Figure 1. X-ray for stomach cancer. With tight filling, the contour of the corner of the stomach is uneven, with a slight retraction (indicated by a black arrow). Along the lesser curvature of the antrum
– rigid platform (indicated by a white arrow).
Figure 2. X-ray for stomach cancer. With double contrasting – convergence of mucosal folds to the flattened wall of the stomach (indicated by an arrow)
Stomach cancer
Figure 1. X-ray for stomach cancer. With tight filling, the distal section is deformed like a rigid tube, its contours are uneven, its walls are rigid, and the lumen is not narrowed.
Figure 2. X-ray for stomach cancer. With double contrast, circular infiltration of the distal stomach is observed, spreading to the lesser and greater curvature of the stomach (indicated by arrows)
Stomach cancer
The symptom of atypical relief is a defect reflecting a tumor node. The shape of this node is uneven, irregular, and the outlines are blurry.
A typical sign of changes in relief in stomach cancer is a persistent stain, or barium depot, caused by ulceration of the tumor. The shape of the spot is incorrect. The contours are uneven and unclear.
In some cases, radiographs reveal powerful hyperplastic, expanded, randomly located folds with a “break-off symptom” or, conversely, the absence of folds
- “symptom of a bald area”
X-ray for stomach cancer. With tight filling, the contour of the lesser curvature of the lower third of the body is uneven (indicated by an arrow), the contour of the greater curvature is without visible changes
Small stomach cancer
Fig.1. X-ray for stomach cancer. With tight filling, the angle of the stomach is straightened, a rigid area with a notch symptom is determined on the lesser curvature (indicated by an arrow).
Fig.2. X-ray for stomach cancer. The wall of the antrum is thickened due to intramural infiltration (indicated by an arrow).
Small stomach cancer
Fig.1. X-ray for stomach cancer. With dosed compression, the contour of the lesser curvature of the lower third is uneven, undermined, and a flat ulceration is determined that does not extend to the contour (indicated by arrows).
Fig.2. X-ray for stomach cancer. Near the angle of the stomach, thickening of the gastric wall is noted, caused by intramural infiltration (marked by an arrow).
Pyloric stenosis
The main causes of pyloric stenosis:
1. Scarring in the pylorus area
2. Stricture after a chemical burn
3. Neoplasm at the outlet of the stomach
4. Tumor growth from neighboring organs. Stages of stenosis:
1. Forming stenosis: there is no clear CC, X-ray examination shows that the stomach is not dilated, peristalsis is normal or slightly increased, the stomach empties completely
2. Compensated: the stomach is of normal size or slightly dilated, on an empty stomach there is liquid, peristalsis is weakened. Evacuation of the contrast mass is delayed for 6-12 hours. Endoscopy reveals severe scar deformation of the pyloroduodenal canal with a narrowing of the lumen to 0.5 cm
3. Subcompensated stenosis: a decrease in the tone of the stomach and its moderate expansion are determined; on an empty stomach, fluid is retained in it. Peristalsis is weakened, barium remains in the stomach for 12-24 hours. With endoscopy - distension of the stomach, narrowing of the lumen of the pyloroduodenal canal to 0.3 cm
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Epidemiology
Gastric cancer is the second most common cause of death from malignant neoplasms. The highest incidence is recorded in Japan, China, Korea, countries of South and Central America, as well as in Eastern Europe, including the former Soviet republics. In the Russian Federation, about 40 thousand primary patients with stomach cancer are registered annually, 35 thousand die. The incidence is 28.4 per 100 thousand population. Since the mid-20th century, there has been a worldwide decline in the incidence of stomach cancer due to patients with intestinal-type cancer of the distal parts of the stomach, while the proportion of cardia cancer is growing, most rapidly among people under 40 years of age.
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Epidemiological classification according to Lauren's
Intestinal type: The tumor has a structure similar to colorectal cancer and is characterized by distinct glandular structures consisting of well-differentiated columnar epithelium with a developed brush border. Diffuse type: the tumor is represented by loosely organized groups or single cells with a high content of mucin (signet ring-shaped) and is characterized by diffuse infiltrative growth.
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Epidemiology of stomach cancer
Peak incidence 50-60 years Men are 2-12 times more likely to get sick Localization: more often distal sections. However, there is a tendency towards an increase in proximal and cardio-esophageal cancer, especially in the countries of Europe and America Asia - distal cancer is much more common (better treatment results and prognosis!)
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Epidemiology of gastric cancer in Europe
2006 - 159,900 new cases and 118,200 deaths, which ranks fourth and fifth in the structure of morbidity and mortality, respectively. Men get sick 1.5 times more often than women; the peak incidence occurs at the age of 60-70 years.
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Biography
Genus. April 23, 1867 in Silkeborg, Denmark. He studied bacteriology under the guidance of R. Koch and E. von Behring, worked together with Karl Salomonsen at the University of Copenhagen. His doctoral dissertation on the bacteriology of diphtheria was completed in 1895, and in 1900 he became professor of pathological anatomy at the university. Introduced Behring's serum to treat diphtheria in Denmark and investigated the relationship between outbreaks of tuberculosis in cows and the spread of this disease in humans. Rat tuberculosis and gastric cancer with Spiroptera neoplastica (Gongylonema neoplasticum). In the 1920s, he conducted a comparative experimental study of cancer caused by coal tar, Spiroptera neoplastica and clinical manifestations. A combination of external influences with a genetic, not general, but organ predisposition to cancer. Nobel Prize in Medicine or Physiology for 1926. “For the first time, it has become possible to experimentally transform normal cells into malignant cancer cells. Thus, it was convincingly shown not that cancer is always caused by worms, but that it can be provoked by external influences” (W. Wernstedt). He died in Copenhagen on January 30, 1928 from rectal cancer.
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Etiology
A. Nutritional risk factors Excessive consumption of table salt and nitrates Lack of vitamins A and C Consumption of smoked, pickled and dried foods Preserving food without using a refrigerator Quality of drinking water B. Environmental and lifestyle factors Occupational hazards (rubber, coal production) Tobacco smoking Ionizing radiation History of gastric resection Obesity B. Infectious factors Helicobacter pylori Epstein-Barr virus
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D. Genetic factors Blood type A (II) Pernicious anemia Familial gastric cancer Syndrome of hereditary diffuse gastric cancer (HDGC). Hereditary non-polyposis colorectal cancer Li Fraumeni syndrome (hereditary cancer syndrome) Hereditary syndromes accompanied by polyposis of the gastrointestinal tract: familial adenomatous polyposis of the colon, Gardner syndrome, Peutz-Jeghers syndrome, familial juvenile polyposis E. Precancerous diseases and changes in the gastric mucosa Adenomatous polyps of the stomach Chronic atrophic gastritis Menetrier's disease (hyperplastic gastritis) Barrett's esophagus, gastroesophageal reflux Dysplasia of the gastric epithelium Intestinal metaplasia
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Etiological factors of stomach cancer
Nutrition Bile reflux Helicobacter pylori Genetic disorders Risk factors - exogenous sources of nitrates and nitrites, endogenous formation of nitrates, increased salt intake, food storage, alcohol. Protective factors are antioxidants and beta-carotene.
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Helicobacter pylori
Etiological factor of some forms of gastritis (hyperacid and hypoacid) Pathogenetic connection with duodenal ulcer, adenocarcinoma and MALT lymphoma of the stomach CagA gene Vacuolating toxin (vac-A) - 50-60% (switching off ion transporting ATPases) Activation of EGF, HB-EGF, VEGF Alcohol dehydrogenase – acetaldelhyde – lipid peroxidation – DNA damage Mucolytic enzymes
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First line therapy - for 7-14 days: PPI: Omeprazole (Ultop, Rabeprazole, Esomeprazole) 20 mg x 2 times a day; or Lansoprazole 30 mg x 2 times a day; or Esomeprazole 40 mg x 2 times per day Clarithromycin (Fromilid) 500 mg x 2 times per day Amoxicillin (Hiconcil) 1000 mg x 2 times per day N.B.: In case of hypersensitivity to penicillin antibiotics, you can replace metronidazole or immediately prescribe quadruple therapy Efficacy of treatment regimens I line exceeds 80%. The effectiveness of treatment is checked by a 13CO(NH)2 breath test 4 weeks after antibiotic treatment or two weeks after PPI.
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Second line therapy - quadruple therapy: Bismuth subsalicylate or subcitrate 1 table. x 4 times / day PPI: Omeprazole (Ultop, Rabeprazole, Esomeprazole) 20 mg x 2 times per day; or Lansoprazole 30 mg x 2 times a day; or Esomeprazole 40 mg x 2 times a day Metronidazole 500 mg x 3 times a day Tetracycline hydrochloride 500 mg x 4 times a day
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Hereditary stomach cancer
A study of families with hereditary forms of gastric cancer showed that inheritance corresponds to a monogenic autosomal dominant type with high penetrance (75-95%) of the gene Morphological form - diffuse adenocarcinoma Hereditary syndromes in which gastric cancer develops with increased frequency - familial hereditary polyposis of the colon, Gardner and Peutz-Jeghers syndromes Lynch syndrome CDH1 is a gene associated with gastric carcinoma. It is located on chromosome 16 and encodes the E-cadherin protein, which is an adhesive protein involved in the formation of intercellular contacts. It also plays a role in transmitting signals from the membrane to the nucleus
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Molecular pathogenesis
p53 suppressors - inactivation by micromutations or deletions of the corresponding chromosomal locus Methylation of the promoter regions of suppressor genes leads to a phenotype of microsatellite instability, inhibition of the expression of the retinoic acid receptor gene (RAR-beta), cell cycle regulators, RUNX family genes
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Paraneoplastic syndromes
Acantosis nigricans Polymyositis with dermatomyositis Ring-shaped erythema, bullous pemphigoid Dementia, cerebellar ataxia Venous thrombosis of the extremities Multiple senile keratomas (Leser-Trélat sign)
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Ring-shaped erythema
Ring-shaped erythema is based on cutaneous vasculitis or a vasomotor reaction
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Bullous pemphigoid
A benign chronic skin disease, the primary element of which is a bubble that forms subepidermally without signs of acantholysis and with a negative Nikolsky sign in all modifications. The autoallergic nature of the disease is most substantiated: autoantibodies to the basement membrane of the epidermis (usually IgG, less often IgA and other classes) were detected.
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Cerebellar ataxia-telangiectasia
Hereditary zinc-dependent immunodeficiency
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Venous thrombosis of the extremities
There are thrombophlebitis of superficial (mainly varicose) veins and thrombophlebitis of deep veins of the lower extremities. Rarer forms of thrombophlebitis include Paget-Schretter disease (thrombosis of the axillary and subclavian veins), Mondor disease (thrombophlebitis of the saphenous veins of the anterior chest wall), thromboangiitis obliterans (buerger's migrating thrombophlebitis), Budd-Chiari disease (thrombosis of the hepatic veins), etc.
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Eruptive seborrheic keratosis (Leser-Trélat syndrome)
Characterized by the sudden appearance of multiple seborrheic keratosis in combination with malignant neoplasms of internal organs
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Diagnostics
Clinical picture Laboratory research data X-ray examination EGD with biopsy Ultrasound of peripheral and retroperitoneal lymph nodes, liver, pelvic organs, anterior abdominal wall of the umbilical region Laparoscopy Results of morphological studies
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Classification of stomach cancer
By localization. Anatomical areas: Cardiac region; Fundus of the stomach; Body of stomach; Antral and Pyloric department. +total defeat
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Stomach Cancer Clinic
Often asymptomatic Abdominal pain (60%) Weight loss (50%) Nausea and vomiting (40%) Anemia (40%) Palpation of a stomach tumor (30%) Hematemesis and melena (25%)
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Syndrome of “small signs” A.I. Savitsky
Changes in the patient’s well-being General weakness Persistent loss of appetite “Stomach discomfort” Weight loss Anemia Loss of interest in others Mental depression
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Primary diagnosis of stomach cancer
Clinical examination of endoscopy with multiple biopsies Histological / cytological examination of biopsy samples
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Clarifying diagnostics A. Basic complex
Polypositional X-ray examination under double contrast conditions (barium suspension and air) EGD with biopsy from unchanged areas of the gastric mucosa outside the area of intended resection Transabdominal ultrasound examination of the abdominal organs, retroperitoneum, pelvis and cervical-supraclavicular areas. Chest X-ray in 2 projections
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Clarifying diagnostics B. Additional methods
Computer or magnetic resonance imaging Diagnostic laparoscopy Endosonography Fluorescent diagnostics Tumor markers (REA, CA-72-4, CA-125)
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Endosonography allows
visualize 5 layers of the unchanged stomach wall; determine the extent of the lesion, infiltration of individual layers; distinguish between a submucosal tumor of the stomach or esophagus and external pressure; assess the condition of the perigastric lymph nodes; identify invasion into neighboring organs and large vessels; in early gastric cancer, it allows, with a probability of up to 80%, to establish the depth of invasion within the mucous-submucosal layer.
Fig. 1 Normal appearance of the stomach
Fig. 2 Submucosal cancer growth
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Indications for diagnostic laparoscopy:
Clarifying diagnostics
subtotal / total lesion appearance of serosa according to ultrasound/CT data presence of multiple enlarged regional lymph nodes according to ultrasound/CT data initial manifestations of ascites changes in the peritoneum visualized by ultrasound/CT
Contraindications:
complicated gastric cancer requiring urgent intervention (stenosis, bleeding, perforation); pronounced adhesions in the abdominal cavity after previous operations
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Laparoscopic fluorescence diagnostics
L Dissemination along the peritoneum is detected in 63.3%. In 16.7% of patients, dissemination was determined only in fluorescence mode. The sensitivity of the method for gastric cancer is 72.3%, the specificity is 64%, and the overall accuracy of the method is 69%.
MNIOI named after. P.A. Herzen
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Indications for CT/MRI:
significant discrepancy between the results of various examination methods in assessing the extent of the tumor process. Impossibility of assessing resectability according to other research methods; invasion of the pancreas; involvement of large vessels; liver metastases; suspicion of intrathoracic metastasis; planning of combined treatment
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Research of sentinel L/U
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Terminology
JGCA version Early cancer – T1 N any Locally advanced cancer – T2-4 N any Russian version Early cancer – T1 N0 Locally advanced cancer – T1-4, N+ – T4 N0
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Endoscopic classification of early gastric cancer (T1, N any, M0)
Type I – elevated (the height of the tumor is greater than the thickness of the mucous membrane) Type II – superficial IIa – elevated type IIb – flat type IIc – deep Type III – ulcerated (ulcerative defect of the mucous membrane)
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Differential diagnosis
Polyps and other benign tumors, incl. and leiomyomas Ulcers Lymphomas Other sarcomas, including leiomyosarcomas, GISTs Metastatic stomach tumors (melanoma, breast cancer, kidney cancer)
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N – Regional lymph nodes
M – Distant metastases
Distant (M) Regional (N)
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Tumor germination: into the lesser and greater omentum; into the liver and diaphragm; into the pancreas; to the spleen; into the biliary tract; into the transverse colon; into the anterior abdominal wall. Lymphogenic metastasis: to regional lymph nodes; to distant lymph nodes (Virchow’s metastasis, metastasis in the left axillary region), Hematogenous metastasis: to the liver; into the lungs; in the bones; into the brain. Implantation metastases: dissemination, local or total; in the pelvis (metastasis of Krukenberg, Schnitzler).
WAYS OF SPREAD OF STOMACH CANCER
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pTNM Pathological classification
pN0 During histological analysis of regional lymphadenectomy material, at least 15 lymph nodes should be examined
G Histopathological differentiation
Gx The degree of differentiation cannot be established G1 High degree of differentiation G2 Moderate degree of differentiation G3 Low degree of differentiation G4 Undifferentiated tumor
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Treatment of stomach cancer
Surgical interventions Chemotherapy Radiation therapy Combination treatment
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Surgery is the only potentially curable treatment for stages I-IV M0; The optimal extent of regional lymphadenectomy has not yet been established. To date, randomized trials have not demonstrated superiority of D2 over D1 resection, which is likely due to the higher complication rate after splenectomy and pancreatic tail resection (ESMO). D2 resection without spleen removal and pancreatic resection is currently recommended glands. At least 14 (optimally 25) LNs must be removed (ESMO)
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Types of surgical interventions
Radical operations: surgical endoscopic Palliative operations
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Endoscopic resection (ER) of the mucosa for early gastric cancer
Indications: stomach cancer of the structure of papillary or tubular adenocarcinoma; I-IIa-b types of tumor up to 2 cm in size IIc type without ulceration up to 1 cm in size.
Frequency of lymphogenous metastases - 0% Local recurrences - 5% 5-year survival rate -95%
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Surgical treatment of resectable gastric cancer stages I-IV Scope of surgery
Gastrectomy Subtotal distal gastrectomy Subtotal proximal gastrectomy Extirpation of the operated stomach
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Selecting the scope of the operation
Distal subtotal gastrectomy is indicated for tumors of exophytic or mixed growth, located below a conventional line connecting a point located 5 cm below the cardia along the lesser curvature, and the gap between the right and left gastroepiploic arteries along the greater curvature. Proximal subtotal gastrectomy is performed for cancer of the cardia and cardioesophageal junction. For cancer of the upper third of the stomach, it is possible to perform both proximal subtotal resection and gastrectomy. In all other cases, gastrectomy is indicated
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When tumors of exophytic and mixed growth forms spread to the esophagus, a deviation of 5 cm from the palpable edge of the tumor in the proximal direction is acceptable. For tumors of endophytic growth form, the spread of cancer cells in the proximal direction can reach 10-12 cm from the visible edge of the tumor. When the retropericardial segment of the esophagus is involved, it is advisable to perform a subtotal resection of the esophagus. Morphological control of resection edges is mandatory
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Selecting online access
For stomach cancer without involvement of the cardia rosette, a superomedian laparotomy to the body of the sternum and a wide diaphragmotomy according to Savinykh are performed. For tumors affecting the rosette of the cardia or spreading to the esophagus to the level of the diaphragm, the operation is performed through a thoracolaparotomy access in the VI-VII intercostal space on the left. If the tumor spreads above the diaphragm, it is necessary to perform a separate laparotomy and thoracotomy in the V-VI intercostal space on the right.
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Regional lymph nodes of the stomach N1
No. 1 right paracardial No. 2 left paracardial No. 3 along the lesser curvature No. 4 greater curvature No. 5 suprapyloric No. 6 infrapyloric
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Regional lymph nodes of the stomach N2
No. 7 left gastric artery No. 8 common hepatic artery No. 9 celiac trunk No. 10 hilum of the spleen No. 11 splenic artery
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Regional lymph nodes of the stomach N3
No. 12 hepatoduodenal ligament No. 13 behind the head of the pancreas No. 14 superior mesenteric vessels No. 15 - middle colic vessels No. 16 - para-aortic lymph nodes No. 17 anterior surface of the head of the pancreas No. 18 along the lower edge of the pancreas No. 19 subdiaphragmatic lymph nodes No. 20 of the esophageal opening aperture
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Regional lymph nodes of the stomach (para-aortic lymph nodes)
No. 110 lower paraesophageal No. 111 supradiaphragmatic No. 112 posterior mediastinum
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Volumes of lymphadenectomy
No. 1 right paracardial No. 2 left paracardial No. 3 along the lesser curvature No. 4 greater curvature No. 5 suprapyloric No. 6 infrapyloric No. 7 along the left gastric artery No. 8 along the common hepatic artery No. 9 around the celiac trunk No. 10 hilum of the spleen No. 11 along the splenic artery No. 12 hepatoduodenal ligament No. 19 subdiaphragmatic No. 20 esophageal opening of the diaphragm No. 110 lower paraesophageal No. 111 supradiaphragmatic No. 112 lymph nodes of the posterior mediastinum No. 13 behind the head of the pancreas No. 14 along the superior mesenteric vessels No. 15 along the middle colic vessels No. 16 paraaortic No. 17 on anterior surface of the head of the pancreas No. 18 along the lower edge of the pancreas
when moving to the esophagus
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Splenectomy for stomach cancer
Increased number of purulent-septic and infectious complications (subphrenic abscesses, pancreatitis, pleurisy, pneumonia) Immunological disorders Negative impact of splenectomy on long-term results
Consequences:
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Absolute indications for splenectomy
tumor ingrowth into the spleen, tumor ingrowth into the distal pancreas, tumor ingrowth into the splenic artery, metastases into the splenic parenchyma, tumor infiltration of the gastrosplenic ligament in the area of the splenic hilum, inability to control hemostasis if the integrity of the splenic capsule is violated (technical splenectomy)
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Splenectomy is not indicated
localization of the tumor in the lower third of the stomach; localization of the tumor along the anterior wall and lesser curvature of the stomach; depth of invasion T1 – T2
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10-year results of D2 lymph node dissection compared with D1 (Hartgrink et al., 2004)
Parameters* D1 D2 Locoregional relapse 21% 19% Locoregional recurrence 37% 26% + distant metastases Distant metastases 11% 15% *All differences are not statistically significant
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Results of D2/D3 lymph node dissection compared with D1 (D'Angelica et al., 2004)
Parameters* D1 D2/D3 Locoregional relapse 53% 56% Peritoneal metastases 30% 27% 3. Hematogenous metastases 49% 53% *All differences are not statistically significant
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Results of D2/D3 lymph node dissection compared with D1 (Roviello et al., 2003)
Parameters* D1 D2/D3 Locoregional relapse 39% 27% Peritoneal metastases 16% 18% Cumulative risk of development 65% 70% relapse *All differences are not statistically significant
Department of Oncology and Radiation Therapy with a PO course Topic: Stomach cancer Lecture 4 for non-oncology residents studying in the specialty - Oncology for students in the specialty - Oncology Lecturer: Doctor of Medical Sciences, Professor Dykhno Yuri Aleksandrovich Krasnoyarsk, 2012
Lecture outline: Lecture outline: 1. Relevance of the topic 2. Epidemiology of stomach cancer 3. Risk factors for stomach cancer 4. Precancerous diseases of the stomach 5. Classification and clinical picture of stomach cancer 6. Basic methods for diagnosing stomach cancer 7. Treatment methods for stomach cancer 8. Long-term results treatment of stomach cancer 9. Medical and social examination 10. Conclusions
Risk factors for stomach cancer Long-term infection Long-term infection with H. pylori Abuse of alcohol and table salt Reflux of duodenal contents into the stomach (secondary bile acids) Reflux of duodenal contents into the stomach (secondary bile acids) Carcinogens coming from water and food (nitrosamines, polycyclic Carcinogens coming from with water and food (nitrosamines, polycyclic hydrocarbons) hydrocarbons)
Environmental factors Condition of the gastric mucosa Dietary factors H. pylori (+) Smoking (+) Alcohol (+) Impaired absorption of vitamins (+) Table salt (+) Nitrates (+) -carotenes (-) Vitamin C (-) Vitamin E ( -) Se, Zn (-) Table salt (+) Nitrates (+) Vitamin C (-) Table salt (+) -carotenes (-) Normal mucosa Superficial gastritis Atrophic gastritis Metaplasia Dysplasia Cancer Scheme of the pathogenesis of gastric cancer T. Wadstorm, 1995
Classification of gastric polyps and the frequency of their transformation into cancer Group Localization Polyp size % malignancy I Antrum Up to 1 cm 2.9 II Antrum 1-2 cm 9.1 III Antrum More than 2 cm 18 Body of the stomach Regardless of size 40.5 IV Multiple
Syndrome of minor signs of stomach cancer (A.I. Savitsky, 1947) Decreased ability to work, rapid fatigue, weakness Decreased ability to work, rapid fatigue, weakness Mental depression, loss of interest in work and others, apathy, alienation Mental depression, loss of interest in work and others , apathy, alienation Unmotivated decrease in appetite, aversion to food Unmotivated decrease in appetite, aversion to food “Gastric discomfort” - a feeling of fullness, bloating, heaviness, pain “Gastric discomfort” - a feeling of fullness, bloating, heaviness, pain Unreasonable weight loss, pallor Unreasonable weight loss , pallor In patients with peptic ulcer and gastritis - modification and appearance of new symptoms In patients with peptic ulcer and gastritis - modification and appearance of new symptoms - pronounced 70% - insufficient 18% - none 12%
Clinical forms of stomach cancer 1. Gastralgic (painful) 2. Dyspeptic 3. Stenotic 4. Anemic 5. Cardiac 6. Bulemic 7. Enterocolitic 8. Ascitic 9. Hepatic 10. Pulmonary 11. Metastatic 12. Febrile 13. Asymptomatic
Spread of stomach cancer Contact path (tumor cells spread in infiltrative tumors by 6-8 cm, and in exophytic tumors - by 2-3 cm from the visible borders of the tumor) (tumor cells spread in infiltrative tumors by 6-8 cm, and in exophytic tumors - by 2-3 cm from the visible borders of the tumor) Implantation (Schnitzler metastases) Lymphogenous (metastases to the navel, Virchow, Krukenberg, etc.) Hematogenous (more often the liver is affected, less often the lungs, pleura, pancreas, kidneys)
Treatment methods for stomach cancer Surgical - Subtotal gastrectomy - Radical gastrectomy - Gastro-, enterostomy Radiation - Preoperative (40-45 Gy) - Intraoperative (15 Gy) - Postoperative (45-60 Gy, radioactive gold) Chemotherapy - 5-fluorouracil - Ftorafur - Mimomycin C - Adriamycin - UFT, S-1 - Polychemotherapy: FAP, FAM, EAP, EFL, etc. proximal distal
Reasons for late diagnosis of stomach cancer Lack of oncological alertness of general practitioners Lack of oncological alertness of general practitioners The practice of diagnosing chronic gastritis without X-ray and endoscopic examination remains The practice of diagnosing chronic gastritis without X-ray and endoscopic examination remains Low capacity of X-ray rooms Low capacity of X-ray rooms Lack of an extensive network gastric centers Lack of an extensive network of gastric centers
Labor prognosis for stomach cancer Heavy physical labor is contraindicated Heavy physical labor is contraindicated Light work, including administrative and economic Light work, including administrative and economic Dietary meals every 2 - 3 hours Dietary meals every 2 - 3 hours Compliance with sanitary and hygienic regime, additional breaks Compliance with the sanitary and hygienic regime, additional breaks Exemption from business trips, travel around the city Exemption from business trips, travel around the city
MSEC for stomach cancer I disability group: I disability group: - patients with stage IV, - with relapse and distant metastases, - with severe agastric asthenia. - patients with stage IV, - with relapse and distant metastases, - with severe agastric asthenia. Disability group II: Disability group II: - after gastric extirpation and combined operations (upon re-examination after a year, it is possible to assign Group III for life based on an anatomical defect). - after gastric extirpation and combined operations (if re-examined after a year, it is possible to assign group III for life according to the anatomical defect).
MSEC after gastrectomy at stages I – II Sick leave for months Sick leave for months III disability group - for those performing light physical labor III disability group - for those performing light physical labor II disability group - for those performing heavy physical labor II disability group - for those performing heavy physical labor
Literature: Basic 1) Davydov, M. I. Oncology: textbook / M. I. Davydov, Sh. Kh. Gantsev, -M. GEOTAR-Media, Additional 1) Oncology: national guide / ch. ed. V. I. Chissov [etc.]; scientific ed. G. A. Frank [and others]. - M.: GEOTAR-Media,) Oncology / trans. from English A. A. Moiseev; ed. D. Casciato [et al.]. - M.: Praktika,) Oncology: modular workshop: textbook / M. I. Davydov, L. Z. Welscher, B. I. Polyakov [and others]. - M.: GEOTAR-Media,) Cherenkov, V. G. Clinical oncology: textbook / V. G. Cherenkov. - 3rd ed., rev. and additional - M.: Medical book, Electronic resources: 1) IHD KrasSMU 2) MedArt DB 3) Medicine DB 4) Ebsco DB 5) Physician consultant. Oncology [Electronic resource]. - M.: GEOTAR-Media, (CD-ROM) Oncology Oncology: modular workshop Clinical oncology Physician consultant. Oncology
Main clinical symptoms
("small signs" syndrome according to
A.I. Savitsky (1951)
Unmotivated general weakness, loss
appetite up to aversion to certain foods
products (primarily meat), gastric
discomfort, rapid satiety, feeling
fullness of the stomach, not pronounced pain
sensations, causeless progressive weight loss,
anemia, depression, loss of interest in life, work and
to others.
The pain is not permanent, and any
patterns are not sharp and strong, they are dull,
diffuse, unclearly localized.
Main growth forms: exophytic,
endophytic (submucosal growth),
infiltrative-ulcerative.
Mixed forms!
cancer diagnosis
Completed by: Orazbay M.
Group:604-1
Faculty: Surgery Internships
Stomach cancer
Men aged 40-60 years are more often affected
Localized in the antrum (60%), along the lesser curvature and in
cardiac region (10-15%), along the greater curvature and in the fornix
stomach (1%)
Metastases: liver (28%), retroperitoneal lymph nodes (20%), peritoneum
(14%), lungs (7%), bones (2%)
Forms: exophytic, endophytic (scirrhus), mixed
5. Exophytic form
In the initial stage it resembles a polyp, not
growth of a completely regular form (that is, a defect
filling), with moderate rigidity and
lack of modeling ability.
Sometimes it is difficult to distinguish from a polyp (FGS!).
However, if there are several defects and they
located in isolation - then this is a polyp. If
single, with signs of lobulation and especially in
nem depot (that is, ulceration) is a tumor.
Subsequently, as the tumor grows, in which it
the main mass is located in the stomach, appears
marginal or central (on relief) defect
filling, which has lumpy, uneven
contours, with a break in the folds of the mucous membrane at the border with
tumor.
The tumor is rigid, usually small or
painless. If ulcerations are present, there may be
barium depots are irregular in shape, often not deep, then
there are tumors that do not reach the base.
The contours of the stomach in the area where the tumor is located are lost
normal outlines become uneven
jagged, rigid. Gastric lumen
decreases.
If the lesion does not affect the muscle layer, then
peristalsis is maintained. If peristalsis is in the zone
there is no tumor, this will indicate
spread of tumor infiltration to
muscle layer.
3. ETIOLOGY OF STOMACH CANCER
atrophic gastritis
achlorhydria (4-5 times more common)
pernicious anemia (18 times more common)
hypertrophic gastritis
intestinal metaplasia
adenomatous polyps (risk 10-20%)
Stomach surgery increases the risk of developing cancer in
In most cases – 15-20 years after gastrectomy
according to Billroth II.
Stage I - tumor diameter no more than 2 cm, germination only
mucous membrane without visible metastases to the lymphatic
Stage II - tumor diameter 4-5 cm, submucosal invasion
and muscle layers, there may be regional metastases;
Stage III - large tumor size, serous invasion
membranes, neighboring organs; there are distant metastases.
After surgery, the tumor usually
classified according to the TNM system.
For stomach cancer, there are 4 growth forms.
1. Polypoid, exophytically growing cancer - clearly demarcated
a mushroom-shaped tumor growing into the lumen of the stomach. This form is slow
grows, ulcerates late and metastasizes, which, naturally,
provides the best outcome.
2. Saucer-shaped cancer is also an exophytic form in the form of a clearly defined
A flat ulcer surrounded by a high shaft of tumor; gives metastases
‘relatively late.
3. Infiltrative ulcerative cancer, which also has. type of ulcer, but without
clear boundaries with diffuse infiltration of the stomach wall.
4. Infiltrating cancer without visible growth boundaries.
The last two forms are highly malignant, early
germinate the serous cover of the stomach, give metastases and dissemination along
PATHOLOGICAL ANATOMY
LOCALIZATION
MACROSCOPIC FORMS OF TUMOR
Mushroom
(polyposis) cancer
Saucer crayfish
Ulcerative infiltrative cancer
BORMANN classification (1926)
ENDOPHYTIC GROWTH
EXOPHYTIC GROWTH
Types of tumor growth on
I - protruding
II - superficial
III - depressed
MICROSCOPIC FORMS OF CANCER
ADENOCARCINOMA (papillary, tubular,
colloid, signet ring cell)
ADENOKANTOMA (scirrhus, brain cancer)
SQUAMOUS CELL CARCINOMA
UNDIFFERENTIATED CARCINOMA
UNCLASSIFIED CARCINOMA
Stomach cancer
G – histopathological classification
Gx - degree of differentiation
cannot be installed
G1 - high degree of differentiation
G2 - medium degree of differentiation
G3 - low degree of differentiation
G4 - undifferentiated tumors
SPREAD OF STOMACH CANCER
1. DIFFUSE INTRAMURAL GROWTH
2. DISTRIBUTION THROUGH LYMPHATIC
3. HEMATOGENIC METASTASIS
4. ABDOMINAL DISTRIBUTION
CAVITIES (IMPLANT
METASTASES)
DIFFUSE INTRAMURAL GROWTH
DISTRIBUTION THROUGH THE ABDOMINAL
METASTASES)
Krukenberg metastasis
Schnitzler's metastasis
Peritoneal carcinomatosis
Cancerous ascites
CLINICAL PICTURE
Laboratory data
HYPOCHROMIC ANEMIA
OLIGOCYTHEMIA
HYPO- AND DYSPROTEINEMIA
INCREASE IN ESR
DECREASE IN HOLARIC ACID SECRETION AND
INCREASED PROTEIN CONTENT AND
AMINO ACIDS
POSITIVE OCCENT BLOOD TESTS (samples
Gregersen and Deen-Weber)
CLINICAL FORMS
STOMACH CANCER
FEVERY
ANEMIC
ISOLATED CACHECTIC
DYSPeptic (Gastralgic)
JAUNDICE
TETANIC
LATENT
DYSPHAGIC
HEMORRHAGIC
INTESTINAL
METASTATIC
INSTRUMENTAL METHODS
DIAGNOSTICS
FIBROGASTROSCOPY
DIAGNOSTICS
ULTRASONIC SCAN
Metastases in the liver parenchyma
PRIMARY TUMOR
Metastasis
at the gate
(endophytic
DIAGNOSTICS
LAPAROSCOPY
Metastases
in the parenchyma
27. X-ray anatomy of the stomach
The stomach is located in the left hypochondrium, but
can shift over a wide range Cardia
located at the level of the X thoracic vertebra,
pylorus - at level I lumbar
vertebra Upper part of the anteromedial
surface of the stomach borders on the transverse
colon Posteriorly and laterally
the stomach is in contact with the spleen
The superior posterior surface of the stomach is located
on the left kidney Normally the stomach is empty, good
gas bubble visible
Departments: vault,
cardiac,
subcardial,
body, sinus,
antral,
pyloric, small
and greater curvature
Shape: vertical (in the form of a hook) for asthenics, horizontal (in the form of
horns) in hypersthenics
X-ray anatomy of the stomach
The relief of the mucous membrane is formed
folds, interfold spaces and
gastric fields
3-5 longitudinally running folds 0.50.8 cm wide
Folds - clearing, darkening grooves
In the area of the cardia, the folds are random, in
in the antrum they converge
Gastric fields are elevations in the place
exit of the ducts of the gastric glands, in the form
minor filling defects (not (amp)gt; 3 mm),
forming a fine network
14. Cancer of the gastric cardia
1. Filling defect or additional shadow
2. Thickening of the gastric vault.
3. Deformation, reduction or absence of gas bubble
4. Narrowing of the cardiac esophagus and delayed passage
5. “Elongated” abdominal esophagus (maybe unevenness
contours)
6. Wraparound symptom
7. Splashing symptom
8. Malignant restructuring of the mucosal relief (chaotic and
uneven smoothness)
9. Symptom of cardia gape (gastroesophageal reflux)
10. Increase in the angle of His (normally 40 degrees, with a tumor up to 90)
11. Shortening of the lesser curvature
12. Gaping of the cardia in endophytic cancer
16. Pyloric stenosis (according to Tager)
Cancerous stenosis
1. Short history
2. Gastric dilatation
moderate
3. Pyloric canal
symmetrical, elongated
4.Base of the bulb
hangs over the pyloric
5. Relief of the mucous membrane
pyloric canal
absent
6. Both curvatures are smooth or
flat concave or slightly
jagged
Scar-ulcerative narrowing
Long history
Sharp, sometimes huge
sizes
Asymmetrical, not elongated
Often deformed, not
hangs over
Preserved, may be ulcerated. niche
and convergence of folds
One is shortened, the other
may be pocket-shaped
protrusions
Cancerous stenosis
7. Palpable
painless lump
(often cartilage density),
slipping.
8. Full peristalsis
absent in the affected area
8. Pharm samples - antispasmodics,
morphine negative.
9. Acidity is reduced
10.No appetite
Either nothing or abruptly
painful vague
circumscribed seal
Can be traced
Positive
Increased often
Often saved
General signs: filling defect (marginal or central, atypical relief,
wall rigidity (aperistaltic zone), with tumor disintegration - barium depot in
filling defect center
Particular characteristics
– Exophytic forms: symptoms of breakage of folds, flow around, delta
– Endophytic forms: straightening of the lesser curvature, uneven contour, deformation
hourglass stomach, aperistaltic zone
– Total defeat: narrowing of the lumen, symptom of microgastrum
The location of cancerous tumors in the stomach is quite typical. The lesser curvature is most often affected,
the outlet section of the stomach, as well as the subcardial and cardiac sections. Relatively rare
the tumor occurs on the greater curvature and in the fundus of the stomach.
Gastrectomy
Gastric polyposis
CT scan
1. NON-invasive method
2. Metastases of the liver, lungs
3. Metastases of lymph nodes
Sensitivity 65 -97
Specificity 49 – 90
5. Carcinomatosis (amp)gt; 5 mm
(20-30% does not detect)
5. Tumor score (T) 50-70%
Lee IJ, Lee JM, Kim SH 2010
DIAGNOSIS AND STAGING
STOMACH CANCER
CLINICAL SYMPTOMS
ENDOSCOPY
Tumor()
Malignant
tumor ()
Rg study with
Tumor (-)
Endoscopy with fluorescence and
or Rg studies
Malignant
tumor (-)
STOMACH CANCER
Malignant
tumor ()
Abdominal ultrasound or
CT scan
Distant metastases
Radical surgery
Palliative surgery or
conservative treatment
Staging of stomach cancer
(the developed countries)
CARCINOMA
Contrast spiral CT abdomen/pelvis
(if contrast cannot be administered - NMR tomography)
Endoscopic ultrasound (/- IAB)
Laparoscopy (?)
Rg examination of the chest, blood test - assessment
risk of surgery
(the developed countries)
Hematological studies
Endoscopic ultrasound
If only affected
Antibiotics and endoscopy with
fluorescence and ultrasound
— Rg-study
chest
— Contrasting
spiral CT
chest/abdomen/pelvis
- Study
bone marrow
TREATMENT OF STOMACH CANCER
SUBTOTAL RESECTION OF THE STOMACH
GASTRECTOMY
Distal
Proximal
PALLIATIVE OPERATIONS
Bypass
gastroenteroanastomosis
Gastrostomy
CHEMOTHERAPY
FTORAFUR – 30 mg per 1 kg of weight, intravenously,
course dose - 30-50 g.
5-FLUOROURACIL – 15 mg per 1 kg of weight, i.v.
single dose 750-1000 mg, every other day,
course dose – 4000-7000 mg.
Conclusion
Clinical
Patient: Female
Age (years): 48
Complaints of pain in the epigastrium, intensifying after eating, a feeling of heaviness
after meal.
Difficulties in diagnosing infiltrative gastric cancer
Chest organs without visible pathological changes.
The esophagus is freely passable, the function of the cardia is preserved. Gas bubble of the stomach without
additional shadows. The stomach is of normal shape and position, empty on an empty stomach.
The relief of the mucous membrane in the fornix and body of the stomach is not changed. In the antrum and prepyloric regions
longitudinal thickened folds and retraction of the contour of the lesser curvature along the
about 4 cm, with a clear step-like border between retracted and unchanged contours. For the rest
throughout, the contours are clear, even, elasticity, and displacement are not impaired. With double
contrasting, the antrum straightens. Peristalsis can be traced in both
curvatures, initial evacuation is timely. Bulb and loop of duodenum without visible
changes.
Based on radiological data, a tumor cannot be excluded.
submucosal infiltration of the antrum of the stomach.
Conclusion: antral erosive gastritis with
multiple complete erosions,
superficial slit-like ulcer of the antrum of the stomach.
17. The tasks of a radiologist in diagnosing stomach cancer
1. Find out whether there are signs of a tumor lesion or not
2. Determine the main character of growth
3. Set internal boundaries, that is, prevalence
tumors inside the stomach (peristalsis, elasticity
walls, overhang)
4. Determine spread beyond the stomach
(mobility, distance of stomach to spine)
5. Identify the presence of local complications (stenoses, perforation)
6. Identify possible additional examinations and
Prepared by Anastasia Pravko, a student of grade 11 “B”
Slide 2: STOMACH CANCER
Gastric cancer is a malignant tumor originating from the epithelium of the gastric mucosa. It is one of the most common oncological diseases. It can develop in any part of the stomach and spread to other organs, especially the esophagus, lungs and liver. Stomach cancer kills up to 800,000 people worldwide every year. This disease has a high mortality rate (more than 700,000 per year), which makes it second in the structure of cancer mortality after lung cancer. Stomach cancer occurs more often in men
Slide 3
According to incidence statistics, stomach cancer ranks first in many countries, in particular in the Scandinavian countries, Japan, Ukraine, Russia and other CIS countries. At the same time, in the USA, France, England, Spain, and Israel over the past twenty years there has been a decrease in the incidence of stomach cancer. Many experts believe that this happened due to improved food storage conditions with the widespread use of refrigeration units, which reduced the need for preservatives. In these countries, the consumption of salt, salted and smoked foods has decreased, and the consumption of dairy products, organic, fresh vegetables and fruits has increased. The high incidence of stomach cancer in the above countries, with the exception of Japan, according to many scientists, is due to the consumption of foods containing nitrites. Nitrosamines are formed from nitrites by conversion in the stomach. Currently, stomach cancer has begun to be detected more often at a young age, in the age groups of 40-50 years. The largest group of gastric cancers are adenocarcinomas and undifferentiated cancers. Cancers usually arise against the background of chronic inflammatory diseases of the stomach. It has now been proven that in a completely healthy stomach, cancer practically does not occur. It is preceded by a precancerous condition. Most often this happens with chronic gastritis with low acidity, ulcers and polyps in the stomach. On average, it takes 10 to 20 years from precancer to cancer.
Slide 4: Structure of the stomach
Slide 5: Precancerous conditions
chronic atrophic gastritis, chronic gastric ulcer, adenomatous polyps, intestinal metaplasia of the gastric mucosa, severe dysplasia of the gastric mucosa, Menetrier's disease (proliferation of the mucous membrane). anemia caused by vitamin B12 deficiency.
Slide 6: Precancerous conditions
Slide 7: First signs of stomach cancer
Firstly, stomach cancer has symptoms common to cancer. Chronic fatigue. Fast fatiguability. Unexplained weight loss.
Slide 8: Small signs of stomach cancer
Secondly, the presence of early stomach cancer can be signaled by a complex of symptoms, or the so-called minor sign syndrome. Discomfort in the stomach after eating: bloating, feeling of fullness. Frequent nausea, vomiting, mild drooling. Pain in the epigastrium: aching, pulling, dull. May occur periodically, often appearing after eating. Loss of appetite unmotivated by other factors. Frequent heartburn, difficulty swallowing food and liquids (if the tumor occurs in the upper part of the stomach). Vomiting of stagnant contents (eaten a day or two ago); vomiting “coffee grounds” or with blood, black loose stools are signs of bleeding in the stomach, requiring an urgent call for an ambulance.
Slide 9: Symptoms of stomach cancer largely depend on the location of the tumor
In case of cancer of the cardiac region (the initial part of the stomach), the symptoms of dysphagia (salivation, difficulty passing rough food) come first. Dysphagia increases as the disease progresses and the lumen of the esophagus narrows. Against this background, regurgitation of food, dull pain or a feeling of pressure behind the sternum, in the heart area or in the interscapular space appear. The cause of these symptoms may be stagnation of food in the esophagus, its expansion. When cancer is localized in the antrum (the final part of the stomach), a feeling of heaviness in the upper abdomen, vomiting of food eaten the day before, and an unpleasant rotten smell of vomit appear relatively early. In case of cancer of the body of the stomach (middle part of the stomach), even with a significant tumor size, local symptoms of the disease are absent for a long time, general symptoms predominate - weakness, anemia, weight loss, etc.
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Slide 10
3. Painful form of stomach cancer. Often there is pain in the upper abdomen, which can radiate to the lower back and be associated with eating. The pain often continues for a long period of time, sometimes all day, and may intensify with movement. With stomach cancer, pain is not natural. They do not subside after eating; there are no “hunger” pains or their seasonality. In some cases, with common forms of stomach cancer, the pain can be quite intense. When the tumor grows into the pancreas or even deeper, patients may complain of back pain. Such patients are usually treated for radiculitis and neuralgia.
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Slide 11: Stages of stomach cancer
The detection rate of cancer from one stage to another increases, and at the same time the patient’s life expectancy and the likelihood of cure decreases. Four stages of disease progression can be identified: Stage zero: Only the gastric mucosa is affected. Treatment of cancer in this case is possible without performing a strip operation, using endoscopic techniques and using anesthesia. In this case, treatment of stomach cancer has the most favorable prognosis - 90% of cases of recovery.
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Slide 12: Stage 1
The tumor penetrates deeper into the mucous membrane and also creates metastases in the lymph nodes around the stomach. The survival rate for cancer treatment at this stage is 60-80%, but such cancer is detected extremely rarely. Stage 2 The tumor does not affect only the muscle tissue of the stomach; there are metastases in the lymph nodes. The five-year survival rate when the disease is diagnosed at stage 2 is 56%.
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Slide 13: Stage 3
The cancer penetrates entirely into the walls of the stomach, and the lymph nodes are affected. Stage 3 gastric cancer is detected quite often (1 case out of seven), but the five-year survival rate in this case is 15–38%. Stage 4 The cancerous tumor penetrates not only the stomach, but also metastasizes to other organs: the pancreas, large vessels, peritoneum, liver, ovaries and even to the lungs. Cancer in this form is diagnosed in 80% of patients. Only in 5% of cases does the doctor’s prognosis for the patient’s life expectancy exceed 5 years.
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Slide 14: Stomach cancer and diagnosis
The main study for gastric cancer is considered to be FGDS, which makes it possible to conduct a detailed examination of the mucous membrane of the esophagus, duodenum and stomach, and detect a tumor and determine its boundaries. X-ray of the stomach is effective for infiltrative forms of cancer. Allows you to assess the functional capabilities of the organ, makes it possible to suspect stomach cancer or a relapse of the tumor. This diagnostic method is necessary for further effective treatment of stomach cancer. Endoscopic ultrasonography allows you to accurately study the condition of all layers of the stomach and in 80-90% of cases accurately determine the depth of the tumor. The direction of magnifying endoscopy occupies one of the leading places in the clarifying diagnosis of gastric pathology, as it allows one to identify minimal violations of the typical architectonics of the mucous membrane and distinguish between areas of intestinal metaplasia and dysplasia or the presence of neoplastic changes. Improvement of endoscopic examination is moving towards the introduction of narrow-spectrum (NBI) endoscopy. These are high-tech methods that make it possible to diagnose stomach cancer at earlier stages, and also help identify tumor foci against the background of chronic diseases. stomach diseases.
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Slide 15: Stomach cancer and diagnosis
Optical coherence tomography - designed to determine the depth of invasion into the wall of the stomach, esophagus or other hollow organ. This new generation equipment makes it possible to determine in detail the thickness of the affected tissue and, possibly, to recognize tumor growth into the submucosal and muscular layers of the stomach. Under the control of optical coherence tomography, tissue from the lymph nodes of the nearby area is collected. Diagnostic laparoscopy is a surgical procedure that is performed under intravenous anesthesia by inserting a camera into the abdominal wall to examine the abdominal organs. Such a study is used in unclear cases, to detect tumor growth into surrounding organs, metastases in the peritoneum, and to take a biopsy. This method is sometimes necessary for further effective treatment of stomach cancer. Stomach cancer and blood testing for tumor markers - proteins that are produced by the tumor and are absent in a healthy body. CEA, Ca 19.9 and Ca 72.4 are used to detect cancer. However, they all have low diagnostic value. They have found their use in patients to detect metastasis.
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Slide 16: Treatment of stomach cancer
Treatment for cancer is different from treatment for other organs. If for carcinomas in other organs surgery is performed only when conventional therapy is powerless, then for stomach cancer it is the opposite. Only surgical intervention can save the patient. This is explained by the fact that the signs of cancer are unstable and may not appear for months; as a result, the patient arrives at the moment when the phase of stenosis and metastasis has begun.
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Slide 17: Treatment methods
Chemotherapy, despite its capabilities, rarely helps stop the development of metastases and destroy cancer cells in adjacent organs. Radiation therapy, which is carried out for most cancers, is not carried out in cases of the stomach. Drug treatment will no longer bring any results, so the only option left is surgery. If the carcinoma is small in size, then a resection of the stomach is performed, removing most of it. But in many cases, the stomach has to be completely removed, and all affected lymph nodes are also removed. During the operation, the esophagus is sutured directly to the intestine.
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Slide 18: Relapse
Even complete cure of stomach cancer does not always have a positive prognosis: there are frequent cases of relapses, which cannot always be eliminated by repeated operations.
19
Last presentation slide: STOMACH CANCER: Rules for preventing stomach cancer:
Detection of precancerous conditions and regular medical examination. Diet. Reduce consumption of fatty, salty, smoked and fried foods, hot and spicy foods, do not abuse alcohol, avoid preservatives and dyes. Be more attentive to the vegetables you eat; they can potentially contain large amounts of nitrates, nitrites, and carcinogens. Observe moderation in the use of medications (especially analgesics, antibiotics, corticoids). Reduce the negative impact of the environment and harmful chemical compounds. Eat more fresh foods rich in vitamins and microelements, as well as dairy products. Maintain a normal diet, avoiding too long breaks between meals and overeating. No smoking.
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