Epidemiology of Stomach Cancer


With more than a million new cases of stomach cancer worldwide each year, the second leading cause of cancer deaths. Since 1940, the decreasing incidence of stomach cancer in Western countries, despite the South and Central America, the Far Eastern countries still remain highly stable.

Stomach cancer incidence in various regions of the world are different, for example, Japan, Chile and Iceland, are extremely high. Most northerners stomach cancer in the United States, the incidence of the poor, and approximately 8/100.000 is seen in blacks' and dropped to seventh in terms of frequency of cancer-related causes of death. However, the incidence has fallen in Japan, though, is still the most common malignancy. The incidence increases with age, patients> 50 years of age is above 75%.

1.4-1.7 times more common in men than women (14). More than 2 times the incidence in men after age 50, while the younger age group, male / female ratio is equal to

Men in terms of gastric cardia tumors than women are affected more than 5-fold (17). In general, the incidence rates of stomach cancer in countries with higher life expectancy than countries with low incidence rates are quite good

Stomach cancer is the first of gastrointestinal cancers in Turkey. According to the Ministry of Health of stomach cancer in men around Erzurum and Van, the first place, takes second place in women (4). However, in Turkey immediately after the bronchial cancers are the most common type of cancer (14). The incidence of stomach cancer, the most common east of Turkey, the lowest seen in the west. This incidence of 9.6 vaka/100.000 men, women are the 5.7/100.000


etiology have been kept in charge of many reasons why the majority of patients with identifiable significant risk factor identified. Feature is a multifactorial disease with environmental and genetic factors. Epidemiological data revealed that different aetiological factors for proximal and distal cancers. Gastroesophageal reflux in the etiology of cardia cancer in the foreground, while the non-cardia cancers as mentioned above, many more factors (diet, environmental, genetic predisposition, etc.) are a result of the interaction.

Diet: Gastric cancer and diet has been known all along that the relationship between the direct and important. Extremely hot food, preserved, smoked, canned and salted food consumption, water contamination with nitrates, Helicobacter pylori infection, less consumption of fresh fruit and vegetables are common in high-risk areas. Formed by intestinal metaplasia in the stomach, causing stomach cancer shown to prevent uptake of foodstuffs that contain nitrates and nitrites from food, especially high-risk areas can be a preventative measure. People who eat plenty of fruit and vegetables decreased rate of cancer development. The high rate of stomach cancer have been reported to consume less

The rising incidence of obesity in the United States junction, and stomach cancers of the proximal region has contributed to the increase in the frequency. High body mass index, gastroesophageal reflux disease, and increased calorie consumption was associated with the distal esophagus and gastric cardia

b) Helicobacter pylori (Hp) infection: adenocarcinoma of the stomach corpus and antrum of Hp has a strong relationship between chronic infection.

Hair Care Information

Home Hair Care, Hair and Skin Care, Natural Hair Care
According to the anatomical structure of normal skin, scalp, less porous and has more oil glands. At the bottom of each hair has a sebaceous gland duct. For this reason, the scalp lubricated and gets dirty very quickly.

The scalp, is also in direct contact with the dust and particles out of the dirty easily. Sweat in the sun too. Change is faster than the epidermis of the scalp. Settlement and growth of the body as well as other skin infections, parasites, head lice, and a suitable environment for the formation of fungal diseases.

Home-made hair care, soap, or a well-chosen head washed with shampoo rinse with plenty of water, enough for hair removal. Hair care is a clean brush and comb. Dirty brush and comb belonging to others and infection tool. Brushing your hair in the direction of the hair, scalp, improve blood circulation. Bottom of the well-fed so that the hair shed blood. Therefore the health of the skin by hand to massage the scalp, hair health is very important. Scalp, flexible, normal-fat, soft-as long as your hair's health is protected.

Adequate and balanced nutrition, hygiene, protection of the head from external influences, and direct sun rays, hair is extremely important in terms of health. Hair care methods, depending on these factors will impact.

Hair Care

Hair care, the psychological effect on the patient makes the hairs stand on a regular basis. Messy, tangled hair can cause patients despair. Because hair is very important in terms of aesthetic appearance of the face and head.

Daily hair care the patient relaxes. Minimizes the adverse effects of the disease. Hair is an important element to looking good.

Hair care with the necessary equipments for the following:

Women's and men's and for the comb, hair brush.

Hair care is made ​​for the following applications.

The patient is taken to one edge of the bed. The patient is laid on the towel. Hair combed. If necessary, connect.

Screening in women, after the split of the hair to the forehead in the middle of the head start.

Scan, a hand-held hair in bunches, and matted hair before. Lubricated. Waited for 24 hours and scanned. Washed after being shot.

Risk Factors of Gastric Cancer

Environmental Factors


Increased consumption of salt

High nitrate consumption

Diet low in vitamin A and C

Ill-prepared foods (smoked, salted)

Extremely hot food

Unhealthy drinking water


Rubber workers in coal mine workers


Helicobacter pylori infection

Epstein-Barr virus infection

Radiation exposure

Passed before the operation for stomach ulcers, stomach

Genetic Factors of Gastric Cancer

A blood group

Pernicious anemia

Family history

Hereditary colon cancer

Li-Fraumeni syndrome

Precursor lesions

Adenomatous polyps of the stomach

Chronic atrophic gastritis


Intestinal metaplasia

Menetrier Disease

The 2-6 fold increased risk of stomach cancer in some studies have reported that Hp infection. Increase in the incidence of gastric cancer with Hp infection mechanism is not fully understood. However, the incidence of Hp infection, atrophic gastritis and chronic low-acidic environment which also seems to increase the incidence of metaplasia and dysplasia. Research has over 10 years of Hp infection in gastric cancer was seen in 5% of people reported positive.

c) Postgastrectomy: the rest of the stomach mucosa after partial gastrectomy and atrophic gastritis develops rapidly in areas close to the stoma with intestinal metaplasia, and was found to be more frequent.

d) Pernicious anemia: Pernicious anemia in people of increased frequency of carcinoma, atrophic gastritis and intestinal metaplasia are frequent in the corpus and fundus is connected. Studies in 2% of gastric carcinoma patients were found to be pernicious anemininde

e) Gender: Stomach cancer in males than in females in almost all countries are 1.2-2.5 times higher. The rate of intestinal type 2 / 1, while the diffuse type is equal to the ratio of male to female. Male dominance is high or low incidence of gastric cancer has been observed in all countries.

f) Menetrier disease (hyperplastic gastropathy): Menetrier disease, epithelial hyperplasia, depending on the stomach surface and gastric foveola pililerinin giant looks to gain, excessive mucus secretion, and hypochlorhydria is characterized by hypoalbuminemia developing gastropathy.

I) intestinal metaplasia: the frequency of intestinal metaplasia, gastric carcinoma, such as the frequency increases in direct proportion with age. This type of change, according to type of diffuse intestinal type carcinomas are more frequent and widespread. Classifications of intestinal metaplasia metaplastic epithelium usually is made ​​according to the type of mucin produced by cells in cell morphology and complete (type I) and incomplete (type II) is divided into two main groups. Type II, type IIa and type IIb are divided into two sub-groups. Type IIa cells secrete mucin. Type IIb is a more differentiated cells, and secrete mainly sulfomusin. Most of this type IIb metaplasia was observed to be associated with cancer.

h) adenoma polyps of the stomach: stomach adenomas in other epithelial polyps (non-neoplastic) are rare compared to. Two centimeters higher than the frequency of large-scale adenomas and carcinomas. Precursor lesions for adenomas and carcinomas, as well as can be seen frequently in conjunction with stomach carcinoma. For this reason, the stomach removed, and the accompanying adenoma detected whether a lesion should be investigated further.

I) Gastric epithelial dysplasia: a precancerous condition of gastric dysplasia (35). Depending on the structure distortion and low-grade and high grade nuclear atypical divided into two. Tubular structures is limited to changes in dysplasia, invasive cancer called basal membrane is exceeded. Low-grade dysplasia, 15% of high-grade dysplasia progresses 0-. For this reason, low-grade dysplasia, repeated biopsies should be followed. High grade dysplasia is much more serious condition, 0-15% back, 14-and 58% will continue in the same way, 25-80% of the cancer becomes invasive. Polyps, or ulcers associated with high-grade dysplasia is likely to invasive cancer at diagnosis. Endoscopic treatment of high grade dysplasia resection or gastrectomy

I) p53 and genetic factors: studies in the early diagnosis of stomach cancer in the stomach lesions and carcinomas, p53 gene mutations in a high degree of atypia was reported high rates encountered. Accumulation of this protein, low-grade carcinomas 43%, 68% of those with high-grade shown. Moreover, p53 mutation has also been used to determine the patient's prognosis at the same time. P53 mutation has been reported that a high proportion of poor prognosis cancers detected. In other words, both the detection of p53 and prognosis in early gastric cancer as a marker in determining the best

Oncogenes, tumor suppressor effect of mutations in the genes, the E-cadherin, 4, 5q, 9p, 18q, and 20q, and tumor suppressor genes on chromosomes, chromosomes, such as loss of heterozygosity (LOH) and the formation of DNA replication errors (especially the simple repetitive sequences), as mentioned above, p53 mutation, somatic mutation of p16, APC (adenomatosis polyposis coli), EGF, TGF, c-erb-B2 overexpression of growth factors such as the stomach is thought to be the roles STUDIES.

Diagnosed with stomach cancer

Clinical Course of Gastric Cancer

Early gastric cancer is usually asymptomatic, advanced carcinomas can be asymptomatic, but often because of abdominal discomfort or weight loss is revealed. Infrequently they are localized in the cardia neoplasms, dysphagia, or obstructive symptoms may lead them as they occur in the pyloric canal. 10% of patients with one or two may show evidence of metastatic disease. The most common signs of distant metastases palpable supraclavicular lymph node (Virchow node), rectal examination revealed a palpable mass (Blumer shelf), ascites, or liver mass. Hematogenous spread most commonly in liver.

Stomach Cancer Diagnosis

Physical examination, cachexia, abdominal distention, hepatomegaly and lymphadenopathy in the sense of liver metastasis. Upper gastrointestinal series, and gastroesophageal junction (GE) GE junction cancer, stricture, filling defects along the gastric wall due to tumor shrinkage may or linitis plastica. diagnosis is essential. Endoscopic ultrasound is helpful to determine the depth of invasion. Identifying metastatic disease, thoracic-abdominal CT is important. CT imaging in determining depth of invasion and nodal involvement, 40-60% correct. Bone scintigraphy is used for patients showing symptoms. PET imaging is very helpful especially in determining occult metastatic disease. Very small, secret sets of peritoneal or hepatic metastases. Tumor markers including CEA and CA 19-9 patients follow-up is beneficial, but often does not rise.

Surgical Treatment of Gastric Cancer

The main treatment is surgical resection of early stage non-metastatic gastric cancer. However, the optimal size of nodal resection, D2, D1 dissection procedure, indicating not improve survival compared with randomized trials are currently under discussion due. Complete resection of the tumor and the surrounding nodes, the only chance for cure, though, much of the United States, 90% of patients with gastric cancer at diagnosis, advanced stage. To use the type of surgical procedure, tumor size, and layout sets (42). Effective for pathologic staging of regional lymph node removal of at least 15 the desired number. One of the most important aspects of surgery is to obtain a negative surgical margin. Only the mucosa and submucosa, defined as carcinoma limited to the high cure rate of early gastric cancer, lymph node metastases may occur in 15% despite 10-D1, and D2 lymphadenectomy with gastrectomy in Japan is still seen as the best treatment to be selected. However, only the selection of patients to endoscopic mucosal resection, tumor size, differentiation, and defined criteria, such as the depth of submucosal invasion. Stage IV patients, surgery, palliation, and passage only applied to problems

Tumors Proximal: Proximal tumors are responsible for 50% of all gastric cancers. This advanced stage tumors are caught and distal cancers have a worse long-term prognosis. There are three types of tumor of the gastroesophageal junction according to Siewert classification: Type I Barrett's esophagus or gastroesophageal junction with the right growing real-esophageal cancer, type II cancers, the squamocolumnar junction, and type III tumors of 2 cm on the actual junction of the stomach cancers are located in the region. Type II and III cancers, the most appropriate surgical treatment remains controversial. Options proximal subtotal gastrectomy and total gastrectomy. Cardia due to the advanced stage at diagnosis, total gastrectomy, some authors, especially to prolong the prognosis in patients with stage II and IV discuss the implementation of the most simple proximal subtotal gastrectomy. However, in some studies, proximal subtotal gastrectomy, total gastrectomy shows that there is lower than the quality of life. MD Anderson proximal gastric lesions and regional lymphadenectomy, total gastrectomy with Roux-NY applied. Total gastrectomy and proximal gastrectomy in the prevention of reflux, and often held easy removal of the lymph nodes around the lesser curvature is provided, according to the proximal gastrectomy in more morbidity and mortality has been observed.

Medium body and distal tumors: tumors of the stomach in the middle of 15-stomach cancer makes up 30%. Regional lymphadenectomy and total gastrectomy with proximal tumors, the approach is recommended for similar reasons. Responsible for approximately 35% of tumors of the distal stomach tumors. These lesions distal subtotal gastrectomy with lymphadenectomy is the standard appropriate. This is because the rule of survival of total gastrectomy and subtotal gastrectomy and subtotal gastrectomy Patients recovering from a better quality of life and is not showing. Also, if possible, surgical resection margin is recommended 5-6 cm

What is stomach cancer, and neoadjuvant treatment

The role of neoadjuvant chemotherapy treatment, most research today is one of the areas. The main advantages of neoadjuvant therapy, around the time of surgery less tumor cell scattering and one measure of the sensitivity of the tumor with chemotherapy. The disadvantage is that treatment of early-stage tumors, too.

Cunningham et al. the British MAGIC (U.S. Medical Research Council Adjuvant Gastric Infusional Chemotherapy) work, setting new standards for has been an approach (51). Can be operated on stomach cancer patients, 3 cycles of chemotherapy treatment (ECF: epirubicin, cisplatin, 5-FU) followed by the initiation and post-operative patient to be operated in three cycles (ECF) chemotherapy, giving more than 23% to 36% overall survival and 5 yılllık rising (CI: 0.60-0.93, p = 0.009), and a better progression-free survival is obtained (CI: 0.53-0.81, p <0.001). In this study, which could affect operating results include the distal esophageal cancer patients, as well as endoscopic ultrasonography and staging criticized because of the lack of staging was suboptimal.

What is the Treatment of Metastatic Disease

Many patients with gastric cancer (20% - 30%) stage IV disease is supposed to be localized to appeal to the patients before and even after a complete staging, determined that an additional% 28-37 metastatic. Five-year survival for patients with Stage IV is close to zero. Thus, newly diagnosed, many patients have lost the chance of cure (39). Chemotherapy in advanced gastric cancer compared with the best support care, improving the quality of life and prolong survival (42). Maintenance-free survival in metastatic disease, often the best support for 3-6 months, 9-11 months with chemotherapy can be extended. For this reason, the idea of implementation of the standard chemotherapy.

Stomach cancer, many chemotherapeutic agents used. 5-FU'dur cornerstone of chemotherapy in gastric cancer. Single-agent response rates of about% 20 -% in the 30s. Major side effects, mucositis, diarrhea, hand foot syndrome, myelosuppression, and is used as a continuous infusion. Other active single agents for the treatment of gastric cancer mitomycin C, anthracyclines (doxorubicin, epirubicin), cisplatin and etoposittir. Response rates vary between 6-30% of these agents.

Palliative chemotherapies, today both progression-free survival and overall survival in patients with gastric cancer was significantly prolonged in duration. FAM than in previous years, using diagrams, such as FAMTX, in recent years, cisplatin, epirubicin, 5-FU'dan of the ECF scheme or docetaxel, cisplatin, 5-FU'dan diagram of the DCF is used (43). ECF is one of the most active and best tolerated regimens, although that increase the activity of docetaxel is markedly more toxic than 5FU/cisplatin

In 1997, Webb et al. ECF (n = 126) with the FAMTX (n = 130) were randomized to regimens (55). FAMTX better survival rates compared with the ECF (21% and 45% respectively, p = 0.0002), higher median survival (5.7 months, 8.9 months, respectively, p = 0.0009) and mean duration of disease-free survival (3.4 months, 7.4 months, respectively, , p = 0.00006) was obtained. DCF with CF (cisplatin, 5FU) v325 phase III study comparing treatment, time to progesyona (5.6 months - 3.7 months, p <0.001, 32% risk reduction), the best response rate (37% - 25% p = 0.01) and median survival (9.2 months - 8.6 months p = 0.02) were better in favor of the DCF (41.56). However, the addition of docetaxel CF'ye especially hematologic: grade 3 / 4 neutropenia and febrile neutropenic led to an increase in toxicity. Clinical benefit in patients with metastatic gastric cancer study with V325 (57) and a better quality of life (QoL) were obtained

REAL-2 study instead of the 5-FU and cisplatin capecitabine'in oxaliplatinin substituting instead demonstrated the effectiveness does not decline (59). Phase I-II trials, irinotecan is used alone or in combination cisplatinle. Acceptable toxicity, response rates were respectively 23% and 41% have been reported. S-1, tegafur (5-FU pro-drug), potassium (gastrointestinal toxicity blocker) and 5-chloro-2.4 (5-FU degradation inhibitor) is a derivative of a new oral floroprimidin. Phase II study, 53.6% 'health, a retrospective study showed a response rate of 32%. Cetuximab, panitumumab, bevacizumab and in combination with chemotherapy in clinical trials, although the use of experimental investigation

Rectum Diseases

Diseases of the rectum

Inflammatory Bowel Disease

Ulcerative colitis

After nearly 10 years of disease onset of colorectal cancer risk is increased gradually. Held for the length of the segment, is proportional to the risk of cancer (32). More poorly differentiated colorectal cancer causes. Higher rate than other cancers.

Crohn's Disease

Ulcerative colitis is less than the risk of developing cancer. However, the incidence of cancer 4-20 times greater than the normal population. Cancer is often inflamed, and fistula segment occurs. Delay in diagnosis are common and the mortality rate was reported to be approximately 80%.

Premalignant lesions

Tubular adenomas, villous adenomas, adenomas premalignant lesions. There are 4 main factors to determine the potential of adenomas of malignancy:

1. Size: 5-6 mm diameter of 1-2 cm in the absence of almost-almost no risk of 5%, There is a 10% risk over 2 cm.

2. Neck; sessile polyps malignancy role % 50 more, risk of polyps to transform into carcinoma is around 10%.

3. Villous structures; villous component increases, increases the potential for malignancy.

4. Dysplasia, dysplasia increases, the risk increases.

Rectum Cancer Diagnosis and Testing

Bleeding is the most common clinical manifestation of cancer of the rectum. Covering the surface of bleeding is usually dark-colored stool and blood is mixed. Rarely, may be in the form of fresh blood, and therefore confused with hemorrhoids. Tenesmus and defecation do a full sense of distal rectal cancer is localized. May be changes in defecation habits. Mucoid diarrhea, villous adenoma into cancer can be monitored. Other findings of the rectal ampulla to be large because of the obstruction is found in cancers of the colon is rare. Severe anal pain, anal canal may be indicative of invasion. Rectal cancers, the findings may not be part of the advanced stage.

Clinical examination with digital rectal examination begins. 8-10 cm of the distal portion of the rectum palpable touch it. Proximal tumors. Rectal cancer is accessible to all rigid. Colonoscopy tumor location, macroscopic appearance of size, distance from the anal and biopsy can be evaluated. Synchronous colorectal cancers by 6% due to the risk of cancer of the colon by colonoscopy all need to be examined. Virtual colonography can be made ​​for the examination of the colon tumors that do not allow relaying.

What is the rectum

Anatomy of the rectum

12-15 cm in length, starting at the line of the inferior of the rectum drop out through the anus, the last part of the gastrointestinal tract. Anatomically; 1 / 3 upper, 1 / 3 medium and 1 / 3 sub-divided into sections including. In practice, each segment is assumed to be approximately 5 cm. The bottom part of the expanded form ampulla. Rectum, is the frontal and sagittal plane curves. Initially called flexure and on the way down following the curvature of the inner does.

Diaphragm through the pelvis forward continues. Anorectal junction of the intestine that is called external flexure. In addition to these, the rectum, leading to the right, middle left and bottom right again, three more shows curvature. The lower end of the anal canal, rectal muscular layer forms on the muscle. Unlike other segments of the colon rectum; Appendices, mesenteric. Rectum upper 2 / 3 of the peritoneum is covered by part of. Front and side portions of the upper sections, sub-section, only the front side is covered with peritonla. Peritoneal last section, bypassing the excavation men, women, by jumping the back wall of the vagina creates excavation. Expanded, the more evident the rectum, plica has called transverse folds.

Neighborhoods of the rectum

Posterior of the rectum 3, 4 and 5 sacral vertebrae, coccyx, the superior rectal artery and vein, priformis muscle, the sacral plexus, and levator ani muscles shows with the neighborhood.

Women, the rectum anteriorly, the peritoneum on the uterine folds, the upper part of vagina; excavation rectouterine and this segment is adjacent to the folds of the ileum. Under the peritoneal folds of the lower portion of the vagina makes the neighborhood. In men, the rectum anteriorly, and fundus of the bladder vesica seminal, ductus deferens, prostate, and is adjacent to the parts of the terminal ureters.

Vascular structure of the rectum

Rectum Arteries

1 - Superior rectal (hemorrhoidal) artery: branch of internal iliac arteries and nourish the rectum.

2 - Medial rectal (hemorrhoidal) artery: the internal iliac artery is a branch of the middle portion of the rectum, nourishes the skin.

3 - İnferioral rectal (hemorrhoidal) artery: the internal pudendal artery is a branch of the rectum inferiorunu feeds. In addition, the branches of the internal pudantalis artery nourishes the anus. Arteries anastomoses do with each other.

Venous circulation

1. Superior rectal vein, the inferior mesenteric vein is poured.

2. Medial rectal vein, internal iliac vein is poured.
3. Inferior rectal vein flows into the internal pudendal vein. The inferior mesenteric vein, portal vein, internal iliac vein, inferior vena cava is poured. These veins each other made, anastomoses As a result rectum around portokaval anastomaz occur.

Lymphatic drainage of the rectum

Lymph vessels in the upper part of the rectal area extends along the superior rectal arteries. Pararectal lymph nodes and lymph nodes in the lower part of the sigmoid Mesocolon rises through the inferior mesenteric lymph nodes. The anal canal and rectum 1 / 3 lower part of the internal iliac lymph nodes draining.

Innervation of the rectum

And the inferior mesenteric plexus and pelvic sympathetic fibers, parasympathetic fibers 2-4. sacral nerves in your income. Rectal nerves, inferior-superior rectal arteries by following these make.

Histology of the rectum

There are four functional layer of the rectum.

1. Mucosa, the epithelium, the supporting components of the lamina propria and the mucosa consists of a thin musklaris. Plica in the mucosa of the rectum, and villi are not tracked. Enterocytes, goblet cells and rich. Plasma cells and lymphocytes in the lamina propria of the submucosa is extending.

2. Submucosa, mucosa and supports the collagen occurs. Lymphatics, nerves, and contains vascular elements. Parasympathetic ganglia, muscularis mucosa, mucosal glands, and sends branches. This is called the submucosal plexus Meissner plexusua.

3. Muscularis propria, the inner circular layer and outer layer in the form of langutudinal ordered structures composed of smooth muscle. Auerbeach plexus is located between these two layers, called the parasympathetic ganglion.

4. Serosa: the outer layer. Major blood vessels and nerves wraps. The top part of the peritonla, the lower part of the mesothelium (simple squamous epithelium) surrounded.

Line and valve connected to the base with the base of the anal canal are 8-10 small. These valves, posterior anal sinus (crypt) is called the mucous glands listed our small pockets. Mezotelle line paved the anal canal. The thickness of the inner circular layer of the anus at the level of the internal anal sphincter generates muskuların propria. Sphincter muscle layer of connective tissue lying on the right Longutudinal sticks. Creates the main external sphincter and levator ani muscles into the correct line extends.

Physiology of the rectum;

Defecation reflex, rectal faeces from request defecation creates his head. 2 In this sense and 3 visceral afferent fibers reach the sacral segments. Works of local reflex arcs. Reaches the brain, consisting of rectal tension. Peristalsis and relaxes the sphincter muscle is generated by the sudden erigentesler Nerve. Pudendalis inhibits nerve somatic motor neurons. Muskulus externus moment to relax. Externus muscle contraction as a conscious means of corticospinal process can be stopped suddenly.

What is cancer of rectum


Colorectal cancer is the most common cancers of the gastrointestinal tract malignancies and 2 takes place. Colorectal cancer incidence increases steadily after age 50 and reaches the highest level between the ages of 60-70. Approximately 20% occur before the age of 50. Young patients with ulcerative colitis or familial polyposis syndromes in the presence of colorectal cancer should be investigated.


Genetic factors in rectal cancer

Rectal cancers, as well as changes in chromosomes are available in all tumors. Many cancer cells, and atypical chromosomal configuration was observed distortion. There are studies showing that the increase in atypia worsened prognosis (1). Molecular genetic studies, early in the adenoma to carcinoma in turn, gene mutation and chromosome deletions has proven to be . Oncogene activation in familial polyposis syndromes and 6,17,18. chromosome deletions have been reported to be effective.

Familial Adenomatous

Polyposis is an autosomal dominant transition. Polyps begin to appear in the age of puberty. Gradually increase the number of polyps are initially sparse. Very high probability of developing cancer Preventive colectomy is performed.

Gardner syndrome, Turcot syndrome, Peutz-Jeghers syndrome and juvenile polyposis syndrome increases the risk of cancer.

Diet factors

The most important environmental risk factors, dietary habits. Fed fat-rich foods of animal societies, the incidence of colorectal cancer has increased. Shown to be effective, especially unsaturated fatty acids in the conversion of adenoma to cancer. Epithelial proliferation of anaerobic bacteria, increasing the microflora by affecting the oil accelerates the degradation products. Fecal bile acids is also a carcinogen, which is transformed into oil and lithocholic acid is metabolized by bacteria. Increasing the concentration of bile acid cholecystectomy, gastric surgery (resection of the terminal ileum) in such cases increases the risk of colorectal Ca.

Carotene, selenium, vitamins C and E, retinoids, reducing the risk of colorectal cancer and plant oils. Dietsel paucity of calcium intake and vitamin D deficiency increases the risk of Ca.

Esophageal Cancer Diagnosis

Esophageal cancer is not specific clinical signs and physical examination findings do not in practice. Therefore, the diagnosis is made ​​based on inspection methods help.

The main procedures of esophageal cancer;

1. The story and physical examination

2. Chest x-ray, complete blood count, biochemistry detail

3. Double-contrast esophagogram

4. Biopsy

5. Thoracic and upper abdominal CT or MRI, 18FDG-PET

6. Endoscopic ultrasound (EUS)

Barium X-ray of the esophagus: an oral barium is given. Location of the lesion, the length, anatomical location, and also gives information about the stomach. SCC, the most common polypoid, ulcerative, infiltrative and superficial spread may occur to a different view. Also in this X-ray and the degree of luminal stenosis or stricture, and fistulas can show if any.

Endoscopy: an indispensable diagnostic tool. Endoscopy, erosion, edema, and a red field, a polyp or mass in the form of images, gives a slightly raised mucosa. In addition, the staining technique can also be used. Lugol's solution and normal mucosa malignant region while the black-brown paint does not hold a view. Thus, increases the chances of tumor detection. Infiltrating tumors of the esophagus wall and lumen of circular contains the almost complete

close to collapse.

Reaches as high as 100% of the diagnosis made ​​by endoscopic cytology of the cell.

Endoscopy is also used in order to provide some palliation in inoperable cases. Dilatation of the tumor, the tumor necrosis with laser or electric current to the bipolar, palliative endoscopic stent placement into the tumor creates initiatives.

Endoscopic ultrasonography (EUS): the relationship between the tumor of the esophagus wall and neighboring organs, is superior to CT in determining lymph node metastases. In addition, the format of lymph glands, and internal echo gives information about the structure of the edge. The lesion depth of invasion, lymph node involvement, and evaluation of environmental organ biopsy can be done if necessary. So reliable, accurate TNM staging is used.

Computed Tomography (CT): Esophageal cancer is a common diagnostic tool for the determination of local and distant spread.

Positron Emission Tomography (PET): Early-stage disease, more structural abnormalities may occur. PET is also impaired in the anatomical structures in the presence of malignant disease, helps to rule out. Switching scheme is shown in approximately 15% of patients treated.

Bronchoscopy: Esophageal cancer is a major part of the trachea or bronchi shows propagation. Choi et al. propagation of such a study conducted in 34% of the cases have deduced.

Laparoscopy: detection of esophageal cancer, liver and peritoneal metastases, laparoscopy has an important place. Peritoneal metastases detected by CT and ultrasound have been identified by laparoscopy.

Laparoscopic ultrasonography (LUS): Peritoneal, diaphragm, the celiac lymph nodes, liver, stomach wall by evaluating the N1 and M1 gastrohepatic ligament, and the biopsy can be performed to detect disease.

Treatment of esophageal

Esophageal cancer is a disease difficult to treat. Divided into two main curative and palliative treatment schedule. Determining the treatment regimen, patient characteristics (age, KPS'u low, and cachectic patients with chronic disease morbidity and mortality is higher), cancer pathology (ADK SCC prognosis is better), stage (early diagnosis increases the chance of cure) and localization (1 / 3 chance of resection is limited localized in the upper region, 1 / 3 localized in the sub-region has a good chance of resection), and evaluated many factors including the patient, single-modality treatment, simultaneous treatment or palliative treatment is one of the options.

However, some patients can not tolerate treatment with multi-modal. In accordance with single-modality treatment in selected patients as either radiotherapy alone (RT) or surgery is preferred.

Treatment Options for Esophageal

Handbook of Evidence-based Radiation Oncology treatment option suggestions are as follows:

Stage I-II-III (resectable): Surgical (close or positive surgical margins + RT)

Neoadjuvant Chemoradiotherapy (KRT) + Surgical

(T2NOMO Perinodal cases of invasion (PNI) (+), lymphovascular invasion (LVI) (+)

or age <40 is, neoadjuvant CRT can be added.)

Definitive CRT (cervical esophageal cancer is preferred.)

Stage I-II-III (inoperable): a definitive CRT

Stage IV: The definitive CRT, only RT, chemotherapy (CT), applicable to any one of the best care options.

Surgical Treatment of Esophageal Cancer

Although the standard surgical approach for early-stage cancer, extensive disease than was detected during surgery is emerging as a clinical and curative in only half of patients are operable. (132) for the implementation of curative surgical treatment of a pre-operative period is necessary to have detailed information about the tumor. Buddha, reliable, healthy life expectancy estimates and whether the treatment modalities

provided with general knowledge.

Surgical approaches include:

1. Attempt left thoracotomy.

2. Ivor Lewis surgery.

3. Transhiatal esophagectomy.

4. Esophagogastrectomy radical en-block.

5. Three-field lymphadenectomy.

6. Palliative interventions.

Transthoracic or transhiatal esophagectomy has been made ​​in comparing the results of the meta-analysis, no difference was found in terms of the 5-year survival. Patients with resectable tumors, the median survival of approximately 11 months. 3-year survival

% 6-35.

The most frequent complications of pulmonary and cardiac problems. Also anastomaz are common. Esophageal cancer surgery is between 2-10% mortality. Preoperative mortality was 17%.


Radiotherapy is a treatment modality used in various phases of esophageal cancer. This treatment is the primary treatment method (RT alone or CRT), combined modality treatment (pre-op, post-op RT), adjuvant treatment (post-op adjuvant RT or CRT) and is applied in the form of palliative RT.

Surgical or relapses after surgery developed simultaneously

applied as a CRT.

Conformal RT or RT as a conventional radiotherapy technique can be applied.

Radiotherapy applied to the patient in the supine position is fixed. If you need help for the used instruments.

Recommended dose of RT 1.8 Gray / Gray fraction of total 50.4. Considerations, the spinal cord more than 45 Gray, 20 Gray's more than 70% of both lung volume and heart volume in more than 50% of the dose of 25 Gray Receiving stopping.

What is esophageal

In the form of muscular tube extending to the stomach from esophageal thin-walled, hollow organ. Above the sixth cervical vertebra, is located below the level of the eleventh thoracic vertebra. In general, males 25 cm (23-30 cm), females 23 cm (20-26 cm) is considered. Teeth up to 15 cm for men in part, for females 14 cm. From the stomach up to the teeth with a combined area of 2 cm shorter than the average 38-42 cm and females. Expands to a width of 2.5-3 cm is full when empty, 1-1.5 cm. (Esophageal carcinoma)

Anatomically divided into three sections;

1. Cervical esophagus: level up to level with the first portion of the thoracic spine.

2. Thoracic esophagus: the first extends from the thoracic spine part of the esophagus.

3. Abdominal esophagus: esophagogastric junction from ending part.

Adjacent to the esophagus, muscles, arteries and organs, causing four significant stenosis;

1.The most narrow place, the upper region of the muscle caused by stenosis.

Stenosis of the middle region of the curve 2.Wall of the esophagus.

3. The middle region of the left main bronchus stenosis çaprazlamasıyla wall of the esophagus.

4.Hiatus and the gastroesophageal sphincter stenosis created by the bottom.

Of the esophagus has a rich lymphatic network. Lymphatic drainage longitudinal direction, up or down may be true. Especially in the lamina propria, muscularis mucosa and submucosa in the intramucosal and submucosal carcinoma because of the spread of the lymphatic network is very common.

Lymphatics of the esophagus and inferior thyroid artery, bronchial and esophageal arteries and the left gastric artery (celiac axis) through the following internal jugular lymph nodes, subcarinal, para-aortic, paratracheal, paracardiac and celiac lymph nodes will be drained.

Risk Factors for Esophageal

The most common etiology of esophageal SCC, as alcohol and tobacco use, nutrition and environmental factors, genetics and the Human Papilloma Virus (HPV) is observed. Predisposing factors of esophagitis, esophageal stasis syndrome, achalasia, caustic burns, alkali corrosion, diverticulum, Plummer-Vinson syndrome, celiac disease, previous gastric resection, previous radiotherapy include app. ADC in the etiology of gastroesophageal reflux disease, Barrett's esophagus, smoking and obesity play a role.

Alcohol and tobacco: the use of alcohol and tobacco in America, Europe and especially France, the most important etiological factor. In chronic smokers who consume alcohol have an increased risk of 20-25, according to times. Tobacco use increases the risk 2-6 fold. With the termination of the use of tobacco, the risk declines by 40%. Strengthen each other's effect when used with alcohol and cigarettes, increase the risk 10-25 times.

Nutrition: Another common feature is the high-risk areas, rich in cereals, whereas the A, C, vitamin E, folic acid, riboflavin, animal protein, fat, fresh fruit and vegetables, lack of or poor nutrition. High vitamin C, beta-carotene are yellow and green vegetables reduces the incidence of SCC.

Carcinogenic substances formed by means of microbial contamination in some foods directly by taking the risk is increased. For example, when corn infected with fungi is composed of nitrosamine derivatives. In addition, the sheer number of vegetables are carcinogenic effect of the molds, and particularly increases the risk of SCC.

Significantly increases the risk of excessive hot food to be continuous.

Trace element deficiencies have also played a role in the empirical studies. One study demonstrated the protective effect of molybdenum-rich diet. In another study, zinc plays a role in epithelial differentiation, cytochemistry events shown to be effective. In addition, zinc deficiency in guinea pigs esophageal mucosa, such as the epithelial changes consisted of hyperkeratosis and acanthosis. Sauvaget and regions with high incidence of SCC zinc, selenium, and reported low levels of molybdenum.

Inheritance: China and Iran, especially in an area north-east of the incidence of esophageal cancer suggests a hereditary factor may be. Also known as hand-foot Plantaris, which leads to an autosomal dominant inherited disease, esophagus cancer by 1 / 3 is observed. Esophageal cancer, one showing the genetic relationship, the best example.

Esophageal cancers, 2 / 3 of the p53 mutation, but the most important oncogene in the pathogenesis cyclin.

Human papillomavirus (HPV): Especially with high-incidence regions of China and South Africa, 40-In 60% of patients with HPV DNA found in SCC. HPV16 and HPV18 may play a role in some cases, esophageal SCC.

Celiac disease: usually increases the incidence of gastrointestinal cancer and lymphoma. Considered to be due to lack of trace elements and vitamins.

Plummer-Vinson (Patterson-Kelly) syndrome: atropine glossopati, dysphagia, and severe iron deficiency anemia seen in this syndrome, especially in the upper esophagus and mouth to develop cancer by 10%.

Achalasia: 30-fold increased risk in these patients with the incidence of SCC is usually placed in the middle of the esophagus ranged from 1-20%.

Diverticula: 0.3-0.7% patients, usually after age 60

percent may develop cancer.

Esophagitis: Extremely hot foods causes chronic esophagitis. This is seen in patients with SCC, especially in the middle and lower esophagus.

Esophageal strictures: as a result of burns due to caustic substances strictures, the risk of SCC increase 20-fold compared to ordinary people. Caustic burns to occur increases, especially in the age of cancer occurrence time is reduced. Food stasis occurs as a result of strictures. Before extending the duration of the contact you have with this nitrozaminlerle esophagitis, after many years can cause epithelial hyperplazisine.

Previous gastric resection: pre-partial gastrectomy in people who would be an increase in the incidence of lower esophageal SCC. The reason for this poor-poor nutrition, and gastroesophageal reflux. The latent period for the formation of cancer in approximately 20-25 years.

Previous radiation therapy: the cervical spine, breast and thyroid after radiotherapy may develop SCC. Period of 50 years, sometimes with the irradiation of cancer development can pass.

Thyroid Gland and Thyroid Hormone Physiology

Embryology and Histology

Thyroid gland during embryological development of the language develops in part through the foramen cecum. Thyroglossal tract of fetal life through the 7th reaches the front side of the neck in the week.

A typical adult weighs 15-20 grams. Slightly smaller than in women. Below the cricoid cartilage, located in front of the trachea.

Cloth, cuboidal and furnished by the follicle epithelium is composed of columnar cells. Colloid in the lumen of the follicles in the middle of 50-75% by weight of the entire gland creates.

B. Thyroid Hormone Physiology

Iodine is required for the synthesis of thyroid hormones. Thyroid follicle cells, plasma membrane protein, iodine through the APR take (capture). The iodine is then oxidized thyroid, tyrosine residues on Tg is connected to the structure of the glycoprotein. The resulting (MIT) and (DIT), thyroxine (T4) and triiodothyronine (T3) 's through to create a combined peroxidase. T3 and T4 hormones to accumulate in the follicle colloid filled lumen. Thyroid hormones are released as a result of hydrolysis of plasma TG.

Pituitary thyroid-stimulating hormone (TSH), the capture of iodine, and thyroid hormone secretion checks. Thyroid-pituitary feedback mechanism is sensitive to the blood level of thyroid hormone and TSH secretion, which controls the dominant mechanism. T4 is the main hormone secreted by the thyroid gland, thyroid transporter proteins in peripheral tissues, and moved here more active metabolically converted to T3.

TSH secretion in response to a small amount of colloid and surrounded by epithelial cells of thyroid hormones into the blood during result of TG in the blood can pass a very small percentage of Tg. TG is used as an indicator of tumor-differentiated thyroid cancer total thyroidectomy and iodine-131 (I-131) after ablation shows a high rate of recurrence detection.

What is Thyroid Papillary Cancer

The most common type of thyroid cancer (70-80%) with papillary thyroid cancer usually occurs 30-40 years of age and gender incidence is 1 to 3. More common in iodine-rich areas. The main type of cancer seen in children after exposure to radiation. Ret oncogene activation is located in the etiological factor.

Low malignant potential. With proper treatment, a 10-year survival of 80-90% (8). Tumor with cystic or solid, or encapsulated into the thyroid, the thyroid capsule, or may have spread to surrounding tissues. Macroscopic calcification and necrosis may occur. Microscopic papillary structures as a small, ground-glass appearance and is typical to see psammoma corpuscles. Desmoplasia reaction in tumors that are common.

The characteristic feature of lymph node infiltration. Can occur in more than 75% of the cases together, the prognosis is controversial effect. Distant metastases are uncommon (5-10%). If we see most often in the lungs, more rarely in the bones, liver and brain, is determined.

According to the WHO classification, papillary carcinoma, classical type, except there are some histopathological subtypes. These follicular, Oncocyte, clear cell, diffuse sclerosing, high-cell, columnar cell, and solid variants. ATA 2009 manual high-cell, columnar cell and diffuse sclerosing types is actually a worse prognosis. Cribriform cancer, papillary thyroid cancer in subgroups according to the same classification as adopted, with focal insular component of papillary cancers were evaluated separately.

The other group is assessed by the WHO classification of papillary separate headings. Under 1 cm, these tumors are incidentally detected papillary thyroid cancers are the most common. Invasion, as long as they did not carry an indication for ablation. Although multicentric iodine treatment should be given to the former guideline emphasized the ATA in 2009, the revised manual is frequent recurrences in this group, but iodine treatment this recurrences frequency reduce highlighted, For this reason, iodine treatment in this patient group was to be a certain indication.


Radiation, is the first in the pathogenesis of thyroid cancer. The most common form of exposure to therapeutic irradiation, and environmental disasters. As a result of radiation to cause DNA strand breaks, increases the potential for development of malignancy. After the Chernobyl disaster, the most important example of the increase in childhood thyroid cancer rates.

Oncogenes also play a role in the formation of thyroid cancer. As an example, point mutations (ret, ras, BRAF, p53 suppressor gene) and chromosomal gene mutation or re-arranging (ret / PTC, TRK, PAX8/PPARδ) can be given. ATA revised guide is recommended to use these molecular Pointers on prognosis and treatment selection.

In general, patients with thyroid cancer before the development of goiter, benign thyroid nodule, lymphocytic thyroiditis or Graves' disease is located. However, these diseases are predisposing factors for thyroid cancer has not been established yet.

Thyroid cancer incidence among women and men during puberty and menopause to be close to 1, but showing great variation in women of reproductive periods, hormonal and reproductive factors also shows that in the pathogenesis.

Replacement of iodine in iodine sufficient areas taken or papillary type, follicular type of thyroid cancer incidence in iodine-deficient areas in the role of diet in the pathogenesis shows.

Follicular Thyroid Cancer

The second common type of thyroid cancer (15%). Female-male incidence of 3 to 1 and the average age is 50. More iodine is the poor regions. The only type of thyroid cancer associated with Dyshormonogenesis. Familial or Cowden Syndrome (transmitted as an autosomal dominant, where the characteristic skin lesions and a tendency to breast cancer syndrome) 's can also be seen as a part of. And ras oncogene activation may be induced by radiation. Ten-year survival rate of papillary thyroid cancer is lower, on average, 60-is 70%.

Unlike papillary thyroid cancer, vascular invasion is seen way. The most frequent foci of metastatic bone, liver and lungs. Regional lymph node metastases are rare.

Frequently observed multifocality, calcification, and there is little indication that desmoplastic reaction. Mature, healthy thyroid tissue, follicular adenoma resembles the distinction is difficult. Diagnosis of malignancy but is placed by the detection of vascular invasion or metastases.

Histopathologically, the distinction between follicular adenoma and to have a thick and irregular capsule, capsule invasion should be seen. Follicular cancers are divided into 2 groups according to the degree. Minimally invasive follicular cancers limited capsular and / or vascular invasion seen. Widely invasive follicular carcinomas of the capsular / vascular invasion, except surrounding soft tissues and / or blood vessels seen in the invasion. Shows the increase in the degree of vascular invasion increased aggressiveness on tumors.

Cell type of cancer called previously, the WHO classification of oncocytes variant of follicular cancer is called. % Of all thyroid cancers, creates 3-4 percent. The median age at diagnosis of making a 61, female-male ratio seen in the 6.5 to 3.5, tour. Usually solitary, encapsulated tumor of the full or almost full. Such as the potential for malignancy in follicular thyroid cancer with vascular or capsular invasion are measured. Invasion, lymph node metastases in distant organs and follicular thyroid cancer is more common. Tg, although it generates is not as high as iodine capture the classic, well-differentiated thyroid cancers.

What is Virtual Endoscopy

Endoscopic technique for the conversion to a 3D-like images. Technical, particularly in sections which are difficult to assess the display of hollow organs and tubular structures, the internal surfaces in a continuum to show the reader the chance to intervene to recognize the interactive, multi-angle viewing option, and 3 to assess the perception of size and providing convenience.

CT virtual endoscopy studies in the field for the first time researchers have been submitted by Vining and colleagues tracheobronchial system, both the colon, bladder and the first studies related to the limited number of patients presented. Later developments in the software program and the detector system defined by the routine use of imaging techniques have become possible. The diagnostic value of the virtual endoscopic imaging is still controversial, however, some applications are carried out more than an academic purpose. Application area of radiological examinations in the virtual, virtual laryngoscopy, virtual bronchoscopy, virtual colonoscopy, virtual cystoscopy, virtual Angioscopy, a virtual display of the paranasal sinuses and middle ear, stomach and small intestine for the applications.

These benchmarks and real applications, which is routinely used in the virtual bronchoscopy, colonoscopy and cystoscopy included. Is actually a series of virtual endoscopic imaging with CT has become possible as a result of technical development. Among the most important role in the development of systems and slip-ring gantry geometry after the spiral scan. Thus, information derived from volume and 3D imaging has been made ​​with computer software developments.

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