (tumor suppressor gene ) Li-Fraumeni Sy

15、ndrome: a familial syndrome involving sarcomas of soft tissue and bone, breast cancers, brain tumors, leukemias, adrenocortical carcinomas, and other cancers. mutations in the P53 gene. Familial Adenomatous Polyposis: mutation in the APC gene 2021-6-1515Transcoelomic spread: Spread of a malignancy i

16、nto body cavities can occur via seeding the surface of the peritoneal, pleural胸腔, pericardial, or subarachnoid spaces蛛網(wǎng)膜下腔Lymphatic spread: most common route of metastasis for carcinomas, uncommon for a sarcoma to metastasize via this routeHaematogenous spread: typical route of metastasis for sarcom

17、as, also the favored route for certain types of carcinoma, such as those originating in the kidney (renal cell carcinoma)Infiltration: Despite pathway of venous or lymphatic flow, some metastatic sites are frequently associated with some primary tumors:breast carcinoma spreads to bonebronchogenic支氣管

18、 carcinomas tend to involve the adrenals and the brainneuroblastomas spread to the liver and bones Despite the large percentage of blood flow, skeletal muscles and spleen are rarely the site of secondary deposits.1. local manifestation Mass, Ache, Ulcer, Bleeding, Obstruction, Metastasis2021-6-1518F

19、irst: clinical diagnosis 2. systemic symptoms. nonspecific symptom: anaemia, low fever, loss of weight, fatigue Cachexia Hypertension- adrenal pheochromocytoma嗜鉻細胞瘤2021-6-1519 Age, course of disease history, family history Physical examination: size, mobility, solidity, lymph node2021-6-1520Benign t

20、umors: are expansive, compressing adjacent tissue do not recur when completely excised do not metastasize usually grow slowly do not cause cachexiaMalignant tumors: are invasive, replacing adjacent tissue often recur even if completely excised may metastasize often grow quickly may cause cachexiaBen

21、ign: a solitary mass well-demarcated from adjacent normal tissues may be encapsulated cutaneous masses are usually easily moveable has a uniform consistencyMalignant: may be solitary or multiple indistinct demarcation from adjacent tissues usually not encapsulated cutaneous mass attached to underlyi

22、ng tissue may have a variable consistency due to soft or liquid center may have finger-like projections, indicative of growth into lymphatic vessels may have metastasized to lungs, liver, or any other organ, with masses observed at surgery necropsy, or by imaging analyses 1.Routine test： blood count

23、： urine analysis： stool test：2021-6-15232：tumor markerThis is particularly useful when the cancer is not clinically detectable. The information provided may do the following: Be diagnostic, distinguishing benign from malignant disease. Correlate with amount of tumor present (tumor burden). Allow sub

24、type classification to stage patients more accurately. Be prognostic, either by the presence or absence of the marker or by its concentration. Guide choice of therapy, Predict response to therapy.2021-6-1524 Proteins, considered the classic tumor markers. Those routinely used are often limited by po

25、or sensitivity and specificity. Their serum or plasma levels generally correlate with tumor burden because they are shed from the expanding neoplasm.2021-6-1525 Carcinoembryonic Antigen (CEA),the most studied tumor marker, its main clinical use is for cancer of the colon and rectum. -Fetoprotein(AFP

26、) used in the detection and management of HCC, consisting of a single-chain polypeptide with a molecular weight of 700 kDa. Levels are elevated in the fetus, fall to low levels after birth, and are elevated during pregnancy. 2021-6-1526Carbohydrate antigen 19-9 (CA 19-9) is widely used as a serum ma

27、rker of pancreatic cancer, its use is limited to monitoring responses to therapy, not as a diagnostic marker.Prostate-specific antigen (PSA) is formed in the prostatic epithelium and secreted into the prostatic ducts. Its function is to digest the gel that is formed in seminal fluid after ejaculatio

28、n. Under normal circumstances, only small amounts of PSA leak into the circulation. With distortion of its architecture, serum PSA levels increase. patients who have undergone curative radical prostatectomy, and women, have no detectable PSA. Carbohydrate antigen 125 (CA 125) are detected in 80% of

29、patients with ovarian cancer. not useful as a screening tool for ovarian cancer, a worse prognosis compared with patients with normal levels. 2021-6-1527DNA-Based MarkersSpecific mutations in oncogenes, tumor suppressor genes, and mismatch repair genes can serve as biomarkers.HER-2/neu amplification

30、 status is now being routinely used to guide treatment with trastuzumab赫賽汀in patients with breast cancer.KRAS gene mutation testing in patients with metastatic colorectal carcinoma to predict response to anti-EGFR monoclonal antibody (MoAb) therapy with cetuximab or panitumumab.RNA-Based MarkersRNA-

31、based markers have been identified in the context of global mRNA expression using high-throughput technologies (gene chips).Flow cytometry and Proteomic Profiling also could be used for the in the protein biomarker discovery and prognosis of cancer.2021-6-1528X-ray examination2021-6-1529calcificatio

32、n fluoroscopic examinationradiographyBarium radiographyAngiographyintravenous pyelography靜脈腎盂造影2021-6-1530contrast examination Ultrasound 2021-6-1532computed tomography MRI2021-6-1534radionuclide imaging） 131I 32P 99mDethyroid cold nodule Normal thyroid2021-6-1535positron emission tomography,PET2021

33、-6-1536Endoscopy 2021-6-1537Fourth: 2021-6-15382021-6-1539 TNM is a cancer staging system that describes the extent of cancer in a patients body. T describes the size of the tumor and whether it has invaded nearby tissue, N describes regional lymph nodes that are involved, and M describes distant me

34、tastasis . TNM is developed and maintained by the International Union Against Cancer (UICC) to achieve consensus on one globally recognised standard for classifying the extent of spread of cancer.2021-6-1540 TTumor Tis：carcinoma in situ To：no primary tumor T14: standard varying at diferent tumor Tx:

35、 size couldnt determined N -Node N0N3 M metastasis MoM12021-6-1541CTNMTNM classification : extent of tumor , local nodes, metastases breast cancer:T0 no evidence of primary tumourTis Carcinoma in situT1 tumour 2cm or less in greatest dimensionT2 tumour more than 2cm but not more than 5cm in greaest

36、dimensionT3 tumour more than 5cm in greatest dimensionT4 tumour of any size with direct extension to chest wall or skin N0 no regional lymph nodes metastasisN1 metastasis to movable ipsilateral axillary lymph node/sN2 metastasis to ipsilateral axillary lymph node/s fixedN3 metastasis to ipsilateral

37、internal mammary lymph node/sN0 no regional lymph nodes metastasisN1 metastasis to movable ipsilateral axillary lymph node/sN2 metastasis to ipsilateral axillary lymph node/s fixedN3 metastasis to ipsilateral internal mammary lymph node/sM0 no distant metastasisM1 distant metastasis (includes metast

38、asis to supraclavicular lymph nodes) Benign - Surgical resection Borderline - Complete excision(including normal tissue around tumor) Maglignant -combined therapy with mainly in surgery. Stage I: mainly in surgery; Stage II: systemic therapy adjuvant to local treatment, Stage : comprehensive therapy

39、, peri-operative chemotherapy and/or radiotherapy. Stage :local treatment adjuvant to systemic therapy. 2021-6-15441.Surgical oncology (1).prophylactic surgery-precancerous lesions (2).diagnostic surgery- excisional biopsy (3).radical surgery-used for 、early 2021-6-1545(4).Palliative surgery(5).Cytoreductive surgery(6).Surgery for