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ONCOLOGIA

DIGESTIVĂ
CANCERE
COLORECTALE
EPIDEMIOLOGIE
• 13-15% din toate cancerele
• I loc [n morbiditatea prin cancer pentru ambele
sexe
• Inciden\`: 2-5/suta de mii loc./an
• Rasa:
- negrii 
- negrii SUA, func\ie de status
 Japonezii:
- SUA 
- Hawai ˜
- Japonia  ([n cre]tere)
 Evreii:
- est 
- vest 
Distribu\ie pe sexe

• Colon drept: 1/1

• Colon st@ng: F > 70 ani

• Rect: F > 55 ani


ETIOLOGIE
• FACTORI GENETICI:
- TEORIA KNUDSON "two-hit"
- STUDIUL CHICAGO - 2 grupe

PROXIMAL DIS TAL


DNA DIPLOID HIPERPLOID
KARIOTIP STABIL VARIABIL
DELE| II RARE FRECVENTE
CANCERE RER (MSI) CANCERE LOH
ALTE ARGUMENTE

1. EMBRIOLOGICE

2. VASCULARIZA|IE

3. HISTOLOGICE

4. METABOLICE

5. EPIDEMIOLOGICE
Cancere LOS

C5q APC dele\ie

C17q p53 dele\ie

C18q DCC dele\ie

SMAD2

C8p
Cancere RER

GENE: M1H1
MSH2 C2, 7, 9, 11

MSH6

PMS1
CLASIFICARE ETIOLOGIC~

I. CANCERE POLIPOASE

II. CANCERE EREDITARE NON

POLIPOASE

III. CANCERE SPORADICE


SINDROAME POLIPOASE
• POLIPI: - ADENOMATO}I
- HAMARTOAME
• SINDROAME:
I. APC GARDNER/TURCOT C5
II. A. ATENUAT~
III. PEUTZ-JEGHERS C18
IV. JUVENIL~ C18
V. COWDEN
HNPCC (LYNCH I)

CRITERII AMSTERDAM:

- 3 pacien\i [n 2 genera\ii

- 2 leg`turi gr. I

- debut [nainte de 50 ani

- proximale
CANCERE SPORADICE
• ST~RI PRECANCEROASE
1. ADENOMUL - argumente:
- histologice
- topografice
- cronologice
- epidemiologice
- experimentale
ADENOMUL PLAT- KUDO
2. BOLI INFLAMATORII:
- distribu\ie mai uniform`
- recidive frecvente
- v@rst` t@n`r`
- diferen\iere redus`
- infiltrare:
 colagenic`
 limfocitar`
• COLITA GRANULOMATOAS~

• RECTITA DE IRADIERE

• ADENDICECTOMIA

• URETEROSTOMIA
• FACTORI ALIMENTARI:

I. GR~SIMI

II. FIBRE  BENZPIRENHIDROLAZA

III. AINS
ANATOMIE PATOLOGIC~

I. CARCINOAME:
- ADK 85%
- cloacogene
- carcinoid
- scuamos
II. MEZENCHIMALE
MACROSCOPIC
I. DISTRIBU|IE
II. SINCRONE 4%
III. FORM~:
a) PROLIFERATIV~ - dr
b) ULCERATIV~
c) INFILTRATIV STENOZANT~ - stg
DISEMINARE

1. LOCAL - CIRCUMFEREN|IAL~

2. VASCULAR

3. LIMFATIC
STADIALIZARE

• DUKES
A - perete
B - str`bate peretele
C - metastaze ganglionare
D - metastaze viscerale
• GITSG
A - mucoas`
B - submucoasa str`b`tut`
B1 - MP
B2 - seroas`
C - ggl regionali
C1 - 1-4 ggl
C2 - > 4 ggl
D - metastaze
CLINIC~

1. tulbur`ri de tranzit

2. tulbur`ri de scaun

3. astenie

4. sl`bire
COLON DREPT
TUMOR~ EXOFITIC~
MARE
MOALE

ULCERA|IE

ANEMIE

DURERE - SURD~
APENDICIT~ ACUT~
COLON ST^NG

• DURERE COLICATIV~

• OCLUZIE
RECT

• INTERFER~ CU DEFECA|IA:
- FORM~
- ASPECT
- REGULARITATE

• DURERE
• RECTORAGIE
MANIFEST~RI PARANEOPLAZICE

1. ACANTOSIS NIGRICANS

2. DERMATOMIOZIT~

3. ENDOCARDIT~ NEBACTERIAN~

4. NEUROMIOPATII
SEMNE

1. ASPECT GENERAL
2. GGL WIRCHOW
3. HEPATOMEGALIE
4. PALPAREA TUMORII:
- transabdominal
- TR
STABILIREA DIGNOSTICULUI
METODE IMAGISTICE

• IRIGOSCOPIA CU DUBLU CONTRAST

• COLONSCOPIA

• HISTOLOGIA
STABILIREA EXTENSIEI

• ECHOENDOSCOPIE

• CT

• RMN
COMPLICA|II

1. FISTULIZARE:

- STOMAC

- VEZIC~

- VAGIN

2. TULBUR~RI DE COAGULARE
TRATAMENT

1. CHIRURGICAL + META HEPATICE

2. CHIMIOTERAPIE FUFOL

3. ENDOSCOPICE
CANCERUL HEPATIC
CANCERUL HEPATIC

Tumori Benigne: Hiperplazia nodular`


Tumorile Maligne Hepatice:

1. Primitive
dependente de tipul celular

2. Secundare
Tumori maligne secundare
Epidemiologie:
- cele mai frecvente
- alte metastaze (sarcoame)
- b`rba\i
- > 60 ani
- cancer primitiv
ANATOMIE PATOLOGIC~
 Bron]ic
 Pancreas adenocarcinoame 60%
 Colo-rectal carcinoame nedif. 30%
 Gastric carcinoame epidermoide
 Renal carcinoame neuroendocrine
 Ovarian
Clinic

• Asimptomatic – imagistic

• Hepatalgii

• +/- alterarea st`rii generale


Diagnostic
TIP TUMORAL ANTIGEN I.H.C.

1 Limfom CD45

2 Melanom Proteina S-100


Ag HMB-45
3 Rabdomiosarcom Desmin`

4 Angiocarcinom Ag F.VIII

5 Germinale  FP
H.C.G.
F Alcalina placenta
6 APUD Cromogranina
Sinaptofizin`
Enolaza neuronspecific`
Tumori primitive
Hepatocarcinomul
C C.H.C. cel mai frecvent
cancer digestiv

Inciden\` > 200/suta de mii loc./an


5-190/suta de mii loc./an
<50/suta de mii loc./an
Raport sexe 8/1 2/1
V@rst`. distribu\ie bimodal`
Etiologie
• Virus B

• Virus C cu/f`r` ciroz`

• Afla toxina B1

• Gena p53
Virusul B
• Cre]te de 7 ori riscul
• Vaccinarea reduce inciden\a
• Mecanisme propuse:
1. Ciroza  displazie  cancer
2. Integrare [n genom:
- dele\ii ADN
- activare gen` myc
VIRUS C argumente generate de istoria
natural`

80% hepatit` cronic`

20% ciroz` 10 ani

35%

1-4% CHC 20 ani


Genotipul 1b.
Coinfec\ia B+C cre]te riscul.
Factori de risc
• Geografici
• Demografici – v@rsta/sex
• Ciroza  indiferent etiologie
- hemocromatoza 45%
- CSP – colangiocarcinom
• Porfiria cutanea tarda (prin virus C?)
• Displazia
Simptome

• Durere – disconfort
• Sl`bire
• Inapeten\a
• Icter
• Ascit`
Semne
• Ficat mare - uni/bi lobular
- dur
- sensibil
• Suflu sistolic, rugos, independent pozi\ional
• Frecatur` (mai des meta, abces)
• Ascit` - transudat
- exudat
- hemoragic`
Diagnostic
1. Biologic T > 3 cm
-des CP>100ng/ml+FP>20ng/ml 85%
2. Imagistic:
a) echografic
b) CT spiral`
c) anteriografie
d) scintigrafie
e) RMN
f) biopsie
Manifest`ri paraneoplazice
1. ENDOCRINE:
• PTH – hipercalcemie
• Eritropoietin` – poliglobulie
• Aldosteron – HTA
• VIP/PGE2 – diaree
• ILG I/II – hipoglicemie
2. PROTEINE CARCINOFETALE

 FP
 CEA
 Fibrinogen
 Des carboxiprotrombina
  L fucozidaza
 Falcalina
 Isoferitine acide
SCOR OKUDA = PROGNOSTIC

PARAMETRU SCOR SUPRAVIE|UIRE


(1pct pt. fiecare)
ASCIT~

ALBUMINEMIE < 3g/dl 0 8-12 luni

BILIRUBINEMIE > 3mg/dl 1-2 2-3 luni

TUMORA > 50% volum 3-4 < 1 lun`


Tratament
• Chirurgical

• OLT
• Hepatectomie
+/- chimioterapie lipiodat`
Intraarteriale
• Chimioterapie
• Chimioterapie lipiodat`
• Embolizarea
- C. I. absolut` – ruptur`
- C.I formal` – fistula AV
a -flux hepatofug
• Radioterapie:
- extern`
- fotonic`
- intern`

• Radioabla\ie

• Alcoolizare
Carcinomul fibrolamelar
- Tineri
- Femei
 FP N
- ANAT PAT - solitar
- conjunctiv
- Chirurgie
Colangiocarcinom 10%

• Canale intrahepatice
• Hil (Klatskin)
• Durere
• Febr`
• Icter
Angiosarcom
• Etiologie: - As, Thorotrast, clorur` de vinil,
hemocromatoz`

• Clinic: - Durere, sl`bire, ascit`

• ANA PAT: - E VIII


- Hepatoblastom
Tumorile c`ilor biliare
extrahepatice

CLINIC~:

• Icter +/- prurit +/- febr`


• Hepatomegalie
• Colestaz`
Diagnostic

 Echoendoscopie
 ERCP
 Ecotomografie
 CT
 RMN
Tratament

• Duodenopancreatectomia cefalic` cu
hepaticojejunostomie

• Protezare
Forme Speciale

• Papilomatoza c`ilor biliare

• Tumori ampulare
Cancerul colecistic
 Adenocarcinom:
- papilar
- infiltrant

Etiologie:
- litiaz`
- vezicul` de por\elan
Diagnostic
• Durere biliar`

• Icter

• Sl`bire

• Mas` palpabil`
TUMORI
PANCREATICE
Clasificare

• Exocrin
• Endocrin = apudoame

• Benigne
• Maligne 90% ADK
Cancer – I. Etiologie
• Genetic`

- autosomal dominant
- K-ras
- HNPCC
- FAP
- MEA I = MEN
• Fumat
• Cafea
• Alcool
• Diet`
• Pancreatit`
• Gastrectomia pt ulcer
ANATOMIE PATOLOGIC~
1. ADK
2. 70% CEFALICE
3. 2,5-3 cm/5-7 cm
4. INVAZIE LOCAL~:
- STOMAC
- COLON
- VP, VSH
5. META: - GGL
- FICAT
- PANCREAS
CLINICA
• CORP

1. SL~BIRE
2. DURERE
3. ASTENIE
• CAP

1. DURERE: - distensia c`ii biliare


- pancreatit`
- invazie
2. ICTER: 70% ictere obstructive maligne
3. SL~BIRE
4. DIABET
5. TROMBOFLEBITA MIGRATORIE
SEMNE

• HEPATOMEGALIE

• S. COURVOISIER
DIAGNOSTIC
• BIOLOGIC:
1. COLESTAZ~
2. CA 19-9
• IMAGISTIC:
1. ECHOENDOSCOPIA
2. CT HELICOIDAL
3. RMN
4. ERCP +RECOLTARE SUC PANCREATIC
5. COLANGIO RMN
6. Rx CONVEN|IONAL~
• HISTOLOGIC: FNA
• PROGNOSTIC:
20% SUPRAVIE|UIESC 1 AN

• TRATAMENT:
I. CHIRURGICAL DEPENDENT DE:
1. M~RIMEA TUMORII
2. LOCALIZAREA EI
3. INVAZIA LOCAL~
4. INVAZIA VASCULAR~
5. METASTAZE
TIPURI
A) CURATIVE:
1. WHIPPLE
2. DUODENOPANCREATECTOMIA
CEFALIC~
3. PANCREATECTOMIA TOTAL~
4. PANCREATECTOMIA REGIONAL~
5. SPLENOPANCREATECTOMIA
ST^NG~
B) PALIATIVE
• PALEATIV:
1. STENTARE
2. Rx TERAPIE 55-70 Gy
3. CHIMIOTERAPIE: 5-FU, GEMCITABIN~
4. COMBINA|IE

• SIMPTOMATIC:
1. ALCOOLIZAREA
2. MORFINICE
ALTE TUMORI
• CISTADENOMUL SEROS:
- MARE
- MULTILOCULAT (1 CHIST < 1 cm)
- FEMEI
- V^RSTNICI
- SE MALIGNIZEAZ~ RAR
• CISTADENOMUL MUCOS:

- MARE > 5 cm

- UNI/MULTILOCULAT

- SE MALIGNIZEAZ~ FRECVENT

- SUPRAVIE|IURE LA 5 ANI - 50%


TUMORI ENDOCRINE
(NESIDIOBLASTOAME,
APUDOAME,
NEUROENDOCRINE)
1. Celulele endocrine tub dig au caractere comune cu
celulele neurale:
- conceptul APUD
- polipeptidele se reg`sesc [n tub dig/SNC
- enolaza
2. Asocierea feocromocitom + cancer medular +
hiperparatiroidie MEA II
MEA = MEN
ASOCIEREA TUMORILOR

• PARATIROID~ 90%

• PANCREAS 85%

• HIPOFIZ~ 65% MEN I WERMER

• ADRENALE 20%

• TIROID~ 20%
TIPURI TUMORI ENDOCRINE

TIP S ECRE\IE LOCALIZARE


CELULAR DOMINANT~
PANCREAS EXTRA
CARCINOID EC S EROTONIN~ EXCEP| IONAL APENDICE,
ECL ? ILEON, RECT,
BRON} II,
S TOMAC
INS ULINOM B INS ULIN~ (PP, 98% 2%
GLUCAGON)
GAS TRINOM G GAS TRIN~ (PP, 70-80% S TOMAC,
INS ULIN~ , DUODEN, OVAR
GLUCAGON)
GLUCAGONOM D GLUCAGON 99% RINICHI
(INS ULIN~ , PP)
VIPom VIP (PP) 80% 99%
S OMATOS TATINOM D S OMATOS TATIN~ 50% DUODEN

NEUROTENS INOM NT NEUROTENS IN~ 90%


ACESTE TUMORI POT FI:
1. MUTE (carcinoid rectal, PP)
2. ENTOPICE
3. ECTOPICE:
- GASTRINOM
- VIPOM
- CORTICOTROPINOM
- PARATIRINOM
DIAGNOSTIC
• DOZAREA RIA
• TESTE DE SUPRESIE }I STIMULARE
• ECHOENDOSCOPIE 80%
• CT
• ANGIOGRAFIE
• SCINTIGRAFIE RECEPTORI SOMATOSTATIN~
GASTRINOMUL
(SINDROM ZOLLINGER-ELLISON)

Tumoare cu celule G situat` [n pancreas


secret@nd gastrin`, malign` 60%

- 0,5/106 popula\ie

- 0,5-1% ulcere duodenale

- 2/1 B/F
CLINIC
1. ULCERE:
- multiple
- rezistente la tratament
- recidiv@nd dup` opera\ii
- localiz`ri rare
- complicate cu HDS, perfora\ii
2. DIAREE/STEATOREE
• DIAGNOSTIC POZITIV:
- gastrinemie
- test de provocare la secretin`
- raport BAO/MAO > 0,6
• DIAGNOSTIC DIFEREN|IAL:
- hiperplazie G antral`
- IR cr
- gastrit` A
• DIAGNOSTIC DE LOCALIZARE
• DIAGNOSTIC DE EXTENSIE
TRATAMENTUL
1. HIPERSECRE|IEI ACIDE:
a) IPP: - DOZ~ 25-360 mg/zi
- DURAT~: 2-48 luni
- REZULTATE F. BUNE 80%
b) SOMATOSTATIN~ 200 g x 2/zi
c) CHIRURGIE
2. PROCESULUI TUMORAL:
- 25% sunt localizate dup` laparatomie
- 30-60% au metastaze
- 10-40% nu se g`sesc

• EXEREZ~ POSIBIL~ {N 30%, DAR


COMPLET~ NUMAI {N 50% = 15%

3. CHIMIOTERAPIE: 5FU + STREPTOZOCIN~


TUMORI CARCINOIDE
TUMORI CE SE DEZVOLT~ DIN
CELULE:
- EC (Kulchitsky Masson)
- ECL (fundice)
• PREVALEN|~ 1,5/100.000
• F>M
• TINERI
LOCALIZARE
I. DIGESTIVE (90%):
1. APENDICE
2. ILEON
3. RECT
4. STOMAC
II. EXTRADIGESTIVE:
1. BRON}II
2. OVAR
3. TIMUS
TIP

• MUT

• ENTOPIC

• ECTOPIC
FIZIOPATOLOGIE
TRIPTOFAN  5OHTP  5OHTriptamin`
DETURNAREA : antreneaz`
1 SC~DEREA SINTEZEI PROTEICE

CA}ECSIE
2. SC~DEREA SINTEZEI AC. NICOTINIC

S. PELAGROID
S IMPTOM MECANIS M
FLUS H 5OHTP , HIS TAMIN~ ,
P G, BRADIKININ~
DIAREE HIP ERMOTILITATE,
5OHTP
BRONHOS P AS M P G, HIS TAMIN~ ,
BRADIKININ~
CARDIOP ATIE FIBROZ~
ENDOCARDIC~ ,
5OHTP
HIP OTENS IUNE 5OHTP
DEP IND DE LOCALIZARE (BRON} IC~ , HEP ATIC~ )
CLINIC
1. FLUSH: - ERITEMATOS DIFUZ
- VIOLACEU TELEANGIECTAZII
- PRELUNGIT L~CRIMARE + HIPO TA
- RO}U-C~R~MIZIU, GEOGRAFIC
POATE FI ALCOOL INDUS
2. DIAREE: - 60% asociere cu fluide
- volum < 1l/zi
- nr. scaune cca 10/zi
3. DURERI ABDOMINALE legate de diaree
4. CARDIOPATIE: - insuficien\` tricuspid`
- stenoz` pulmonar`
5. BRONHOSPASM
TRATAMENTUL
SINDROMULUI CARCINOID

DE ELEC|IE: SOMATOSTATINA
200g/zi - 6 s`pt`m@ni
TRATAMENTUL SINDROMULUI CARCINOID

DROG DOZ~ /ZI FLUS H DIAREE 5-OH EFECTE


S ECUNDARE
IFN 3MU + + + FEBR~ ,
CITOPENIE,
AS TENIE
KETANS ERIN~ 40mg + +
(ANTAGONIS T
RECEPTOR 5-HT2)
METHYSERGID 3-8 + + FIBROZ~
RETROPERIT
ANTAGONI} TI +
KININE
ANTAGONI} TI H1 6-30 + +
(CIPROHEPTADIN~ )
ANTAGONI} TI H2 1800 +
TRATAMENTUL
1. TUMORII
2. METASTAZELOR HEPATICE
3. CHIMIOTERAPIE:
- STREPTOZOCIN~
- 5FU
- ADRIABLASTIN
MEZOTELIOMUL
PERITONEAL
• INCIDEN|~:
- 20% din total
- 2-3/106 locuitori
• ETIOLOGIE:
- asbestoza
- thorotrast
- iradiere
- genetic` 1, 3, 6, 9, 22, p53
CLINIC~
• DURERI: - DIFUZE
- HIPOCONDRUL DREPT
• GREA|~, V~RS~TURI
• DIAREE
• SL~BIRE
• FEBR~
SINDROAME PARANEOPLAZICE

• ADH  Hipo Na

• ST  Trombocitoz`

• ILF  Hipoglicemie
DIAGNOSTIC

• ECHOGRAFIE

• CT

• LAPARASCOPIE

• HISTOLOGIE + ac. hialuronic (alcian)


TRATAMENT

• DOXORUBICIN

• IFN