Symptomatic treatment of cancer patients. Treatment of tumors - radical and palliative

Today, one can observe an increase in cancer diseases against the backdrop of negative factors external environment and prevalence internal diseases person. This is what causes the development of malignant and benign tumors, and their localization can be very diverse. In this regard, new technologies are being developed, new principles are being created, and many experiments are being conducted in order to find the safest and most effective treatment for oncology.

General principles of treating cancer patients

Modern methods of fighting cancer are built on the same principles; the basis of effective treatment is speed, safety and complexity. It is impossible to completely get rid of oncology, but there is a chance to significantly improve the patient’s quality of life by maintaining normal condition body and prevent relapses.

The main objectives of treating cancer patients.

Application combination treatment, regardless of stage and extent pathological process.Combination of modern technologies with basic treatment methods. Long-term treatment planning, continuity of therapeutic measures throughout the patient’s life. Constant monitoring of the cancer patient, treatment correction based on the latest diagnostic tests.

In addition, the main goal of modern medicine is timely diagnosis, which is the key to effective treatment.

Drug treatment of oncology

The use of medications for the treatment of cancer patients is carried out taking into account the stage and location of the malignant process. Antitumor vaccines, hormonal and symptomatic therapy medicines. Such treatment cannot be carried out as an independent method, and it is only an addition to the main measures in the presence of a malignant process in the body.

Let's look at the most common types of cancer and the essence of their drug therapy.

Breast and prostate cancer - if cancer is localized in the breast and prostate, it is rational to use the course hormone therapy. Painkillers, restoratives and antitumor drugs are also prescribed. The essence hormonal treatment is to stop the synthesis of hormones that cause progressive tumor growth. Must be appointed cytostatic drugs, which destroy atypical cells, creating all the conditions for their death. Cancer of the brain or bone marrow - for such diseases, drug therapy is less significant and should be carried out surgery. But in order to maintain general condition, medications are prescribed to increase brain activity and improve memory. Patients with brain cancer experience various mental disorders, therefore symptomatic therapy is carried out. Bone cancer and cartilage tissue– Medicines are prescribed to strengthen bones. Very often, in patients with a tumor, fractures or cracks occur in the bones even with minor loads. Therefore, it is very important to strengthen the structure of bone tissue through vitamin therapy and other medications.

What drugs are used to treat cancer?

All medications used in the fight against cancer can be divided into several groups.

Hormonal drugs - drugs that reduce testosterone levels, these are Herceptin, Taxol, tamoxifen, Avastin, Thyroxin, Thyroidin. Toxic drugs - aimed at destroying cancer cells, through toxic effects on them, these are Celebrex, Avastin, Docetaxel. Also narcotic drugs - Morphine, Omnopon and Tramadol. Antiviral - the essence of the purpose of this group of drugs is to maintain immunity. In oncology, both local and internal anti-inflammatory drugs are used. Cytotoxins and cytostatics - under the influence of these drugs, the tumor resolves and decreases in volume, which is necessary for subsequent surgical intervention. Antitumor universal drugs are Ftorafur, antimetabolites, Doxorubicin and others.

Radiation and chemotherapy

Radiation therapy and chemotherapy are the main treatments for cancer. Prescribed in the preoperative and postoperative period.

Radiation therapy

Radiation therapy is prescribed if cancer cells are sensitive to this type of radiation. This is a small cell cancer, which is most often localized in the respiratory organs, uterus, in the head area, and can also affect the lungs.

Several radiation therapy techniques are used:

remote; intracavity; using neutrons, radioactive isotopes and protons.

It is rational to use the radiation method of oncology treatment before surgery in order to localize the main focus of the tumor. The goal of postoperative radiation therapy is to destroy any remaining cancer cells.

Chemotherapy

Chemotherapy is also the main method of treating cancer, but is used in parallel with radical measures. The drugs that are used actively fight pathological cells. Healthy tissues are also negatively affected, but to a lesser extent. This selectivity of chemicals lies in the rate of cell growth. Cancerous structures multiply quickly, and they are the first to be hit by chemotherapy.

For testicular cancer, uterine cancer, Ewing's sarcoma, and breast cancer, chemotherapy is the main treatment method and can completely overcome cancer in the first and second stages.

Radical tumor removal

A surgical operation aimed at removing the main focus of the tumor and nearby tissues is used in the first, second and third stages of the disease. The last stage of cancer does not respond to surgery, and surgery is contraindicated. This is because at stage 4 cancer metastasis occurs, and it is impossible to remove all metastases from the body. The operation in this case will only harm the patient and weaken him (with the exception of palliative surgery).

Radical therapy in oncology takes first place. Complete removal of the tumor in the early stages can completely eliminate cancer. During the surgical operation, not only the lesion and part of the affected organ are removed, but also regional lymph nodes. After the operation, a mandatory tissue examination is carried out, after which a course of drug treatment is prescribed.

There are two main options for surgery – organ-preserving and extended.

Extended surgery is performed mainly for cancer of the rectum, uterus, and genitals. It involves the removal of the organ itself and regional lymph nodes. Another technology for extended operations has been created - super-radical, in which, in addition to the causative organ, several nearby ones are also removed. Contraindications: the presence of distant metastases. Organ-preserving surgery is performed when the cancer is clearly localized without metastatic processes. It is performed for breast cancer and tumors in the facial area. This allows you to save the organ, which significantly affects psychological condition patient. In some cases, after radical removal, cosmetic procedures for recovery, which also improves the patient’s quality of life.

Palliative care

Of the entire complex of oncology treatment, it is important to highlight palliative measures. They are aimed not at treatment, but at improving the quality and life expectancy of patients with stage 4 cancer. Such patients do not have a chance for a full recovery, but this does not mean that they can die peacefully. Modern medicine offers such patients a set of procedures that eliminate the main symptoms of cancer. This includes pain relief, cancer reduction through gentle surgery, taking restorative medications, and physiotherapeutic procedures.

Treatment of patients at stage 4 is a difficult task, such patients suffer from excruciating pain, severe weight loss, psychological disorders. Therefore, separate treatment is carried out for each of the complications of cancer.

Symptomatic treatment includes:

narcotic analgesics - morphine, fentanyl, buprenorphine; non-narcotic analgesics - paracetamol, metamizole, ibuprofen, diclofenac.

If treatment is ineffective pain syndrome You can contact the Cancer Pain Treatment Center. Eliminating pain is the main goal in treating a cancer patient.

In modern medicine, three main methods are used to treat malignant tumors: chemotherapy, radiation therapy and surgical treatment. Chemotherapy involves the use of medications that have the ability to destroy malignant cells. Radiation therapy consists of exposing the tumor to a narrow beam of radiation. Concerning surgical treatment, then it involves surgical removal of malignant tumors or parts thereof.

Unfortunately, even with significant advances in modern oncology, some types of cancer cannot be cured. Therefore, patients are often prescribed complex treatment, which involves a combination of several methods. Most effective way surgical removal of the tumor is considered. The problem is that the operation cannot be performed in all cases due to the anatomical features and location of the tumor.

Types of oncological operations

Oncological operations are divided into two types: radical and palliative. Radical intervention involves complete removal of the tumor and is considered the most effective method cancer treatment. In cases where it is impossible to remove the tumor, palliative surgery is performed, which is also called symptomatic. This treatment method does not cure the patient, but it can significantly alleviate the symptoms of cancer and improve the patient's well-being.

Radical removal of cancer is usually effective at stages 1-2, while palliative operations are used in advanced cases in order to prolong the patient’s life.

How are cancer removal operations performed?

Since malignant cells often spread beyond the tumor, it is often removed “with a reserve”, that is, in addition to the tumor itself, the tissue surrounding it is also removed. This is done to prevent relapse of the disease. For example, with breast cancer, it is often necessary to remove not only the tumor, but also the entire mammary gland, and sometimes the subclavian and axillary lymph nodes. In most cases, especially if treatment was started in the early stages, this method can prevent the development of metastases and cure the patient.

After tumor removal surgery, plastic or cosmetic surgery is often performed to remove scars and other external defects.

Cancer surgery can be performed using either a traditional scalpel or more modern instruments such as a laser, ultrasonic scalpel or radiofrequency knife. New equipment makes it possible to reduce the trauma of the procedure, avoid bleeding and other complications, and shorten the recovery period. For example, when laryngeal cancer is removed with a laser, the patient is often able to preserve his voice, which is not always possible with traditional operations.

Removal of malignant tumors requires special care and caution from specialists. During the procedure, it is necessary to follow the rules of ablastics to prevent the proliferation of malignant cells. Thus, the skin incision must be performed exclusively within healthy tissues, while traumatizing tumor tissues is not permissible.

Some types of cancer are difficult to cure and lead to the death of the patient. However, in many cases, cure is still possible. The successful outcome of the procedure largely depends on the characteristics of the tumor, including its type, size, stage and the presence of metastases. Another important factor determining the success of treatment is early diagnosis diseases. The chances of cure in the early stages are very high, so you need to be careful about your own health and undergo regular medical examinations.

Currently, oncology has powerful cancer treatment methods that can achieve success, especially in the early stages of the disease. There are three main methods for treating tumor disease: surgical, radiation and drug. The latter is often combined with all systemic methods of influencing the tumor: hormone therapy, immunotherapy, and sometimes different types of biotherapy.

Surgical method involves direct removal of the tumor in compliance with the mandatory rules of ablastics and specific principles of oncological surgery. Radiation therapy- exposure of the tumor to a flow of one or another type of radiation (X-rays, gamma rays, flow of fast electrons, etc.). Chemotherapy- introduction into the body of drugs that have a damaging effect primarily on tumor cells. In some cases, chemotherapy drugs can completely destroy the tumor, but more often they can inhibit its development.

The surgical method and radiation treatment are local methods that act directly on the growth zone of the tumor itself, surrounding tissues and regional metastasis pathways. Chemotherapy - system method treatment, since the drugs act on tumor cells anywhere in the body. According to modern concepts, all malignant tumors are systemic diseases. The most appropriate use of chemotherapy. The lack of possibility (with rare exceptions) of isolated effects of chemotherapy on tumor cells limits its use.

The experience accumulated by modern oncological practice allows, with a full diagnosis (localization, stage, degree of differentiation, local prevalence or generalization), to clearly recommend the most effective methods of treating the process. In cases of early stages of malignant neoplasms or with prolonged local spread, which is quite typical for tumors of the head and neck, it is justified and effective.

but surgical or radiation treatment, i.e. local, which is still the main method of treating most tumors.

Surgical interventions have been used in the treatment of cancer patients for a long time. Real successes from the use of operations appeared after the formation of basic ideas about tumor disease as a disease of the cell, i.e. at the end of the nineteenth and beginning of the twentieth centuries. At the same time, the main variants of operations were developed and special rules of ablastics were developed, careful adherence to which significantly increases the success rate of surgical intervention. In a modified form, most of these standard operations are still used today.

Beginning of development radiation treatment malignant tumors dates back to the first third of the twentieth century. This treatment method has become the method of choice for a number of neoplasms. In radiation treatment, various options for remote and contact effects on the tumor have been developed: remote and intracavitary gamma therapy, x-ray therapy, introduction of radiation carriers into tumor tissue (needles, threads), etc. Various devices and modifications are used to protect healthy tissues entering the irradiation zone.

Since the 40s. In the 20th century, special drug therapy for malignant tumors developed. Chemotherapy includes all methods of drug treatment of a tumor: chemotherapy, hormone therapy, immunotherapy. The search for other treatment methods is ongoing. Cancer biotherapy methods and photodynamic therapy are being actively developed.

With rare exceptions, any special antitumor treatment should be prescribed after morphological verification of the pathological process. In addition to confirming the malignancy of the process, the macroscopic form of growth and the degree of differentiation of the tumor determined by morphological examination are of great importance for choosing the optimal treatment tactics.

Modern standards of radical treatment of cancer patients involve the use of all existing methods special antitumor treatment in various combinations, which allows you to obtain significantly more effective results than from using one of the types of treatment. For each type and location of tumors, there are known optimal treatment options that most often ensure recovery.

The best results, as a rule, are obtained by complex therapy, if it is indicated and feasible based on the objective status of the patient. All options for special antitumor treatment are not indifferent to the patient; they often cause significant damage to activity internal organs, hormonal status and immunity. After establishing a diagnosis of a tumor disease and assessing the prevalence and degree of malignancy, before solving treatment and tactical problems, it is necessary to characterize the general condition of the patient. Using traditional examination methods, it is necessary to assess the condition of the cardiovascular system, respiratory system, gastrointestinal tract, kidneys, liver, pancreas and endocrine system. Functional disorders detected during the examination significantly influence the choice of treatment tactics.

In each specific case of a tumor disease, the therapeutic tactics of primary treatment are determined by a council consisting of three specialists: a surgeon, a radiation therapist and a chemotherapist. This is how it is determined which of the existing treatment options, at what stage, in what mode, should be used for a given patient. In cases of relapses and metastases, as well as when another tumor appears, discussion of the primary treatment plan ex consilium must also be strictly followed. The possibility of performing radical treatment in full is discussed collectively, taking into account possible complications of the course of both the tumor process itself and concomitant pathology. The latter often significantly limits treatment options. They, as well as a detailed description of the tumor itself, should be presented at the consultation.

In oncological practice one should distinguish between:

"combined treatment - when using several different methods that have the same focus; for example, a local effect on a tumor - radiation and then surgery, or in the reverse order - surgery then radiation;

combined treatment - the use within one method of various methods of its implementation, for example, two types of irradiation - remote gamma therapy and any of the options for contact irradiation, chemotherapy + hormone therapy, etc.;

"comprehensive treatment - includes antitumor effects of both local-regional and general types, for example

radiation, surgery, polychemotherapy. The order in which they are carried out can also be different, but involves the use of three or more types of treatment: radiation + chemotherapy + surgery, possibly including photodynamic therapy and/or biotherapy, etc. For most tumors after radical treatment, the risk of relapse and metastases is especially relevant over the next 5 years. After this period, mortality among people who underwent treatment for a tumor practically coincides with that in the corresponding age groups. The first 2 years after radical treatment are especially unfavorable with regard to the possibility of tumor growth resumption. In the 3rd year, the frequency of relapses and metastases drops sharply. After 3 years after radical treatment, the leading points in the absence of signs of relapse for almost all patients are the degree of dysfunction, complications and consequences of special treatment. During the 4th and 5th years, only isolated cases of resumption of tumor growth are observed, as a result of which the risk of relapse or metastasis in this period ceases to be leading in the prognostic assessment of the patient.

Standard types of tumor treatment are different for locally advanced processes, disseminated and “systemic” tumor diseases. In most cases, in processes that have a locoregional spread, primary treatment is also only local. The main types of local regional therapy are surgical and radiation treatment, photodynamic therapy.

Options for systemic chemotherapy have been developed for tumor pathologies that initially have a systemic spread: leukemia or tumors with early, usually subclinical, metastasis (breast cancer, germ cell tumors, etc.).

7.1. SURGICAL TREATMENT METHOD

Surgical method remains a leader in the treatment of a significant number of oncological diseases. The tasks solved during surgery are different. In this regard, several variants of the operation are distinguished, depending on the purpose of the surgical intervention.

Most often, the operation is performed when a morphological diagnosis has been established and there is an adequate idea of ​​the extent of the tumor. In such cases it is done radical surgery, removal of the primary tumor within healthy tissue, with the intention of removing the entire tumor with the hope of a complete cure. Surgery may be supplemented with chemotherapy and/or radiation. The problem of radical intervention in oncology has not yet been resolved and is highly debatable. The principle is not always justified: wider resection means less chance of local relapse. Most patients die not from locoregional, but from distant metastases.

If the tumor has spread significantly, the additional use of radiation and drug exposure to the tumor before surgery makes it possible to reduce the volume of the tumor, as a result of which it is often possible to perform a surgical intervention that can be regarded as radical. In such cases, extended operations are performed, when the volume of tissue removed includes adjacent or distant lymphatic collectors. In some cases, combined operations are required. Combined operations mean operations in which, in addition to the affected organ, the organ is partially or completely removed. adjacent organ. Although the idea of ​​radicalism in oncology is very conditional, since true biological radicalism is assessed not at the time of intervention, but only after several years, give clinical assessment treatment option is absolutely necessary.

Basic principles of oncological surgery: adherence to zonality and casing. When performing surgery for malignant neoplasms, it is mandatory to adhere to the principles ablastics and antiblastics. For this purpose, the anatomical and case-based operation on the organ is observed, and areas of regional metastasis are removed en bloc with the affected organ. In the surgical field, the arteries are first ligated, then the veins, since reverse order ligation of blood vessels leads to increased blood pressure in the tumor area and increasing its lymphogenous spread. During the operation, it is necessary to be as gentle as possible towards the affected organ to reduce canceremia, which is observed during surgery in 40% of patients. An indispensable condition is frequent change

surgical linen and delimiting the tumor with napkins to prevent implantation metastases. The tumor is removed within healthy tissue, the fascial sheath, or with a part of the organ, sometimes affected neighboring organs. Removal of regional lymphatic collectors is carried out in a single block. Histological control along the resection line is necessary. When choosing the boundaries of resection, maximum preservation of the function of tumor-free parts of organs is necessary. Currently, the following principles are actively applied antiblastics, such as the use of specific antitumor agents during surgery: the introduction of chemotherapy into the cavity, irradiation of the surgical field after tumor removal.

The need to fulfill these requirements is proven by the fact that the results of 5-year follow-up after surgical treatment of most malignant tumors in general surgical hospitals are on average more than three times lower than after treatment in specialized oncology clinics (for example, for stomach cancer 12% versus 37%) .

Palliative and symptomatic operations They are also used to provide a complete understanding of the nature and extent of the tumor. In domestic practice, it is customary to distinguish between these concepts. Symptomatic surgery eliminates a symptom, sometimes by affecting the tumor (see Chapter 28 “Symptomatic treatment”). For palliative surgery, temporary healing effect is carried out by influencing the volume of the tumor, and the leading symptom of the disease is usually eliminated.

Symptomatic treatment can be carried out at any stage of treatment or monitoring of a cancer patient. Such operations are sometimes performed before the start of radical treatment, for example, tracheostomy - before the start of radiation treatment if there is a threat of laryngeal stenosis, epicystostomy - if there is urinary retention, etc. If radical treatment is not feasible, then surgical treatment is not performed in full. In this case, surgical intervention is not aimed at curing the patient, but at improving his condition. The most common complications requiring symptomatic surgical intervention are tumors of the hollow organs. These may be obstructions - stenosis of the outlet of the stomach, esophagus, obstructive colonic or small intestinal obstruction.

Then in frequency follow bleeding, perforation of hollow organs, and the formation of fistulas (interorgan). Quite often an inflammatory process develops - in the form of infiltration, abscess, etc. Tumor bronchial stenosis leads to the development of atelectasis of the corresponding segment or lobe of the lung and pneumonia. Tumor growth can lead to compression of the corresponding tubular structures and the development of hydronephrosis (with compression of the ureter), venous thrombosis, compressive intestinal obstruction, and severe neurological disorders. Symptomatic surgical intervention is usually much smaller in volume than the standard one, and is performed only with the aim of eliminating any symptom caused by the tumor: stopping bleeding, eliminating the source of inflammation, opening an abscess, crossing a large nerve trunk for pain relief, etc. Currently, an operation that began as symptomatic, usually performed for emergency reasons, for example, for pulmonary, uterine, gastrointestinal bleeding, is expanded, if possible, to palliative (cytoreductive).

Palliative(from lat. pallio- cover, smooth out) the operation option involves an intervention in which the goal is not to completely eliminate the tumor. A more radical treatment option than symptomatic surgery is palliative surgery performed on the primary lesion.

In the presence of distant metastases, when cure is obviously unattainable, perform palliative operations- removal of the primary tumor in the scope of a standard radical intervention or partial removal of the tumor. Palliative surgery for local spread of a tumor quite often represents an intervention of approximately the same volume as a standard one, but clearly not radical, when the spread of the tumor to neighboring vital organs does not allow the required volume of tissue to be captured. The remains of the tumor are marked with markers to mark the area of ​​subsequent irradiation and evaluate the effectiveness further treatment or monitoring the progression of the process. Indications for palliative resection arise for tumors that are highly sensitive to radiation and drug treatments, for example, hematological malignancies. In such cases, the surgeon removes the bulk of the tumor or metastases with the hope of success of additional treatment.

Palliative operations also have a certain significance in alleviating the severe suffering of patients. They lead to a reduction in pain, improved function of surrounding organs, and elimination of other painful symptoms. In connection with the achievements of modern chemotherapy, such interventions, which eliminate a large mass of tumor in the body, make it possible to carry out systemic treatment even at the stage of generalization of the process.

Currently, palliative surgical interventions are also performed on organs where solitary or single (no more than 3) metastases are found. These organs are most often the lungs and liver. Single distant metastases can be of a wide variety of localizations: ovaries, tissue of the anterior abdominal wall or the outer integument of the chest, etc. From the organs of the head and neck, most often in the thyroid gland there are solitary metastases from distant organs (kidney cancer, hematosarcomas, germ cell tumors, etc.).

Solitary and even single metastases to the brain, solitary bone metastases can also be removed surgically. In some cases, only distant metastases are removed if they are single or grouped locally (in the lung, liver, etc.), and the nature of the primary process does not threaten rapid dissemination. For example, similar properties have been noted in kidney tumors. Additional Methods(drug and hormonal therapy) are prescribed after surgery to slow down the progression of the process (adjuvant chemotherapy).

Indications for palliative interventions are expanding as radiation and medicinal methods treatment. Advances in chemoradiation treatment in the early 1990s. allowed to significantly increase survival rate in a number of localizations of tumors of internal organs, when radical intervention is obviously impossible due to technical features. Thus, palliative operations became a component of combined treatment. In such cases they are called cytoreductive(kytos- cell, + reductio- decrease). The surgeon may be tasked with performing cytoreductive surgery, when radical surgery is not possible, surgery is performed only to remove the maximum mass of the tumor, followed by chemotherapy and/or radiation. This technique is widely used in patients with testicular and ovarian cancer, as well as other

tumors at an advanced stage of the process, as an obligatory part of complex treatment, if the morphological structure allows one to count on a good effect from chemoradiotherapy. After this, the primary focus or metastases remain and conditions appear for effective treatment of the tumor using chemotherapy or radiation therapy. Maintaining a satisfactory quality of life with such treatment is especially valuable. Currently, this tactic is used in leading oncological institutions in our country and in other tumor locations. Primary tumors of any location (kidney, colon, breast, etc.) can be removed in the presence of distant metastases.

In the absence of adequate ideas about the morphological structure and extent of the tumor, use diagnostic surgical interventions. An operation involving a tumor biopsy is performed if there are objective difficulties in making a morphological diagnosis. These difficulties are associated either with a strongly expressed stromal component in the tumor and, therefore, there are no informative cells in repeatedly obtained punctates, or due to its location in a difficult-to-reach place (under the base of the skull, in the deep areas of the face). Sometimes ideas about the morphological structure of the tumor are not obtained due to the difficulty of interpreting the rare cytological picture, etc.

In such cases, a diagnostic operation is performed to either remove a piece of the tumor or enucleate the tumor, if this is not associated with technical difficulties. During the operation, material is also collected due to the need to obtain a significant amount of material for adequate diagnosis, for example, hemoblastoses, or to perform some specific, biochemical reactions and tests with tumor tissue, for example, determining the level of hormone receptors in the tumor. In some cases, it is necessary to establish the stage of the process, then an inspection of the chest or abdominal cavity and biopsy from different areas are performed to clarify the nature and extent of the process. The diagnostic category includes second-look operations - a diagnostic operation that is performed to assess residual tumor in patients without clinical manifestations of the disease after chemotherapy. These surgical interventions are not widely used because they do not improve survival.

In the absence of a full diagnosis, if a tumor is suspected, a prophylactic surgery in order to remove tissue that can turn into a malignant tumor, or according to clinical data, the onset of tumor growth cannot be excluded. In the treatment of precancerous diseases in terms of secondary prevention, such preventive operations are of primary importance for the complete cure of hyperkeratoses. Often in these cases, until complete excision of the formation with the underlying tissues, it is not possible to make a reliable diagnosis that excludes the onset of tumor development. For the purpose of tumor prevention, and often with therapeutic purpose, in the initial stages of the process, for example, polyps in the colon, suspicious pigmented and other hyperkeratotic pre-tumor formations on the skin are removed. IN in rare cases Prophylactic surgery in the form of removal of the entire organ may be suggested, for example in women with a family history of breast cancer, when the risk of developing a malignant tumor is very high.

Preventive operations on areas of regional metastasis consist of removing tissue and lymph nodes from these areas in a standard volume preventively. Indications for such operations may be, for example, the lack of adequate follow-up of these areas. Thus, scar changes in the thyroid gland bed after surgery do not allow reliable palpation control to exclude the development of metastases. For frequently metastasizing or locally advanced tumors, operations along the paths of regional metastasis are also performed preventively. If the area of ​​regional metastasis is covered by the relocated pedicle of the musculocutaneous fat flap, preventive intervention is also necessary.

In the presence of realized metastases, operations can be radical, palliative and symptomatic. In the largest areas of lymph node accumulation, standard variants of such operations have been developed: Duquesne’s operation on the lymphatic tract groin area, axillary lymphadenectomy, etc. For tumors in the head and neck area, the Crile operation and fascial sheath excision of the neck tissue are performed (see Chapter 22 “Tumors of the head and neck”).

Restorative (reconstructive) operations, performed after major surgical interventions in different departments

body, allow you to restore the appearance of the patient or the function of the organ after the primary operation. Reconstructive operations are performed either simultaneously with the main surgical intervention, or delayed after the corresponding disorders have arisen as a result of treatment. For example, restoration of missing parts of the face, replacement of bone tissue, installation of metal or synthetic prostheses after surgery, restoration of the integrity of the pharynx in the presence of a pharyngostomy after surgery, restoration of a limb, etc.

Often during surgery, several operations are performed simultaneously. Before surgery, the possibility and necessity of simultaneously performing radical surgery and eliminating the leading symptom of the tumor are assessed. The diagnosis of associated complications largely determines the course of the upcoming surgical intervention. In modern conditions, extended or combined radical and reconstructive operations are more often performed simultaneously.

In all of the above cases, it could be done auxiliary operations, for example, for installing catheters into a vein or artery, which avoids numerous punctures.

Of all special methods antitumor treatment only for surgical treatment, an exception can be made in terms of establishing a morphological diagnosis before performing surgical treatment. The use of radiation treatment and chemotherapy cannot be started without a morphological diagnosis and study of the extent of the tumor.

In surgery, a surgeon’s scalpel and methods of physical influence on the tumor such as cryogenic and laser are used, which are also regarded as surgical treatment options. Each of these methods has its own specific indications for use and special characteristics of the final therapeutic effect. Cryodestruction is often used as a gentle surgical treatment option in the initial stages of external tumor localizations with the subsequent formation of minimal scarring, which is especially important in the facial area. Laser coagulation, in addition to similar indications, can be used for the purpose of recanalization of the respiratory tract and esophagus. In some cases, using these methods, it is possible to radically remove small primary tumors of the larynx, bronchopulmonary tree, and various parts of the stomach.

intestinal tract, bladder, i.e. tumors of internal organs.

Wonderful surgeon A.I. Savitsky said: “A large tumor - a small operation, a small tumor - a large operation.” This formula has now been changed and in practice has the following wording: “A large tumor is still more surgery" Often, operations for large tumors require significant interventions. Then, as a rule, the use of reconstructive plastic techniques in the surgical area is involved. More often, such interventions are accompanied by the simultaneous removal of tissue and lymph nodes in areas of regional metastasis.

The use of modern methods of pain relief, both during surgery and in postoperative period, made it possible to significantly expand the scope of surgical interventions in patients with low functional indicators. For example, tracheoplastic operations on the neck, segment or zonectomies for lung cancer due to respiratory failure, kidney resection for bilateral lesions or low levels of function of the contralateral kidney.

In modern oncological surgery, two distinct trends can be clearly seen. On the one hand, indications for surgical interventions for common tumors are expanding, up to hemicorporectomy. Surgeries that were previously considered impossible are being reported. A clinical study of the development of various tumors has shown that some of them have only local spread for quite a long time (cancer of the esophagus, stomach, as well as cancer of most tumors of the head and neck organs), while hematogenous spread in these tumors occurs late. This was a completely justified basis for the development of extended operations on the primary lesion.

After operations, patients rarely live more than 5 years, at best 2-3 years. The expansion of indications for surgical interventions is usually due to the lack of other treatment options. The death of patients in most cases occurs from the development of micrometastases, which “with a scalpel cannot be kept up with.”

Operations such as gastrectomy with dissection of lymph nodes and multivisceral resections of adjacent

organs, extended pancreatoduodenal resections, operations for cancer of the ethmoidal labyrinth with access to brain structures, called craniofacial resections, etc. Modern technical support allows, during such extended operations, to monitor the absence of a tumor along the resection border by cytological or histological examination of the corresponding tissue areas.

The expansion of the scope of surgical interventions was facilitated by the achievements of modern anesthesiology and resuscitation, thanks to which postoperative mortality began to decrease. When assessing the general condition and deciding on surgery, it should be remembered that elderly and senile age in the absence of pronounced functional disorders is not a contraindication to surgical treatment. In cancer patients, there is a high probability of venous embolism, therefore, before surgery, the condition of the veins of the lower leg is examined using ultrasound. And then during the operation and for several days after it, variable pneumatic compression or electrical stimulation of the lower leg muscles is used.

Another modern trend in oncology surgery is minimizing surgical damage while maintaining the radical nature of the operation. The indicators that determine such opportunities are carefully weighed. Typical radical operations were developed, as a rule, before the advent of modern diagnostic methods. They often turn out to be unjustifiably crippling. Currently, economical resections are used in the early stages. Functionally sparing, organ-preserving operations are often performed at stage III of the process.

The same trend in modern oncological surgery sometimes suggests refusing surgery in order to preserve the affected organ if this ensures a satisfactory quality of life in a obviously incurable process. In such cases, the calculation of the success of further treatment is based on chemoradiotherapy.

It is necessary to distinguish between the concepts of “operability” and “resectability”. Operability- characteristics of the general somatic condition of the patient. Resectability characterizes the condition of the tumor. For example, if early-stage oral cancer is diagnosed in a patient who has recently suffered a stroke with severe consequences,

consequences, then we should talk about a resectable tumor in an inoperable patient.

In general, the lack of a guaranteed cure when using surgical methods indicates that the prospects for the development of oncology are associated with the search for new means of chemotherapy and radiation treatment and their complex use along with surgical interventions.

7.2. APPLICATION OF CRYODESTRATION AND LASER RADIATION IN ONCOLOGICAL PRACTICE

Since the 70s. last century in oncological practice, a new method of influencing the tumor using low temperatures began to be used, which was called cryodestruction(tumor destruction by freezing). It is used both as an independent method and in combination with other treatment methods, in particular surgical, radiation and medicinal.

Unlike radiation and chemotherapy, cryodestruction does not have a negative effect on immunity and hematopoiesis. Its antitumor effect is based on complex physical, chemical and biological processes. During cryodestruction, cell destruction occurs by breaking intracellular structures with ice crystals (“osmotic shock of the cell”) and enhancing the oxidation of lipids, which are a structural component of cell membranes. A peculiar biological inertia of the cryonecrosis focus occurs, which allows us to call this method “physiological extirpation.” Currently, the effect of exposure to low temperatures in the range from 0 to -196? C has been studied.

Solid, liquid and gaseous substances can be used as refrigerants. They are not equivalent in their freezing properties. In oncology surgery, preference is given to the use of liquid nitrogen, the boiling point of which is -196°C, which allows for deep freezing of tumor tissue.

To date, a significant amount of various cryogenic equipment has been created, specifically designed for a particular location and nature of tumors. Thus, cryogenic autonomous applicators are most often used in otorhinolaryngology.

gological and dental practice (KM-22, KUAS-01). The applicator reservoir is filled with liquid nitrogen from a Dewar flask. Freezing is carried out by contacting the working surface of the tips with the tumor. For extensive or multiple tumors of the skin and lips, a nitrogen cryospray (KR-02) is used, with which you can accurately dose the cryoagent.

In oncological practice, stationary cryosurgical devices operating on liquid nitrogen (KAUM-01, KPRK-01) are also widely used and allow combining the contact effect on the tumor with the possibility of spraying a cryoagent. These devices have an automatically controlled mode of freezing and subsequent thawing of tissue.

The final effect during cryodestruction depends not only on the temperature of the refrigerant, but also on the temporary modes of exposure, including the cooling rate, minimum temperature indicators, its exposure, time and rate of heating and, finally, the number of repeated cycles. A cycle usually refers to the period of time from the beginning of freezing to complete thawing. Of all these conditions, the cooling rate is the most important, since the formation of the number and size of ice crystals both inside and outside the tumor cell depends on this. When carrying out cryodestruction, it is necessary to take into account that the distance between the freezing boundaries and the necrosis zone along the surface and in depth is 5-6 mm, therefore the freezing area should always extend beyond the pathologically altered tissue by this amount. This circumstance must be taken into account, in particular, when choosing the size of the working surface of the applicator.

To achieve a therapeutic effect when performing cryodestruction of tumors, the following conditions must be met:

Cooling should be carried out at high speed until the lowest temperatures are obtained;

Use multiple cryotherapy in one session (up to 2-3 cycles), since the volume of necrotic tissue is directly dependent on the number of cycles;

Freezing of tissues should extend beyond the outer border of the tumor by 1.5-2 cm.

After freezing the tumor, the tissue at the site of exposure becomes hyperemic and edematous, on the 3rd day it acquires a bluish tint and a watery consistency, on the 7-10th day it becomes covered.

It appears as a dark brown scab, which is delimited from healthy tissue by a dark or bright red border. At the 3rd week, necrotic masses are rejected and granulation tissue, complete healing occurs in 25-30 days. A gentle scar remains at the site of the former tumor.

Due to its good clinical effect, cryodestruction has found wide application in neurosurgery, ENT-oncology, gynecological oncology, and when tumors are localized in the head and neck area. This method is widely used for malignant tumors skin, especially with multiple lesions. When performing cryodestruction, no special anesthesia is required, except in cases where the tumor deeply infiltrates the underlying tissue.

In outpatient practice, cryodestruction is used in the treatment of benign tumors of the nasal cavity, mouth, ear, etc. (pigmented tumors, hemangiomas, papillomas, polyps, etc.).

In recent years, to enhance the effect of cryodestruction, it has been used in combination with local hyperthermia, which has reduced the relapse rate for oral cancer by 3-4 times. A similar effect was obtained by combining cryodestruction with ultrasound treatment of the tumor. In the latter case, the effect of low temperatures increases and the course of reparative processes accelerates.

The cryodestruction method has the following positive properties:

Increases the radicality of surgical treatment, improves long-term treatment results;

Prevents dissemination of tumor cells during surgery;

Has a hemostatic effect;

Allows you to relieve severe pain syndrome with widespread tumor process;

Allows treatment of external localizations of benign and malignant tumors on an outpatient basis and does not affect the ability of patients to work;

After cryodestruction, there is no need for drug treatment of the cryonecrosis focus;

Does not require pain relief.

Cryodestruction is used in head and neck oncology and during surgical interventions. For example, after performing a laryngofissure, cryodestruction of a laryngeal tumor is performed.

Along with the method of cryodestruction, the use of lasers.

The name "laser" means the amplification of light through stimulated emission of radiation. The theoretical foundations of this effect of quantum electronics were developed in the late 50s of the last century by domestic scientists N.G. Basov and A.M. Prokhorov. The first operating installations of optical quantum generators - lasers - were designed in 1960 in the USA. In the early 60s of the last century in our country, the USA and some other countries, the first studies were carried out to study the effect of laser radiation on biological objects. They showed that the use of sharp focusing at high power and irradiation energy makes it possible to evaporate and cut biological tissues, which led to the use of lasers in surgery and oncology.

Process laser exposure begins with the absorption of energy by a biological object. Some energy is usually lost due to reflection of radiation and scattering of light by tissue particles. The final effect of laser radiation depends on many factors: radiation wavelength, continuous or pulsed radiation mode, density, radiation power, the nature of the biological object (features of the tissue and its blood supply), etc.

Radiation in the red and infrared regions of the spectrum, when absorbed by tissues, is converted into heat, which can be spent on evaporation of liquid media, generation of acoustic vibrations and stimulation of various biochemical reactions. In continuous radiation mode, the thermal effect predominates, which is manifested at medium power levels by coagulation, and at high power levels by evaporation of biological tissues. In the pulsed mode, the laser effect is “explosive” and is accompanied, along with the thermal effect, by the formation of compression and rarefaction waves propagating deep into the object.

In clinical oncology, laser radiation of high density and power is used. Under the influence of such laser radiation, extremely rapid evaporation of interstitial and intracellular fluid occurs, and then combustion of the dry residue

ka. The amount of exposure determines the degree of tissue destruction. The movement of the laser beam when used as a “laser scalpel” leads to the evaporation of tissue and the formation of a linear incision. Such wounds have characteristic morphological features that sharply distinguish them from wounds of other origins. They are characterized by coagulative necrosis followed by the formation of a thermal necrotic eschar. The latter usually tightly covers the surface of the wound.

Immediately after laser exposure, it can be difficult to determine the full volume of necrotic tissue. The border of tissues subjected to coagulation necrosis stabilizes mainly within a day. During this period of time, edema, hyperemia, and perivascular diapedetic hemorrhages of varying severity develop in the remaining tissues over a short distance along the border with thermal necrosis. Histologically, a zone of coagulative necrosis, the peripheral part of which is a narrow loose layer, and a zone of inflammatory edema are clearly distinguished. In laser wounds, unlike wounds of other origins, the transition zones from coagulated tissue to viable tissue are weakly expressed or even absent. Regeneration in these cases begins in the cells of the area not damaged by laser radiation.

One of the first domestic medical high-energy laser installations was Impulse-1. Its emitter is a neodymium optical quantum generator with a wavelength of 1.06 microns and a nominal output energy of 500 joules per pulse. The low mobility of this installation limits the possibilities of its application. Currently, it is used only for tumor diseases of the skin.

Gas carbon dioxide lasers operating in pulsed and continuous modes are most widely used as a “laser scalpel”. Depending on the density and power of radiation, the effects of cutting or surface coagulation of tissues appear. Such laser systems include “Scalpel-1” with a wavelength of 10.6 microns and a maximum output power of at least 5 W with possible regulation over a wide range. The mobility of its light guide has six degrees of freedom.

The Romashka-1 installation, like the Scalpel-1, was developed on the basis of continuous gas carbon dioxide lasers with an output power of up to 30 W. It can also be used for

action on tumor tissues, but is less convenient for working in deep surgical wounds.

"Romashka-2" is the first domestic microsurgical unit. It is intended for evaporation, coagulation and preparation of fine biological structures in superficial and deep operating fields focused radiation during manipulations, including under an operating microscope. In these cases, aiming an invisible laser beam at an object is carried out using a special indicator visible helium-neon radiation combined with it. This installation generates radiation with a wavelength of 10.6 microns, a power of at least 15 W, and the diameter of the focused radiation spot does not exceed 1.5 mm. Exposure time can range from 0.1 to 9.9 s depending on the required operating mode of the emitter. In its design features, “Romashka-2” is in many ways reminiscent of “Scalpel-1”, differing from the latter only in the presence of an optical unit for combining carbon dioxide and helium-neon radiation. This device has recently found increasing use in ENT oncology.

Currently, laser systems using argon and yttrium aluminum garnet with neodymium, equipped with flexible monofilament light guides, make it possible to deliver laser radiation to any internal organ and carry out highly efficient bloodless cutting or photocoagulation of tissue. The domestic installation of this type is Um-101.

In oncological practice, laser radiation is most often used to treat skin tumors, using pulsed or continuous devices. In these cases, the advantages of a pulsed laser are especially evident. The impact begins with the creation of an immobilization barrier around the tumor with a series of pulses in a circle, retreating from the visible boundaries of the tumor by 5-10 mm. As a result, thrombosis of blood and lymphatic vessels occurs, which prevents the possible spread of tumor cells beyond the pathological focus. After this, a biopsy is performed to finally establish a morphological diagnosis, and then they begin to irradiate the remains of the neoplasm itself.

Treatment of skin tumors with continuous lasers is carried out in principle using the same technique. A focused beam is used to surround the tumor along the periphery, including visually nearby

healthy areas of the skin, gradually moving it onto the tumor itself and “evaporating” it in this way.

In all cases it is necessary local anesthesia 0.5% novocaine solution. For skin tumors located close to the eye, the latter should be reliably protected. If this turns out to be impossible, then it is better to abandon the use of the laser.

Rapid wound healing after the use of lasers, which occurs mainly on an outpatient basis, usually with good cosmetic results, contributes to early medical rehabilitation of patients.

In laser surgery of tumors of the upper respiratory tract, the most widely used lasers are CO 2 argon, yttrium aluminum garnet and neodymium with a high power density, designed to operate in continuous or pulsed mode, which allows obtaining both a cutting and coagulating effect.

Mandatory conditions for successful laser surgery are good visibility and exophytic tumor growth with clear boundaries. These can be hemangiomas, lymphangiomas, adenomas, papillomas and fibromas of the nasopharynx, benign tumors of the pharynx, polyps and granulomas of the larynx and the very initial stages of malignant tumors.

Infiltrative growth or high local prevalence of even exophytic tumors limit the use of laser radiation, at least for the purpose of radical treatment.

For tumors of the larynx, trachea or bronchi, esophagus, along with the complete elimination of small tumors, in some cases it is possible to perform transtumoral recanalization of these organs for palliative purposes.

Nowadays it is increasingly used laser method for the treatment of precancerous diseases of the mucous membrane of the lips and oral cavity, as an effective way to prevent malignant neoplasms.

In abdominal surgery for oncological diseases of internal organs, lasers are used mainly in cutting mode.

7.3. RADIATION THERAPY

Radiation therapy- method of treatment using ionizing radiation. The beginning of the development of the radiation method of treating cancer

high-quality tumors occurred at the end of the 30s of the twentieth century. First, X-ray therapy was introduced into practice, which significantly improved the results of treatment of oncological diseases. With the development of radiation treatment methods, X-ray therapy was practically abandoned. Currently, it is successfully used for some local superficial tumors: lip cancer, skin basal cell carcinoma, etc. X-ray therapy has been replaced by remote and contact gamma therapy, megavoltage therapy, which have significantly improved treatment results and significantly reduced the number of immediate and long-term complications of radiation. The proton beam has the greatest damaging effect on the tumor and spares healthy tissues entering the irradiation zone.

Among various treatment methods in clinical oncology, radiation therapy occupies one of the leading places. According to WHO, 70-75% of cancer patients require radiation therapy. Radiation therapy is currently the leading method of conservative treatment. It can be used both as a radical and as a palliative treatment option for cancer patients. Every fifth cancer patient can be cured with radiation.

The advantages of radiation therapy include its good tolerability and the possibility of achieving a permanent cure in the early stages of some tumors while preserving the function of the affected organ. The use of radiation treatment as palliative, independent therapy in inoperable cases is the most effective among other treatment measures.

The main goal of radiation therapy is the maximum damaging effect on the tumor with minimal damage to healthy tissue. Study of radiobiological characteristics different types energy, their damaging effect on tumors of different structures, at a certain depth, made it possible to develop techniques that create optimal irradiation conditions in each specific case. This is achieved primarily by using various types radiation and various energies, since the penetrating ability and the nature of the spatial distribution of doses depend on the radiation energy and its type (electromagnetic radiation, elementary particles).

Radiation therapy is based on the principle of destruction of tumor cells by ionizing radiation both in the primary focus,

and in areas of regional metastasis. Ionizing, i.e. ion-forming radiation may have an electromagnetic nature(γ-rays, - photon, quantum radiation) or - in the form of elementary particles (corpuscular radiation - electrons, positrons, etc.).

Electromagnetic radiation (γ-rays) is emitted by the decaying nuclei of natural and artificial radioactive substances, or it arises secondarily when charged particles collide with the nuclei of a decelerating substance, for example in X-ray tubes, linear accelerators. The resulting X-ray radiation from different sources differs in wavelength and differs from natural γ-radiation, which is reflected in some parameters of radiation exposure in human tissue and is taken into account when calculating the dose. Radiation in the form of a flux of neutrons and positrons penetrates most deeply and is therefore used to irradiate deep-lying tumors, and due to its high density it is effective, and therefore is used to irradiate recurrent tumors.

To carry out radiation therapy, they use radiation generated by various devices (X-ray machines, cyclic and linear accelerators of light particles with an energy of 5-45 MeV, accelerators of heavy particles with energies of 200 MeV and above), as well as radiation from natural and artificial radioactive isotopes: cobalt, cesium , California, iodine, etc. The effect of radiation treatment largely depends on the source, therefore, the nature of the radiation and the dose of radiation treatment.

There are the following two main methods of radiation therapy:

Remote (x-ray therapy, gamma therapy, therapy with bremsstrahlung radiation and fast electrons, therapy with protons, neutrons, pi-mesons with energy - 200 MEV and above);

Contact - it uses various methods of bringing radiation sources to the tumor (intracavitary, interstitial, application). Application - involves bringing the source close to the tumor tissue or at a distance of 1-2 cm. Currently, endostats with automatic supply of the radiation source after fixing the device in the desired position, usually inside a cavity (after-loading), are most widely used. With intracavitary irradiation, the source is introduced into the cavity of the affected organ - rectum, uterus, etc.

Interstitial irradiation is carried out by surgically introducing radioactive sources directly into the tumor. It is carried out using special instruments and using protective devices for doctors and medical personnel. Patients undergoing interstitial radiation therapy are kept in special “active” rooms equipped with protective devices. The interstitial method of radiation therapy can be successfully used to treat cancer of the skin, lip, tongue, and oral mucosa. Radioactive sources have the form of threads, beads, granules, wires, and a high dose is created in the tumor (at a distance of up to 2 cm from the drug), while in the surrounding tissues the dose drops sharply. When carrying out radiation treatment, it is very important to distribute the drugs into the tumor so that it is irradiated evenly. The latter is difficult to achieve if the tumor is large, irregular in shape, or does not have clear boundaries, so interstitial radiation therapy is used mainly for limited tumors, the volume of which can be clearly defined. All contact types of radiation are distinguished by a sharp drop in dose at the distances closest to the source. A type of contact irradiation is a method of selective accumulation of radioactive isotopes in certain tissues. The radioisotope is taken orally per os or administered parenterally. For example, this is how treatment is carried out with radioactive iodine (see section 30.6 “Thyroid cancer”) or radioactive phosphorus (32 P), which accumulates mainly in the reticular and bone tissues, which is used for erythremia or multiple bone metastases.

The interstitial method uses continuous irradiation up to the intended total dose. The total focal dose is usually adjusted to 60-70 Gy over 6-7 weeks.

The principle of action of irradiation on a living cell is as follows. During irradiation, ions of different signs are formed in tumor tissue and, as a result, chemically aggressive free radicals appear that damage the structure and function of basic biological molecules, primarily DNA. Radiation-chemical changes occur inside and outside the cell, DNA nuclei and the membrane complex are damaged. Gross disturbances in the properties of proteins, cytoplasm, enzymes, and all metabolic processes occur, which causes cell death. As a result, there comes a time-

destruction (necrosis) of tumor tissue and its subsequent replacement with connective tissue. In medical practice, sublethal and potentially lethal doses of radiation are used. Lethal doses are not used to avoid damage to healthy tissue.

Irradiation has a damaging effect on all tissues of the body. The most sensitive to radiation in children and adults are the red bone marrow, gonads, epithelium of the gastrointestinal tract, and the lens of the eye. Least sensitive fibrous tissue, parenchyma of internal organs, cartilage, bone, nervous tissue, muscles and, accordingly, tumors that develop from these tissues. Sensitivity to radiation is always higher in tumor tissue than in the original and surrounding normal tissues, although the latter are always to a certain extent exposed to the damaging effects of radiation. The histological structure of the tumor, therefore, makes it possible to judge the sensitivity of the tumor to radiation.

The most sensitive to irradiation are tumors that have a source of tissue whose cells are constantly dividing, tumors of low differentiation, having an exophytic growth pattern and with good oxygenation. On the contrary, highly differentiated tumors that have an endophytic growth pattern, a large volume and, as a result, poorly oxygenated cells, are little sensitive to radiation exposure. The irradiation technique and dose are selected depending on these factors, and the radiotherapeutic interval must be taken into account (the difference in the ability to recover and radiodamage of tumor and normal tissues with the same absorbed radiation dose).

The damaging effect of radiation not only on tumor cells, but also on cells of healthy tissues should be taken into account; therefore, during radiation treatment, measures are taken to maximally spare the normal tissue structures surrounding the tumor and inevitably falling into the irradiation zone in order to avoid unwanted radiation reactions and complications that can worsen the condition the body both during treatment and throughout the subsequent period of the patient’s life. New means of protecting intact organs and tissues are constantly being developed. The interval between the end of irradiation and the operation should be sufficient to fully realize the effect of radiation exposure and should not coincide with the time of the height of radiation reactions, thereby ensuring the best healing of the postoperative wound.

Thanks to technological progress and advances in radiobiology, various techniques increasing the radiotherapeutic interval. These include physical, biological and chemical agents.

Physical include, in addition to the optimal choice of the type of radiation and its energy, various devices and irradiation parameters (shaped fields, blocks for protecting certain areas of the body, multi-field, moving irradiation methods, the use of wedge-shaped filters, widely used in irradiating head and neck tumors, gratings, solutions, variations in irradiation fractionality, etc.). Selective heating of the tumor tissue to 39-40°C is used, which increases blood flow, thereby improving tumor oxygenation. At a temperature of 42-47? C, the recovery processes after irradiation are inhibited. In the practice of head and neck tumor departments, extensive inoperable metastases are usually subjected to such treatment.

Biological means include irradiation methods under conditions of oxygen barotherapy, hypo- and hyperthermia, hyperglycemia, etc. With excessive oxygen saturation, the sensitivity of cells to radiation increases, so the damaging effect in the tumor is more pronounced than without hyperbaric oxygenation techniques at the same dose. Irradiation under hypoxic conditions is used to protect healthy tissue. Hypoxyradiotherapy allows you to increase the dose of radiation therapy with remote irradiation by 20-40%. During surgery, with general hypoxia, a dose of up to 25 Gy is delivered to the tumor bed per irradiation session. An artificial temporary increase in sugar levels in the blood, and therefore in the tumor, causes an increase in oxidation processes in its tissue and increases sensitivity to radiation. Under conditions of photosensitivity, the sensitivity of the tumor to radiation increases significantly.

Chemical agents include methods of using drugs that protect healthy tissue (radioprotectors) or increase the radiodamage of a tumor (some chemotherapeutic drugs, metronidazole, etc.).

Radiation therapy is prescribed only for a morphologically verified process. An exception is allowed only in urgent situations, for example, when the mediastinum is damaged with superior vena cava syndrome or when the trachea is compressed by a tumor congruence.

Lomerate. The diagnosis in such cases is based on X-ray examination data, and then the issue of urgent radiation exposure is decided by a council.

Radiation can be radical, palliative, or used in combination with surgery. Radical radiation therapy involves complete suppression of the viability of a malignant tumor. For many neoplasms of average radiosensitivity, if the disease is detected in the early stages, this is a completely realistic task. For cancer of the head and neck organs, radical radiation therapy often leads to the cure of the initial stages of cancer of the larynx, lower lip, and nasopharynx. Sometimes high sensitivity of cancer of the mucous membrane of the oral cavity and tongue is detected with complete recovery of the process from radiation treatment. On its own, radiation is used in the treatment of malignant tumors of the cervix, oral cavity, pharynx, larynx and esophagus. When planning radical radiation treatment, the area of ​​clinical spread of the primary tumor and the area of ​​first-order lymphatic collectors are irradiated to target subclinical metastases. In case of metastases, the irradiation fields are expanded, capturing regional lymph nodes without signs of clinical damage. Radiation treatment is most successful in early stages of the disease, high radiosensitivity of the tumor without metastases, or a single small regional metastasis.

Radiation therapy in combination with surgery is used in three variants, which have their own indications - preoperative radiotherapy, postoperative and performed both in the pre- and postoperative period.

First of all, through preliminary calculations, they strive to create the most favorable spatial distribution of absorbed radiation energy in the patient’s body, taking into account the reactions of irradiated tumor and normal tissues. Studying the immediate and delayed radiobiological effect allows us to develop optimal options for fractionation, rhythm and dose of radiation, which differ for different locations and types of tumor.

Especially great attention in radiotherapy, the focus is on studying the radiobiological basis of fractionation (taking into account the time factor). With different fractionations, the unequal restorative ability of tissues after partial

damage, the task is to optimally select a rational rhythm of irradiation sessions.

In radiation therapy of the head and neck organs, in an independent plan, to obtain a radical or palliative effect, a selected rhythm of daily irradiation of 2 Gy (5 times a week; per week - 10 Gy) is widely used. The total focal dose in this case is (with average radiosensitivity of the tumor) 60-70 Gy. Radiation therapy is carried out according to a split program: the first course - up to a total focal dose of 30 Gy, followed by a break in treatment for 2-3 weeks. The second course is also carried out with a single focal dose of 2 Gy up to a total focal dose of 40 Gy (total total dose - 70 Gy). This achieves an extension of the radiotherapeutic interval and, ultimately, better tolerability of radiation treatment. Undesirable radiation reactions (general and local) are weakly expressed, and the effectiveness of treatment increases.

Multifractionation of irradiation is currently considered optimal, i.e. administering a dose appropriate for a given tumor and a given type of surrounding tissue in the form of splitting daily dose into several fractions, while the total focal dose does not decrease, the duration of irradiation does not increase, and the local early radiation reaction is significantly reduced. Such regimens also reduce the number of late complications from radiation.

When implementing radiation treatment programs for malignant neoplasms of the head and neck of various localizations, the irradiation zone includes the tumor, the area of ​​regional metastases and subclinical zones of metastasis. Thus, for tumors of the nasopharynx, the method of choice is external beam radiation therapy, sometimes in combination with intracavitary irradiation. Four-field irradiation is used - two lateral opposing fields measuring 6-8x12 cm and two anterior ones in the zygomatic region measuring 4X6 cm. The central beam is directed at an angle of 30?.

The total dose depends on the histological structure. For lymphoepithelioma, it is 55 Gy (with a single dose of 2 Gy). Irradiation of clinically detectable metastases and areas of subclinical spread is carried out from the anterior figured field measuring 16-18x12-14 cm, covering the entire neck and subclavian areas. The middle part of the neck is shielded with a lead block to protect the larynx and spinal cord. Single dose 1.8-2 Gy. The total total dose is 45-50 Gy. To the area of ​​detected metastatic

For such conglomerates, the dose is increased to 65 Gy. In elderly patients, it is advisable to conduct a split course of radiation therapy. Sometimes external irradiation is supplemented with intracavitary irradiation; this therapy is called combined radiation therapy.

Under the influence of irradiation, the following changes occur in tumor tissue in a certain sequence: reduction of the tumor due to the death of the elements most sensitive to radiation, development of granulation tissue and encapsulation of groups of malignant cells, appearance of tumor vascularization, then development of fibrous tissue.

The objectives of preoperative irradiation are to destroy the most radiosensitive cells and reduce the viability of the remaining tumor elements, reduce inflammation, stimulate the development of connective tissue and encapsulate individual complexes of cancer cells, obliterate small vessels, thereby reducing the risk of metastasis, reducing the size of the tumor and more clearly delineating it from healthy ones fabrics. All this can lead to the transfer of a tumor that is on the verge of operability to an operable state. When conducting preoperative radiation therapy, the total focal dose is adjusted to 40-45 Gy, 2 Gy daily.

For these same localizations, radiation is also used in combination, mainly with surgery. Radiation exposure can be used both before surgery and in the postoperative period. In the preoperative period, the goal of radiation therapy is to reduce the size of the tumor and perform the operation in more ablastic conditions. When irradiating the areas of the primary tumor and regional metastasis, the most malignant and proliferating cells are damaged. The latter are mostly located along the periphery of the tumor. As a result of irradiation, the size of the tumor decreases, which often contributes to the transition of the tumor to an operable state; in general, the differentiation of the remaining tumor cells increases. Due to the increase in post-radiation sclerosis along the periphery of the tumor, the separation from healthy tissue improves. All this increases the resectability of the tumor. As a result of irradiation, the likelihood of developing relapse and metastases after surgery is reduced, since after irradiation the risk of cell dissemination during surgery is reduced.

Postoperative radiation exposure helps to destroy tumor cells remaining during non-radical or conditionally radical operations. It is aimed at preventing relapses and reducing the possibility of metastasis. In some cases, irradiation is performed before and after surgery. Radiation is a component of combined and complex treatment of most cancer sites, including the most common tumors. Irradiation is used for cancer of the lung, breast, ovaries, uterine body, bladder, etc.

Radiation may be given during surgery. Depending on the objectives, either the tumor bed is irradiated, delivering a single large dose, or the tumor is irradiated before its removal, or the residual tumor is irradiated if radical surgery is not possible, or an unremovable tumor is irradiated.

Currently, radiation therapy alone is more often used as a palliative measure or aimed at reducing pain and improving quality of life. In this case, irradiation inhibits tumor growth, reduces its biological activity, and reduces its size due to the death of the most aggressive cells, an accompanying inflammatory reaction. As a result, there is a decrease in pain and signs of compression of internal organs and nerve trunks. Irradiation of certain areas of the brain and spinal cord is carried out in a dose of no more than 20-30 Gy. Sometimes irradiation is undertaken as an attempt at treatment when it is impossible to use more radical methods, taking into account the possible individual sensitivity of the tumor. In rare cases, remote gamma therapy is used systemically, as a method similar to the effect of chemotherapy in the generalization of the process. Either the entire body is irradiated (total irradiation), or large volumes of half the body (subtotal irradiation).

As part of complex treatment, the use of radiation with polychemotherapy or hormone therapy is effective. Treatment can be carried out simultaneously or sequentially. Most often, chemoradiation treatment is carried out for small cell lung cancer, lymphosarcoma, breast cancer, germ cell tumors, etc. With the advent of new chemotherapy drugs and the development of new methods of special antitumor treatment, more and more

combinations and options for complex therapy, which include radiation, find their application in modern oncology.

Irradiation is carried out in two main ways: contact and remote. With the latter, static and moving installations are used. Contact methods include application, intracavitary and interstitial. At contact methods irradiation, the radiation source is located in close proximity to the tumor or is injected into the tumor. The type of irradiation is selected depending on the depth of the tumor and its relationship with surrounding organs.

The depth of radiation penetration into tissue depends on the mass of the particle and its charge. There are photon and corpuscular radiation. Quantum radiation has virtually no mass and penetrates deep into tissue. It is used for external radiation exposure in the form of gamma machines. Of the corpuscular types of radiation, neutrons and protons are used. Neutrons are used in the treatment of radioresistant tumors or relapses.

In external and contact radiation therapy, gamma radiation from radioactive cobalt is most widely used. In gamma devices of various designs, radioactive cobalt serves as a high-activity charge (about 600 curies). Gamma radiation differs from X-rays by shifting the maximum ionization from the surface of the skin by 0.5 cm deep into the subcutaneous tissue, which achieves an increase in the depth dose without pronounced radiation reactions from the skin. In our country, such devices as “AGAT-S”, “AGAT-R”, “ROKUS-M” are widely known. Further improvement of gamma devices was the development of rotary devices “AGAT-R-2” and “AGAT-R-3”. These devices are designed for remote gamma therapy with automatic playback individual programs in static and moving modes.

An undoubted advantage over gamma radiation is bremsstrahlung generated by cyclic or linear electron accelerators. It has a high penetrating ability and is characterized by a shift of the maximum dose deep into the tissue, while the cutaneous and subcutaneous dose is significantly reduced, which is very important in the treatment of head and neck tumors. The penetrating ability of the beam of accelerated electrons generated by these same devices is much less. Thus, the penetration depth of electrons at an energy of 15 MEV is

8 cm , 25 MEV - 14 cm, while the deeper layers of tissue are not exposed to irradiation, therefore, for shallow depths of the pathological focus (which is typical for tumors of the head and neck), the use of electron radiation has undoubted advantages. Electron irradiation has proven effective in the treatment of radioresistant, shallow tumors, relapses, and metastases in the neck and supraclavicular areas.

The use of heavy particles is considered a promising method for the treatment of malignant neoplasms. When carrying out radiation therapy by the contact method, radioactive cobalt preparations are used in the form of needles, granules or pieces of wire, which are used in intracavitary, interstitial and application methods of treatment. The arsenal of technical means for carrying out intracavitary treatment methods includes various types of hose gamma devices of the “AGAT-V” type. Thus, “AGAT-V-3” is intended for the treatment of tumors of the female genital organs, rectum and malignant neoplasms of the oral cavity with a source of increased activity.

The therapeutic dose around the solid radioactive drug, automatically administered by the device using an endostat that fixes the drug in the oral cavity, is distributed within a radius of 2 cm; As the radius increases, the dose decreases. It is possible to deliver a large focal dose to the tumor with a sharp decrease in dose towards healthy tissues. The clinical use of radioactive cobalt preparations with the help of such technical means makes it possible to achieve a favorable spatial distribution of doses, reduce the duration of irradiation sessions, ensure strict geometric localization of drugs relative to the irradiation target, and more fully solve the problem of radiation safety of personnel.

The sensitivity of cells to radiation exposure is not the same at different stages of the cell cycle. Actively dividing cells are most sensitive to radiation. Some tumor cells are at rest at the time of irradiation. They are more resistant to radiation and therefore do not die under the influence of radiation therapy. To enhance the effectiveness of radiation treatment, various methods have been developed to synchronize the cell cycle of tumor cells.

Medicines can be used as radiomodifiers that enhance the damaging effect of ionization

posing radiation on tumor tissue, while the damaging effect on normal tissue is minimal. Chemotherapeutic agents have several interactions with radiation therapy. Chemotherapy drugs increase the sensitivity of tumor cells to radiation exposure and inhibit the recovery ability of sublethal and potentially lethal damage to tumor cells. The most effective is to change cell kinetics using therapy with phase-specific antitumor agents. For this latter purpose, fluorouracil and cisplatin are used, sometimes in combination. Similar properties of gemcitabine, interferon, etc. are used.

For solid tumors, treatment also begins with polychemotherapy, after which the issue of radiation or surgical treatment is decided, since radiation can be both preoperative and postoperative. The combination of polychemotherapy and radiation therapy can improve immediate and long-term treatment results for various types of tumors.

In case of high sensitivity of the tumor to chemotherapeutic drugs, radiation therapy is carried out in combination with drug therapy (for small cell lung cancer, lymphogranulomatosis, lymphosarcoma, Ewing's tumor, breast cancer, testicular seminoma, etc.). Chemotherapy is currently the primary systemic treatment, and radiation therapy may be added to improve local control or prophylactic radiation.

When irradiating tumors in children serious problems create healthy tissues of a growing organism, which, when exposed to ionizing radiation, cause early and late complications. Early radiation reactions vary in intensity depending on the nature of the irradiated tissues and the dose of radiation exposure. Skin erythema, swelling of brain tissue, demyelination of the spinal cord, and pulmonitis develop. Stomatitis, glossopharyngitis, laryngitis, and esophagitis develop on the mucous membrane of the upper respiratory tract and in the area of ​​the oral cavity and laryngopharynx. All these phenomena quickly stop with moderate anti-inflammatory local treatment and cessation of radiation therapy. Late changes are much more serious, sometimes irreversible. Depending on which organ was in the irradiation zone,

changes develop in the heart, lungs, brain and spinal cord, bone skeleton and soft tissues. These changes can cause profound disability and even death (especially in childhood).

At present, it is still practically impossible to completely avoid radiation reactions and complications, but the severity of these reactions due to the use of new technology and equipment has decreased significantly. There are local and general radiation reactions.

Occurring during treatment local reactions appear up to 3 months after the end of irradiation. They are called early. These include radiation changes in the skin (erythema, dry and moist epidermitis) and mucous membranes (edema and hyperemia, keratinization, desquamation of the epithelium, membranous and confluent radioepithelitis, erosions, laryngitis and esophagitis). To treat local radiation damage, creams containing methyluracil, corticosteroids, and high-quality fortified fats are used. For the oral cavity, irrigation, rinsing with antiseptic solutions, herbal infusions and decoctions, and applications with oil compositions with fat-soluble vitamins are widely used.

General functional disorders of the central nervous system, hematopoietic organs, and gastrointestinal tract are currently rare with local forms of irradiation. Such reactions can manifest themselves in the form of headache, drowsiness, and fluctuations in blood pressure. Appetite may be reduced, nausea, vomiting, and moderate leukemia and thrombocytopenia may occur. As a symptomatic remedy, it is important to maintain a sleep schedule and take long walks in the fresh air; hemostimulants, antihistamines and other medications are taken orally for symptomatic purposes.

Reactions that develop 3 months or even several years after irradiation are called late or radiation complications. Late radiation changes in tissue are a consequence of degenerative processes followed by secondary processes, in particular ischemia and fibrosis. Fibrous changes are most commonly observed during radiation therapy for head and neck tumors. subcutaneous tissue and less commonly, indurative edema, quite often observed in the chin and submandibular areas. If there are errors in program planning, radiation ulcers can form,

which usually, due to a sharp decrease in reparative abilities, heal poorly and require long-term treatment, while antibiotics, antiseptics, hormonal and absorbable agents are used locally and systemically. In some cases, if conservative treatment is ineffective, it is necessary to excise external radiation ulcers with plastic closure of the defect with an arterialized flap from the non-irradiated area.

Clinical syndrome (general radiation reaction) in the form of weakness, lethargy, nausea, disturbances of appetite and sleep, lympho- and leukopenia can be observed in weakened patients with tumors of the head and neck or in cases of gross violations of the methods and techniques of radiation therapy.

Radiation treatment is contraindicated in a number of situations on the part of the tumor: threat of perforation, disintegrating tumor, in inflammatory diseases provoked by the tumor. Of the accompanying general conditions and diseases, absolute contraindications for irradiation are thrombo- and leukopenia, anemia, sepsis, cachexia, and active forms of tuberculosis.

7.4. MEDICINE ANTI-TUMOR

THERAPY

Drug therapy is the third specific treatment option for malignant tumors, the importance of which is constantly increasing due to the intensive development of this area of ​​oncological science and the emergence of more and more effective drugs. According to American authors, about 6.5% of cancer patients can be cured only with drugs.

Drug therapy of malignant tumors - use for medicinal purposes various means, differing in action and effect, which either inhibit proliferation or irreversibly damage tumor cells. Due to the fact that the etiology of malignant tumors is not fully understood, etiotropic treatment is impossible. Rather, we can talk about the pathogenetic orientation of the treatment of malignant tumors, which affects some structures of the tumor cell or weakens some links in tumor development. In this regard, the use of chemotherapy is particularly indicative.

Currently, drug antitumor therapy includes all types of systemic effects: chemotherapy, endocrine, immune, as well as actively developing areas of biotherapy. Chemotherapy drugs have a direct cytotoxic effect on a malignant tumor, while hormone therapy and immunotherapy affect tumor tissue indirectly.

Currently, more than 100 drugs are known to be used in the treatment of malignant tumors. They are divided into groups: alkylating compounds, antimetabolites, antitumor antibiotics, herbal drugs and a group of mixed drugs.

In most cases, it is known which component of the tumor cell destroys the chemotherapy drug or in which metabolic biochemical process of the tumor tissue it is introduced. Polychemotherapy courses, i.e. the use of several drugs affects different structures of the tumor cell or tumor stroma, which is much more effective than monochemotherapy.

The antitumor activity of alkylating compounds (cyclophosphamide sarcolysine, prospidium, chloride, nitrosourea derivatives) is due to their ability to dissociate in aqueous solutions to form carbonium, sulfonium or azonium cations that react with nucleophilic groups nucleic acids and cell proteins. Alkylating agents replace a hydrogen atom with an alkyl group in organic compounds, which blocks DNA replication. The biological effect of these drugs is manifested in damage to the mechanisms that ensure cell viability, which leads to the cessation of its division and death. Alkylating drugs belonging to the group of chlorethylamines or ethyleneamines, which are very active against tumors of hematopoietic and lymphoid tissue, as well as some solid tumors, have become widely used.

Nitrosomethylurea preparations belong to the group of organic compounds with high biological activity and differ from classical alkylating cytostatics in that only after a series of metabolic transformations they enter into the same biochemical reactions as alkylating substances. The ability to dissolve in lipids ensures their rapid passage through the cytoplasmic membrane system and the blood-brain barrier.

Antitumor antimetabolites (5-fluorouracil, methotrexate, 6-mercaptopurine, etc.) chemical structure are analogues of substances that ensure normal biochemical reactions in cells. The chemical identity of antimetabolites allows them to enter into competitive relationships with normal metabolites, especially with nucleic acid precursors, block metabolic processes at different stages and thereby disrupt the synthesis of nucleic acids. Antimetabolites inhibit the synthesis of purines and pyrimidines and inhibit enzymes. All this is necessary for the construction of DNA; in addition, antimetabolites distort RNA synthesis. This leads to profound disturbances in cell metabolism and the transfer of genetic information due to defects in the structure of DNA and RNA. The range of uses of antimetabolites is quite wide, including the possibility of their use for the treatment of head and neck tumors.

Antitumor antibiotics interact with cell DNA, changing its template activity in the processes of replication and transcription. Antibiotics provide covalent DNA binding, inhibition of topoisomerase II, and the formation of free radicals. The selective effect of bleomycin on squamous cell forms of cancer has been established, and therefore it is widely used in the treatment of cancer of the larynx, skin, etc.

In recent years, much attention has been paid to antitumor drugs of the taxane series, which are of plant origin and have shown activity against a number of tumors that are usually not sensitive to chemotherapy. Among herbal drugs, mitosis inhibitors are distinguished, which disrupt the formation of the cell spindle and damage the cytoskeleton, thereby disrupting the movement of intracellular transport. Taxol is a drug obtained from the bark of the yew coniferous tree. Chemical drugs of plant origin also include vincristine, vinblastine, teniposide, etoposide, etc. Drugs in this group are actively used in various schemes chemotherapy for head and neck tumors.

At the end of the 60s. last century, a new group of antitumor compounds was discovered - complex salts of cisdichloraminoplatinum (platinum diamine dichloride). According to the mechanism of action, platinum derivatives are similar to alkylating drugs. Currently, many platinum drugs are included in the treatment regimens for most head and neck tumors.

The selectivity of the effect of chemotherapy on tumor tissues is relative; cells of normal, undamaged tissues are largely affected. The question of choosing appropriate drugs is of particular importance, since the use of drugs to which a given tumor is not sensitive can only harm the patient due to the pronounced toxicity of chemotherapy in general.

The vast majority of cytostatics are intended for use as systemic chemotherapy. For this purpose, drugs are administered orally or parenterally (subcutaneously, intramuscularly, intravenously). The general medicinal effect in this case is aimed at suppressing the growth of tumors, both primary and metastatic, regardless of the location of the tumors. This method is designed for a general resorptive antitumor effect.

Antitumor drugs are also used for predominantly local effects, but the systemic effect remains. For local chemotherapy, cytostatics in appropriate dosage forms ah (applications, ointments, solutions) are applied to superficial tumor lesions. For skin tumors, for example, colhamine ointment is used. Cytostatics can be injected into the serous cavities (in the presence of ascites or pleurisy) or into the spinal canal (intrathecally) in case of damage to the meninges, intravesically in case of bladder tumors, etc. Regional chemotherapy is the effect of an antitumor drug in increased concentration by introducing it into the vessels feeding neoplasm. This technique limits the flow of chemotherapy into other organs and tissues.

Various classes of drugs are used as monotherapy or in combination with the expectation of a cumulative effect. Drug treatment has a systemic effect, since tumor growth is suppressed not only in the area of ​​the primary lesion, but also in areas of regional metastasis and distant foci. It is used both as an adjunct to surgery and radiation treatment and on its own. The combined use of all special types of therapy in oncology has an even more intense effect. This significantly expands therapeutic possibilities. The choice of drug therapy option and assessment of the possibilities of complex action are carried out taking into account the sensitivity of the tumor and the stage of the disease.

The combined cumulative effect of chemotherapy drugs makes it possible to cure a number of tumor diseases using only this method. These are some hemoblastoses, malignant testicular tumors, chorionic carcinoma. The latter, being one of the most aggressive tumors in women, is sensitive to polychemotherapy in more than 80% of women. In the same percentage of cases, this disease is cured using polychemotherapy, even with distant metastases in the lungs.

For tumors of any localization, clinical observations often reveal the development of micrometastases soon after surgical treatment, which forced the development of methods for treating metastases before their clinical manifestation. This principle was implemented in the so-called adjuvant systemic therapy: courses of treatment are carried out after surgery to prevent the development of relapses and metastases. Polychemotherapy is most often used for this purpose. Adjuvant chemotherapy has begun to be included in the standard of treatment for breast cancer, germ cell tumors, some types of sarcomas, etc.

Later, chemotherapy began to be used in preoperative (induction, neoadjuvant) mode. The goal of this treatment is to reduce the primary tumor and its metastases, improve long-term treatment results, patient survival and quality of life. With this treatment regimen, studying the tumor tissue in the surgical specimen allows one to evaluate the effectiveness of the chosen therapy based on the degree of tumor damage. The detected changes are called drug pathomorphosis. Effective combinations of drugs can be used in the postoperative period or in case of relapse of this disease.

Chemotherapy in combination with radiation treatment is often used as a radiosensitizer, due to which a pronounced therapeutic effect can be obtained with low doses of radiation that are not cytotoxic. A significant radiosensitizing effect is obtained from the use of taxanes, gemcitabine, vinorelbine.

The prospects for increasing the effectiveness of chemotherapy for malignant neoplasms are associated not only with the search for new cytostatics that act quite selectively, but also certain opportunities are opened by the targeted study of already known cytostatics to improve their therapeutic properties by

selection of new combinations (usually 3-4 drugs), changes in drug administration regimens, individualization of treatment, etc. The selection of drugs is carried out subject to certain conditions: each of the drugs used in combination must be individually active against a given tumor.

Each of the cytostatics that make up the combination should have a different type of clinical toxicity, which allows them to be taken in full doses, without much risk of additive side effects; the selection of cytostatics according to their effect on various phases of the cell cycle is taken into account. As a result, combination chemotherapy (polychemotherapy) reduces the likelihood of secondary resistance and can lead to an increase in the intensity and selectivity of tumor damage without increasing side effects.

The study of the role of hormones in the development of malignant tumors has shown that there is a fundamental possibility of therapeutic influence on this process using hormone therapy. This creates conditions for the use of hormones or genetic analogues of hormones as antitumor agents. In practice, hormone therapy is effective only for solid malignant neoplasms of hormone-producing or hormone-dependent organs (breast cancer, prostate cancer, endometrial cancer). From tumors of the head and neck to certain hormonal influences susceptible to thyroid cancer. Modern approaches to hormone therapy for tumors include several main areas:

Reducing the level of hormones that stimulate tumor growth by direct action on the endocrine glands or through regulatory systems;

Blocking the stimulating effect of hormones on tumor cells by acting on target cells, including using specific drugs;

Increasing the sensitivity of tumor cells to cytostatics and the use of hormones as carriers of antitumor drugs.

Hormone therapy for thyroid cancer is limited in use due to the fact that, of its many morphological variants, differentiated, mainly papillary tumors can be hormone-dependent. Administration of thyroxine (thyroid hormone) in increased doses has an inhibitory effect on

thyroid-stimulating function of the pituitary gland and, as a result, stabilizes the growth or causes regression of the primary tumor and metastases. This effect manifests itself only in highly differentiated tumors. Hormone therapy, like chemotherapy, is a promising and constantly evolving field of drug treatment for malignant tumors.

In the occurrence and development of the tumor process, the state of the body’s immunological reactivity is of no small importance. Immune processes largely determine the prognosis of the disease and the effectiveness of the treatment measures taken. It has been proven that there is a decrease in immunity in all patients receiving cytostatics and glucocorticoids, which are often included in polychemotherapy systems. Effective chemotherapy, along with clinical improvement, leads to positive changes in the state of the body’s immunological reactivity; issues of immunocorrection when using chemotherapy are carefully studied.

7.5. SIDE EVENTS OF RADIATION AND CHEMOTHERAPY. COMPLICATIONS, TREATMENT OF COMPLICATIONS

Tissues that have a high level of proliferation are severely damaged by chemotherapy. This manifests itself in the form of inhibition of hematopoiesis, alopecia, dysfunction of the reproductive system, and disorders of the gastrointestinal tract. All these phenomena often require therapeutic measures, both local and general.

Local changes are more typical of radiation exposure. There is a decrease in reparative processes and a long-term absence of a tendency to epithelization. Postoperative wounds take longer to heal. Chemoradiation treatment has the same local effect. To activate the healing processes, applications and bandages with stimulating, anti-inflammatory and other symptomatic agents are used.

The most alarming are the general phenomena of intoxication, accompanied by changes in the blood formula, impaired renal and liver function. If there are signs of violation liver failure it is necessary to exclude the presence of hepatitis

titus of any origin, since sluggish serum or infectious hepatitis can worsen the patient’s condition for a long time.

To prevent renal failure, which can often be provoked by cytostatic drugs (platinum drugs, methotrexate, etc.), hyperhydration is carried out with the introduction of 2.5-3.0 liters of fluid (5-20% glucose solution, glucose-novocaine mixture, Ringer's solution), alkalization of urine - administration of sodium bicarbonate. In addition, vitamins C, group B, ATP, cocarboxylase, cardiac glycosides, diuretics, rheopolyglucin, etc. are introduced.

For the treatment of renal and hepatic failure, uric acid nephropathy, see Chapter. 28 “Symptomatic treatment.”

7.6. CANCER BIOTHERAPY

Cancer biotherapy- a new direction in cancer therapy; During treatment, drugs of biogenic origin are used. Biotherapy refers to several types of agents that differ significantly in their mechanism of action. Cancer biotherapy includes such methods of influencing the tumor as the use of vaccines, cytokines, inhibitors of growth factors and enzymes, monoclonal antibodies, the use of agents that disrupt angiogenesis in the tumor, and genetic engineering therapy. Some of them are aimed at strengthening natural immunity, activating T- and B-cell units, macrophages, natural killer cells, and the complement system. Other drugs are used to enhance the resources of a sick body, which are much broader than our known idea of ​​immunity.

All tumors are usually monoclonal in nature, i.e. are descendants of one mutant cell, marker mutations are present in all tumor cells. This makes it possible to detect a sufficient number of molecules in mutant DNA when analyzing both the tumor itself and lymph nodes, blood, and bone marrow containing tumor cells.

The basis for the detection of tumor-associated antigens was the facts known in clinical practice - regression of the primary focus of melanoma and metastases of renal cell carcinoma in the lungs. Discovery of tumor antigens to which an antitumor immune response can be achieved from cellular and

humoral components of immunity, was the reason for the creation antitumor vaccines. The first attempts at antitumor vaccination date back to the beginning of the 20th century. Currently, several classes of tumor-associated antigens are known. Some antigens are inherent only to tumors, many of them (cancer-testis antigens). Some antigens are characteristic of normal cells at certain stages of differentiation, which reflects the long-noticed fact that tumor cells return to embryonic or earlier stages of cell formation from stem to mature (differentiation antigens). Some genes are inherent in completely normal cells, but are present in excess in tumor cells (overexpressed antigens). Viral antigens are important in the viral mechanism of carcinogenesis, in which it is believed that the antitumor response is to a certain extent retained by immunocompetent cells. There are other classes of antigens that are not recognized by the immune system as foreign. To enhance the provocation of the immune response, adjuvants of bacterial origin are used, for example, Bacillus Calmette-Guérin (BCG), which stimulate nonspecific immune reaction, both humoral and cellular.

So-called whole-cell vaccines are created based on autologous tumor cells. The effect of these vaccines can be enhanced by the introduction of microbial adjuvants or by the use of genetic engineering techniques. Modified tumor cells serve as the basis for the preparation of antitumor vaccines.

The discovery of tumor-associated antigens and monoclonal antibodies made it possible to use them in the diagnosis and treatment of cancer. The first attempts to use radionuclide-labeled monoclonal antibodies showed that a new, highly specific and very promising diagnostic approach has appeared in oncology, which, if improved, can displace all other diagnostic techniques. At present, attempts are already being made to use this method for tumor therapy.

Almost any therapeutic agent associated with a specific mAb is fixed at the site of antigen production, i.e. directly in the tissues of the malignant neoplasm. This use of drugs is called “targeted chemotherapy.”

otherapy - targeted therapy.” This type of treatment uses drugs whose action is aimed at specific “targets” in the tumor or in tissues that support the functioning of the tumor. These molecules usually have a complex protein nature, are present predominantly in the tumor, and their presence in tumor tissue is more important for the tumor than for normal tissues of the body. Such targeted drugs include, for example, antitumor antibodies. This also includes methods of influencing the tumor, such as suppressing the expression of protective proteins by tumor cells, normalizing tumor cell apoptosis by introducing the unmutated p53 gene and other factors.

A significant role in the diagnosis and therapy of cancer belongs to monoclonal antibodies (mAbs). They are produced in B lymphocytes in response to foreign substances entering the human body. This technique is based on the use of antibodies targeting a specific tumor antigen. The name is based on the technical features of creating the drug: antibody-producing cells are descendants of one cell, i.e. "monoclonal". At the end of the 90s. monoclonal antibodies appeared and began to be introduced into clinical practice. The first drug to be created was rituximab, or Mabthera, which is a monoclonal antibody to the CD20 antigen. The combination of antibodies with the CD20 antigen induces apoptotic signals and complement-dependent cytotoxicity in the cell, as well as cytotoxicity carried out by antibodies without the participation of complement.

For diagnostic purposes, MCAs are used to detect antigens in tumor cells and to determine the location of tumors in the body. Thus, for the diagnosis of hematological diseases, for the differential diagnosis of malignant tumors and the patient’s immune status, mAbs to human differentiation antigens are widely used. Based on these reactions, the determination of the origin of tumors is based on their low degree of differentiation (immunohistochemistry). The localization of tumor cells in the body is traced by introducing labeled mAbs and recording the sites of their fixation on a gamma camera. Therapeutic drugs based on mAbs are characterized by a selective effect on tumor cells, which significantly reduces toxic side reactions from treatment.

In recent years, much research has been devoted to angiogenesis, the formation of new vessels in malignant tumors. This process is the most important factor determining tumor progression and has a significant impact on the sensitivity of the tumor to chemotherapy and hormonal therapy, as well as on the prognosis of the disease. The most important positive regulator of angiogenesis is the vascular permeability factor. A number of factors have been discovered that play a significant role in angiogenesis. Accordingly, chemotherapy drugs are being developed and have already been developed that inhibit and disrupt the process of formation of blood vessels that provide the tumor with plastic material. Bevacizumab is the first antiangiogenic drug that inhibits the growth of a network of blood vessels in tumor tissue, which reduces the flow of nutrients and oxygen. The drug acts selectively on protein natural origin, called vascular endothelial growth factor (VEGF), which is a key mediator of angiogenesis.

Currently, all these areas are actively developing, but for the most part, drugs developed on the basis of biotherapy are still rarely used in clinical practice.

7.7. PHOTODYNAMIC THERAPY

Photodynamic therapy - a fundamentally new approach to the treatment of cancer patients and some precancerous diseases. The founder of phototherapy is considered to be Nilsson Rydberg Finsent, who won the Nobel Prize in 1908 for his work in this field. The mechanism of action is as follows. The photosensitizer administered intravenously is concentrated in the tumor. It turned out that cancer cells accumulate 10-15 times more photosensitizer than healthy cells. 3 hours after intravenous administration of the photosensitizer, it remains only in cancer cells. If at this time a beam of light is directed at the area where the tumor is growing, a photochemical reaction occurs in the cells, as a result of which the tumor cells die. Moreover, the light will only hit cancer cells. The diseased organ is irradiated with a beam of red light with a certain wavelength, the source of which is a laser. Light itself is harmless to body cells. It can only heat tissue, and low-energy laser radiation excites the photosensitizer, it transfers energy

light to oxygen in a living cell. As a result of the photochemical reaction, singlet oxygen and other highly active free radicals are formed, which are toxic to cancer cells. Those cells that contain a lot of photosensitizer suffer irreversible damage and die. The tumor is replaced by normal connective tissue. The high selectivity of the method is its main advantage.

The indication for the use of photodynamic therapy can be any superficial tumor - on the skin, mucous membranes or in a hollow organ (basal cell skin cancer, facial skin cancer, lip and tongue cancer, genital cancer, bladder cancer, multiple melanoma, intradermal cancer metastases mammary gland, etc.). This type of treatment is often used for recurrent tumors, since repeated use of chemotherapy and radiation treatment is futile. Although experience in the use of photodynamic therapy is only accumulating, the existing experience allows us to regard this method of treating malignant tumors as very promising. Complete tumor regression under the influence of photodynamic therapy is recorded in 48-81% of patients.

7.8. ASSESSMENT OF THE TREATMENT EFFECT

For any treatment option, in addition to the immediate therapeutic effect, the frequency of relapses and the timing of their occurrence, the duration of remission, overall and relapse-free survival are assessed.

Evaluation of the therapeutic effect antitumor drugs are administered immediately after completion of therapy. The objective effect is assessed as follows.

1. Complete remission - complete disappearance of all clinical and laboratory manifestations of the tumor process for a period of at least 4 weeks. For hemoblastoses involving the bone marrow, complete normalization of the myelogram and hemogram is necessary.

2. Partial remission - reduction of all measurable tumors by at least 50% for a period of at least 4 weeks.

3. Stabilization - a decrease of less than 50% in the absence of new lesions or an increase in tumor foci of no more than

by 25%.

4. Progression - an increase in tumor size by 25% or more and/or the appearance of new lesions.

The dimensions of the primary tumor and metastases are determined as the product of the two largest perpendicular diameters. If two measurements are not possible, one size is determined. Other efficacy estimates have been developed for some tumor sites. For example, for bone metastases: complete regression - complete disappearance of all lesions on radiographs or scans; partial effect - partial reduction of metastases, their recalcification or reduction in the density of osteoblastic lesions; stabilization - no changes within 8 weeks from the start of treatment; progression - an increase in existing or the appearance of new metastases. When assessing the objective effect, the dynamics of biochemical and immunological tumor markers are also taken into account.

More often, the assessment is carried out according to the criteria of objective and subjective effect developed by the WHO expert committee. The patient's condition must be assessed at any stage of observation and treatment, and therefore the same techniques are used in almost all necessary cases. The subjective effect is assessed by the patients themselves: by the reduction or disappearance of pain, positive change in body weight - weight gain or disappearance of edema.

The general condition of the patient can be assessed using a 5-point system (WHO).

0 - fully active, able to perform the work that was performed before the illness, without restrictions.

1 - has difficulty performing physical or strenuous work. Able to perform light and sedentary work.

2 - serves himself completely, but is not able to do the work. Spends most of the daytime in bed.

3 - serves himself with restrictions. Spends more than 50% of his time lying down.

4 - complete disability, unable to care for himself, bedridden.

A more accurate assessment is made by Karnofsky scale(Table 7.1) to determine functional activity.

Table 7.1.Karnofsky scale

Description of physical condition	Activity, %
Normal, no complaints, no signs of disease
Capable of normal activities minor symptoms or signs of illness
Normal effortful activities, some symptoms or signs of illness
Takes care of himself, is not capable of normal activities or active work
Needs help sometimes, but is able to meet most of his needs
Requires significant medical attention and frequent medical attention
Disabled person in need of medical assistance, including medical
Severe disability, hospitalization is indicated, although death is not expected
Hospitalization is necessary, the patient requires active supportive treatment
Dying, rapid progression of pathological processes

RADICAL TREATMENT

RADICAL TREATMENT

One in which the very causes, and not the signs of the disease, are treated.

Dictionary of foreign words included in the Russian language. - Chudinov A.N., 1910 .

See what "RADICAL TREATMENT" is in other dictionaries:

Radical treatment- treatment that eliminates the cause of a disorder. In psychiatry, according to a number of researchers, such methods of therapy are extremely insufficient... Encyclopedic Dictionary of Psychology and Pedagogy

TREATMENT- (therapia), a set of measures aimed at eliminating the stalemate. processes developing in a sick body, as well as eliminating or alleviating the suffering and complaints of a sick person. The history of the evolution of L. Already among cultural peoples there is a deep... ...

Treatment aimed at preventing the deterioration of a person’s health in the event of any disease; in this case, it is believed that the patient will either experience a natural recovery, or the progression of the disease will be slowed down so much... Medical terms

Intensive treatment, the goal of which is to achieve complete recovery of the patient, and not simply to alleviate the symptoms of his disease. For comparison: Treatment is conservative. Source: Medical Dictionary... Medical terms

CONSERVATIVE TREATMENT- (conservative treatment) treatment aimed at preventing the deterioration of a person’s health in the event of any disease; in this case, it is believed that the patient will either experience a natural recovery or progression of the disease... ... Explanatory dictionary of medicine

RADICAL TREATMENT- (radical treatment) intensive treatment, the goal of which is to achieve complete recovery of the patient, and not simply reduce the symptoms of his disease. For comparison: Treatment is conservative... Explanatory dictionary of medicine

- (cura) the totality of all actions taken to improve the patient’s condition. The science that studies measures using artificial aids to lead each case of disease to the most favorable outcome in the most possible time. a short time And… … Encyclopedic Dictionary F.A. Brockhaus and I.A. Efron

URETHRA- URETHRA. Contents: Anatomy.........................174 Research methods..................178 Pathology....... .............183 Anatomy. The urethra, urethra, urinary tube, is a continuation of the bladder and... ... Great Medical Encyclopedia

OSTITIS FIBROUS- (ostitis fibrosa), syn. fibrous osteodystrophy (osteodystrophia fibrosa), bone loss, first accurately delineated by Recklinghausen in 1891; The name also belongs to him (ostitis fibrosa von Recklinghausen). However, it should be noted... Great Medical Encyclopedia

TUMOR, TREATMENT METHODS- honey General principles, complex and surgical treatment are discussed here. General principles Distinguish between radical and palliative treatment of tumors. Radical treatment is aimed at eliminating the tumor and assumes the possibility of complete... ... Directory of diseases

Books

• , Kaplan Robert-Michael. Dr. Kaplan, a specialist in ophthalmology and Tibetan medicine, suggests new system to improve vision. The author combines modern methods with standard diagnostic methods...
• Radical restoration of vision. The Power in Your Eyes by Robert-Michael Kaplan. Dr. Kaplan, a specialist in ophthalmology and Tibetan medicine, offers a new system for improving vision. The author combines modern methods with standard methods...

The goal of palliative treatment is to make life easier for the patient and his loved ones.”

Most solid tumors with metastases in adults are incurable, so the goal of treatment in such cases is to eliminate the painful symptoms of the disease and, if possible, make the patient’s life easier. Upon learning of their diagnosis, many patients experience fear of suffering and what they will endure. To optimize treatment, it is necessary that from the moment of diagnosis it be carried out comprehensively, with the participation of specialists from different fields. The degree of involvement of these specialists during treatment varies.

However, the following goals of palliative treatment can be distinguished:

• ensure maximum benefit for the patient from the participation of all specialists by providing him with medical, psychological, social and spiritual assistance at all stages of cancer;
• to reduce, if possible, the negative psychological impact and experiences of the patient during the transition from “active” treatment to palliative;
• to help patients “come to terms with their illness” and be able to live as actively as possible for the rest of their lives;
• support the patient and their caregivers during treatment, and after death, help the family cope with the loss.

"System"

Specialists providing assistance to the patient are united in a group that has a complex organization and ensures the entire process of diagnosis, clarification of the stage of the disease and treatment. However, it is precisely this circumstance that often confuses the patient and his relatives, especially if the hospital is based in several buildings or there is a need to transfer the patient to a specialized center or the diagnosis has not been definitively established. Disadvantages associated with the relative autonomy of departments, the need to make extensive notes in the medical history, etc., have decreased with the advent of multidisciplinary teams and their composition includes doctors of a new specialty - patient care. Thanks to this organization of work, continuity in work improves different specialists, patients are less likely to have to repeat themselves when questioned, have a better idea of ​​the purpose of each doctor's visit, and know who to turn to if they feel "lost in the system."

Difficulties associated with the need to communicate sad news

The message of sad news always causes negative emotions and dissatisfaction in the patient and his family members. Many patients leave the doctor without wanting to listen to their diagnosis and prognosis in more detail, without knowing what achievements exist in the treatment of their disease, or, on the contrary, they want to receive more information than they were told. There are few free people who prefer to know less, completely trusting their doctor (perhaps less than 5%). Patients who are dissatisfied with the amount of information provided to them have a more difficult time getting used to their diagnosis, more often experience anxiety and become depressed. It is important to know how much information a patient needs at one or another stage of his illness. Information is dosed taking into account the characteristics of the patient and his disease.

Good news strengthens the patient's trust in the doctor, reduces uncertainty, and allows the patient and his family to be better prepared practically, psychologically, and emotionally for treatment. In the event of sad news, the matter is not limited to its communication. This is a process in which the news is often repeated, the diagnosis is explained, the patient and their loved ones are informed about the state of affairs in this area, and perhaps prepare them for the death of a person close to them.

Delivering sad news - ten steps

This approach can be used as general scheme and adapt it to specific situations. Remember that the patient has the right, but not the obligation, to listen to sad news.

• Preparation. Check out the facts. Make an appointment. Find out from the patient who he allows to be present. Make sure you are not disturbed (turn off your cell phone).
• Find out what the patient already knows. Both the doctor and the patient’s relatives usually underestimate the degree of his awareness.
• Find out if the patient needs additional information.
• Do not prevent the patient from denying your news. Denial is a way of coping. Let the patient control the amount of information.
• Warn the patient that you are about to deliver unpleasant news. This will give him time to collect his thoughts and see if he can listen to your information.
• Explain the situation to the patient if he asks for it. Speak more simply and clearly. Avoid harsh statements and medical jargon. Check whether the patient understood you correctly. Be as optimistic as possible.
• Listen to the concerned patient. Avoid premature encouragement.
• Do not interfere with the outpouring of the patient's feelings.
• Summarize what has been said and make a plan, this will avoid confusion and uncertainty.
• Express your willingness to help the patient. Communicating sad news is a process. Give the patient time to ask you questions; It is advisable to give him written information indicating the care specialist to whom the patient can contact in the future. Specify the time, place and purpose of the next meeting with the patient or the next study.

Uncertainty

Uncertainty is one of the psychological states that is especially difficult for a person to experience. This is the condition in which most patients with oncological pathology remain from the moment they develop dangerous symptoms and the start of the examination until the end of treatment. The doctor also faces a dilemma when trying to reassure an anxious patient and inform him about his illness with an uncertain prognosis. This is especially difficult when it is necessary to obtain informed consent from the patient for clinical trials or treatment methods, the effectiveness of which is problematic.

In such cases, there are always fears of discomfort, disfigurement, disability, addiction, and death.

Most patients who are told that they have a malignant tumor have already encountered a similar disease in the past among relatives or friends. It is advisable for the doctor to know how such an experience affected the patient. You can cheer him up. Misconceptions must be corrected. If concerns are justified, they should be acknowledged and the associated anxiety should be addressed.

Psychological support in the long term

Paradoxically, patients often feel a greater need for support after completion of treatment, when they need to reassess their lives and overcome the upcoming difficulties associated with survival. They often receive psychological support through observation programs and may feel helpless when regular contact with specialists ceases. This problem is compounded by the fact that there are only a few curable cancers in adults, so patients must live with the fear of relapse.

Symptomatic treatment

Physicians and other health care professionals involved in the day-to-day care of cancer patients have a significant clinical responsibility for assessing symptoms and managing them.

Symptoms may vary:

• directly related to a malignant tumor;
• manifestation of side or toxic effects of palliative therapy;
• affecting the physical, psychosocial, emotional and spiritual sphere of the patient;
• caused by another reason not related to the underlying disease.

Therefore, the symptoms detected in the patient require careful assessment in order to create the optimal plan to eliminate them.

Eliminating pain

Elimination of pain - an important part both palliative and radical treatment of cancer patients. In approximately 80-90% of cases, pain can be eliminated by prescribing conventional painkillers orally in combination with drugs from other groups in accordance with WHO recommendations. Ineffective pain relief can worsen other symptoms, including fatigue, anorexia and nausea, constipation, depression and feelings of hopelessness. Pain can also become an obstacle to regularly taking chemotherapy drugs and visiting a doctor on time. Relieving pain at the cost of increasing side effects is unacceptable in most cases, so there is a need to develop effective interventions.

The most common causes of intractable pain in cancer patients may be the following.

• A simplified approach to examination, which does not allow establishing the true cause of pain and its type, or identifying and assessing the general unfavorable background. lowering the pain threshold. If this background is not taken into account, the prescription of analgesics alone will not be able to eliminate pain. Correction of the psychological background is necessary.
• Lack of a systematic approach to pain management, including a lack of understanding of the WHO three-step regimen for pain management in cancer patients, the role of adjuvant analgesics, and opioid dose titration. “Panic prescription” of analgesics often leads to the development of side effects.

The ideal treatment for pain involves addressing its cause. Therefore, correctly selected palliative chemotherapy, radiation or hormonal therapy comes first. In palliative treatment, the use of analgesics is a generally accepted criterion for assessing response to therapy. However, even if the patient is prescribed a course of antitumor therapy, the use of analgesics does not lose its meaning, since the analgesic effect of therapy does not occur immediately and, moreover, can be incomplete and short-lived.

Categories of pain in cancer

The role of a carefully collected anamnesis in the treatment of pain can hardly be overestimated, since it allows doctors to clarify its mechanism and, therefore, select the optimal pain therapy.

Is the pain acute or chronic?

A malignant tumor does not always cause pain in a patient. Sudden pain can be a consequence of an acute complication of both the tumor itself and antitumor therapy, and sometimes it is completely associated with other causes. Examples of such causes include a pathological bone fracture leading to the need for orthopedic treatment, acute pathology of the abdominal organs requiring urgent surgical examination, or mucositis that develops during or after radiation therapy.

On the other hand, chronic increasing pain may indicate tumor progression and infiltration of soft tissues and nerve roots.

What type of pain?

Somatic pain, for example with metastases in the bones, phlegmon, is localized and constant.

Visceral pain is usually vaguely localized, variable in nature, and often accompanied by nausea and other symptoms (for example, with metastases to the liver or abdominal lymph nodes).

Neuropathic pain, classically described as “shooting pain,” is usually localized to the distribution of the affected nerve (eg, nerve root compression pain).

How does the patient interpret pain?

Pain has a strong emotional component and is significantly influenced by mood and morale. Understanding how a patient interprets their pain can help create a more realistic plan to manage it. For example, does the appearance of “new” pain cause anxiety in the patient, does it reduce his general activity, does the patient consider it a harbinger of the terminal stage of his disease. Eliminating anger, fear or irritation helps achieve more effective pain relief.

Drug treatment of pain

The principles of the three-step pain treatment regimen are as follows.

• The analgesic is selected depending on the intensity of the pain, and not on the stage of the tumor process.
• Analgesics for long-term use are prescribed to prevent pain. It is also necessary to have analgesics ready to quickly relieve pain when it intensifies.
• Prescribing one pain medication is rarely sufficient.
• Treatment should begin with a fast-acting analgesic, and then switch to long-acting drugs and maintain a stable dose.
• Spioids are usually used in combination with non-narcotic analgesics.
• Adjuvant analgesics are usually prescribed based on the cause and type of pain.

First stage. Analgesia with non-narcotic drugs

Paracetamol is a non-narcotic analgesic. It also serves as an antipyretic, but does not have an anti-inflammatory effect. Side effects when prescribed at a therapeutic dose are rare. As an alternative, you can prescribe drugs from the NSAID group, for example, ibuprofen at a dose of 400 mg 3 times a day, although this leads to the need for simultaneous administration of gastroprotectors and control of renal excretory function. Paracetamol can be used in combination with NSAIDs without fear of serious complications.

Second stage. Analgesia with weak opioids

Patients should continue treatment with non-narcotic analgesics. If the analgesic effect is insufficient, a weak opioid drug is prescribed. Subtherapeutic doses of codeine, which are often found in over-the-counter medications, should be avoided.

Third stage. Analgesia with potent opioids

If the pain does not stop, basic analgesic therapy with non-narcotic analgesics should be continued, but weak opioids should be replaced with strong ones. Treatment begins with a fast-acting drug given every 4 hours, with a double dose at night. The analgesic effect occurs after approximately 30 minutes, reaches a maximum at 60 minutes and lasts 4 hours if the dose is selected correctly. The dose prescribed “on demand” when pain intensifies should be one-sixth of the daily dose of the drug. Laxatives should be prescribed at the same time and antiemetics should be available.

Morphine solution or tablets (fast-acting drug):

• 10 mg every 4 hours (eg, at 6 a.m., 10 a.m., 2 p.m., 6 p.m., and 20 mg at 10 p.m.);
• dose “on demand” - 10 mg;
• oral administration is more preferable, although the drug can also be administered subcutaneously and intravenously;
• treatment with morphine is carried out while taking laxatives; if necessary, the patient is given antiemetic drugs;
• basic therapy also includes taking paracetamol in combination with or without NSAIDs.

Opioid dose selection

The morphine dose is adjusted every 24 hours until the optimal dose. The on-demand dose received during the previous 24 hours should be included in the adjusted dose. For example, if over the past day the patient received 30 mg of morphine “on demand”, in addition to the 60 mg prescribed as basic therapy, the following correction is carried out:

• the single dose is increased to 15 mg;
• the dose taken at night is adjusted to 30 mg;
• The on-demand dose is set to 15 mg.

After dose stabilization (i.e., when the patient receives the drug “on demand” no more than once a day), morphine is prescribed, for example, at a dose of 10 mg every 4 hours and at a dose of 20 mg at 22 hours.

• The total daily dose is 60 mg.
• Extended-release morphine at a dose of 30 mg 2 times a day.
• Rapid-release morphine is prescribed “on demand” at a dose of 10 mg. The bioavailability of morphine when taken orally is approximately 30%.

A significant part of it is metabolized (first pass effect) and excreted along with metabolites by the kidneys. The dose of morphine is subject to significant individual variations. Over time it has to be increased somewhat. Morphine has important feature- proportional relationship between the total daily dose and the dose taken “on demand”. Clinical experience and the results of clinical trials indicate that there is no pain that cannot be controlled with opioids, the only question is the dose of the drug. However, for some types of pain, this dose is too high and therefore unacceptable due to side effects, such as sedation. In such cases, for example when neuropathic pain, adjuvant analgesics play a particularly important role.

Opioid toxicity.

• Nausea and vomiting: metoclopramide 10-20 mg 4 times a day or haloperidol 1.5-3 mg at night.
• Constipation: regular use of co-dantramer or co-dantrusate.
• Drowsiness: usually the severity of this effect decreases by the 3rd day after the next dose increase.
• Dry mouth: unlimited fluid intake, oral care.
• Hallucinations: haloperidol in a dose of 1.5-3 mg orally or subcutaneously in an acute situation.
• Respiratory depression occurs only in cases where the dose of the drug exceeds the dose required to achieve analgesia, or when the drug accumulates, for example due to impaired renal excretory function.
• Dependence (physical and mental) and addiction.

Alternatives to potent opioids for chronic pain.

• Diamorphine: Used when parenteral analgesic administration is necessary.
• Fentanyl: Patients with chronic persistent pain are prescribed a transdermal form of the drug (fentanyl patch), and if the pain increases, morphine is administered. The sedative effect and the ability to cause constipation are less pronounced. When the first patch is applied, an alternative opioid is administered simultaneously.
• Methadone: can be used instead of morphine, administered orally, the toxic effects are the same, although the analgesic is less predictable. In cases of liver dysfunction, methadone treatment is safer.

Adjuvant analgesics

The need for adjuvant analgesics may arise at any stage of pain management. To make the best choice of medications, it is important to understand the mechanism of pain, but once you prescribe a drug, you must also be prepared to stop it if it is not effective enough. Otherwise, the patient will accumulate a lot of drugs, the prescription of which will be difficult to regulate, and the effectiveness of treatment will be low. Adjuvant analgesics include the following drugs.

• Glucocorticoids. These drugs are advisable to use in case of increased intracranial pressure, compression of nerve trunks and roots, overstretching of the Glissonian capsule (with metastases to the liver), and infiltration of soft tissues. Dexamethasone is often prescribed at a dose of up to 16 mg/day in acute situations, but this should be adjusted frequently and, if possible, reduced to maintenance. Side effects include fluid retention, gastric irritation, hypomania, hyperglycemia, and iatrogenic Cushing's syndrome.
• Tricyclic antidepressants are especially indicated in the treatment of neuropathic pain. Amitriptyline is prescribed at a dose of 2 mg at night and gradually increased depending on the effect. Side effects include sedation, dry mouth, constipation, dizziness and urinary retention.
• Anticonvulsants. Gabapentin is the only drug approved for use in all types of neuropathic pain. Carbamazepine is also effective, although it can only be prescribed in cases where tricyclic antidepressants do not help, since the simultaneous use of these drugs is fraught with serious side effects.
• Anxiolytics. Benzodiazepines are indicated for anxiety, agitation, restlessness, and insomnia, conditions that contribute to increased pain. They also have sedative and antiemetic properties and can be used to prevent nausea.
• Neuroleptics, such as haloperidol, have antiemetic and sedative effect. They are especially indicated for hallucinations caused by opioid analgesics.
• Bisphosphonates. Double-blind clinical trials have shown that bisphosphonates reduce pain from bone metastases in patients with breast, lung, and prostate cancer and reduce the incidence of complications associated with bone metastases, such as pathological fractures. They are also used in myeloma. The analgesic effect begins to appear within 2 weeks. The role of these drugs in the treatment of other tumors is unclear. Bisphosphonates are currently administered intravenously [eg, pamidronic acid (pamidronate medac) or zoledronate at 3-4 week intervals], although oral formulations are being developed. When treating with bisphosphonates, monitoring of renal function and serum calcium levels is necessary (risk of hypocalcemia).

Other treatments

Pain relief methods

For some malignant tumors, such as pancreatic cancer, which grows into neighboring tissues, they resort to blockade of the celiac plexus. In case of tumor infiltration of the nerve trunks in the armpit, a brachial plexus block is performed to eliminate pain.

For pathological fractures, when surgical fixation of the fragments is impossible, epidural anesthesia is indicated.

For severe pain that does not respond to conventional treatments, pain management specialists should be consulted.

Palliative radiotherapy

External beam radiation therapy can help treat pain associated with local tumor infiltration, such as metastatic lesions in the bone. However, it should be remembered that the maximum analgesic effect of radiation therapy is achieved within several weeks. Additionally, radiation may make the pain worse initially. Pain management during and after radiation therapy should be given due attention.

The use of radioisotopes that accumulate in bones, such as strontium, is justified for diffuse pain associated with osteoblastic metastases, for which conventional painkillers are ineffective. Radioisotopes are especially actively absorbed in areas with intense bone turnover. There is a risk of severe myelosuppression with this treatment method.

Maintenance therapy

There are also a number of other treatments available to complement pain management.

These include the following:

• transcutaneous electrical nerve stimulation;
• occupational therapy;
• physiotherapy;
• acupuncture, aromatherapy and other reflexology methods;
• relaxation therapy, including massage and hypnosis;
• psychotherapy and patient education.

Elimination of nausea and vomiting

Nausea and vomiting occur in approximately 70% of patients with advanced cancer. As with treating pain, eliminating these symptoms also requires understanding their mechanisms.

• Iatrogenic. Prescribing opioids may cause nausea. Chemotherapy may cause nausea and vomiting at the beginning or during treatment. Radiation therapy, especially if the brain or small intestine is exposed to radiation, can cause nausea.
• Metabolic. Elevated serum calcium may be accompanied by dehydration, constipation, abdominal pain, and confusion. Some patients experience nausea and vomiting without accompanying symptoms. Uremia also causes nausea, often without any other symptoms. If a metabolic mechanism for the occurrence of nausea and vomiting is suspected, it is necessary to perform a biochemical blood test to determine the calcium content in the serum and kidney function.
• Increased intracranial pressure associated with metastatic lesions of the brain and its membranes. Anamnesis plays a role in diagnosis (changes in the nature of the headache). It is necessary to examine the fundus to exclude papilledema.
• Subacute or acute intestinal obstruction, especially if the patient is diagnosed with a malignant tumor of the abdominal organs. The presumptive level of obstruction can be established on the basis of anamnesis [time of onset of nausea and vomiting, contents of vomit (unchanged food, fecal vomit), presence of stool and passage of gas, abdominal pain]. To clarify the diagnosis and the possibility of eliminating intestinal obstruction, CT scan of the abdomen and intubation enterography are performed.
• Pseudo-obstruction of the intestine. If this pathology is suspected, along with other studies, a digital rectal examination should also be performed. If a patient notices the appearance of watery stools against the background of symptoms of intestinal obstruction, then it is most likely due to the fact that the fluid in the dilated intestine flows around the feces in the area of ​​the obstruction.
• Pain. Insufficiently effective pain relief can cause nausea.

Many neurotransmitter receptors are involved in the development of nausea and vomiting. Most of them are located in various areas of the central nervous system. However, peripheral receptors and neural pathways also play a significant role. Optimal selection of an antiemetic drug requires an understanding of the mechanisms of nausea and knowledge of the point of application of the drug.

• The antiemetic drug is selected taking into account the most likely cause and taken by the most appropriate route.
• If vomiting makes it impossible to take the drug orally, it is prescribed sublingually, buccally, rectally, intravenously, intramuscularly or subcutaneously. Long-term subcutaneous administration of the drug using a perfusion pump is especially effective.
• Patients should take antiemetic drugs regularly.
• If nausea and vomiting do not disappear within 24 hours, a second-line drug is prescribed.
• Elimination of nausea and vomiting includes measures aimed at correcting each of the causes of these symptoms (hypercalcemia, renal excretory function, treatment with drugs that can cause vomiting, intestinal obstruction).
• Metoclopramide is classified as prokinetic. It can be prescribed with caution in cases of impaired gastric emptying or subacute intestinal obstruction, but if vomiting or colicky abdominal pain worsens, the drug should be discontinued. In case of complete intestinal obstruction, metoclopramide cannot be prescribed. Cyclizine neutralizes the effect of metoclopramide, so both drugs should not be prescribed at once.
• It should be remembered that there may be several reasons that cause nausea and vomiting in a cancer patient. If they are unknown or first-line therapy is ineffective, it is advisable to prescribe levomeprazine, which acts on several types of receptors at once. Due to its wide spectrum of pharmacological activity, this drug is often effective even in cases where combination therapy with selective antiemetic drugs does not help. The anxiolytic properties of levomeprazine make it preferable for this category of patients, although when prescribed at a dose of more than 6.25 mg/day, it often has a pronounced sedative effect.

Eliminate constipation

Causes of constipation

There are many causes of constipation in cancer patients.

• Drugs, especially opioid analgesics and some antiemetics, such as 5-HT3 receptor blockers.
• Dehydration associated with insufficient fluid intake frequent vomiting or diuretic therapy.
• Anorexia: insufficient food intake and changes in its quality composition.
• Reduced physical activity and general weakness.
• Hypercalcemia, especially if it is combined with dehydration, nausea, abdominal pain, confusion, although these associated symptoms may be absent.
• Spinal cord compression: Constipation is usually a late manifestation.
• Intestinal obstruction associated with adhesions due to tumor infiltration, surgery or radiation therapy, as well as obstruction of the intestine by a tumor or compression of the pelvic organs by a tumor.

Clinical manifestations

• Retention of stool or absence of stool.
• Nausea and vomiting.
• Abdominal pain, usually colicky.
• “Paradoxical diarrhea” (the appearance of watery stools against the background of constipation).
• Urinary retention.
• Acute psychosis.

Diagnostics

History: Questioning the patient is especially important to identify contributing factors and preventable causes of constipation, such as those related to difficulties caring for the patient at home.

Digital rectal examination.

X-ray of the abdomen is indicated only in cases where it is necessary to differentiate intestinal obstruction from pseudo-obstruction.

Blood test: calcium content in blood serum.

Treatment

Non-medicinal.

• Use more liquids and foods rich in fiber.
• Increased physical activity.
• Possibility of privacy. Respect for the patient's self-esteem.

Medication.

• Prevention. For example, when starting treatment with opioid analgesics, laxatives (usually softening or stimulant) are always prescribed. The constipating potential of the fentanyl patch is less pronounced than that of morphine. When pain intensity stabilizes, it is advisable to switch to treatment with a transdermal form of fentanyl.
• Osmotic laxatives. Hyperosmolar mixtures, which are not absorbed into the gastrointestinal tract, retain water in the intestinal lumen, thereby increasing the volume of intestinal contents and stimulating peristalsis. Side effects of this group of drugs include cramping pain in the stomach, thirst, increased gas formation in the intestines (for example, when using magnesium sulfate or lactulose - a synthetic disaccharide that is not digested.
• Stimulant laxatives. The most commonly prescribed laxatives in this group are senna preparations. They act mainly on the transport of electrolytes in the intestinal mucosa and enhance peristalsis. May cause cramping abdominal pain. Another stimulant laxative is danthrone, used only for palliative treatment. It is especially effective for constipation caused by opioid analgesics. When prescribing deuteron, patients should be warned about the appearance of a red tint to their urine. The drug is used only in combination with softening laxatives, such as codantamer or codantrusate.
• Softening laxatives. Drugs in this group, such as docusate, reduce the surface tension of stool, facilitating the penetration of water into it.
• Drugs that increase the volume of intestinal contents are indicated for patients with a relatively satisfactory condition in whom the ability normal nutrition almost intact. When using these drugs (for example, flea seed plantain), you need to take up to 2-3 liters of liquid per day.
• Rectal preparations: glycerol (suppositories with glycerin) soften stool and serve as a lubricant for the fecal plug palpated in the rectum; Peanut butter enemas to soften stool: given before bed, and in the morning do a high phosphate enema to stimulate stool.

Treatment of cachexia and anorexia

Cachexia

Cachexia is understood as an increase in energy consumption independent of will, leading to a sharp decrease in the mass of both muscle and fat tissue.

• Occurs in more than 85% of patients with advanced stage cancer.
• Often associated with anorexia, cachexia is different from fasting because weight loss cannot be prevented by increasing nutrient intake alone.
• Cachexia most often develops in patients with advanced solid tumors, especially lung and gastrointestinal cancer.
• The mechanisms of development of cachexia are unclear, although the role of cytokines circulating in the blood is obvious, such as tumor necrosis factor, which causes metabolic disorders, in particular protein breakdown, lipolysis, and enhancing gluconeogenesis.
• Cachexia is the main cause of symptoms that appear at the end of the disease and lead to physical impotence, psychological and social maladjustment. It is painful both for the patient and for his family.

Anorexia

Decreased or lack of appetite.

It can be combined with increased fatigue and cachexia in advanced tumor processes and have no other specific cause.

However, when examining you should be aware of possible preventable causes of anorexia:

• nausea;
• constipation;
• depression;
• metabolic disorders, such as increased calcium levels in the blood, uremia;
• infection, such as oral candidiasis;
• intestinal obstruction, ascites.

Treatment

The cause should be eliminated if possible. The measures taken usually do not affect cachexia.

General measures

Nutrition optimization. It is recommended to eat often, in small portions, and eat when you feel hungry. Food should be high in calories and have a relatively small volume. To stimulate appetite, you can drink a small amount of alcohol.

It is necessary to ensure that food brings pleasure to the patient and does not cause negative emotions. Caregivers should not be overly persistent.

It is necessary to stimulate the patient's activity whenever possible.

Drug treatment

Nutritional supplements. High-calorie protein mixtures (for example, Ensure). Glucocorticoids (eg, prednisolone 25 mg once daily) can improve appetite and general condition and reduce nausea, but do not increase muscle mass.

Progesterone improves appetite, although there is no convincing evidence that it causes weight gain.

Sometimes, against the background of active antitumor therapy, enteral and parenteral nutrition is advisable, but with tumor progression it is not justified.

Elimination of symptoms of respiratory damage

Causes of shortness of breath in cancer patients

There are many reasons for shortness of breath in patients with a malignant tumor with metastases. They may be treatable, so patients should be carefully examined.

Pulmonary causes.

• Lung tumor.
• Pneumonia.
• Effusion in the pleural cavity (if fluid accumulates again, the advisability of pleurodesis should be discussed).
• Carcinomatous lymphangitis.
• Obstruction of a large airway with collapse of the lung distal to the obstruction.
• Concomitant chronic obstructive pulmonary disease.

Cardiovascular causes.

• Effusion into the pericardial cavity.
• Congestive heart failure.
• Pulmonary embolism.
• Obstruction of the superior vena cava.
• Anemia.
• Heart rhythm disturbances. Neuromuscular disorders.
• Muscle weakness and rapid fatigue.
• Armored breast cancer (cancer en cuirasse) manifested by tumor infiltration of the chest wall.
• Respiratory depression, such as that associated with opioids.
• Damage to peripheral nerves, such as the phrenic nerve.
• Tumor infiltration of the vagus nerve: hoarse voice, sometimes “bull” cough. An examination by an ENT specialist is indicated: palliative injection of a soft tissue filler into the vocal fold may help eliminate this symptom.

Psychological state of the patient.

• Fear, anxiety.

Treatment

If possible, eliminate the cause of shortness of breath

An integrated approach is required using non-drug treatment methods, such as breathing exercises, physiotherapy, relaxation therapy, and massage. We need to help patients so that their expectations are realistic.

A number of medications can be tried as a palliative measure to reduce shortness of breath.

• Opioids. Morphine at a dose of 2.5 mg 4 times a day orally reduces respiratory drive and weakens the response to hypoxia and hypercapnia. It reduces the discomfort associated with shortness of breath and also suppresses cough.
• Benzodiazepines reduce anxiety, cause sedation, and may also relax muscles. Concerns regarding the possibility of respiratory depression are usually unfounded, particularly when treated with lorazepam 1-2 mg orally on demand.

Oxygen therapy can eliminate or reduce hypoxia. It may also reduce shortness of breath, which appears to be due to a facial refreshing effect or a placebo effect. Caution should be exercised in patients with chronic obstructive pulmonary disease.

Treatment of lymphedema

Impaired lymphatic drainage leads to excessive accumulation of interstitial fluid called lymphedema. Lymphedema most often occurs on the extremities. It is a dense swelling, in which, after pressing with a finger, a hole does not form on the tissue, limits the patient’s activity and is difficult to treat. The causes of lymphedema are:

• tumor infiltration of lymphatic vessels;
• violation of the integrity of the lymphatic system associated with excision of lymph nodes, and changes in it caused by radiation therapy.

Lymphedema of the limb should be differentiated from edema associated with thrombotic or tumor occlusion of the deep veins. It is very important to distinguish between these conditions, since their treatment is different.

Prevention of lymphedema

Prevention of lymphedema is more rational and effective than treatment. It is important to give the patient a correct understanding of this complication. If necessary, you can contact a lymphedema specialist. Massage and exercise.

It is important to avoid injury and infection of the affected limb by wearing protective gloves when working on garden plot, defence from sun rays performing venipuncture on a healthy limb). Vigorous treatment for skin infections.

Treatment

Daily skin care. Self-massage and exercise. Wearing elastic stockings.

For refractory edema, elastic bandaging of the limb may be necessary before fitting elastic stockings. There are no drugs to treat lymphedema.

Psychological support and correction of mental disorders

Assessing the mental state, providing psychological support and correcting mental disorders should be an integral part of the treatment of a cancer patient. Psychological problems may be associated with such emotions and conditions as:

• denial and confusion;
• anger;
• anxiety;
• sadness and depression;
• feeling of loss;
• alienation;
• insufficient management of one's condition.

Doctors should know that psychological problems the patient is often neglected, and take time to examine mental status. It is always necessary to be attentive to the problems of the patient and those caring for him. The patient's mental state can be assessed using various rating scales and systems.

• Hospital Anxiety and Depression Scale.
• Functional assessment of the effectiveness of cancer treatment.
• Functional vital indicator in cancer patients.
• European Quality of Life Questionnaire.

Treatment

Self-help. Patients should be involved in monitoring treatment, helping them set realistic goals and formulate coping strategies.

Formal support. Patients have the opportunity to seek help from an experienced consultant at a clinic or hospital information center. Specialists providing palliative treatment have the opportunity, if necessary, to seek help from a psychologist and psychiatrist.

Psychotherapy. If the patient has severe anxiety and depression, it is advisable to conduct behavioral and short-term psychotherapy.

Psychiatric treatment. The attending physician of a cancer patient must recognize in time mental disorders, requiring consultation with a psychiatrist and medication correction (for example, antidepressants or anxiolytics). Psychotropic medications help approximately 25% of cancer patients with anxiety and depression.

Help with terminal excitation

Assessment of the patient's condition

Even with approaching death, due attention should be paid to the mental state of the patient, since in some cases it is possible to alleviate suffering and reduce pre-death excitement.

The following factors may cause additional suffering to the patient:

• insufficiently effective pain relief;
• retention of urine or stool;
• nausea;
• dyspnea;
• fear;
• side effects of drugs.

However, the scope of examination of a dying patient should be limited so as not to cause him additional suffering. It is important to achieve an optimal state of physical and psychological comfort to ensure a dignified and peaceful end to life.

Treatment for terminal cancer

All drugs that are not essential for the patient are discontinued. In practice, this means that only analgesics, anxiolytics and antiemetics are left. If the dying patient is unconscious, glucocorticoids are usually discontinued.

Oral administration of drugs should be avoided. Subcutaneous administration using an infusion pump is often preferred. This does not require hospitalization, although significant efforts may be required from health care workers and relatives caring for the patient.

Intravenous administration of drugs is also undesirable (sometimes it is simply impossible). Cannulating a vein is painful and may cause additional suffering.

Drugs should be administered as required. Subcutaneous infusion is optimal, allowing relief of painful symptoms without the need for additional doses. It is important that caregivers have ready access to the drug to administer it as needed.

Opioids. Treatment with these drugs, if previously administered, should be continued, but the dose of the drug should be reconsidered for subcutaneous administration. The dose on demand is 1/6 of the daily dose. If the patient has not been given opioids before, but intense pain needs to be eliminated, a small dose of diamorphine is administered, for example, 5-10 mg subcutaneously for 24 hours, and if the pain intensifies, an additional 2.5 mg subcutaneously. Observe the effect and increase the dose if necessary.

Anxiolytics, such as midazolam, are administered at a dose of 10 mg/day subcutaneously and 2.5-5 mg on demand. The effect of the drug should be carefully monitored, as there is often a need to significantly increase the dose. The drug also has antiemetic properties. Sometimes, despite increasing the dose of midazolam, agitation increases. In such cases, levomeprazine is additionally prescribed, which has a sedative property. First, 25 mg is administered subcutaneously, then an additional 50 mg over 24 hours. Depending on the effect, the dose can be increased. Haloperidol is also effective, prescribed in a dose of 5 mg subcutaneously on demand.

Antiemetics are added to treatment at the same time as opioids.

Increased bronchial secretion is often more burdensome for the patient’s relatives than for him. A conscious patient is more concerned about dry mouth - an inevitable side effect of drug suppression of bronchial secretion. If the patient is unconscious, then it is usually sufficient to change the position of his body or carefully evacuate the mucus using suction. Usually, hyoscine hydrobromide is administered subcutaneously at a dose of 400 mcg or the drug is added to the syringe of the perfusion pump. Instead of hyoscine hydrobromide, glycopyrronium can also be prescribed. The side effects of these drugs are the same as those of M-anticholinergic drugs.

Explanatory work. It is necessary that the patient’s relatives (and the patient himself, if he is conscious) know what purpose this or that doctor’s prescription serves. It should be explained how important it is to achieve adequate pain relief while avoiding significant sedation. Caregivers should know what drugs are contained in the subcutaneous infusion solution, monitor their effect and adjust the dose if necessary. Time spent at the bedside of a dying patient will allow relatives to experience the loss with greater understanding and without anger or suspicion and will leave them with fewer questions regarding the last hours of his life.

Referring to an outpatient or inpatient palliative care service for advice or assistance for refractory symptoms or other care before or after death.

Complex symptomatic treatment

Care for a dying patient in a hospital is increasingly becoming formalized with the participation of teams of different specialists. This is in line with NICE guidelines covering the physical, social, psychological and spiritual aspects of such care.

Today, one can observe an increase in cancer diseases against the backdrop of negative environmental factors and the prevalence of internal human diseases. This is what causes the development of malignant and benign tumors, and their localization can be very diverse. In this regard, new technologies are being developed, new principles are being created, and many experiments are being conducted in order to find the safest and most effective treatment for oncology.

General principles of treating cancer patients

Modern methods of fighting cancer are built on the same principles; the basis of effective treatment is speed, safety and complexity. It is impossible to completely get rid of cancer, but there is a chance to significantly improve the patient’s quality of life by maintaining the normal state of the body and preventing relapses.

The main objectives of treating cancer patients.

• The use of combined treatment, regardless of the stage and extent of the pathological process.
• Combination of modern technologies with basic treatment methods.
• Long-term treatment planning, continuity of therapeutic measures throughout the patient’s life.
• Constant monitoring of the cancer patient, correction of treatment based on the latest diagnostic tests.

In addition, the main goal of modern medicine is timely diagnosis, which is the key to effective treatment.

Drug treatment of oncology

The use of medications for the treatment of cancer patients is carried out taking into account the stage and location of the malignant process. Antitumor vaccines, hormonal and symptomatic drug therapy are used. Such treatment cannot be carried out as an independent method, and it is only an addition to the main measures in the presence of a malignant process in the body.

Let's look at the most common types of cancer and the essence of their drug therapy.

• Breast and prostate cancer – when cancer is localized in the breast and prostate, it is rational to use a course of hormonal therapy. Painkillers, restoratives and antitumor drugs are also prescribed. The essence of hormonal treatment is to stop the synthesis of hormones that cause progressive tumor growth. Cytostatic drugs are necessarily prescribed, which destroy atypical cells, creating all the conditions for their death.
• Cancer of the brain or bone marrow - for such diseases, drug therapy is less significant; surgical treatment must be carried out. But in order to maintain general condition, medications are prescribed to increase brain activity and improve memory. Patients with brain cancer experience various mental disorders, therefore symptomatic therapy is carried out.
• Cancer of bones and cartilage - medications are prescribed to strengthen bones. Very often, in patients with a tumor, fractures or cracks occur in the bones even with minor loads. Therefore, it is very important to strengthen the structure of bone tissue through vitamin therapy and other medications.

What drugs are used to treat cancer?

All medications used in the fight against cancer can be divided into several groups.

• Hormonal drugs are drugs that reduce testosterone levels, these are Herceptin, Taxol, tamoxifen, Avastin, Thyroxin, Thyroidin.
• Toxic drugs - aimed at destroying cancer cells by toxic effects on them, these are Celebrex, Avastin, Docetaxel. Also narcotic drugs - Morphine, Omnopon and Tramadol.
• Antiviral - the essence of the purpose of this group of drugs is to maintain immunity. In oncology, both local and internal anti-inflammatory drugs are used.
• Cytotoxins and cytostatics - under the influence of these drugs, the tumor resolves and decreases in volume, which is necessary for subsequent surgical intervention.
• Antitumor universal drugs are Ftorafur, antimetabolites, Doxorubicin and others.

Radiation and chemotherapy

Radiation therapy and chemotherapy are the main treatments for cancer. Prescribed in the preoperative and postoperative period.

Radiation therapy

Radiation therapy is prescribed if cancer cells are sensitive to this type of radiation. This is a small cell cancer, which is most often localized in the respiratory organs, uterus, in the head area, and can also affect the lungs.

Several radiation therapy techniques are used:

• remote;
• intracavitary;
• using neutrons, radioactive isotopes and protons.

It is rational to use the radiation method of oncology treatment before surgery in order to localize the main focus of the tumor. The goal of postoperative radiation therapy is to destroy any remaining cancer cells.

Chemotherapy

Chemotherapy is also the main method of treating cancer, but is used in parallel with radical measures. The drugs that are used actively fight pathological cells. Healthy tissues are also negatively affected, but to a lesser extent. This selectivity of chemicals lies in the rate of cell growth. Cancerous structures multiply quickly, and they are the first to be hit by chemotherapy.

For testicular cancer, uterine cancer, Ewing's sarcoma, and breast cancer, chemotherapy is the main treatment method and can completely overcome cancer in the first and second stages.

Radical tumor removal

A surgical operation aimed at removing the main focus of the tumor and nearby tissues is used in the first, second and third stages of the disease. The last stage of cancer does not respond to surgery, and surgery is contraindicated. This is because at stage 4 cancer metastasis occurs, and it is impossible to remove all metastases from the body. The operation in this case will only harm the patient and weaken him (with the exception of palliative surgery).

Radical therapy in oncology takes first place. Complete removal of the tumor in the early stages can completely eliminate cancer. During the surgical operation, not only the lesion and part of the affected organ are removed, but also regional lymph nodes. After the operation, a mandatory tissue examination is carried out, after which a course of drug treatment is prescribed.

There are two main options for surgery – organ-preserving and extended.

• Extended surgery is performed mainly for cancer of the rectum, uterus, and genitals. It involves the removal of the organ itself and regional lymph nodes. Another technology for extended operations has been created - super-radical, in which, in addition to the causative organ, several nearby ones are also removed. Contraindications: presence of distant metastases.
• Organ-conserving surgery is performed when cancer is clearly localized without metastatic processes. It is performed for breast cancer and tumors in the facial area. This allows the organ to be preserved, which significantly affects the patient’s psychological state. In some cases, after radical removal, cosmetic restoration procedures are performed, which also improves the patient’s quality of life.

Palliative care

Of the entire complex of oncology treatment, it is important to highlight palliative measures. They are aimed not at treatment, but at improving the quality and life expectancy of patients with stage 4 cancer. Such patients do not have a chance for a full recovery, but this does not mean that they can die peacefully. Modern medicine offers such patients a set of procedures that eliminate the main symptoms of cancer. This includes pain relief, cancer reduction through gentle surgery, taking restorative medications, and physiotherapeutic procedures.

Treatment of patients at stage 4 is a difficult task, such patients suffer from excruciating pain, severe weight loss, and psychological disorders. Therefore, separate treatment is carried out for each of the complications of cancer.

Symptomatic treatment includes:

• narcotic analgesics – morphine, fentanyl, buprenorphine;
• non-narcotic analgesics - paracetamol, metamizole, ibuprofen, diclofenac.

If pain treatment is ineffective, you can contact the Cancer Pain Treatment Center. Eliminating pain is the main goal in treating a cancer patient.