oncologia digestivĂ 2
TRANSCRIPT
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ONCOLOGIA ONCOLOGIA DIGESTIVĂDIGESTIVĂ
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CANCERE CANCERE COLORECTALECOLORECTALE
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EPIDEMIOLOGIEEPIDEMIOLOGIE
• 13-15% din toate cancerele13-15% din toate cancerele• I loc [n morbiditatea prin cancer I loc [n morbiditatea prin cancer
pentru ambele sexepentru ambele sexe• Inciden\`:Inciden\`: 2-5/suta de mii loc./an 2-5/suta de mii loc./an• Rasa:Rasa:
- negrii - negrii - negrii SUA, func\ie de status- negrii SUA, func\ie de status
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Japonezii:Japonezii:
- SUA - SUA
- Hawai - Hawai ˜̃- Japonia - Japonia ([n cre]tere)([n cre]tere)
Evreii:Evreii:
- est - est - - vest vest
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Distribu\ie pe sexeDistribu\ie pe sexe
•Colon drept: 1/1Colon drept: 1/1
•Colon st@ng: F > 70 aniColon st@ng: F > 70 ani
•Rect: F > 55 aniRect: F > 55 ani
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ETIOLOGIEETIOLOGIE
• FACTORI GENETICI:FACTORI GENETICI:
- TEORIA KNUDSON "two-hit"- TEORIA KNUDSON "two-hit"
- STUDIUL CHICAGO - 2 grupe- STUDIUL CHICAGO - 2 grupe
PROXIMAL DISTALDNA DIPLOID HIPERPLOID
KARIOTIP STABIL VARIABIL
DELE| II RARE FRECVENTE
CANCERE RER (MSI) CANCERE LOH
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ALTE ARGUMENTEALTE ARGUMENTE
1. EMBRIOLOGICE1. EMBRIOLOGICE
2. VASCULARIZA|IE2. VASCULARIZA|IE
3. HISTOLOGICE3. HISTOLOGICE
4. METABOLICE4. METABOLICE
5. EPIDEMIOLOGICE5. EPIDEMIOLOGICE
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Cancere LOSCancere LOS
C5qC5q APCAPC dele\iedele\ie
C17qC17q p53 p53 dele\iedele\ie
C18qC18q DCCDCC dele\iedele\ie
SMAD2SMAD2
C8pC8p
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Cancere RERCancere RER
GENE: M1H1GENE: M1H1
MSH2MSH2 CC2, 7, 9, 112, 7, 9, 11
MSH6MSH6
PMS1PMS1
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CLASIFICARE ETIOLOGIC~CLASIFICARE ETIOLOGIC~
I. CANCERE POLIPOASEI. CANCERE POLIPOASE
II. CANCERE EREDITARE NON II. CANCERE EREDITARE NON
POLIPOASEPOLIPOASE
III. CANCERE SPORADICEIII. CANCERE SPORADICE
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SINDROAME POLIPOASESINDROAME POLIPOASE
• POLIPI:POLIPI: - ADENOMATO}I - ADENOMATO}I
- HAMARTOAME- HAMARTOAME• SINDROAME:SINDROAME:
I. APC GARDNER/TURCOT CI. APC GARDNER/TURCOT C55
II. A. ATENUAT~II. A. ATENUAT~III. PEUTZ-JEGHERS CIII. PEUTZ-JEGHERS C1818
IV. JUVENIL~ CIV. JUVENIL~ C1818
V. COWDEN V. COWDEN
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HNPCC (LYNCH I)HNPCC (LYNCH I)
CRITERII AMSTERDAM:CRITERII AMSTERDAM:
- 3 pacien\i [n 2 genera\ii- 3 pacien\i [n 2 genera\ii
- 2 leg`turi gr. I- 2 leg`turi gr. I
- debut [nainte de 50 ani- debut [nainte de 50 ani
- proximale- proximale
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CANCERE SPORADICECANCERE SPORADICE
• ST~RI PRECANCEROASEST~RI PRECANCEROASE1. ADENOMUL - argumente:1. ADENOMUL - argumente:
- histologice- histologice- topografice- topografice- cronologice- cronologice- epidemiologice- epidemiologice- experimentale- experimentale
ADENOMUL PLAT- KUDOADENOMUL PLAT- KUDO
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2. BOLI INFLAMATORII:2. BOLI INFLAMATORII:
- distribu\ie mai uniform`- distribu\ie mai uniform`
- recidive frecvente- recidive frecvente
- v@rst` t@n`r`- v@rst` t@n`r`
- diferen\iere redus`- diferen\iere redus`
- infiltrare:- infiltrare:
colagenic`colagenic`
limfocitar`limfocitar`
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• COLITA GRANULOMATOAS~COLITA GRANULOMATOAS~
• RECTITA DE IRADIERERECTITA DE IRADIERE
• ADENDICECTOMIAADENDICECTOMIA
• URETEROSTOMIAURETEROSTOMIA
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• FACTORI ALIMENTARI:FACTORI ALIMENTARI:
I. GR~SIMII. GR~SIMI
II. FIBRE II. FIBRE
BENZPIRENHIDROLAZABENZPIRENHIDROLAZA
III. AINSIII. AINS
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ANATOMIE PATOLOGIC~ANATOMIE PATOLOGIC~
I. CARCINOAME:I. CARCINOAME:
- ADK 85%- ADK 85%
- cloacogene- cloacogene
- carcinoid- carcinoid
- scuamos- scuamos
II. MEZENCHIMALEII. MEZENCHIMALE
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MACROSCOPICMACROSCOPIC
I. DISTRIBU|IEI. DISTRIBU|IE
II. SINCRONE 4%II. SINCRONE 4%
III. FORM~:III. FORM~:
a) PROLIFERATIV~ - dra) PROLIFERATIV~ - dr
b) ULCERATIV~b) ULCERATIV~
c) INFILTRATIV STENOZANT~ - c) INFILTRATIV STENOZANT~ - stgstg
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DISEMINAREDISEMINARE
1. LOCAL - CIRCUMFEREN|IAL~1. LOCAL - CIRCUMFEREN|IAL~
2. VASCULAR2. VASCULAR
3. LIMFATIC3. LIMFATIC
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STADIALIZARESTADIALIZARE
•DUKESDUKES
A - pereteA - perete
B - str`bate pereteleB - str`bate peretele
C - metastaze ganglionareC - metastaze ganglionare
D - metastaze visceraleD - metastaze viscerale
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•GITSG GITSG A - mucoas`A - mucoas`
B - submucoasa str`b`tut`B - submucoasa str`b`tut`
BB11 - MP - MP
BB22 - seroas` - seroas`
C - ggl regionaliC - ggl regionali
CC11 - 1-4 ggl - 1-4 ggl
CC22 - > 4 ggl - > 4 ggl
D - metastazeD - metastaze
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CLINIC~CLINIC~
1. tulbur`ri de tranzit1. tulbur`ri de tranzit
2. tulbur`ri de scaun2. tulbur`ri de scaun
3. astenie3. astenie
4. sl`bire4. sl`bire
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COLON DREPTCOLON DREPT
TUMOR~ EXOFITIC~TUMOR~ EXOFITIC~
MAREMARE
MOALEMOALE
ULCERA|IEULCERA|IE
ANEMIEANEMIE
DURERE - SURD~DURERE - SURD~
APENDICIT~ ACUT~APENDICIT~ ACUT~
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COLON ST^NGCOLON ST^NG
• DURERE COLICATIV~DURERE COLICATIV~
• OCLUZIEOCLUZIE
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RECTRECT
• INTERFER~ CU DEFECA|IA:INTERFER~ CU DEFECA|IA:
- FORM~- FORM~
- ASPECT- ASPECT
- REGULARITATE- REGULARITATE
• DUREREDURERE
• RECTORAGIERECTORAGIE
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MANIFEST~RI PARANEOPLAZICEMANIFEST~RI PARANEOPLAZICE
1. ACANTOSIS NIGRICANS1. ACANTOSIS NIGRICANS
2. DERMATOMIOZIT~2. DERMATOMIOZIT~
3. ENDOCARDIT~ NEBACTERIAN~3. ENDOCARDIT~ NEBACTERIAN~
4. NEUROMIOPATII4. NEUROMIOPATII
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SEMNESEMNE
1. ASPECT GENERAL1. ASPECT GENERAL
2. GGL WIRCHOW2. GGL WIRCHOW
3. HEPATOMEGALIE3. HEPATOMEGALIE
4. PALPAREA TUMORII:4. PALPAREA TUMORII:
- transabdominal- transabdominal
- TR- TR
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STABILIREA DIGNOSTICULUISTABILIREA DIGNOSTICULUIMETODE IMAGISTICEMETODE IMAGISTICE
• IRIGOSCOPIA CU DUBLU CONTRASTIRIGOSCOPIA CU DUBLU CONTRAST
• COLONSCOPIACOLONSCOPIA
• HISTOLOGIAHISTOLOGIA
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STABILIREA EXTENSIEISTABILIREA EXTENSIEI
• ECHOENDOSCOPIEECHOENDOSCOPIE
• CTCT
• RMNRMN
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COMPLICA|IICOMPLICA|II
1. FISTULIZARE:1. FISTULIZARE:
- STOMAC- STOMAC
- VEZIC~- VEZIC~
- VAGIN- VAGIN
2. TULBUR~RI DE COAGULARE2. TULBUR~RI DE COAGULARE
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TRATAMENTTRATAMENT
1. CHIRURGICAL + META HEPATICE1. CHIRURGICAL + META HEPATICE
2. CHIMIOTERAPIE FUFOL2. CHIMIOTERAPIE FUFOL
3. ENDOSCOPICE3. ENDOSCOPICE
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CANCERUL HEPATICCANCERUL HEPATIC
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CANCERUL HEPATICCANCERUL HEPATIC
Tumori Benigne: HiperplaziTumori Benigne: Hiperplaziaa nodular` nodular` Tumorile Maligne Hepatice:Tumorile Maligne Hepatice:
1.1. PrimitivePrimitive dependente de dependente de
tipul celulartipul celular
2.2. Secundare Secundare
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Tumori maligne secundareTumori maligne secundare
Epidemiologie:Epidemiologie:
- cele mai frecvente- cele mai frecvente
- alte metastaze (sarcoame)- alte metastaze (sarcoame)
- b`rba\i- b`rba\i
- > 60 ani- > 60 ani
- cancer primitiv- cancer primitiv
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ANATOMIE PATOLOGIC~ANATOMIE PATOLOGIC~
Bron]icBron]icPancreas adenocarcinoame 60%Pancreas adenocarcinoame 60%Colo-rectal carcinoame nedif. 30%Colo-rectal carcinoame nedif. 30%Gastric carcinoame epidermoideGastric carcinoame epidermoideRenal carcinoame Renal carcinoame
neuroendocrineneuroendocrineOvarianOvarian
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ClinicClinic
• Asimptomatic – imagisticAsimptomatic – imagistic
• HepatalgiiHepatalgii
• +/- alterarea st`rii generale+/- alterarea st`rii generale
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DiagnosticDiagnosticTIP TUMORALTIP TUMORAL ANTIGEN I.H.C.ANTIGEN I.H.C.
11 LimfomLimfom CDCD4545
22 MelanomMelanom Proteina S-100Proteina S-100Ag HMB-45Ag HMB-45
33 RabdomiosarcomRabdomiosarcom Desmin`Desmin`
44 AngiocarcinomAngiocarcinom Ag F.VIIIAg F.VIII
55 GerminaleGerminale FPFPH.C.G.H.C.G.F Alcalina placentaF Alcalina placenta
66 APUDAPUD Cromogranina Cromogranina Sinaptofizin`Sinaptofizin`Enolaza neuronspecific`Enolaza neuronspecific`
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Tumori primitiveTumori primitive
HepatocarcinomulHepatocarcinomul
C C C.H.C. C.H.C. cel mai frecventcel mai frecvent cancer digestivcancer digestiv
Inciden\` Inciden\` > 20> 2000/suta de mii loc./an/suta de mii loc./an
5-195-1900/suta de mii loc./an/suta de mii loc./an
<5<500/suta de mii loc./an/suta de mii loc./an
Raport sexe Raport sexe 8/1 8/1 2/12/1
V@rst`. V@rst`. distribu\ie bimodal`distribu\ie bimodal`
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EtiologieEtiologie
• Virus BVirus B
• Virus C cu/f`r` ciroz`Virus C cu/f`r` ciroz`
• Afla toxina B1Afla toxina B1
• Gena p53Gena p53
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Virusul BVirusul B
• Cre]te de 7 ori risculCre]te de 7 ori riscul• Vaccinarea reduce inciden\aVaccinarea reduce inciden\a• Mecanisme propuse:Mecanisme propuse:
1. Ciroza 1. Ciroza displazie displazie cancercancer
2. Integrare [n genom:2. Integrare [n genom:
- dele\ii ADN- dele\ii ADN
- activare gen` myc- activare gen` myc
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VIRUS VIRUS CC argumente generate de argumente generate de istoria natural`istoria natural`
Genotipul 1b.Genotipul 1b.Coinfec\ia B+C cre]te riscul.Coinfec\ia B+C cre]te riscul.
80%
20%
1-4%
hepatit` cronic`
ciroz` 10 ani
35%
CHC 20 ani
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Factori de riscFactori de risc
• GeograficiGeografici• Demografici – v@rsta/sexDemografici – v@rsta/sex• Ciroza Ciroza indiferent etiologie indiferent etiologie
- hemocromatoza 45%- hemocromatoza 45%
- CSP – - CSP – colangiocarcinomcolangiocarcinom
• Porfiria cutanea tarda (prin virus C?)Porfiria cutanea tarda (prin virus C?)• Displazia Displazia
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SimptomeSimptome
• Durere – discoDurere – disconnfortfort
• Sl`bireSl`bire
• Inapeten\aInapeten\a
• IcterIcter
• Ascit`Ascit`
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SemneSemne
• Ficat mare - uni/bi lobularFicat mare - uni/bi lobular
- dur- dur
- sensibil- sensibil• Suflu sistolic, rugos, independent pozi\Suflu sistolic, rugos, independent pozi\
ionalional• Frecatur` (mai des meta, abces)Frecatur` (mai des meta, abces)• Ascit` - transudatAscit` - transudat
- exudat- exudat
- hemoragic`- hemoragic`
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DiagnosticDiagnostic
1. Biologic 1. Biologic T > 3 cmT > 3 cm -des -des CP>100ng/ml+CP>100ng/ml+FP>20ng/ml FP>20ng/ml
85%85%2. Imagistic:2. Imagistic:
a) echografica) echograficb) CT spiral`b) CT spiral`c) anteriografiec) anteriografied) scintigrafied) scintigrafiee) RMNe) RMNf) biopsief) biopsie
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Manifest`ri paraneoplaziceManifest`ri paraneoplazice
1. ENDOCRINE1. ENDOCRINE::• PTH – hipercalcemiePTH – hipercalcemie• Eritropoietin` – poliglobulieEritropoietin` – poliglobulie• Aldosteron – HTAAldosteron – HTA• VIP/PGEVIP/PGE22 – diaree – diaree• ILG I/II – hipoglicemieILG I/II – hipoglicemie
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2. PROTEINE CARCINOFETALE2. PROTEINE CARCINOFETALE
FPFP CEACEA FibrinogenFibrinogen Des Des carboxiprotrombinacarboxiprotrombina L fucozidazaL fucozidaza FalcalinaFalcalina Isoferitine acideIsoferitine acide
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SCOR OKUDA SCOR OKUDA == PROGNOSTIC PROGNOSTIC
PARAMETRUPARAMETRU
(1pct pt. fiecare)(1pct pt. fiecare)SCORSCOR SUPRAVIE|UIRESUPRAVIE|UIRE
ASCIT~ASCIT~
ALBUMINEMIE < 3g/dlALBUMINEMIE < 3g/dl 00 8-12 luni8-12 luni
BILIRUBINEMIE > 3mg/dlBILIRUBINEMIE > 3mg/dl 1-21-2 2-3 luni2-3 luni
TUMORA > 50% volumTUMORA > 50% volum 3-43-4 < 1 lun`< 1 lun`
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TratamentTratament
• Chirurgical Chirurgical
• OLTOLT• Hepatectomie Hepatectomie
+/- chimioterapie lipiodat`+/- chimioterapie lipiodat`
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IntraarterialeIntraarteriale
• ChimioterapieChimioterapie• Chimioterapie lipChimioterapie lipiiodat`odat`• EmbolizareaEmbolizarea
-- C. C. I. I. absolutabsolut`̀ – ruptur` – ruptur`
- C.I formal` – fistula AV- C.I formal` – fistula AV
a -flux hepatofuga -flux hepatofug
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• Radioterapie:Radioterapie:
- extern`- extern`
- fotonic` - fotonic`
- intern`- intern`
• Radioabla\ieRadioabla\ie
• AlcoolizareAlcoolizare
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Carcinomul fibrolamelarCarcinomul fibrolamelar
- TineriTineri- Femei Femei FP NFP N- ANAT PAT - solitarANAT PAT - solitar
- conjunctiv- conjunctiv- Chirurgie Chirurgie
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Colangiocarcinom 10%Colangiocarcinom 10%
• Canale intrahepaticeCanale intrahepatice• Hil (Klatskin)Hil (Klatskin)• DurereDurere• Febr`Febr`• Icter Icter
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AngiosarcomAngiosarcom
• Etiologie:Etiologie: - As - As,, Thorotrast, clorur` Thorotrast, clorur` de vinil, de vinil, hhemocromatozemocromatoz`̀
• Clinic:Clinic: - Durere, sl`bire, ascit` - Durere, sl`bire, ascit`
• ANA PAT: ANA PAT: - E VIII- E VIII
- Hepatoblastom- Hepatoblastom
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Tumorile c`ilor biliare Tumorile c`ilor biliare extrahepaticeextrahepatice
CLINIC~:CLINIC~:
• Icter +/- prurit +/- febr`Icter +/- prurit +/- febr`• HepatomegalieHepatomegalie• Colestaz`Colestaz`
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DiagnosticDiagnostic
EchoendoscopieEchoendoscopie
ERCPERCP
EcotomografieEcotomografie
CTCT
RMNRMN
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TratamentTratament
• DuodenopaDuodenopanncreatectomia cefalic` createctomia cefalic` cu hepaticojejunostomiecu hepaticojejunostomie
• Protezare Protezare
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Forme SpecialeForme Speciale
• Papilomatoza c`ilor biliarePapilomatoza c`ilor biliare
• Tumori ampulareTumori ampulare
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Cancerul colecisticCancerul colecistic
Adenocarcinom:Adenocarcinom:
- papilar- papilar
- infiltrant- infiltrant
Etiologie:Etiologie:
- litiaz`- litiaz`
- vezicul` de por\elan- vezicul` de por\elan
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DiagnosticDiagnostic
• Durere biliar`Durere biliar`
• IcterIcter
• Sl`bireSl`bire
• Mas` palpabil`Mas` palpabil`
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TUMORITUMORIPANCREATICEPANCREATICE
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ClasificareClasificare
• ExocrinExocrin
• Endocrin = apudoameEndocrin = apudoame
• BenigneBenigne
• Maligne 90% ADKMaligne 90% ADK
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Cancer – I. EtiologieCancer – I. Etiologie
• Genetic` Genetic`
- autosomal dominantautosomal dominant- K-rasK-ras- HNPCCHNPCC- FAPFAP- MEA I = MENMEA I = MEN
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• FumatFumat• CafeaCafea• AlcoolAlcool• Diet`Diet`• Pancreatit`Pancreatit`• Gastrectomia pt ulcerGastrectomia pt ulcer
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ANATOMIE PATOLOGIC~
1. ADK2. 70% CEFALICE3. 2,5-3 cm/5-7 cm4. INVAZIE LOCAL~:
- STOMAC - COLON - VP, VSH
5. META: - GGL - FICAT - PANCREAS
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CLINICA
•CORP
1. SL~BIRE2. DURERE3. ASTENIE
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• CAP
1. DURERE: - distensia c`ii biliare- pancreatit`- invazie
2. ICTER: 70% ictere obstructive maligne3. SL~BIRE4. DIABET5. TROMBOFLEBITA MIGRATORIE
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SEMNE
•HEPATOMEGALIE
•S. COURVOISIER
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DIAGNOSTIC
• BIOLOGIC:1. COLESTAZ~2. CA 19-9
• IMAGISTIC:1. ECHOENDOSCOPIA2. CT HELICOIDAL3. RMN4. ERCP +RECOLTARE SUC PANCREATIC5. COLANGIO RMN6. Rx CONVEN|IONAL~
• HISTOLOGIC: FNA
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•PROGNOSTIC:20% SUPRAVIE|UIESC 1 AN
•TRATAMENT:I. CHIRURGICAL DEPENDENT DE:
1. M~RIMEA TUMORII2. LOCALIZAREA EI3. INVAZIA LOCAL~4. INVAZIA VASCULAR~5. METASTAZE
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TIPURI
A) CURATIVE:1. WHIPPLE2. DUODENOPANCREATECTOMIA
CEFALIC~3. PANCREATECTOMIA TOTAL~4. PANCREATECTOMIA REGIONAL~5. SPLENOPANCREATECTOMIA
ST^NG~
B) PALIATIVE
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• PALEATIV:1. STENTARE2. Rx TERAPIE 55-70 Gy3. CHIMIOTERAPIE: 5-FU, GEMCITABIN~4. COMBINA|IE
• SIMPTOMATIC:1. ALCOOLIZAREA2. MORFINICE
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ALTE TUMORI
•CISTADENOMUL SEROS:- MARE- MULTILOCULAT (1 CHIST < 1
cm)- FEMEI- V^RSTNICI- SE MALIGNIZEAZ~ RAR
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•CISTADENOMUL MUCOS:
- MARE > 5 cm
- UNI/MULTILOCULAT
- SE MALIGNIZEAZ~ FRECVENT
- SUPRAVIE|IURE LA 5 ANI - 50%
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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 IIMEA = MEN
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ASOCIEREA TUMORILOR
• PARATIROID~ 90%
• PANCREAS 85%
• HIPOFIZ~ 65% MEN I WERMER
• ADRENALE 20%
• TIROID~ 20%
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TIPURI TUMORI ENDOCRINE
LOCALIZARETIPCELULAR
SECRE\IEDOMINANT~
PANCREAS EXTRA
CARCINOID ECECL
SEROTONIN~?
EXCEP| IONAL APENDICE,ILEON, RECT,
BRON}II,STOMAC
INSULINOM B INSULIN~ (PP,GLUCAGON)
98% 2%
GASTRINOM G GASTRIN~ (PP,INSULIN~,
GLUCAGON)
70-80% STOMAC,DUODEN, OVAR
GLUCAGONOM D GLUCAGON(INSULIN~, PP)
99% RINICHI
VIPom VIP (PP) 80% 99%SOMATOSTATINOM D SOMATOSTATIN~ 50% DUODEN
NEUROTENSINOM NT NEUROTENSIN~ 90%
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ACESTE TUMORI POT FI:1. MUTE (carcinoid rectal, PP)2. ENTOPICE 3. ECTOPICE:
- GASTRINOM- VIPOM- CORTICOTROPINOM- PARATIRINOM
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DIAGNOSTIC
• DOZAREA RIA
• TESTE DE SUPRESIE }I STIMULARE
• ECHOENDOSCOPIE 80%
• CT
• ANGIOGRAFIE
• SCINTIGRAFIE RECEPTORI
SOMATOSTATIN~
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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
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CLINIC
1. ULCERE:- multiple- rezistente la tratament- recidiv@nd dup` opera\ii- localiz`ri rare- complicate cu HDS, perfora\ii
2. DIAREE/STEATOREE
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• 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
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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
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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~
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TUMORI CARCINOIDE
TUMORI CE SE DEZVOLT~ DIN CELULE:
- EC (Kulchitsky Masson)- ECL (fundice)
• PREVALEN|~ 1,5/100.000• F > M• TINERI
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LOCALIZARE
I. DIGESTIVE (90%):1. APENDICE2. ILEON3. RECT4. STOMAC
II. EXTRADIGESTIVE:1. BRON}II2. OVAR3. TIMUS
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TIP
• MUT
• ENTOPIC
• ECTOPIC
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FIZIOPATOLOGIE
TRIPTOFAN 5OHTP 5OHTriptamin`DETURNAREA : antreneaz` 1 SC~DEREA SINTEZEI PROTEICE
CA}ECSIE
2. SC~DEREA SINTEZEI AC. NICOTINIC
S. PELAGROID
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SIMPTOM MECANISM FLUSH 5OHTP, HISTAMIN~,
PG, BRADIKININ~ DIAREE HIPERMOTILITATE,
5OHTP BRONHOSPASM PG, HISTAMIN~,
BRADIKININ~ CARDIOPATIE FIBROZ~
ENDOCARDIC~, 5OHTP
HIPOTENSIUNE 5OHTP
DEPIND DE LOCALIZARE (BRON}IC~, HEPATIC~)
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CLINIC1. FLUSH: - ERITEMATOS DIFUZ
- VIOLACEU TELEANGIECTAZII - PRELUNGIT L~CRIMARE + HIPO TA - RO}U-C~R~MIZIU, GEOGRAFICPOATE FI ALCOOL INDUS
2. DIAREE: - 60% asociere cu fluide - volum < 1l/zi - nr. scaune cca 10/zi
3. DURERI ABDOMINALE legate de diaree4. CARDIOPATIE: - insuficien\` tricuspid`
- stenoz` pulmonar`5. BRONHOSPASM
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TRATAMENTUL SINDROMULUI
CARCINOID
DE ELEC|IE: SOMATOSTATINA 200g/zi - 6
s`pt`m@ni
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TRATAMENTUL SINDROMULUI CARCINOID
DROG DOZ~/ZI FLUSH DIAREE 5-OH EFECTESECUNDARE
IFN 3MU + + + FEBR~,CITOPENIE,ASTENIE
KETANSERIN~(ANTAGONISTRECEPTOR 5-HT2)
40mg + +
METHYSERGID 3-8 + + FIBROZ~RETROPERIT
ANTAGONI}TIKININE
+
ANTAGONI}TI H1(CIPROHEPTADIN~)
6-30 + +
ANTAGONI}TI H2 1800 +
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TRATAMENTUL
1. TUMORII2. METASTAZELOR HEPATICE3. CHIMIOTERAPIE:
- STREPTOZOCIN~- 5FU- ADRIABLASTIN
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MEZOTELIOMUL PERITONEAL
• INCIDEN|~:- 20% din total- 2-3/106 locuitori
• ETIOLOGIE:- asbestoza- thorotrast- iradiere- genetic` 1, 3, 6, 9, 22, p53
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CLINIC~
• DURERI: - DIFUZE
- HIPOCONDRUL DREPT
• GREA|~, V~RS~TURI
• DIAREE
• SL~BIRE
• FEBR~
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SINDROAME PARANEOPLAZICE
• ADH Hipo Na
• ST Trombocitoz`
• ILF Hipoglicemie
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DIAGNOSTIC
• ECHOGRAFIE
• CT
• LAPARASCOPIE
• HISTOLOGIE + ac. hialuronic (alcian)
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TRATAMENT
• DOXORUBICIN
• IFN