63,6 75(ģ&,
I WPROWADZENIE DO CHIRURGII ONKOLOGICZNEJ 1. (7,2/2*,$ , (3,'(0,2/2*,$ 12:27:25Ð: =â2ģ/,:<&+ : 32/6&( , 1$ ģ:,(&,( ............... Joanna A. Didkowska
3
:VWÆS ...................................................................................................................................................................... 1RZRWZRU\ ] RyOLZH RJÏ HP .................................................................................................................................. 1RZRWZRU\ ] RyOLZH J RZ\ L V]\L ............................................................................................................................ 1RZRWZRU\ ] RyOLZH SU]H \NX ................................................................................................................................. 1RZRWZRU\ ] RyOLZH R GND .................................................................................................................................. 1RZRWZRU\ ] RyOLZH MHOLWD JUXEHJR ........................................................................................................................ 1RZRWZRU\ ] RyOLZH Z WURE\ ................................................................................................................................. 1RZRWZRU\ ] RyOLZH SÆFKHU]\ND Ï FLRZHJR ......................................................................................................... 1RZRWZRU\ ] RyOLZH WU]XVWNL .................................................................................................................................. 1RZRWZRU\ ] RyOLZH NUWDQL ..................................................................................................................................... 1RZRWZRU\ ] RyOLZH S XFD ..................................................................................................................................... &]HUQLDN VNÏU\ ......................................................................................................................................................... 1RZRWZRU\ ] RyOLZH SLHUVL ...................................................................................................................................... 1RZRWZRU\ ] RyOLZH V]\MNL PDFLF\ .......................................................................................................................... 1RZRWZRU\ ] RyOLZH MDMQLND .................................................................................................................................... 1RZRWZRU\ ] RyOLZH WU]RQX PDFLF\ ........................................................................................................................ 1RZRWZRU\ ] RyOLZH QHUNL ...................................................................................................................................... 1RZRWZRU\ ] RyOLZH SÆFKHU]D PRF]RZHJR ........................................................................................................... 1RZRWZRU\ ] RyOLZH JUXF]R X NURNRZHJR ............................................................................................................. 1RZRWZRU\ ] RyOLZH M GUD ......................................................................................................................................
3 6 10 11 12 13 15 16 17 18 18 19 20 22 22 23 24 25 26 27
2. BIOLOGIA NOWOTWORÓW ............................................................................................................................ Andrzej Tysarowski, Artur Kowalik
31
:VWÆS ...................................................................................................................................................................... 0ROHNXODUQH L JHQHW\F]QH PHFKDQL]P\ SURZDG] FH GR UR]ZRMX L SURJUHVML QRZRWZRUX .................................... 0XWDFMH JHQÏZ VXSUHVRURZ\FK L SURWRRQNRJHQÏZ MDNR F]\QQLNL ]DEXU]DM FH UÏZQRZDJÆ SRPLÆG]\ SRG]LD DPL UÏ QLFRZDQLHP L yPLHUFL NRPÏUHN L SU]\F]\QLDM FH VLÆ GR LQLFMDFML SURFHVX QRZRWZRU]HQLD .... .RQFHSFMD PDFLHU]\VW\FK NRPÏUHN QRZRWZRURZ\FK ..................................................................................... 5ROD PLNUR51$ Z NDUF\QRJHQH]LH .................................................................................................................. :S \Z PLNURyURGRZLVND JX]D QD SURPRFMÆ L SURJUHVMÆ QRZRWZRUX .................................................................... ,PPXQRHG\FMD UROD XN DGX RGSRUQRyFLRZHJR Z SURJUHVML QRZRWZRUX ....................................................... 5ROD XQDF]\QLHQLD Z SURJUHVML QRZRWZRUX .................................................................................................... 0HFKDQL]P\ SURZDG] FH GR SRZVWDQLD SU]HU]XWÏZ ............................................................................................. 0RGHOH Z\MDyQLDM FH ]MDZLVNR VHOHNFML NRPÏUNL QRZRWZRURZHM ]GROQHM GR Z\WZRU]HQLD SU]HU]XWÏZ ........ =MDZLVNR VHOHNW\ZQHJR ]DVLHGODQLD RJQLVN ZWÏUQ\FK SU]H] RNUHyORQH W\S\ QRZRWZRUÏZ ...........................
31 33
6SLV WUHĂFL
33 45 47 49 49 54 59 60 61
XIII
XIV
'LDJQRVW\ND QD SRWU]HE\ VSHUVRQDOL]RZDQHJR OHF]HQLD FKRU\FK QD ] RyOLZH QRZRWZRU\ OLWH 3UDNW\F]QH Z\NRU]\VWDQLH GDQ\FK X]\VNDQ\FK ] EDGDÍ SRGVWDZRZ\FK ............................................................... :VWÆS ............................................................................................................................................................... 'LDJQRVW\ND PROHNXODUQD Z UDNX SLHUVL .......................................................................................................... 'LDJQRVW\ND PROHNXODUQD Z UDNX S XFD .......................................................................................................... 'LDJQRVW\ND PROHNXODUQD Z UDNX MHOLWD JUXEHJR ............................................................................................ 'LDJQRVW\ND PROHNXODUQD Z UDNX MDMQLND ........................................................................................................ 'LDJQRVW\ND JHQHW\F]QD UDND SURVWDW\ ........................................................................................................... 'LDJQRVW\ND UDND WU]XVWNL ................................................................................................................................ 'LDJQRVW\ND JHQHW\F]QD UDND HQGRPHWULXP .................................................................................................. 'LDJQRVW\ND JHQHW\F]QD UDND WDUF]\F\ ........................................................................................................... 'LDJQRVW\ND JHQHW\F]QD UDND R GND ............................................................................................................ 'LDJQRVW\ND JHQHW\F]QD PLÆVDNÏZ WNDQHN PLÆNNLFK ..................................................................................... 'LDJQRVW\ND PROHNXODUQD Z QRZRWZRUDFK SRGyFLHOLVNRZ\FK SU]HZRGX SRNDUPRZHJR *,67 .................. 'LDJQRVW\ND PROHNXODUQD ZH Z ÏNQLDNRPLÆVDNX JX]RZDW\P VNÏU\ ............................................................. 'LDJQRVW\ND JHQHW\F]QD Z QRZRWZRUDFK NRyFL ............................................................................................. 'LDJQRVW\ND PROHNXODUQD Z F]HUQLDNX ........................................................................................................... 'LDJQRVW\ND JHQHW\F]QD Z UDNX QHUNL ............................................................................................................ 'LDJQRVW\ND JHQHW\F]QD Z UDNX XURWHOLDOQ\P SÆFKHU] PRF]RZ\ ............................................................... 'LDJQRVW\ND JHQHW\F]QD QRZRWZRUÏZ RyURGNRZHJR XN DGX QHUZRZHJR ................................................... 'LDJQRVW\ND JHQHW\F]QD QRZRWZRUÏZ OLW\FK Z NLHUXQNX REHFQRyFL IX]ML ] XG]LD HP 175. ................... 'LDJQRVW\ND JHQHW\F]QD QRZRWZRUÏZ R QLH]QDQ\P SXQNFLH Z\MyFLD ..........................................................
62 62 62 71 75 76 77 78 78 79 80 80 80 81 82 82 82 83 83 83 83
3. =(632â< :<67Č38-ć&( 8 26Ð% = *(1(7<&=1ć 35('<632=<&-ć '2 =$&+252:$1,$ 1$ 12:27:25< =â2ģ/,:( ........................................................................................................................... Tomasz Byrski, Marek Jasiówka
87
=HVSR \ Z\VWÆSXM FH X RVÏE ] JHQHW\F]Q SUHG\VSR]\FM GR ]DFKRURZDQLD QD UDND SLHUVL L OXE MDMQLND .............. =DVDG\ SRVWÆSRZDQLD Z SU]\SDGNX QRVLFLHOVWZD PXWDFML Z JHQDFK %5&$ ................................................... =HVSR \ Z\VWÆSXM FH X RVÏE ] JHQHW\F]Q SUHG\VSR]\FM GR ]DFKRURZDQLD QD G]LHG]LF]QHJR UDND MHOLWD JUXEHJR ................................................................................................................................................................... =HVSÏ /\QFKD +13&& t KHUHGLWDU\ QRQSRO\SRVLV FRORUHFWDO FDQFHU ............................................................ =HVSÏ URG]LQQHM SROLSRZDWRyFL JUXF]RODNRZDWHM )$3 t IDPLOLDO DGHQRPDWRXV SRO\SRVLV .......................... 5HFHV\ZQD SRVWDÂ SROLSRZDWRyFL JUXF]RODNRZDWHM 0$3 t 087<+ DVVRFLDWHG SRO\SRVLV ........................... DJRGQD SRVWDÂ URG]LQQHM SROLSRZDWRyFL JUXF]RODNRZDWHM MHOLWD JUXEHJR $)$3 t DWWHQXDWHG )$3 ........... =HVSÏ SROLSRZDWRyFL P RG]LHÍF]HM -36 t MXYHQLOH SRO\SRVLV V\QGURPH ......................................................
87 89
4. 32'67$:2:( 5(*8â< &+,585*,&=1(*2 /(&=(1,$ &+25<&+ 1$ 12:27:Ð5 ...................... $UNDGLXV] -H]LRUVNL 3LRWU â 5XWNRZVNL :RMFLHFK 0 :\VRFNL
101
:VWÆS ...................................................................................................................................................................... 2SHUDFMH GLDJQRVW\F]QH .......................................................................................................................................... %LRSVMD ZÆ] D FK RQQHJR ZDUWRZQLF]HJR ...................................................................................................... 2SHUDFMH UDG\NDOQH ................................................................................................................................................. 2SHUDFMH SDOLDW\ZQH ............................................................................................................................................... 2SHUDFMH SURILODNW\F]QH OXE UHGXNXM FH U\]\NR ]DFKRURZDQLD .............................................................................. 2SHUDFMH SU]HU]XWÏZ ............................................................................................................................................... 3U]\N DG\ LQQ\FK WHFKQLN VWRVRZDQ\FK Z FKLUXUJLL RQNRORJLF]QHM .........................................................................
101 104 104 104 105 105 106 106
5. PODSTAWY LECZENIA SYSTEMOWEGO ........................................................................................................ /XFMDQ :\UZLF]
109
3RG]LD OHF]HQLD V\VWHPRZHJR ................................................................................................................................ 'REÏU PHWRG OHF]HQLD V\VWHPRZHJR .....................................................................................................................
109 109
6SLV WUHĂFL
93 93 94 96 97 97
7RNV\F]QRy OHF]HQLD V\VWHPRZHJR ........................................................................................................................ 0HFKDQL]P\ G]LD DQLD L F]HQLH F\WRVWDW\NÏZ ...................................................................................................... /HF]HQLH FHORZDQH .................................................................................................................................................. ,PPXQRWHUDSLD QRZRWZRUÏZ ................................................................................................................................ 6WUDWHJLD OHF]HQLD V\VWHPRZHJR QRZRWZRUÏZ ......................................................................................................
111 114 115 116 116
6. LECZENIE CELOWANE I IMMUNOTERAPIA ................................................................................................... âXNDV] .ZLQWD 3LRWU :\VRFNL
119
,QKLELWRU\ NLQD] &'. .......................................................................................................................................... :HZQ WU]NRPÏUNRZH V]ODNL V\JQD RZH ................................................................................................................. .OXF]RZH V]ODNL V\JQD RZH Z NRPÏUNDFK QRZRWZRURZ\FK ................................................................................. 3, . $.7 P725 L 5$6 5$) 0(. (5. ................................................................................................................ 6]ODN KHGJHKRJ ............................................................................................................................................... ,PPXQRORJLD L LPPXQRWHUDSLD ............................................................................................................................... $QW\JHQ\ QRZRWZRURZH ................................................................................................................................. ,QGXNFMD VZRLVWHM RGSRZLHG]L LPPXQRORJLF]QHM ............................................................................................ ,PPXQRVXSUHVMD L SURJUHVMD ............................................................................................................................ ,PPXQRWHUDSLD QRZRWZRUÏZ .........................................................................................................................
119 119 120 120 121 121 121 122 123 123
7. PODSTAWY RADIOTERAPII ................................................................................................................................ $OHNVDQGUD 1DSLHUDOVND .U]\V]WRI ģORVDUHN
141
:VWÆS ...................................................................................................................................................................... 5RG]DMH UDGLRWHUDSLL ................................................................................................................................................ 7HFKQLNL WHOHUDGLRWHUDSLL .......................................................................................................................................... 'HILQLFMD GDZNL IUDNF\MQHM L FD NRZLWHM .................................................................................................................... 0HWRG\ Z\WZDU]DQLD SURPLHQLRZDQLD MRQL]XM FHJR L EXGRZD QRZRF]HVQHJR DNFHOHUDWRUD OLQLRZHJR .............. 5R]N DG GDZNL SURPLHQLRZDQLD MRQL]XM FHJR ........................................................................................................ 3RGVWDZ\ UDGLRELRORJLF]QH ..................................................................................................................................... ']LD DQLH SURPLHQLRZDQLD QD SR]LRPLH NRPÏUNRZ\P .................................................................................. 6NXWNL G]LD DQLD SURPLHQLRZDQLD MRQL]XM FHJR .............................................................................................. 2GF]\Q\ SRSURPLHQQH ............................................................................................................................................ :\]QDF]DQLH GDZNL SURPLHQLRZDQLD 3URFHV L SODQRZDQLH UDGLRWHUDSLL ............................................................... =DVDG\ SODQRZDQLD UDGLRWHUDSLL .............................................................................................................................. $NFHSWDFMD SODQX OHF]HQLD ....................................................................................................................................... .RQFHSFMD REV]DUÏZ WDUF]RZ\FK Z UDGLRWHUDSLL .................................................................................................... 5RG]DMH ZVSÏ F]HVQ\FK WHFKQRORJLL UDGLRWHUDSHXW\F]Q\FK ...................................................................................
141 141 142 144 146 150 152 152 153 153 154 159 161 161 163
8. /(&=(1,( &+25<&+ 1$ 12:27:25< : :,(.8 32'(6=â<0 ............................................................. $OHNVDQGUD âDFNR 0DUFLQ (NLHUW (ZHOLQD âDWD :RĮQLDN -XOLD 5XGQR 5XG]LęVND -RODQWD 6]HODFKRZVND
167
:VWÆS ...................................................................................................................................................................... 2FHQD FKRU\FK Z ZLHNX SRGHV] \P L SODQRZDQLH OHF]HQLD .................................................................................... =DVDG\ OHF]HQLD FKLUXUJLF]QHJR FKRU\FK Z ZLHNX SRGHV] \P ............................................................................... =DVDG\ UDGLRWHUDSLL X FKRU\FK VWDUV]\FK ................................................................................................................. =DVDG\ OHF]HQLD V\VWHPRZHJR X FKRU\FK VWDUV]\FK ............................................................................................... 5DN SLHUVL ................................................................................................................................................................. 5DN JUXF]R X NURNRZHJR ........................................................................................................................................ 1LHGUREQRNRPÏUNRZ\ UDN S XFD ............................................................................................................................ (ZHOLQD âDWD :RĮQLDN 0DUFLQ (NLHUW $OHNVDQGUD âDFNR -RODQWD 6]HODFKRZVND 5DN MHOLWD JUXEHJR ...................................................................................................................................................
167 167 169 170 170 171 173 174
6SLV WUHĂFL
175
XV
9. PODSTAWY REHABILITACJI .............................................................................................................................. +DQQD 7FKyU]HZVND .RUED
179
)L]MRWHUDSLD Z FHOX RJUDQLF]HQLD VNXWNÏZ RSHUDF\MQHJR OHF]HQLD UDND S XF ......................................................... )L]MRWHUDSLD SDFMHQWÏZ SR RSHUDFMDFK ] SRZRGX PLÆVDNÏZ NRyFL L WNDQHN PLÆNNLFK ........................................... 5HKDELOLWDFMD L IL]MRWHUDSLD SDFMHQWÏZ RSHURZDQ\FK ] SRZRGX QRZRWZRUÏZ J RZ\ L V]\L ................................. 5HKDELOLWDFMD SV\FKLF]QD L IL]MRWHUDSLD SDFMHQWHN OHF]RQ\FK ] SRZRGX UDND SLHUVL ................................................ )L]MRWHUDSLD SDFMHQWÏZ SR UDG\NDOQHM SURVWDWHNWRPLL ] SRZLN DQLHP Z SRVWDFL Z\VL NRZHJR QLHWU]\PDQLD PRF]X ................................................................................................................................................ )L]MRWHUDSLD FKRU\FK ] XV]NRG]HQLDPL QHXURORJLF]Q\PL QLHGRZ DG\ SRUD HQLD Z Z\QLNX FKRURE\ OXE OHF]HQLD RQNRORJLF]QHJR .................................................................................................................................. )L]MRWHUDSLD FKRU\FK OHF]RQ\FK Z ]DNUHVLH JLQHNRORJLL RQNRORJLF]QHM ................................................................... )L]MRWHUDSLD FKRU\FK RSHURZDQ\FK ] SRZRGX F]HUQLDND ....................................................................................... )L]MRWHUDSLD SR RSHUDFMDFK XVXQLÆFLD ZÆ] ÏZ FK RQQ\FK t SURILODNW\ND L WHUDSLD SDFMHQWÏZ ] ZWÏUQ\P REU]ÆNLHP OLPIDW\F]Q\P .........................................................................................................................................
180 180 181 181
182 183 183 183
10. OPIEKA PALIATYWNA, I LECZENIE BÓLU U CHORYCH NA NOWOTWORY .......................................... /HV]HN *RWWZDOG :RMFLHFK /HSSHUW
187
:VWÆS ...................................................................................................................................................................... 2SLHND SDOLDW\ZQD .................................................................................................................................................. 'HILQLFMD L ]DGDQLD RSLHNL SDOLDW\ZQHM QDG FKRU\PL QD QRZRWZRU\ ] RyOLZH ................................................. )RUP\ RSLHNL SDOLDW\ZQHM Z 3ROVFH ................................................................................................................. %ÏO X FKRU\FK QD QRZRWZRU\ .................................................................................................................................. %ÏO t GHILQLFMD L SRG]LD ................................................................................................................................... 5R]SR]QDQLH L RFHQD NOLQLF]QD EÏOX ................................................................................................................ 6WUDWHJLD OHF]HQLD EÏOX QRZRWZRURZHJR .......................................................................................................
187 187 187 188 189 189 190 190
11. 352),/$.7<.$ 32:,.â$Ę =$.5=(32:2 =$7252:<&+ W CHIRURGII ONKOLOGICZNEJ .................................................................................................................... -HU]\ :LQG\JD
201
:VWÆS ...................................................................................................................................................................... 0HWRG\ ]DSRELHJDQLD \OQHM FKRURELH ]DNU]HSRZR ]DWRURZHM Z FKLUXUJLL ........................................................... 2FHQD U\]\ND Z\VW SLHQLD \OQHM FKRURE\ ]DNU]HSRZR ]DWRURZHM L SRZLN DÍ NUZRWRF]Q\FK X SDFMHQWD SRGGDZDQHJR RSHUDFML FKLUXUJLF]QHM ..................................................................................................................... 5\]\NR UR]ZRMX \OQHM FKRURE\ ]DNU]HSRZR ]DWRURZHM X SDFMHQWÏZ SRGGDZDQ\FK ]DELHJRP ] ]DNUHVX FKLUXUJLL RQNRORJLF]QHM ............................................................................................................................ 2SHUDFMH QD MHOLFLH JUXE\P L RGE\WQLF\ ........................................................................................................... 2SHUDFMH JLQHNRORJLF]QH ................................................................................................................................. 2SHUDFMH XURORJLF]QH ....................................................................................................................................... 2SHUDFMH QHXURFKLUXUJLF]QH ............................................................................................................................ 2SHUDFMH Z REUÆELH SLHUVL ................................................................................................................................ 2SHUDFMH Z REUÆELH NODWNL SLHUVLRZHM .............................................................................................................. 6NXWHF]QRy SURILODNW\NL SU]HFLZ]DNU]HSRZHM Z FKLUXUJLL RQNRORJLF]QHM RSHUDFMH QD MHOLFLH JUXE\P L RGE\WQLF\ RSHUDFMH JLQHNRORJLF]QH L XURORJLF]QH .................................................................................. 6NXWHF]QRy SURILODNW\NL SU]HFLZ]DNU]HSRZHM Z QHXURFKLUXUJLL RQNRORJLF]QHM .................................................... 6NXWHF]QRy SURILODNW\NL SU]HFLZ]DNU]HSRZHM Z FKLUXUJLL RQNRORJLF]QHM SLHUVL .................................................... 6NXWHF]QRy SURILODNW\NL SU]HFLZ]DNU]HSRZHM Z WRUDNRFKLUXUJLL RQNRORJLF]QHM ................................................... &]DV VWRVRZDQLD SLHUZRWQHM SURILODNW\NL SU]HFLZ]DNU]HSRZHM Z FKLUXUJLL RQNRORJLF]QHM ....................................
XVI
182
6SLV WUHĂFL
201 201 204 207 209 209 209 210 210 210 211 212 212 213 213
12. /(&=(1,( į<:,(1,2:( : &+,585*,, 21.2/2*,&=1(- ........................................................................ 0LFKDã -DQNRZVNL 6WDQLVãDZ .ãčN $OHNVDQGUD .DSDãD
219
:VWÆS ...................................................................................................................................................................... 'HILQLFMH L SRGVWDZRZH SRMÆFLD .............................................................................................................................. 1LHGR \ZLHQLH L ]DEXU]HQLD RG \ZLHQLD ......................................................................................................... 6DUNRSHQLD ....................................................................................................................................................... 2W\ Ry VDUNRSHQLF]QD ..................................................................................................................................... .DFKHNVMD QRZRWZRURZD ................................................................................................................................ 8RJÏOQLRQD UHDNFMD ]DSDOQD ............................................................................................................................ =HVSÏ SRQRZQHJR RG \ZLHQLD UHIHHGLQJ V\QGURPH .................................................................................. =DVDGD NRPSOHWQRyFL \ZLHQLD ........................................................................................................................ =DSRWU]HERZDQLH QD VN DGQLNL RG \ZF]H ....................................................................................................... 1LHGR \ZLHQLH QRZRWZRURZH ................................................................................................................................ &]ÆVWRy Z\VWÆSRZDQLD ................................................................................................................................... 1LHGR \ZLHQLH D FKRURED QRZRWZRURZD ....................................................................................................... :S \Z QLHGR \ZLHQLD QD Z\QLNL OHF]HQLD FKLUXUJLF]QHJR .............................................................................. 2FHQD VWDQX RG \ZLHQLD ......................................................................................................................................... 3U]HVLHZRZD RFHQD QLHGR \ZLHQLD ................................................................................................................. 0HWRG\ RFHQ\ VWDQX RG \ZLHQLD .................................................................................................................... ,QWHUZHQFMD \ZLHQLRZD ......................................................................................................................................... 2JÏOQH ]DVDG\ SRVWÆSRZDQLD ......................................................................................................................... 'URJD SRGD \ .................................................................................................................................................. \ZLHQLH GRXVWQH ............................................................................................................................................ 'LHW\ SU]HP\V RZH .......................................................................................................................................... \ZLHQLH GRMHOLWRZH ......................................................................................................................................... \ZLHQLH SR]DMHOLWRZH ..................................................................................................................................... \ZLHQLH LPPXQRPRGXOXM FH ......................................................................................................................... 0LHMVFH WHUDSLL \ZLHQLRZHM Z SURFHVLH GLDJQRVW\F]QR WHUDSHXW\F]Q\P .............................................................. ,QWHUZHQFMD \ZLHQLRZD Z RNUHVLH RNR RRSHUDF\MQ\P .................................................................................. 3RZLN DQLD SRRSHUDF\MQH ................................................................................................................................ \ZLHQLH GRPRZH ................................................................................................................................................... \ZLHQLH FKRU\FK Z ]DDZDQVRZDQ\P VWDGLXP FKRURE\ QRZRWZRURZHM .............................................................
219 219 219 221 222 222 222 222 225 226 226 226 226 227 227 227 230 232 232 232 232 234 238 241 243 246 246 250 252 252
13. 67$1< 1$*â( : &+,585*,, 21.2/2*,&=1(- ........................................................................................ 'DZLG 0XUDZD 0DWHXV] :LFKWRZVNL
257
:VWÆS ...................................................................................................................................................................... 1LHGUR QRy ............................................................................................................................................................ 1LHGUR QRy SU]HZRGX SRNDUPRZHJR ........................................................................................................... 1LHGUR QRy GUÏJ Ï FLRZ\FK ......................................................................................................................... 1LHGUR QRy XN DGX PRF]RZHJR .................................................................................................................... 1LHGUR QRy GURJL RGGHFKRZHM ...................................................................................................................... 1RZRWZRURZ\ XFLVN UG]HQLD NUÆJRZHJR ....................................................................................................... 3HUIRUDFMD ................................................................................................................................................................ .UZDZLHQLH .............................................................................................................................................................. = DPDQLD SDWRORJLF]QH ............................................................................................................................................
257 258 258 259 260 260 261 262 263 264
14. DIAGNOSTYKA I LECZENIE CHORYCH Z PRZERZUTAMI Z NIEZNANEGO OGNISKA PIERWOTNEGO ................................................................................................................................ :RMFLHFK 0 :\VRFNL -RDQQD % :\VRFND =RUDQ 6WRMĀHY
267
'HILQLFMD L F]ÆVWRy Z\VWÆSRZDQLD .......................................................................................................................... .ODV\ILNDFMD L SRG]LD ...............................................................................................................................................
267 268
6SLV WUHĂFL
XVII
3RVWÆSRZDQLH GLDJQRVW\F]QH .................................................................................................................................. /HF]HQLH ...................................................................................................................................................................
269 270
15. BADANIA KLINICZNE W CHIRURGII ONKOLOGICZNEJ ............................................................................ :RMFLHFK 0 :\VRFNL 3LRWU â 5XWNRZVNL
273
:VWÆS ...................................................................................................................................................................... 5RG]DMH EDGDÍ NOLQLF]Q\FK ...................................................................................................................................... )D]\ EDGDQLD NOLQLF]QHJR ........................................................................................................................................ 3RGVWDZRZH UHJX \ SURMHNWRZDQLD EDGDQLD SURVSHNW\ZQHJR .............................................................................. :\EUDQH DVSHNW\ EDGDÍ NOLQLF]Q\FK Z FKLUXUJLL RQNRORJLF]QHM .............................................................................
273 273 274 275 275
II DIAGNOSTYKA
XVIII
16. DIAGNOSTYKA KLINICZNA .............................................................................................................................. %DUWRV] 6NRQLHF]Q\ :RMFLHFK =HJDUVNL
279
8ZDJL RJÏOQH .......................................................................................................................................................... %DGDQLH SRGPLRWRZH .............................................................................................................................................. %ÏO .................................................................................................................................................................... '\VIDJLD ........................................................................................................................................................... 2EMDZ\ G\VSHSW\F]QH ...................................................................................................................................... .UHZ Z VWROFX .................................................................................................................................................. =DEXU]HQLD Z RGGDZDQLX VWROFD ..................................................................................................................... &KU\SND NDV]HO L NUZLRSOXFLH .......................................................................................................................... .UZLRPRF] QDGPLHUQH RGGDZDQLH PRF]X L ]DOHJDQLH PRF]X ...................................................................... .UZDZLHQLH ] GUÏJ URGQ\FK ............................................................................................................................ 2EMDZ\ QHXURORJLF]QH ..................................................................................................................................... &KXGQLÆFLH ....................................................................................................................................................... 7HPSHUDWXUD FLD D ............................................................................................................................................ 3RZLÆNV]RQH ZÆ] \ FK RQQH ............................................................................................................................ =PLDQD FKDUDNWHUX ]QDPLRQ VNÏUQ\FK ............................................................................................................ %DGDQLH SU]HGPLRWRZH ........................................................................................................................................... %DGDQLH VNÏU\ L WNDQNL SRGVNÏUQHM .................................................................................................................. %DGDQLH ZÆ] ÏZ FK RQQ\FK ............................................................................................................................. %DGDQLH J RZ\ L V]\L ........................................................................................................................................ %DGDQLH NODWNL SLHUVLRZHM ................................................................................................................................. %DGDQLH MDP\ EU]XV]QHM ................................................................................................................................... %DGDQLH SHU UHFWXP ......................................................................................................................................... 6LHGHP REMDZÏZ RVWU]HJDZF]\FK QRZRWZRUÏZ ] RyOLZ\FK .................................................................................
279 280 280 281 281 282 282 283 283 283 284 284 284 284 285 285 285 286 286 286 288 289 289
17. DIAGNOSTYKA OBRAZOWA ............................................................................................................................ 0DãJRU]DWD %HQNH $QGU]HM &LHV]DQRZVNL 0DUHN 'HGHFMXV (OİELHWD âXF]\ęVND -DNXE 3DãXFNL :RMFLHFK 5XGQLFNL 0DUWD :RMHZyG]ND 0LURFKD
291
8OWUDVRQRJUDILD ....................................................................................................................................................... (OİELHWD âXF]\ęVND :RMFLHFK 5XGQLFNL =DOHW\ XOWUDVRQRJUDILL Z RQNRORJLL .................................................................................................................. 2JUDQLF]HQLD XOWUDVRQRJUDILL Z RQNRORJLL ....................................................................................................... 86* MDP\ EU]XV]QHM L PLHGQLF\ ....................................................................................................................... 86* WNDQHN PLÆNNLFK QDU] GÏZ SRZLHU]FKRZQ\FK RUD] SLHUVL .................................................................... 8OWUDVRQRJUDILD yUÏGRSHUDF\MQD ......................................................................................................................
291
6SLV WUHĂFL
291 292 294 300 303
5HQWJHQRGLDJQRVW\ND WRPRJUDILD NRPSXWHURZD UH]RQDQV PDJQHW\F]Q\ .......................................................... $QGU]HM &LHV]DQRZVNL -DNXE 3DãXFNL :VWÆS ............................................................................................................................................................... 5HQWJHQRGLDJQRVW\ND ...................................................................................................................................... 5DGLRJUDILD NODV\F]QD ...................................................................................................................................... 7RPRJUDILD NRPSXWHURZD ............................................................................................................................... 5H]RQDQV PDJQHW\F]Q\ WRPRJUDILD UH]RQDQVX PDJQHW\F]QHJR ................................................................. =DVWRVRZDQLH EDGDÍ REUD]RZ\FK Z GLDJQRVW\FH QRZRWZRUÏZ Z SRV]F]HJÏOQ\FK REV]DUDFK DQDWRPLF]Q\FK ................................................................................................................................................ 2FHQD VWRSQLD ]DDZDQVRZDQLD QRZRWZRUÏZ =DVWRVRZDQLH WHFKQLN GLDJQRVW\NL REUD]RZHM 7. L 05, Z RFHQLH 710 ............................................................................................................... 2FHQD RGSRZLHG]L QD OHF]HQLH RQNRORJLF]QH ................................................................................................. 6NULQLQJ ............................................................................................................................................................ 5DN Z WURERZRNRPÏUNRZ\ ............................................................................................................................ =DVWRVRZDQLH L]RWRSÏZ UDGLRDNW\ZQ\FK Z FKLUXUJLL RQNRORJLF]QHM ..................................................................... 0DãJRU]DWD %HQNH 0DUHN 'HGHFMXV :SURZDG]HQLH L SRGVWDZ\ PHG\F\Q\ QXNOHDUQHM .......................................................................................... &]Æy V]F]HJÏ RZD .......................................................................................................................................... 3R]\WRQRZD WRPRJUDILD HPLV\MQD Z FKLUXUJLL RQNRORJLF]QHM ................................................................................ 0DUWD :RMHZyG]ND 0LURFKD 0DUHN 'HGHFMXV :VWÆS ............................................................................................................................................................... 5DGLRIDUPDFHXW\NL VWRVRZDQH Z 3(7 .............................................................................................................. 3U]HELHJ EDGDQLD 3(7 ...................................................................................................................................... 3U]HFLZZVND]DQLD PHG\F]QH GR EDGDQLD 3(7 7. ........................................................................................... 6WDQGDU\]RZDQD ZDUWRy Z\FKZ\WX UDGLR]QDF]QLND ..................................................................................... 2JÏOQH ZVND]DQLD RQNRORJLF]QH GR Z\NRQDQLD EDGDQLD 3(7 ........................................................................ .OLQLF]QH ]DVWRVRZDQLH 3(7 t ZVND]DQLD V]F]HJÏ RZH ...................................................................................
304 304 305 305 306 308 315 320 322 324 326 328 328 334 344 344 344 346 347 347 348 349
18. DIAGNOSTYKA PATOMORFOLOGICZNA ..................................................................................................... $QQD 1DVLHURZVND *XWWPHMHU
365
:VSÏ SUDFD FKLUXUJD ] SDWRPRUIRORJLHP .............................................................................................................. 0HWRG\ GLDJQRVW\F]QH ............................................................................................................................................ 0DWHULD F\WRORJLF]Q\ ELRSVMD DVSLUDF\MQD FLHQNRLJ RZD L F\WRORJLD ] XV]F]HQLRZD ..................................... 0DWHULD WNDQNRZ\ ........................................................................................................................................... %DGDQLH yUÏGRSHUDF\MQH .................................................................................................................................. 3U]HELHJ EDGDQLD SDWRPRUIRORJLF]QHJR ................................................................................................................ 5ROD SDWRPRUIRORJD Z RFHQLH F]\QQLNÏZ SURJQRVW\F]Q\FK L SUHG\NF\MQ\FK ........................................................
365 366 366 368 369 370 372
19. DIAGNOSTYKA ENDOSKOPOWA NOWOTWORÓW .................................................................................. -DURVãDZ 5HJXãD 0LFKDã ) .DPLęVNL
377
'LDJQRVW\ND HQGRVNRSRZD X SDFMHQWÏZ ] SRGHMU]HQLHP FKRURE\ QRZRWZRURZHM .............................................. *DVWURVNRSLD HQGRVNRSLD JÏUQHJR RGFLQND SU]HZRGX SRNDUPRZHJR ....................................................... .RORQRVNRSLD HQGRVNRSLD GROQHJR RGFLQND SU]HZRGX SRNDUPRZHJR ....................................................... (QGRVNRSRZD FKRODQJLRSDQNUHDWRJUDILD ZVWHF]QD (&3: .......................................................................... (QGRVRQRJUDILD (86 ] ELRSVM EH] ELRSVML .................................................................................................... (QGRVNRSLD MHOLWD FLHQNLHJR ............................................................................................................................. %URQFKRVNRSLD GLDJQRVW\F]QD ......................................................................................................................... 5ROD HQGRVNRSLL Z EDGDQLDFK SU]HVLHZRZ\FK ............................................................................................... 5DN MHOLWD JUXEHJR ........................................................................................................................................... 1DG]ÏU HQGRVNRSRZ\ SR OHF]HQLX FKLUXUJLF]Q\P QRZRWZRUÏZ ........................................................................... 5DN MHOLWD JUXEHJR ........................................................................................................................................... 5DN R GND .....................................................................................................................................................
377 377 380 382 384 386 386 388 388 389 389 389
6SLV WUHĂFL
XIX
20. %$'$1,( :Č=â$ &+â211(*2 :$572:1,&=(*2 ................................................................................. Dawid Murawa
391
:VWÆS ...................................................................................................................................................................... 3URFHGXUD ELRSVML ZÆ] D ZDUWRZQLF]HJR ................................................................................................................ 5DGLRIDUPDFHXW\NL .................................................................................................................................................. 6RQG\ JDPPD ......................................................................................................................................................... 0RG\ILNDFMH L Z\EÏU ]QDF]QLNÏZ ............................................................................................................................ /RNDOL]DFMH QDU] GRZH ELRSVML ZÆ] D ZDUWRZQLF]HJR ............................................................................................ 5DN SLHUVL ......................................................................................................................................................... &]HUQLDN ...........................................................................................................................................................
391 392 395 395 395 396 396 397
21. BADANIA PRZESIEWOWE .................................................................................................................................. =ELJQLHZ , 1RZHFNL 3DZHã :LQWHU $QQD &KDEHU &LRSLęVND 0LFKDã ) .DPLęVNL
399
%DGDQLD SU]HVLHZRZH Z UDNX SLHUVL ........................................................................................................................ %DGDQLD SU]HVLHZRZH Z UDNX V]\MNL PDFLF\ ............................................................................................................ %DGDQLD SU]HVLHZRZH Z UDNX MHOLWD JUXEHJR ..........................................................................................................
400 402 402
22. :<%5$1( :6.$ĭ1,., %$'$Ę /$%25$725<-1<&+ 8 &+25<&+ 1$ 12:27:Ð5 ...................... $GDP 'XUF]\ęVNL 3LRWU +RJHQGRUI $UNDGLXV] -H]LRUVNL
405
:\EUDQH ELD NRZH PDUNHU\ QRZRWZRURZH ........................................................................................................... :\EUDQH PROHNXODUQH PDUNHU\ QRZRWZRURZH ...................................................................................................... 7\S\ PDUNHUÏZ PROHNXODUQ\FK ........................................................................................................................ 0ROHNXODUQH PDUNHU\ QRZRWZRURZH Z Z\EUDQ\FK QRZRWZRUDFK OLW\FK ............................................................. 5DN SLHUVL ......................................................................................................................................................... 5DN MHOLWD JUXEHJR ........................................................................................................................................... 5DN QLHGUREQRNRPÏUNRZ\ S XFD .................................................................................................................... 5DN WU]XVWNL ......................................................................................................................................................
405 409 409 410 410 411 412 412
III ZAGADNIENIA PRAWNE
XX
23. INFORMOWANIE PACJENTA I OSÓB TRZECICH ......................................................................................... 5DIDã .XELDN
419
:SURZDG]HQLH ........................................................................................................................................................ nUÏG D SUDZQH L GHRQWRORJLF]QH RERZL ]NX XG]LHODQLD LQIRUPDFML PHG\F]QHM ..................................................... 3RGPLRW\ XSUDZQLRQH GR X]\VNDQLD LQIRUPDFML PHG\F]QHM ................................................................................... 'HF\GHQFL ........................................................................................................................................................ 2VRE\ WU]HFLH ................................................................................................................................................... 3U]HGPLRWRZ\ ]DNUHV LQIRUPDFML ............................................................................................................................. 6SRVÏE L F]DV SU]HND]DQLD LQIRUPDFML ..................................................................................................................... 2JUDQLF]HQLD RERZL ]NX LQIRUPDF\MQHJR .............................................................................................................. =U]HF]HQLH VLÆ SUDZD GR LQIRUPDFML ................................................................................................................. 3U]\ZLOHM WHUDSHXW\F]Q\ ...................................................................................................................................
419 421 422 422 423 425 428 430 430 430
24. ZGODA NA ZABIEG MEDYCZNY – WYBRANE ASPEKTY ............................................................................ 5DIDã .XELDN
435
:SURZDG]HQLH (ZROXFMD UR]ZL ]DÍ L NRQVHNZHQFMH SUDZQH Z\NRQDQLD ]DELHJX EH] VNXWHF]QHM SUDZQLH ]JRG\ .... 5RG]DMH ]JÏG ]H Z]JOÆGX QD SRGPLRW GHF\GXM F\ R OHF]HQLX ............................................................................... =JRGD VDPRG]LHOQD SDFMHQWD ..........................................................................................................................
435 437 437
6SLV WUHĂFL
=JRGD ]DVWÆSF]D VXEVW\WXF\MQD .................................................................................................................... =JRGD NXPXODW\ZQD UÏZQROHJ D .................................................................................................................. =JRGD V GRZD ................................................................................................................................................. 3U]HGPLRW L V]F]HJÏ RZRy ]JRG\ .......................................................................................................................... )RUPD ]JRG\ ........................................................................................................................................................... :\NRQDQLH ]DELHJX ]D ]JRG GRPQLHPDQ ...........................................................................................................
439 442 443 444 448 451
25. DOKUMENTACJA MEDYCZNA – WYBRANE ZAGADNIENIA .................................................................... 5DIDã .XELDN
455
:SURZDG]HQLH nUÏG D UHJXODFML ............................................................................................................................. 'HILQLFMH GRW\F] FH GRNXPHQWDFML PHG\F]QHM ........................................................................................................ =DVDG\ SURZDG]HQLD GRNXPHQWDFML PHG\F]QHM ...................................................................................................... 8GRVWÆSQLDQLH GRNXPHQWDFML PHG\F]QHM ................................................................................................................ 8ZDJL ZSURZDG]DM FH .................................................................................................................................... 3RGPLRW\ XSUDZQLRQH GR GRVWÆSX GR GRNXPHQWDFML PHG\F]QHM ................................................................... 6SRVRE\ XGRVWÆSQLHQLD ................................................................................................................................... 3URFHGXUD XGRVWÆSQLHQLD L NRQVHNZHQFMH EH]SRGVWDZQHM RGPRZ\ .............................................................. 2S DW\ ]D XGRVWÆSQLHQLH GRNXPHQWDFML PHG\F]QHM ........................................................................................ 3U]HFKRZ\ZDQLH GRNXPHQWDFML .............................................................................................................................. 2GSRZLHG]LDOQRy NDUQD ]D ID V]RZDQLH GRNXPHQWDFML PHG\F]QHM ......................................................................
455 457 458 459 459 459 465 467 468 470 471
26. 2'32:,('=,$/12ģý &<:,/1$ /(.$5=$ &+,585*$ 21.2/2*$ ² WYBRANE ZAGADNIENIA ................................................................................................................................. 5DIDã .XELDN
475
5H LP\ RGSRZLHG]LDOQRyFL F\ZLOQHM ........................................................................................................................ 2JÏOQH SU]HV DQNL RGSRZLHG]LDOQRyFL RGV]NRGRZDZF]HM ...................................................................................... 6]NRGD ............................................................................................................................................................. :LQD ................................................................................................................................................................ =ZL ]HN SU]\F]\QRZ\ ...................................................................................................................................... kZLDGF]HQLD QDOH QH SDFMHQWRZL ] W\WX X XV]NRG]HQLD FLD D OXE UR]VWURMX ]GURZLD .............................................. =ZURW NRV]WÏZ ................................................................................................................................................. =DGRyÂXF]\QLHQLH ............................................................................................................................................. 5HQWD ................................................................................................................................................................ 3U]\F]\QLHQLH VLÆ GR SRZVWDQLD OXE ]ZLÆNV]HQLD V]NRG\ ........................................................................................ 5RV]F]HQLD RVÏE WU]HFLFK Z Z\SDGNX yPLHUFL SDFMHQWD ......................................................................................... 8ZDJL ZSURZDG]DM FH .................................................................................................................................... =ZURW NRV]WÏZ OHF]HQLD L SRJU]HEX ................................................................................................................ 2ERZL ]HN ]DS DW\ UHQW\ RVRERP WU]HFLP ..................................................................................................... 2GV]NRGRZDQLH L ]DGRyÂXF]\QLHQLH ] W\WX X ]QDF]QHJR SRJRUV]HQLD V\WXDFML \FLRZHM ............................... =DGRyÂXF]\QLHQLH ]D QDUXV]HQLH SUDZ SDFMHQWD .....................................................................................................
475 477 477 478 481 483 483 484 486 488 489 489 490 490 491 493
27. 2'32:,('=,$/12ģý .$51$ /(.$5=$ &+,585*$ 21.2/2*$ =$ 6.87., %âČ'8 0('<&=1(*2 ................................................................................................................... 5DIDã .XELDN
497
:SURZDG]HQLH ........................................................................................................................................................ 3RMÆFLH E ÆGX PHG\F]QHJR ..................................................................................................................................... 2JÏOQH SU]HV DQNL RGSRZLHG]LDOQRyFL NDUQHM ......................................................................................................... =DNUHV RGSRZLHG]LDOQRyFL NDUQHM ]D VNXWNL E ÆGÏZ PHG\F]Q\FK 3U]\SLVDQLH QLHXP\yOQRyFL ............................... 5RG]DMH E ÆGÏZ PHG\F]Q\FK .................................................................................................................................. 2GSRZLHG]LDOQRy NDUQD ]D VNXWNL E ÆGX PHG\F]QHJR SRSH QLRQHJR SU]H] RVRE\ G]LD DM FH Z ]HVSROH ...........
497 497 498 502 507 509
Skorowidz ...................................................................................................................................................................
515
6SLV WUHĂFL
XXI
FG WDEHOL
52
.RPÏUNL XN DGX RGSRUQRyFLRZHJR
5ROD Z XN DG]LH RGSRUQRyFLRZ\P Z UR]ZRMX QRZRWZRUX
$3& DQWLJHQ SUHVHQWLQJ FHOOV t NRPÏUNL SUH]HQWXM FH DQW\JHQ '& L'& 0 0
3REXG]DM VZRLVWH DQW\JHQRZR OLPIRF\W\ 7K L 7F QD GURG]H NU]\ RZHM SUH]HQWDFML DQW\JHQX L W\P VDP\P XF]HVWQLF] Z NV]WD WRZDQLX VLÆ VZRLVWHM RGSRZLHG]L RGSRUQRyFLRZHM )DJRF\WXM DQW\JHQ\ L WUDQVSRUWXM MH GR ZÆ] ÏZ FK RQQ\FK 3RVLDGDM QD SRZLHU]FKQL 0+& ,, 3RVLDGDM ]GROQRy SUH]HQWDFML DQW\JHQX ]DUÏZQR Z 0+& , SUH]HQWDFMD 7F MDN L 0+& ,, SUH]HQWDFMD 7K 0R QD Z\UÏ QL D SURIHVMRQDOQH $3& J ÏZQLH '& PDNURIDJL L OLPIRF\W\ % ]GROQH GR SREXG]HQLD G]LHZLF]\FK 7K L OLPIRF\WÏZ 7 SDPLÆFL LPPXQRORJLF]QHM E QLHSURIHVMRQDOQH $3& QS DVWURF\W\ ILEUREODVW\ L NRPÏUNL JOHMRZH QD NWÏU\FK SRZLHU]FKQL GRFKRG]L GR HNVSUHVML 0+& ,, SRG ZS \ZHP ,)1 γ
'& GHQGULWLF FHOOV t NRPÏUNL GHQGU\W\F]QH
:\ND]XM G]LD DQLH SU]HFLZQRZRWZRURZH 6 SURIHVMRQDOQ\PL $3& 3REXG]DM OLPIRF\W\ Z W\P WDN H W]Z OLPIRF\W\ G]LHZLF]H NWÏUH QLJG\ ZF]HyQLHM QLH ]HWNQÆ \ VLÆ ] DQW\JHQHP dSULPLQJr OLPIRF\WÏZ =DOLF]D VLÆ GR QLFK NRPÏUNL /DQJHUKDQVD Z VNÏU]H NRPÏUNL GHQGU\W\F]QH REHFQH Z QDU] GDFK OLPIDW\F]Q\FK NRPÏUNL GHQGU\W\F]QH JUXGNL FK RQQHM )'& t IROOLFXODU GHQGULWLF FHOOV NRPÏUNL GHQGU\W\F]QH NUZL REZRGRZHM 3%'& t SHULSKHUDO EORRG GHQGULWLF FHOOV
L'& t QLHGRMU]D H NRPÏUNL GHQGU\W\F]QH
:\ND]XM G]LD DQLH SURPXM FH UR]ZÏM QRZRWZRUX 6 UHNUXWRZDQH SU]H] NRPÏUNL QRZRWZRURZH ]D SRPRF &;&/ &;&/ β GHIHQV\Q\ 9(*) 0DM Z DyFLZRyFL SURDQJLRJHQQH :\ZR XM LPPXQRVXSUHVMÆ 5HNUXWXM QHXWURILOH ]H V]SLNX NRVWQHJR :\G]LHODM ,'2 GLRNV\JHQD]\ LQGROHDPLQ\ NWÏUD NDWDEROL]XM F WU\SWRIDQ JHQHUXMH SRZVWDZDQLH ]ZL ]NÏZ WRNV\F]Q\FK GOD OLPIRF\WÏZ 7
0DNURIDJL 0 &' E &' &' &' &' &' &'
:\ND]XM G]LD DQLH SU]HFLZQRZRWZRURZH )DJRF\WXM L QLV]F] EDNWHULH (OLPLQXM NRPÏUNL QRZRWZRURZH SRSU]H] DNW\ZDFMÆ NRPÏUHN R Z DyFLZRyFLDFK F\WRWRNV\F]Q\FK SUH]HQWDFMD DQW\JHQX OLPIRF\WRP :\WZDU]DM F\WRNLQ\ SUR]DSDOQH ,/ ,/ ,/ ,/ ,)1 α ,)1 β 3RZVWDM Z RGSRZLHG]L QD ,)1 γ /36 *0 &6) SRODU\]DFMD Z NLHUXQNX 0 SU]HZDJD 0 Z VWRVXQNX GR 0
7$0 WXPRU DVVRFLDWHG PDFURSKDJHV t PDNURIDJL 0 &' &' &' &' &' &'
:\ND]XM G]LD DQLH SURPXM FH UR]ZÏM QRZRWZRUX %LRU XG]LD Z UR]ZRMX L SURJUHVML QRZRWZRUX 0RJ VWDQRZL RNR R PDV\ QRZRWZRUX :\ZR XM LPPXQRVXSUHVMÆ VSU]\MDM F SURJUHVML QRZRWZRUX D WDN H SURFHVRZL JRMHQLD UDQ :\WZDU]DM F]\QQLNL SURDQJLRJHQQH 9(*) E)*) ,/ β 71) α ,/ 3'*)β L ELRU XG]LD Z WZRU]HQLX QRZ\FK QDF]\Í NUZLRQRyQ\FK Z JX]LH :\G]LHODM V\QWD]\ 12 L DUJLQD]\ NWÏUH NDWDEROL]XM F VN DGQLNL RG \ZF]H QLH]EÆGQH GOD IXQNFML OLPIRF\WÏZ 7 L 1. KDPXM LFK DNW\ZQRy GRGDWNRZR HQ]\P\ WH GRSURZDG]DM GR SRZVWDQLD DUJLQLQ\ L 12 FR XSRyOHG]D IXQNFMÆ 7&5 P LQ SU]H] MHJR QLWUR]\ODFMÆ QLWU\ODFML XOHJDM WDN H LQQH ELD ND QD SRZLHU]FKQL OLPIRF\WÏZ 7 :\WZDU]DM F]\QQLNL Z]URVWRZH G]LD DM FH QD NRPÏUNL QRZRWZRURZH (*) ,/ ,/ 3*(
I. Wprowadzenie do chirurgii onkologicznej
FG WDEHOL
.RPÏUNL XN DGX RGSRUQRyFLRZHJR
5ROD Z XN DG]LH RGSRUQRyFLRZ\P Z UR]ZRMX QRZRWZRUX 8F]HVWQLF] Z SU]HEXGRZLH VXEVWDQFML SR]DNRPÏUNRZHM Z\G]LHODM F HQ]\P\ SURWHROLW\F]QH 003 003 003 X3$ :\WZDU]DM ELD ND VXEVWDFML SR]DNRPÏUNRZHM QS ILEU\QÆ L NRODJHQ
0'6& P\HORLG GHU ULYHG VXSSUHVRU FHOOV t NRPÏUNL VXSUHVRURZH SRFKRG]HQLD V]SLNR ZHJR &' E *U
3UHNXUVRU\ PDNURIDJÏZ QHXWURILOL L NRPÏUHN GHQGU\W\F]Q\FK :\ND]XM G]LD DQLH SURPXM FH UR]ZÏM QRZRWZRUX :\G]LHODM V\QWD]\ 12 L DUJLQD]\ NWÏUH NDWDEROL]XM F VN DGQLNL RG \ZF]H QLH]EÆGQH GOD IXQNFML OLPIRF\WÏZ 7 L 1. KDPXM LFK DNW\ZQRy GRGDWNRZR HQ]\P\ WH GRSURZDG]DM GR SRZVWDQLD DUJLQLQ\ L 12 FR XSRyOHG]D IXQNFMÆ 7&5 P LQ SU]H] MHJR L LQQ\FK ELD HN SRZLHU]FKQLRZ\FK QLWUR]\ODFMÆ
$'&& DQWLERG\ GHSHQGHQW FHOOXODU F\WRWR[LFLW\ t F\WRWRNV\F]QRy NRPÏUNRZD ]DOH QD RG SU]HFLZFLD &;&/ &;& PRWLI FKHPRNLQH OLJDQGV t FKHPRNLQ\ ] PRW\ZHP &;& (*) HSLGHUPDO JURZWK IDFWRU t QDVNÏUNRZ\ F]\QQLN Z]URVWX )DV/ t F\WRNLQD QDOH FD GR URG]LQ\ 71) )*) ILEUREODVW JURZWK IDFWRU t F]\QQLN Z]URVWX ILEUREODVWÏZ )2;3 IRUNKHDG ER[ 3 t F]\QQLN WUDQVNU\SF\MQ\ )2;3 *0 &6) JUDQXORF\WH PDFURSKDJH FRORQ\ VWLPXODWLQJ IDFWRU t F]\QQLN VW\PXOXM F\ WZRU]HQLH NRORQLL JUDQXORF\WÏZ L PDNURIDJÏZ ,/ t LQWHUOHXNLQ\ ,)1 t LQWHUIHURQ 0+& PDMRU KLVWRFRPSDWLELOLW\ FRPSOH[ t J ÏZQ\ XN DG ]JRGQRyFL WNDQNRZHM X F] RZLHND 0+& QRV] QD]ZÆ +/$ 0+& NODV\ , 0+& , ]QDMGXM VLÆ QD ZV]\VWNLFK M GU]DVW\FK NRPÏUNDFK RUJDQL]PX Z\QRV] QD SRZLHU]FKQLÆ NRPÏUNL DQW\JHQ\ IUDJPHQW\ ELD HN SRZVWDM F\FK Z NRPÏUNDFK Z FHOX ]DSUH]HQWRZDQLD LFK OLPIRF\WRP 7 0+& NODV\ ,, 0+& ,, Z\VWÆSXM QD NRPÏUNDFK SUH]HQWXM F\FK DQW\JHQ 003 PDWUL[ PHWDOORSURWHLQDVH t PHWDORSURWHLQD]D PDFLHU]RZD 3'*) SODWHOHW GHULYHG JURZWK IDFWRU t S \WNRSRFKRGQ\ F]\QQLN Z]URVWX 3*( t SURVWDJODQG\QD 7$0 7XPRU $VVRFLDWHG 0DFURSKDJHV t WHUPLQ RNUHyODM F\ ORNDOL]DFMÆ 2GQRVL VLÆ GR ZV]\VWNLFK PDNURIDJÏZ NWÏUH ]RVWD \ ]UHNUXWRZDQH SU]HNV]WD FRQH SU]H] V\JQD \ QRZRWZRUX L ]QDMGXM VLÆ Z PLNURyURGRZLVNX JX]D Z MHJR REUÆELH OXE EH]SRyUHGQLP V VLHG]WZLH 0 L 0 WR WHUPLQ\ RSLVXM FH IXQNFMÆ OXE VWDQ SRODU\]DFML PDNURIDJD -HVW WR XSURV]F]RQ\ PRGHO NWÏU\ G]LHOL PDNURIDJL QD GZD J ÏZQH WU\E\ G]LD DQLD 7$0 PRJ SU]\M  SRODU\]DFMÆ 0 OXE 0 : SUDNW\FH MHGQDN V\WXDFMD Z\JO GD QDVWÆSXM FR :H ZF]HVQ\FK ID]DFK UR]ZRMX JX]D Z MHJR RWRF]HQLX PRJ ]QDMGRZD VLÆ PDNURIDJL 0 NWÏUH SUÏEXM JR ]QLV]F]\ -HGQDN NRPÏUNL QRZRWZRURZH SRWUDIL RV]XND XN DG RGSRUQRyFLRZ\ :\G]LHODM V\JQD \ FKHPLF]QH QS ,/ 7*) β NWÏUH SU]HSURJUDPRZXM PDNURIDJL QDS \ZDM FH GR JX]D : UH]XOWDFLH Z ZLÆNV]RyFL UR]ZLQLÆW\FK JX]ÏZ OLW\FK ]GHF\GRZDQD ZLÆNV]Ry 7$0 WR PDNURIDJL R IHQRW\SLH 0 SRGREQ\P 7&5 7 FHOO UHFHSWRU t UHFHSWRU OLPIRF\WX 7 71) WXPRU QHFURVLV IDFWRU t F]\QQLN PDUWZLF\ QRZRWZRUX 75$,/ 71) UHODWHG DSRSWRVLV OLJDQG t ]ZL ]DQ\ ] F]\QQLNLHP PDUWZLF\ QRZRWZRUX OLJDQG LQGXNXM F\ DSRSWR]Æ X 3$ XURNLQDVH W\SH SODVPLQRJHQ DFWLYDWRU t DNW\ZDWRU SOD]PLQRJHQX W\SX XURNLQD]\ 9(*) YDVFXODU HQGRWKHOLDO JURZWK IDFWRU t F]\QQLN Z]URVWX yUÏGE RQND QDF]\QLRZHJR
: ID]LH HOLPLQDFML PHFKDQL]P\ RGSRUQRyFL VZRLVWHM L QLHVZRLVWHM V Z VWDQLH QLV]F]\Â NRPÏUNL QRZRWZR URZH FR XWUXGQLD L VSRZDOQLD UR]ZÏM JX]D 8ZD D VLÆ H ]D SU]HFLZQRZRWZRURZH G]LD DQLH XN DGX RGSRUQRyFLRZHJR RGSRZLHG]LDOQH V 1. 7F 7K '& L PDNURIDJL 0 Z\MDyQLHQLD VNUÏWÏZ L RSLV t ]RE WDE : ID]LH UÏZQRZDJL Z SURFHVLH VHOHNFML NOR QÏZ NRPÏUHN QRZRWZRURZ\FK SRG ZS \ZHP XN DGX
2GSRUQRy VZRLVWD DGDSWDF\MQD QDE\WD FHFKXMH VLÆ VSH F\ILF]QRyFL Z RGQLHVLHQLX GR RNUHyORQ\FK PDNURF] VWHF]HN UR]ZLMD VLÆ Z F]DVLH GRSURZDG]D GR SRZVWDQLD SDPLÆFL LPPX QRORJLF]QHM ,VWQLHM GZD W\S\ RGSRZLHG]L VZRLVWHM NRPÏUNRZD L KXPRUDOQD 2GSRUQRy QLHVZRLVWD ZURG]RQD NWÏUHM PHFKDQL]P\ V VWDOH REHFQH Z RUJDQL]PLH REHMPXMH EDULHU\ IL]\F]QH QS FL J Ry QDVNÏUND REHFQRy UHFHSWRUÏZ 355 UHFHSWRUÏZ UR]SR]QDM F\FK Z]RUFH QD SRZLHU]FKQL NRPÏUHN IDJRF\WXM F\FK QHXWURILOL PDNURIDJÏZ NWÏUH ZL F VLÆ ] ELD NDPL 3$03 SDWRJHQÏZ SDWRJHQ DVVRFLDWHG PROHFXODU SDWWHUQV GRSURZD G]DM GR V\QWH]\ GHIHQV\Q L F\WRNLQ SUR]DSDOQ\FK 71) ,/ ,/ ELD NR & UHDNW\ZQH RUD] IDJRF\WR]\ SDWRJHQÏZ
RGSRUQRyFLRZHJR SRMDZLDM VLÆ ZDULDQW\ JHQHW\F]QH L IHQRW\S\ QRZRWZRURZH R PQLHMV]HM LPPXQRJHQQR yFL NWÏUH V Z VWDQLH XQLNQ  HOLPLQDFML SU]H] XN DG RGSRUQRyFLRZ\ )D]D UÏZQRZDJL E\ZD QDMG X V] ] ID] SURFHVX LPPXQRHG\FML = NROHL Z ID]LH XFLHF]NL GRPLQXM NRPÏUNL XN DGX RGSRUQRyFLRZHJR PDM FH ]GROQRy SURPRZDQLD Z]URVWX QRZRWZRUX ZyUÏG NWÏU\FK Z\PLHQL QDOH \ 7UHJ )2;3 7K PDNURIDJL 0 0'6& Z\MDyQLHQLD VNUÏWÏZ L RSLV t ]RE WDE 'RGDWNRZR VDPH NRPÏUNL QRZRWZRURZH XQLNDM UR] SR]QDQLD L HOLPLQDFML SU]H] XN DG RGSRUQRyFLRZ\ RUD] KDPXM DNW\ZQRy Z\EUDQ\FK HOHPHQWÏZ RGSRZLHG]L LPPXQRORJLF]QHM 8QLNDQLH UR]SR]QDQLD SU]H] NRPÏUNL XN DGX RGSRU QRyFLRZHJR PR H E\ UHDOL]RZDQH Z NRPÏUNDFK QRZRWZRURZ\FK SU]H] REQL HQLH HNVSUHVML 0+& , UROÆ ELD HN 0+& , Z\MDyQLRQR Z RSLVLH SRG WDE L QD U\F > t @ ] XV]F]DQLH DQW\JHQÏZ ] SRZLHU]FKQL NRPÏUHN QRZRWZRURZ\FK OXE LFK PQLHMV] HNVSUHVMÆ QD SRZLHU]FKQL NRPÏUHN QRZRWZR URZ\FK NWÏUD ] NROHL PR H E\ VSRZRGRZDQD SU]H]
%LRORJLD QRZRWZRUöZ
53
3$3 t SURVWDWLF DFLG SKRVSKDWDVH RUD] F]\QQLNLHP LPPXQRVW\PXOXM F\P *0 &6) XPR OLZL D ]QDPLHQQ SRSUDZÆ URNRZDQLD FKRU\FK QD ]DDZDQVRZDQHJR RSRUQHJR QD NDVWUDFMÆ UDND JUXF]R X NURNRZHJR L MHVW Z FKZLOL REHFQHM MHG\Q V]F]HSLRQN RSDUW QD NRPÏU NDFK '& ]DUHMHVWURZDQ Z RQNRORJLL
6]F]HSLRQNL RSDUWH QD EDNWHULDFK /LVWHULD PRQRF\WRJHQHV MHVW SDWRJHQHP ZHZQ WU]NR PÏUNRZ\P SU]HFKRG] F\P F\NO \FLRZ\ ZHZQ WU] OHXNRF\WÏZ Z W\P NRPÏUHN SUH]HQWXM F\FK DQW\JHQ QLH SURZDG] F GR ]QLV]F]HQLD NRPÏUNL JRVSRGDU]D 7\P VDP\P EDNWHULD WD MHVW LGHDOQ\P QRyQLNLHP DQW\ JHQÏZ NWÏUH PRJ XOHJDÂ G XJRWUZD HM HNVSUHVML L SUH ]HQWDFML Z NRPÏUNDFK '& =DVWRVRZDQLH X FKRU\FK QD ]DDZDQVRZDQHJR UDND WU]XVWNL V]F]HSLRQNL RSDUWHM QD /LVWHULL PRG\ILNRZDQHM DQW\JHQHP QRZRWZRURZ\P t PH]RWHOLQ RUD] V]F]HSLRQNL VN DGDM FHM VLÆ ] NRPÏ UHN UDND WU]XVWNL PRG\ILNRZDQ\FK JHQHP *0 &6) Z EDGDQLX ,, ID]\ XPR OLZL R ]QDPLHQQ SRSUDZÆ URNRZDQLD
yZLDGF]\ \ ]DUÏZQR R HIHNW\ZQ\P UR]SR]QDZDQLX NRPÏUHN QRZRWZRURZ\FK MDN L R XSRyOHG]HQLX PHFKD QL]PÏZ HIHNWRURZ\FK ZDUXQNXM F\FK LFK HOLPLQDFMÆ 2EVHUZDFMH WH X]DVDGQLD \ SRV]XNLZDQLH PR OLZRyFL DNW\ZRZDQLD IXQNFML F\WRWRNV\F]Q\FK OLPIRF\WÏZ UR] SR]QDM F\FK NRPÏUNL QRZRWZRURZH : NRQVHNZHQFML ]DF]ÆWR SURZDG]L SUÏE\ QDG L]RODFM NRPÏUHN QDFLH NDM F\FK JX] NWÏUH SR VW\PXODFML L SURSDJDFML Z ZDUXQ NDFK H[ YLYR SRQRZQLH SRGDZDQR FKRU\P %DGDQLD QDG VWUDWHJL WUDQVIHUX OLPIRF\WÏZ SURZDG]RQH RG SRF] WNX ODW ;; Z SRWZLHUG]D \ LFK DNW\ZQRy Z QLHZLHONLFK SRSXODFMDFK FKRU\FK 1DMQRZV]\P UR] ZLQLÆFLHP VWUDWHJLL DGRSW\ZQHJR WUDQVIHUX OLPIRF\WÏZ MHVW JHQHW\F]QD PRG\ILNDFMD OLPIRF\WÏZ SROHJDM FD QD ZSURZDG]HQLX GR QLFK JHQX NRGXM FHJR UHFHSWRU 7&5 UR]SR]QDM F\ ]GHILQLRZDQ\ DQW\JHQ QRZRWZRURZ\ 6WUDWHJLD WD PDM FD MDN GR WHM SRU\ ]DVWRVRZDQLH MHG\ QLH Z SU]\SDGNX QRZRWZRUÏZ SRVLDGDM F\FK VWDELOQ\ SRMHG\QF]\ L XQLNDOQ\ DQW\JHQ QRZRWZRURZ\ SU]H GH ZV]\VWNLP QRZRWZRU\ KHPDWRORJLF]QH FKDUDN WHU\]XMH VLÆ EDUG]R Z\VRN DNW\ZQRyFL SURZDG] F Z ZLÆNV]RyFL UDSRUWRZDQ\FK GR WHM SRU\ SU]\SDGNÏZ GR FD NRZLWHM UHPLVML FKRURE\ QRZRWZRURZHM
6]F]HSLRQNL 51$ 0HFKDQL]P G]LD DQLD V]F]HSLRQHN P51$ SROHJD QD GRVWDUF]HQLX GR NRPÏUHN QDMF]ÆyFLHM GHQGU\W\F]Q\FK IUDJPHQWÏZ P51$ NRGXM F\FK DQW\JHQ \ FKDUDNWHU\ VW\F]QH GOD NRPÏUHN QRZRWZRURZ\FK ']LÆNL HQNDSVX ODFML Z QDQRF] VWNDFK OLSLGRZ\FK P51$ MHVW FKURQLRQH SU]HG GHJUDGDFM Z RUJDQL]PLH L WUDILD GR NRPÏUHN GHQGU\W\F]Q\FK SR SRGDQLX SRGVNÏUQ\P OXE GRPLÆ yQLRZ\P 3R LQWHUQDOL]DFML SU]H] NRPÏUNL SUH]HQWX M FH DQW\JHQ GRFKRG]L Z QLFK GR SURGXNFML ELD HN QD PDFLHU]\ ZSURZDG]RQHJR P51$ NWÏUH QDVWÆSQLH V SU]HWZDU]DQH L SUH]HQWRZDQH QD SRZLHU]FKQL NRPÏ UHN Z NRQWHNyFLH F] VWHF]HN 0+& NODV\ , RUD] 0+& NODV\ ,, 7R XPR OLZLD LQGXNFMÆ VSHF\ILF]QHM RGSRZLHG]L OLPIRF\WÏZ 7 t ]DUÏZQR F\WRWRNV\F]Q\FK &' MDN L SRPRFQLF]\FK &' : UDQGRPL]RZDQ\P EDGDQLX ID]\ ,,E .(<127( FKRU\P SR UHVHNFML F]HUQLDND ,,,%t,9 SRGDZDQR V]F]HSLRQNÆ P51$ Z VNRMD U]HQLX ] SHPEUROL]XPDEHP OXE VDP SHPEUROL]XPDE 6NRMDU]HQLH V]F]HSLRQNL ] LQKLELWRUHP 3' Z\ND]D R Z\UD|Q\ WUHQG Z NLHUXQNX SRSUDZ\ F]DVX SU]H \FLD ZROQHJR RG QDZURWX FKRURE\
$GRSW\ZQ\ WUDQVIHU OLPIRF\WyZ %RJDWH QDFLHNL OLPIRF\WDUQH REVHUZRZDQH Z SU]\SDG NX ZLHOX QRZRWZRUÏZ DOH Z V]F]HJÏOQRyFL F]HUQLDND
.RQLXJDW\ SU]HFLZFLDãR²OHN F\WRWRNV\F]Q\ .RQLXJDW\ SU]HFLZFLD RtOHN $'& t DQWLERG\tGUXJ FRQMXJDWHV VWDQRZL QRZDWRUVN JUXSÆ OHNÏZ FHOR ZDQ\FK NWÏUD F]\ VSHF\ILF]QRy SU]HFLZFLD PRQR NORQDOQ\FK ] EH]SRyUHGQLP G]LD DQLHP SU]HFLZQRZR WZRURZ\P F\WRWRNV\F]Q\FK ]ZL ]NÏZ FKHPLF]Q\FK 3RGVWDZRZ\P HOHPHQWHP $'& MHVW SU]HFLZFLD R PR QRNORQDOQH XNLHUXQNRZDQH SU]HFLZNR VSHF\ILF]QH PX ELD NX E RQRZHPX REHFQHPX QD SRZLHU]FKQL NRPÏUHN QRZRWZRURZ\FK FR SR]ZDOD QD SUHF\]\MQH GRVWDUF]HQLH DGXQNX F\WRWRNV\F]QHJR GR RNUHyOR QHM NRPÏUNL GRFHORZHM $'& VN DGD VLÆ ] WU]HFK NOX F]RZ\FK HOHPHQWÏZ SU]HFLZFLD D PRQRNORQDOQHJR F]QLND OLQNHUD RUD] DGXQNX F\WRWRNV\F]QHJR W]Z SD\ORDG F]QLN RGSRZLDGD ]D VWDELOQH SU]\ F]HQLH GR SU]HFLZFLD D F] VWHF]HN OHNX F\WRWRNV\F]QHJR FR SU]HFLZG]LD D XZDOQLDQLX FKHPLRWHUDSHXW\NX Z NU H QLX ]DQLP NRPSOHNV ELD ND E RQRZHJR L SU]HFLZFLD D ]RVWDQLH ]LQWHUQDOL]RZDQ\ Z NRPÏUFH GRFHORZHM .RQ VWUXNFMD OLQNHUÏZ PD RJURPQH ]QDF]HQLH GOD DNW\Z QRyFL NRQNUHWQHJR $'& 7DN ]ZDQH UR]F]HSLDOQH OLQNHU\ FOHDYHDEOH V VNRQVWUXRZDQH Z WDNL VSRVÏE DE\ Z NRQNUHWQ\FK ZDUXQNDFK PLNURyURGRZLVND JX]D OXE ZHZQ WU]NRPÏUNRZR RGSRZLHGQLH S+ Z\VRNLH VWÆ HQLH JOXWDWLRQX REHFQRy RNUHyORQ\FK SURWHD] XZDOQLD \ DGXQHN F\WRWRNV\F]Q\ MHV]F]H SU]HG UR]
/HF]HQLH FHORZDQH LbLPPXQRWHUDSLD
135
SRGVWDZLH EDGDQLD KLVWRSDWRORJLF]QHJR RUD] ED GDÍ REUD]RZ\FK NWÏUH XPR OLZLDM QLH W\ONR RNUH yOHQLH REV]DUX PDNURVNRSRZ\FK ]PLDQ OHF] WDN H LGHQW\ILNDFMÆ REV]DUÏZ U\]\ND REHFQRyFL PLNURSU]H U]XWÏZ =DNUHV OHF]HQLD SURPLHQLDPL PR H REHM PRZD ]DUÏZQR REV]DU\ FKRURE\ PDNURVNRSRZHM RNUHyODQH MDNR *79 t JURVV WXPRXU YROXPH L ]DZLH UDM FH Z VRELH JX] QRZRWZRURZ\ L SU]HU]XW\ UHJLR QDOQH OXE RGOHJ H MDN L REV]DU\ HOHNW\ZQH NWÏUH PRJ REHMPRZD UHJLRQDOQH ZÆ] \ FK RQQH F]\ REV]DU\ SRGGDQH ]DELHJRZL RSHUDF\MQHPX EH] REHFQHJR Z EDGDQLDFK REUD]RZ\FK JX]D MDN QS SRRSHUDF\MQD UDGLRWHUDSLD SLHUVL REHMPXM FD JUX F]R SLHUVLRZ\ L UHJLRQDOQH ZÆ] \ FK RQQH 2EMÆ WRy WD *79 MHVW SRZLÆNV]RQD R REV]DU\ Z NWÏ U\FK ] GX \P SUDZGRSRGRELHÍVWZHP ]QDMGXM VLÆ NRPÏUNL QRZRWZRURZH 7DN RNUHyORQD REMÆWRy QD]\ZDQD MHVW &79 FOLQLFDO WDUJHW YROXPH 1D W\P HWDSLH XVWDOD VLÆ UÏZQLH NWÏUH ]GURZH QDU] G\ ]QDMGXM VLÆ Z REV]DU]H OHF]RQ\P RUD] Z\VRNRy GDZNL IUDNF\MQHM FD NRZLWHM L VSRVÏE MHM SRGDZD QLD : ]DOH QRyFL RG ]DDZDQVRZDQLD SRGW\SX KLVWRSDWRORJLF]QHJR L ORNDOL]DFML GRELHUDQ\ MHVW RSW\PDOQ\ VFKHPDW QDSURPLHQLDQLD ]DZLHUDM F\ F]DV OHF]HQLD MHJR F]ÆVWRWOLZRy L VSRVÏE IUDNFMR QRZDQLD : SURFHVLH W\P RNUHyODQ\ MHVW UÏZQLH PDUJLQHV QLH]EÆGQ\ GR SUDZLG RZHJR ]UHDOL]R ZDQLD ]DSODQRZDQHJR OHF]HQLD XZ]JOÆGQLDM F\ UXFKRPRy Z WUDNFLH SRGDZDQLD IUDNFML ]PLDQ\ SRPLÆG]\ SRV]F]HJÏOQ\PL IUDNFMDPL F]\ WH UXFKR PRy RGGHFKRZ RUD] QLHSHZQRy X R HQLD FKR UHJR 7DN RNUHyORQ\ REV]DU QD]\ZDP\ 379 SODQQHG WDUJHW YROXPH 3ODQRZDQLH JHRPHWU\F]QHJR XN DGX ZL ]HN L UR]N DGX GDZNL 7R HWDS UHDOL]RZDQ\ ]D SRPRF V\VWHPX SODQRZDQLD OHF]HQLD ] Z\NRU]\VWDQLHP ]DDZDQVRZDQ\FK DOJRU\WPÏZ REOLF]HQLRZ\FK 1D SRGVWDZLH SU]\JRWRZDQ\FK REU\VÏZ QDU] GÏZ ]GURZ\FK L REV]DUÏZ WDUF]RZ\FK *79 &79 379 Z\ELHUD VLÆ RSW\PDOQ WHFKQLNÆ L HQHUJLÆ GDZNL RUD] RNUHyOD VLÆ FHOH SODQX OHF]HQLD 5DGLRWHUDSHXWD RQNRORJLF]Q\ ZH ZVSÏ SUDF\ ] IL]\NDPL PHG\F] Q\PL GRELHUD RSW\PDOQH GDZNL SR]ZDODM FH QD RVL JQLÆFLH ]DN DGDQHJR FHOX WHUDSHXW\F]QHJR SU]\ VSH QLHQLX ]D R HÍ RFKURQ\ WNDQHN ]GURZ\FK )L]\N PHG\F]Q\ QD SRGVWDZLH ]D R HÍ NOLQLF]Q\FK SURZDG]L SURFHV RSW\PDOL]DFML L SU]\JRWRZXMH UR] N DG GDZNL SURPLHQLRZDQLD 2EOLF]HQLD Z\NRQ\ ZDQH V Z RSURJUDPRZDQLX V\VWHPLH SODQRZDQLD OHF]HQLD NWÏU\ ZVSÏ SUDFXMH ] V\VWHPDPL REUD]R ZDQLD 7. RUD] 05, L DSDUDWDPL WHUDSHXW\F]Q\PL
156
I. Wprowadzenie do chirurgii onkologicznej
DNFHOHUDWRUDPL .D G\ SODQ SR MHJR REOLF]HQLX PXVL E\ ]DDNFHSWRZDQ\ SU]H] OHNDU]D VSHFMDOLVWÆ Z G]LHG]LQLH UDGLRWHUDSLL RQNRORJLF]QHM RUD] IL]\ND VSHFMDOLVWÆ Z G]LHG]LQLH IL]\NL PHG\F]QHM 1DVWÆSQLH ND G\ REOLF]RQ\ UR]N DG GDZNL PXVL ]RVWD ]ZHU\IL NRZDQ\ SU]H] LQQ\ QLH]DOH Q\ SURJUDP NRPSXWH URZ\ OXE SRSU]H] SRPLDU GDZNL 3R]\W\ZQD ZHU\ ILNDFMD XSRZD QLD GR UHDOL]DFML OHF]HQLD QD DSDUDFLH WHUDSHXW\F]Q\P ]RE U\F 5HDOL]DFMD UDGLRWHUDSLL /HF]HQLH SURPLHQLDPL RGE\ZD VLÆ Z SRPLHV]F]HQLDFK NWÏUH VSH QLDM Z\PRJL RFKURQ\ UDGLRORJLF]QHM F]\OL EXQNUDFK WHUDSHXW\F]Q\FK 3DFMHQW MHVW SRGGDZDQ\ OHF]H QLX ZL ]N SURPLHQLRZDQLD MRQL]XM FHJR NWÏU JHQHUXMH OLQLRZ\ SU]\VSLHV]DF] HOHNWURQÏZ 1DOH \ GRGD H OHF]HQLH PR H VLÆ RGE\ZD QD DSDUD FLH GOD NWÏUHJR Z\NRQDQR REOLF]HQLD UR]N DGX GDZNL 3U]HG UR]SRF]ÆFLHP QDSURPLHQLDQLD FKR UHJR XN DGD VLÆ QD VWROH WHUDSHXW\F]Q\P Z SR]\FML Z\EUDQHM SRGF]DV SU]\JRWRZDÍ Z SURFHVLH SODQR ZDQLD OHF]HQLD D MHJR X R HQLH MHVW ZHU\ILNRZDQH L NRU\JRZDQH ]D SRPRF REUD]RZDQLD UHQWJHQRZ VNLHJR WHFKQLND ,*57 t UDGLRWHUDSLD VWHURZDQD REUD]HP .ROHMQ\P HWDSHP MHVW QDSURPLHQLD QLH L Z\NRQDQLH SURFHGXU VSUDZG]DM F\FK MDNRy SRGDQLD GDZNL : ]DOH QRyFL RG WHFKQLNL PR OLZH MHVW PRQLWRURZDQLH SRZLHU]FKQL SDFMHQWD Z WUDN FLH OHF]HQLD SURPLHQLDPL 6*57 t VXUIDFH JXLGHG UDGLRWKHUDS\ PRQLWRURZDQLH UXFKÏZ RGGHFKR Z\FK EUDPNRZDQLH RGGHFKRZH OXE yOHG]HQLH SR R HQLD JX]D OXE VSHFMDOQ\FK ]QDF]QLNÏZ Z F]D VLH QDSURPLHQLDQLD WUDFNLQJ 6WDQGDUGRZD UDGLR WHUDSLD RGE\ZD VLÆ ]Z\NOH SU]H] SLÆÂ GQL Z W\JR GQLX SU]H] t W\JRGQL 6FKHPDW\ SDOLDW\ZQH OXE VWHUHRWDNW\F]QH SU]HSURZDG]D VLÆ Z F]DVLH NUÏW V]\P GR W\JRGQL D Z F]ÆyFL ] QLFK ]DN DGD VLÆ SRGDZDQLH GDZNL ] RGVWÆSHP MHGQHJR OXE GZÏFK GQL : WUDNFLH WUZDQLD UDGLRWHUDSLL UHDOL]XMH VLÆ Z VSRVÏE IUDNFMRQRZDQ\ SODQ OHF]HQLD ZF]HyQLHM SU]\JRWRZDQ\ ]ZHU\ILNRZDQ\ L ]DDNFHSWRZDQ\ D SUDZLG RZ\ SU]HELHJ QDSURPLHQLDQLD PRQLWRUXMH VLÆ SRG N WHP SRZWDU]DOQRyFL RGWZRU]HQLD SR]\ FML WHUDSHXW\F]QHM :V]\VWNLH LQIRUPDFMH GRW\F] FH SRGDQHM GDZNL MDN L Z\NRQDQH QD SRWU]HE\ ZHU\ ILNDFML EDGDQLD REUD]RZHJR V ]DSLV\ZDQH Z ED]LH GDQ\FK 2EVHUZDFMD RVWU\FK RGF]\QÏZ : WUDNFLH OHF]H QLD SURPLHQLDPL SDFMHQW MHVW PRQLWRURZDQ\ SRG N WHP Z\VWÆSRZDQLD RGF]\QÏZ SRSURPLHQQ\FK SU]H] SURZDG] FHJR GR OHNDU]D VSHFMDOLVWÆ UDGLR WHUDSLL RQNRORJLF]QHM 5DGLRWHUDSLD PR H E\ SU]H
SURZDG]RQD Z ZDUXQNDFK DPEXODWRU\MQ\FK OXE Z WU\ELH KRVSLWDOL]DFML 3DFMHQFL NWÏU]\ GREU]H WROH UXM OHF]HQLH QLH Z\PDJDM GRGDWNRZ\FK SURFH GXU WHUDSHXW\F]Q\FK :\VW SLHQLH RVWUHJR RGF]\QX SRSURPLHQQHJR Z\PDJD QLHMHGQRNURWQLH Z F]H QLD OHNÏZ PLHMVFRZ\FK OXE RJÏOQRXVWURMRZ\FK : FHOX ]PQLHMV]HQLD U\]\ND SRZLN DÍ RVWU\FK VWR VRZDQH V SUHSDUDW\ VNÏUQH $GDSWDFMD OHF]HQLD : WUDNFLH WUZDQLD OHF]HQLD PRQLWRUXMH VLÆ ]PLDQ\ REMÆWRyFL JX]D L DQDWRPLL FKRUHJR D Z SU]\SDGNX ]QDF]Q\FK UÏ QLF PRG\IL NXMH VLÆ SODQ OHF]HQLD &RG]LHQQD ZHU\ILNDFMD REUD ]RZD SR]ZDOD QD SUHF\]\MQ UHDOL]DFMÆ ]DN DGDQHJR
SODQX QDSURPLHQLDQLD :SURZDG]RQD Z RVWDWQLFK ODWDFK UDGLRWHUDSLD DGDSWDF\MQD RQ OLQH SR]ZDOD QD FRG]LHQQ NRUHNWÆ UHIHUHQF\MQHJR SODQX OHF]H QLD L XZ]JOÆGQLHQLH ]PLDQ Z SR R HQLX JX]D OXE REMÆWRyFLDFK V VLDGXM F\FK ]GURZ\FK WNDQHN 2EVHUZDFMD FKRUHJR SR OHF]HQLX 3DFMHQFL SR ]DNRÍF]RQHM UDGLRWHUDSLL Z\PDJDM NRQWUROL SRG N WHP Z\VW SLHQLD HZHQWXDOQ\FK SÏ|Q\FK SRZL N DÍ OHF]HQLD SURPLHQLDPL =H Z]JOÆGX QD FKDUDN WHU G]LD DQLD SURPLHQLRZDQLD MRQL]XM FHJR F]Æy ] QLFK PR H Z\VW SL QDZHW ZLHOH ODW SÏ|QLHM =DUÏZQR RVWUH MDN L SÏ|QH SRZLN DQLD RFHQLD VLÆ Z VNDODFK 572* OXE &7&($
$
%
&
'
5\FLQD 6\VWHP\ VWDELOL]DFML FKRUHJR QD F]DV UHDOL]DFML UDGLRWHUDSLL 7HUPRSODVW\F]QH PDWHULD \ PDVNL V UR]JU]HZDQH Z WHP SHUDWXU]H RNR R & D QDVWÆSQLH IRUPRZDQH L GRSDVRZ\ZDQH GR NV]WD WÏZ FLD D SDFMHQWD $ % & ' 0DWHUDFH SRGFLyQLHQLRZH GRSDVRZDQH GR NV]WD WX WX RZLD OXE NRÍF]\Q SRSUDZLDM NRPIRUW FKRUHJR Z F]DVLH QDSURPLHQLDQLD L ]ZLÆNV]DM SRZWDU]DOQRy X R HQLD SRGF]DV NROHMQ\FK VHVML QDSURPLHQLDQLD & nUÏG R PDWHULD Z DVQ\
3RGVWDZ\ UDGLRWHUDSLL
157
DXWRQRPLL FKRUHJR L DOLHQDFMÆ VSR HF]Q %OLVNR ]DEXU]HÍ SV\FKLF]Q\FK Z\VWÆSXMH MDNR UHDNFMD QD FKR UREÆ OXE REMDZ FKRURE\ E G| UHDNFMD QD MHM OHF]HQLH :F]HVQH Z\NU\ZDQLH L WUDIQD GLDJQR]D ]DOH Z GX HM PLHU]H RG GRN DGQRyFL EDGDÍ SRGPLRWRZHJR L SU]HGPLRWRZHJR NWÏUH V SRGVWDZRZ\P HWDSHP
SURFHVX GLDJQRVW\F]QHJR : SR F]HQLX ] QRZRF]H VQ\PL WHFKQLNDPL ODERUDWRU\MQ\PL L REUD]RZ\PL EDGD QLD WH XPR OLZLDM VWZRU]HQLH NRPSOHNVRZHJR REUD]X NOLQLF]QHJR VWDQRZL FHJR IXQGDPHQW VNXWHF]QHJR OHF]HQLD
%$'$1,( 32'0,272:( 'LDJQRVW\ND QRZRWZRUÏZ Z\PDJD V]F]HJÏ RZHM DQD OL]\ REMDZÏZ NOLQLF]Q\FK RSDUWHM QD U]HWHOQ\P Z\ZLD G]LH L VSHFMDOLVW\F]QHM ZLHG]\ %DGDQLH SRGPLRWRZH PLPR SRVWÆSX WHFKQRORJLF]QHJR SR]RVWDMH IXQGD PHQWHP GLDJQRVW\NL t XPR OLZLD ZF]HVQH UR]SR]QDQLH QRZRWZRUÏZ L RGSRZLHGQLH SRVWÆSRZDQLH WHUDSHX W\F]QH :VSÏ F]HVQH EDGDQLD REUD]RZH ODERUDWR U\MQH RUD] PROHNXODUQH GRVWDUF]DM FHQQ\FK LQIRUPDFML GLDJQRVW\F]Q\FK MHGQDN WR GREU]H SU]HSURZDG]RQ\ Z\ZLDG SR]ZDOD QD XNLHUXQNRZDQLH GDOV]\FK EDGDÍ HOLPLQXM F QLHSRWU]HEQH SURFHGXU\ RUD] PLQLPDOL]XM F RSÏ|QLHQLD Z UR]SR]QDQLX 'RN DGQH ]HEUDQLH Z\ZLDGX MHVW V]F]HJÏOQLH LVWRWQH Z GLDJQRVW\FH FKRUÏE QRZRWZRURZ\FK ]H Z]JOÆGX QD QLHVSHF\ILF]QRy L ] R RQRy ZLHOX REMDZÏZ 2EMD Z\ WDNLH MDN ]PÆF]HQLH FKXGQLÆFLH F]\ EÏO PRJ E\ P\O FH L ZVND]\ZD QD ZLHOH LQQ\FK VFKRU]HÍ .OX F]RZH MHVW XZ]JOÆGQLHQLH F]DVX WUZDQLD REMDZÏZ LFK LQWHQV\ZQRyFL RUD] F]\QQLNÏZ ]DRVWU]DM F\FK OXE DJRG] F\FK /HNDU] SRZLQLHQ ]ZUÏFL XZDJÆ QD GUREQH V]F]HJÏ \ WDNLH MDN ]PLDQ\ Z FRG]LHQQ\FK QDZ\NDFK SDFMHQWD XWUDWÆ DSHW\WX F]\ SUREOHP\ ]H VQHP NWÏUH PRJ ZVND]\ZD QD SRF] WNRZH VWD GLXP QRZRWZRUX 5ROD Z\ZLDGX MHVW V]F]HJÏOQLH ZLGRF]QD Z SU]\SDG NDFK QRZRWZRUÏZ R SRZROQ\P SU]HELHJX WDNLFK MDN UDN MHOLWD JUXEHJR F]\ UDN SURVWDW\ NWÏU\FK REMDZ\ PRJ E\ REHFQH SU]H] ODWD ]DQLP ]RVWDQLH SRVWD ZLRQD GLDJQR]D 3RQDGWR XZ]JOÆGQLHQLH Z\ZLDGX URG]LQQHJR SR]ZDOD ]LGHQW\ILNRZD RVRE\ ] SRGZ\ V]RQ\P U\]\NLHP ]DFKRURZDQLD FR XPR OLZLD ZF]HV QH ZGUR HQLH RGSRZLHGQLFK EDGDÍ SU]HVLHZRZ\FK :VSÏ F]HVQH VWDQGDUG\ GLDJQRVW\F]QH ]DOHFDM VWRVR ZDQLH VFKHPDW\F]Q\FK QDU]ÆG]L WDNLFK MDN NZHVWLRQD ULXV]H F]\ VNDOH RFHQ\ REMDZÏZ DE\ ]DSHZQL VSÏMQRy L MDNRy ]ELHUDQ\FK LQIRUPDFML $E\ Z\HOLPLQRZD E ÆG\ ]ZL ]DQH ] SU]HRF]HQLHP LVWRWQ\FK LQIRUPDFML EDGDQLH SRGPLRWRZH SURZDG]L VLÆ ZHG XJ yFLyOH RNUHyORQHJR VFKHPDWX 1DOH \ NROHMQR
280
II. Diagnostyka
X]\VNDÂ LQIRUPDFMH QD WHPDW DNWXDOQ\FK GROHJOLZRyFL FKRUHJR F]DVX Z\VW SLHQLD L WUZDQLD REMDZÏZ F]\QQL NÏZ SU]\QRV] F\FK XOJÆ OXE QDVLODM F\FK GROHJOLZRyFL GRW\FKF]DVRZHJR SU]HELHJX FKRURE\ GROHJOLZRyFL ]H VWURQ\ LQQ\FK QDU] GÏZ L XN DGÏZ ZVSÏ LVWQLHM F\FK L SU]HE\W\FK FKRUÏE SU]HE\W\FK RSHUDFML SU]\MPRZD Q\FK OHNÏZ QDUD HQLD QD VXEVWDQFMH WRNV\F]QH DOHUJLL L QLHWROHUDQFML OHNÏZ Z\ZLDGX URG]LQQHJR ZDUXQNÏZ \FLRZ\FK L VWRVRZDQ\FK SU]H] FKRUHJR X \ZHN
Ból %ÏO MHVW MHGQ\P ] QDMF]ÆVWV]\FK REMDZÏZ FKRUÏE QRZRWZRURZ\FK Z\VWÆSXM F\P QD HWDSLH UR]SR]QD QLD X t SDFMHQWÏZ D Z VWDGLXP ]DDZDQVR ZDQ\P X t SDFMHQWÏZ &KDUDNWHU\]XMH VLÆ RQ ] R RQ HWLRORJL D MHJR QDVLOHQLH L FKDUDNWHU ]DOH RG ORNDOL]DFML RUD] W\SX QRZRWZRUX : NRQWHNyFLH GLDJQR VW\NL QDOH \ Z]L Â SRG XZDJÆ PHFKDQL]P\ IL]MRSDWROR JLF]QH RUD] ORNDOL]DFMÆ SURFHVX QRZRWZRURZHJR
0HFKDQL]P\ SRZVWDZDQLD EyOX nowotworowego %ÏO QRZRWZRURZ\ PR H PLHÂ FKDUDNWHU QRF\FHSW\ZQ\ t Z\QLNDM F\ ] SRGUD QLHQLD UHFHS WRUÏZ EÏORZ\FK QRF\FHSWRUÏZ SU]H] ERG|FH FKH PLF]QH PHFKDQLF]QH OXE WHUPLF]QH SU]\N DGHP PR H E\Â EÏO VSRZRGRZDQ\ QDFLHNDQLHP WNDQHN OXE XFLVNLHP QD QDU] G\ ZHZQÆWU]QH QHXURSDW\F]Q\ t Z\QLNDM F\ ] XV]NRG]HQLD VWUXNWXU XN DGX QHUZRZHJR QS QDFLHNX QHUZÏZ REZRGR Z\FK OXE UG]HQLD NUÆJRZHJR REMDZLD VLÆ SLHN F\P SU]HV]\ZDM F\P EÏOHP F]ÆVWR WRZDU]\V] PX SDUH VWH]MH L SU]HF]XOLFD PLHV]DQ\ t F] F\ FHFK\ REX SRZ\ V]\FK PHFKD QL]PÏZ Z\VWÆSXM F\ QS Z UDNX WU]XVWNL JG]LH QDFLHNDQLH VSORWÏZ QHUZRZ\FK SURZDG]L GR SU]H
ZOHN HJR RSDVXM FHJR EÏOX EU]XFKD SURPLHQLXM FHJR GR SOHFÏZ
/RNDOL]DFMD EyOX Z ]DOHİQRĤFL od typu nowotworu 5DN S XF t EÏO Z NODWFH SLHUVLRZHM NWÏUHPX F]ÆVWR WRZDU]\V]\ NDV]HO L GXV]QRy ]ZL ]DQ\ ] QDFLHND QLHP yFLDQ NODWNL SLHUVLRZHM OXE RS XFQHM 5DN MHOLWD JUXEHJR t QHXURSDW\F]Q\ EÏO Z RNROLF\ NURF]D OXE GROQHM SDUWLL SOHFÏZ Z\QLNDM F\ ] QDFLH NÏZ QHUZÏZ NXOV]RZHJR OXE ]DV RQRZHJR 5DN WU]XVWNL t SU]HZOHN \ RSDVXM F\ EÏO EU]XFKD SURPLHQLXM F\ GR SOHFÏZ 5DN SLHUVL t EÏO VSRZRGRZDQ\ QDFLHNDQLHP ORNDO Q\FK VWUXNWXU WDNLFK MDN PLÆyQLH F]\ ZÆ] \ FK RQQH RUD] SU]HU]XWDPL GR NRyFL 6]SLF]DN PQRJL t EÏO NRVWQ\ Z\QLNDM F\ ] QLV]F]HQLD VWUXNWXU NRVWQ\FK 1RZRWZRU\ XN DGX PRF]RZR S FLRZHJR t EÏO Z SRGEU]XV]X OXE Z RNROLF\ OÆG|ZLRZHM Z\QLNDM F\ ] QDFLHNDQLD GUÏJ PRF]RZ\FK
'\VIDJLD '\VIDJLD F]\OL WUXGQRyFL Z SU]H \NDQLX MHVW REMDZHP VXJHUXM F\P SURFHV SDWRORJLF]Q\ Z REUÆELH JÏUQHJR RGFLQND SU]HZRGX SRNDUPRZHJR 2EMDZ WHQ PR H Z\VWÆSRZDÂ Z SU]HELHJX QRZRWZRUÏZ SU]H \NX JDU G D NUWDQL DOH WDN H Z SU]\SDGNDFK QDFLHNÏZ SU]HU]X WRZ\FK VWUXNWXU yUÏGSLHUVLD
.ODV\ÀNDFMD G\VIDJLL '\VIDJLD MHVW NODV\ILNRZDQD Z VNDOL RG OHNNLHM GR FLÆ NLHM Z ]DOH QRyFL RG QDVLOHQLD REMDZÏZ L URG]DMX SU]\M PRZDQHJR SRNDUPX 6WRSLHÍ , t G\VIDJLD OHNND SDFMHQW RGF]XZD WUXG QRyFL Z SR \NDQLX MHG\QLH SRNDUPÏZ VWD \FK SU]\ F]\P SU]\MPRZDQLH S \QÏZ SR]RVWDMH QLH]DEXU]RQH 6WRSLHÍ ,, t G\VIDJLD XPLDUNRZDQD SDFMHQW PD WUXGQRyFL Z SR \NDQLX SRNDUPÏZ VWD \FK L EDUG]LHM JÆVW\FK S \QÏZ WDNLFK MDN ]XS\ NUHP\ 6WRSLHÍ ,,, t G\VIDJLD FLÆ ND VSR \ZDQLH ]DUÏZQR VWD \FK SRNDUPÏZ MDN L S \QÏZ MHVW ]QDF]QLH XWUXG QLRQH Z\PDJD F]ÆVWR PRG\ILNDFML GLHW\ GR IRUP\ SÏ S \QQHM OXE S \QQHM 6WRSLHÍ ,9 t G\VIDJLD EDUG]R FLÆ ND DIDJLD SDFMHQW QLH MHVW Z VWDQLH SR \NDÂ QDZHW S \QÏZ NRQLHF]QH MHVW \ZLHQLH SR]DMHOLWRZH OXE SU]H] ]J ÆEQLN
0HFKDQL]P\ SRZVWDZDQLD G\VIDJLL '\VIDJLD PR H PLH QDVWÆSXM FH SU]\F]\Q\ QLHGUR QRy PHFKDQLF]QD t VSRZRGRZDQD REHF QRyFL JX]D QRZRWZRURZHJR NWÏU\ ]ZÆ D yZLDW R SU]H \NX OXE JDUG D ]DEXU]HQLD PRWRU\F]QH t XV]NRG]HQLH QHUZÏZ OXE PLÆyQL RGSRZLHG]LDOQ\FK ]D NRRUG\QDFMÆ SR \NDQLD QS Z SU]HELHJX QDFLHNDQLD QHUZÏZ F]DV]NRZ\FK SU]H] JX] XFLVN VWUXNWXU ]HZQÆWU]Q\FK t QS QDFLHN QRZRWZRUX QD ZÆ] \ FK RQQH yUÏGSLHUVLD SRZRGXM F\ GHIRUPD FMÆ SU]H \NX
2EMDZ\ WRZDU]\V]ĈFH G\VIDJLL 2G\QRIDJLD t EROHVQRy SRGF]DV SU]H \NDQLD F]Æ VWR ]ZL ]DQD ] RZU]RG]HQLHP OXE VWDQHP ]DSDOQ\P Z REUÆELH JDUG D OXE SU]H \NX =DFK \VW\ZDQLH t V]F]HJÏOQLH SRGF]DV VSR \ZDQLD S \QÏZ FR PR H SURZDG]L GR DVSLUDFML WUHyFL SRNDU PRZHM L LQIHNFML GUÏJ RGGHFKRZ\FK &KXGQLÆFLH t Z\QLNDM FH ] RJUDQLF]RQHJR SU]\MPR ZDQLD SRNDUPÏZ 5HJXUJLWDFMD t FRIDQLH VLÆ WUHyFL SRNDUPRZHM GR MDP\ XVWQHM
3U]\NãDG\ QRZRWZRUyZ ] G\VIDJLĈ 5DN SU]H \NX t QDMF]ÆVWV]D SU]\F]\QD PHFKDQLF]QHM QLHGUR QRyFL 5DN JDUG D t XWUXGQLHQLD SR \NDQLD F]ÆVWR SRSU]H G]DM REMDZ\ WDNLH MDN EÏO F]\ ]PLDQD EDUZ\ J RVX 5DN NUWDQL t PR H SURZDG]LÂ GR XWUXGQLHQLD SU]H S \ZX SRZLHWU]D L SU]HFKRG]HQLD SRNDUPX 5DN WDUF]\F\ t QDFLHNL QRZRWZRURZH QD WFKDZLFÆ L SU]H \N SRZRGXM G\VNRPIRUW L XWUXGQLHQLD SR \ NDQLD 3U]HU]XW\ GR yUÏGSLHUVLD t QS Z UDNX S XF OXE SLHUVL SRZRGXM FH XFLVN QD SU]H \N
Objawy dyspeptyczne 2EMDZ\ G\VSHSW\F]QH WDNLH MDN EÏO Z QDGEU]XV]X XF]XFLH ZF]HVQHM V\WRyFL QXGQRyFL F]\ Z\PLRW\ V F]Æ VWR ]ZL ]DQH ] FKRUREDPL QRZRWZRURZ\PL R GND L SU]H \NX 5DN R GND ]H Z]JOÆGX QD VZRM SRG VWÆSQ QDWXUÆ MHVW F]ÆVWR UR]SR]QDZDQ\ Z ]DDZDQVR ZDQ\P VWDGLXP
'LDJQRVW\ND NOLQLF]QD
281
$
&
%
'
5\FLQD *X] N WQLF\ X NRELHW\ OHWQLHM ,PPXQRKLVWRFKHPLF]QD RFHQD QLHVWDELOQR yFL PLNURVDWHOLWDUQHM Z UDNX JUXF]R RZ\P RNUÆ QLF\ 8WUDWD HNVSUHVML 0/+ ZVND]XMH QD UDND ] QLHVWDELOQRyFL PLNURVDWHOLWDUQ KLSHUPHW\ODFMÆ SURPRWRUD 0/+ L Z\NOXF]D VXSUHVRURZ GURJÆ NDUF\QRJHQH]\ S $ UDN JUXF]R RZ\ N WQLF\ KHPDWRNV\OLQD L HR]\QD SRZ ³ % XWUDWD HNVSUHVML ELD ND 0/+ NRQWUROD GRGDWQLD Z OLPIRF\WDFK Z SRGyFLHOLVNX SRZ ³ & ]DFKRZDQD HNVSUHVMD ELD ND 06+ NRQWUROD GRGDWQLD Z OLPIRF\WDFK Z SRGyFLHOLVNX SRZ ³ ' EUDN HNVSUHVML ELD ND S ZLOG W\SH SRZ ³
$
&
%
'
5\FLQD *X] WU]RQX WU]XVWNL yUHGQLF\ FP X PÆ F]\]Q\ OHWQLHJR t ELRSVMD FKL UXUJLF]QD $ QDFLHN UDND JUXF]R RZHJR ZH Z ÏNQLVW\P SRGyFLHOLVNX EDUZLHQLH KHPD WRNV\OLQ L HR]\Q SRZ ³ % EDGDQLH LPPXQRKLVWRFKHPLF]QH F\WRNHUDW\Q SRZ ³ & EDGDQLH LPPXQRKLVWRFKH PLF]QH S HNVSUHVMD M GURZD SRZ ³ ' UR]URVW ZHZQ WU]SU]HZRGRZ\ WU]XVWNL SDQFUHDWLF LQWUDHSLWKHOLDO QHRSODVLD t 3DQ,1 +LJK *UDGH EDGDQLH LPPXQRKLVWRFKHPLF] QH F\WRNHUDW\Q SRZ ³
'LDJQRVW\ND SDWRPRUIRORJLF]QD
375
1DG]ÏU RQNRORJLF]Q\ Z URG]LQDFK Z\VRNLHJR U\]\ND UDND MHOLWD JUXEHJR ']LHG]LF]Q\ QLH]ZL ]DQ\ ] SROLSRZDWRyFL UDN MHOLWD JUXEHJR ]HVSÏ /\QFKD t FR ODWD RG t URNX \FLD L FR URN RG URNX \FLD 3ROLSRZDWRy URG]LQQD JUXF]RODNRZDWD )$3 t VLJPRLGRVNRSLD FR URN RG t GR URNX \FLD ] QDVWÆSF] NROHNWRPL Z PRPHQFLH Z\NU\FLD JUXF]RODNÏZ MHyOL SROLS\ QLH ]RVWDQ Z\NU\WH WR SR URNX \FLD FR t ODW 2]QDNRZDQLH ORNDOL]DFML QRZRWZRUX
%UDN ZVND]Dę 6WDELOQ\ ]HVSÏ MHOLWD GUD OLZHJR OXE SU]HZOHN \ EÏO EU]XFKD Z\M WHN MHGQRNURWQH EDGDQLH Z SU]\ SDGNX EUDNX RGSRZLHG]L QD Z DyFLZH OHF]HQLH 2VWUD ELHJXQND 5R]VLDQ\ JUXF]RODNRUDN R QLH]QDQ\P SXQNFLH Z\M yFLD MHyOL Z\QLN EDGDQLD QLH ZS \QLH QD VSRVÏE OHF]HQLD 3RWZLHUG]RQH HQGRVNRSRZR NUZDZLHQLH ] JÏU QHJR RGFLQND SU]HZRGX SRNDUPRZHJR
Przeciwwskazania :V]\VWNLH Z\PLHQLRQH GOD JDVWURVNRSLL 2VWUD ID]D FKRUÏE ]DSDOQ\FK MHOLWD 2VWUH ]DSDOHQLH XFK\ NÏZ &L D
3RZLNãDQLD &]ÆVWRy SRZLN DÍ GLDJQRVW\F]QHM NRORQRVNRSLL V]D FXMH VLÆ QD D yPLHUWHOQRy ] QLPL ]ZL ]DQ QD t EDGDÍ 'R QDMF]ÆyFLHM REVHUZRZDQ\FK SRZLN DÍ QDOH 3HUIRUDFMD .UZDZLHQLH =DEXU]HQLD U\WPX VHUFD =DND HQLD
Wyniki =DELHJ QDOH \ UR]SRF] Â RG GRN DGQHJR REHMU]HQLD RNROLF\ RGE\WX L EDGDQLD SHU UHFWXP : WUDNFLH ND GHJR EDGDQLD GRN DGQHM RFHQLH SRZLQQD ]RVWDÂ SRGGDQD E RQD yOX]RZD FD HJR MHOLWD JUXEHJR D Z Z\EUD Q\FK SU]\SDGNDFK UÏZQLH NRÍFRZHJR RGFLQND MHOLWD FLHQNLHJR = ND GHM ]PLDQ\ SRGHMU]DQHM R FKDUDNWHU QRZRWZRURZ\ QDOH \ SREUDÂ PDWHULD GR EDGDQLD KLVWR
382
II. Diagnostyka
SDWRORJLF]QHJR NOHV]F]\NDPL OXE SÆWO GLDWHUPLF]Q 'RW\F]\ WR SU]HGH ZV]\VWNLP ]PLDQ R FKDUDNWHU]H ]ZÆ HQLD SROLSRZDW\FK OXE RZU]RG]LD \FK 2FHQD PRU IRORJLL SROLSD MHVW QLHZ\VWDUF]DM FD GR ZQLRVNRZDQLD R MHJR EXGRZLH KLVWRSDWRORJLF]QHM ZV]\VWNLH SROLS\ ] Z\M WNLHP GUREQ\FK WM PP SR R RQ\FK G\VWDO QLH SROLSÏZ KLSHUSODVW\F]Q\FK SRZLQQ\ E\Â RVWDWHF] QLH XVXQLÆWH L ]EDGDQH KLVWRORJLF]QLH -HyOL SODQXMH VLÆ SROLSHNWRPLÆ SRELHUDQLH Z\FLQNÏZ MHVW QLHZVND]DQH
: WUDNFLH JDVWURVNRSLL OXE NRORQRVNRSLL PR OLZH MHVW ]DVWRVRZDQLH GRGDWNRZ\FK WHFKQLN ]ZLÆN V]DM F\FK GRN DGQRy GLDJQRVW\F]Q GOD SRZLHU] FKRZQ\FK ]PLDQ QRZRWZRURZ\FK WDNLFK MDN :LGHRHQGRVNRSLD ] SRZLÆNV]HQLHP t SR]ZD ODM FD QD F\IURZH OXE RSW\F]QH SRZLÆNV]HQLH REUD]X GR UD]\ L SREUDQLH ELRSVML ] IUDJ PHQWÏZ ]PLDQ SRGHMU]DQ\FK R ZLÆNV]\ VWRSLHÍ dKLVWRORJLF]QHJR ]DDZDQVRZDQLDr &KURPRHQGRVNRSLD ZLUWXDOQD t HQGRVNRSLD Z VNRSDVPRZD Z\NRU]\VWXM FD Z\EUDQH VSHN WUXP G XJRyFL IDO ZLG]LDOQ\FK G]LÆNL F]HPX SRSUDZLD ZL]XDOL]DFMÆ VLDWNL QDF]\QLRZHM E RQ\ yOX]RZHM ]ZLÆNV]DM F PR OLZRy RGUÏ QLHQLD ]PLDQ QRZRWZRURZ\FK RG QLHQRZRWZRURZ\FK L Z\NU\FLD ]PLDQ S DVNLFK U\F L 6]WXF]QD LQWHOLJHQFMD $, t REHMPXM FD IXQN FMH SRSUDZ\ Z\NU\ZDQLD FRPSXWHU DVVLVWHG GHWHFWLRQ RUD] FKDUDNWHU\]RZDQLD FRPSXWHU DVVLVWHG FKDUDFWHULVDWLRQ
(QGRVNRSRZD FKRODQJLRSDQNUHDWRJUDÀD ZVWHF]QD (&3: %DGDQLH SROHJD QD ]DNRQWUDVWRZDQLX GUÏJ Ï FLRZ\FK OXE SU]HZRGX WU]XVWNRZHJR :LUVXQJD ]D SRPRF FHZQLND ZSURZDG]RQHJR SU]H] EURGDZNÆ 9DWHUD RG VWURQ\ GZXQDVWQLF\ SRG NRQWURO GXRGHQRVNRSX 8 ZLÆNV]RyFL SDFMHQWÏZ EDGDQLH Z\NRQ\ZDQH MHVW Z J ÆERNLHM VHGDFML OXE Z ]QLHF]XOHQLX ] LQWXEDFM
Przygotowanie pacjenta 3DFMHQW QLH SRZLQLHQ MHy SU]H] JRG]LQ L SL SU]H] JRG]LQ\ SU]HG ]DELHJLHP G X HM Z SU]\SDGNX ]DEXU]HÍ RSUÏ QLDQLD R GND
$
%
$
%
5\FLQD 3ROLS JUXF]RODNRZDW\ RNUÆ QLF\ ZLG]LDQ\ Z yZLHWOH ELD \P $ RUD] ]D SRPRF WHFKQLNL 1%, % nUÏG R IRW GU - 3DFKOHZVNL
5\FLQD 0D \ UDN MHOLWD JUXEHJR Z\NU\W\ Z EDGDQLX SU]HVLHZRZ\P ZLG]LDQ\ Z yZLHWOH ELD \P $ RUD] ]D SRPRF WHFKQLNL 1%, % nUÏG R IRW GU - 3DFKOHZVNL
6]F]HJÏOQHM XZDJL Z\PDJD ]HEUDQLH Z\ZLDGÏZ Z NLHUXQNX XF]XOHQLD QD yURGNL NRQWUDVWRZH SU]HGH ZV]\VWNLP MRGRZH 3DFMHQFL ] QLHGUR QRyFL SU]HZRGX Ï FLRZHJR ZVSÏOQHJR RUD] ]PLDQDPL WRUELHORZDW\PL Z WU]X VWFH SRZLQQL RWU]\PDÂ SURILODNW\NÆ DQW\ELRW\ NRZ DPRNV\F\OLQD OXE DPSLF\OLQD J GR \OQLH QD PLQXW SU]HG ]DELHJLHP
0RG\ILNDFMD OHF]HQLD SU]HFLZNU]HSOLZHJR OXE SU]H FLZ S \WNRZHJR (&3: EH] VILQNWHURWRPLL UR] FLÆFLH EURGDZNL 9DWHUD QLH Z\PDJD PRG\ILNDFML (&3: VILQNWHURWRPLD NZDV DFHW\ORVDOLF\ORZ\ t EH] PRG\ILNDFML KHSDU\QD GUREQRF] VWHF]NRZD t RVWDWQLD GDZND QD JRG]LQ SU]HG ]DELHJLHP DFH QRNXPDURO t RGVWDZLÂ OXE ]DPLHQLÂ QD KHSDU\QÆ GUREQRF] VWHF] NRZ t GQL SU]HG ]DELHJLHP
'LDJQRVW\ND HQGRVNRSRZD QRZRWZRUöZ
383
&RORJXDUG ([DFW 6FLHQFHV t WHVW PROHNXODUQ\ RFHQLDM F\ LORyFLRZR PXWDFMH JHQX .5$6 PHW\ODFMÆ 1'5* L %03 RUD] $&7% Z '1$ ]H ] XV]F]RQ\FK NRPÏUHN UDND Z SR F]HQLX ] RFHQ REHFQRyFL NUZL XWDMRQHM Z NDOH : VLHUSQLX U )'$ ]DDNFHSWRZD R X \FLH WHVWX &RORJXDUG GR ZF]HVQHJR Z\NU\ZDQLD UDND MHOLWD JUXEHJR 0HW\ODFMD JHQX 6(37 t RFHQD PHW\ODFML JHQX 6(37 Z '1$ Z RVRF]X NUZL NU FHM SR]ZDOD QD ZF]HVQH Z\NU\FLH UDND MHOLWD JUXEHJR : U R]QDF]DQLH PHW\ODFML JHQX 6(37 ]RVWD R ]DDNFHSWRZDQH SU]H] )'$ MDNR WHVW GR ZF]HVQHJR Z\NU\FLD UDND Z JUXSLH RVÏE QLHZ\UD DM F\FK ]JRG\ QD LQQH PHWRG\ EDGDÍ VNULQLQJRZ\FK
5DN QLHGUREQRNRPyUNRZ\ SãXFD 0XWDFMD (*)5 t HNVSUHVMD NLQD]\ (*)5 Z\VWÆSXMH Z ZLÆNV]RyFL UDNÏZ QLHGUREQRNRPÏUNRZ\FK S XF 1DMF]ÆVWV]H PXWDFMH Z\VWÆSXM FH F]QLH Z RNR R UDNÏZ S XF WR GHOHFMD Z REUÆELH HNVRQX RUD] SXQN WRZD PXWDFMD Z HNVRQLH 0XWDFMH WH Z\VWÆSXM F]Æ yFLHM X NRELHW RVÏE QLHSDO F\FK L $]MDWÏZ L SURZDG] GR NRQVW\WXW\ZQHJR ]ZLÆNV]HQLD DNW\ZQRyFL NLQD]\ W\UR ]\QRZHM (*)5 0XWDFMH (*)5 REHFQH Z UDNX S XF LVWRW QLH ]ZLÆNV]DM FKHPLRZUD OLZRy QD LQKLELWRU\ NLQD]\ W\UR]\QRZHM WDNLH MDN JHILW\QLE L HUORW\QLE =RVWD R WR XGRZRGQLRQH Z ZLHOX UDQGRPL]RZDQ\FK ZLHORRyURG NRZ\FK EDGDQLDFK NOLQLF]Q\FK VL D ]DOHFHÍ ,$ 0XWDFMD JHQX .5$6 t NRQVW\WXW\ZQD DNW\ZDFMD JHQX .5$6 Z\VWÆSXMH X RNR R FKRU\FK ] QLHGURE QRNRPÏUNRZ\P UDNLHP S XFD -HGQRF]DVRZD RFHQD PXWDFML JHQÏZ .5$6 L (*)5 Z\ND]D D H Z\VWÆSXM RQH QDMSUDZGRSRGREQLHM ZH Z]DMHPQLH Z\NOXF]DM
F\FK VLÆ SRSXODFMDFK 0XWDFMD JHQX .5$6 SRZRGXMH EUDN ZUD OLZRyFL JX]D QD FKHPLRWHUDSLÆ RSDUW QD LQKLELWRUDFK NLQD]\ W\UR]\QRZHM (*)5 HUORW\QLE L JHIL W\QLE L MHVW F]\QQLNLHP ] \P URNRZQLF]R *HQ IX]\MQ\ $/. t Z\VWÆSXMH X t FKRU\FK ] QLH GUREQRNRPÏUNRZ\P UDNLHP S XF -HVW JHQHP NRGX M F\P NLQD]Æ W\UR]\QRZ L MHJR REHFQRy SR]ZDOD ]DVWRVRZD Z OHF]HQLX MHM LQKLELWRU t NU\]RW\QLE VL D ]DOHFHÍ ,,$ (NVSUHVMD (5&& t VWDQRZL F]Æy XN DGX UHSHUXM FHJR '1$ SR MHJR XV]NRG]HQLX SU]H] SURPLHQLRZD QLH 89 OXE QS FLVSODW\QÆ 5DN QLHGUREQRNRPÏUNRZ\ S XF R QLVNLHM HNVSUHVML (5&& URNXMH JRU]HM RG UDND R Z\VRNLHM HNVSUHVML DOH OHSLHM RGSRZLDGD QD WHUDSLÆ FLVSODW\Q
Rak trzustki =LGHQW\ILNRZDQR EOLVNR UÏ Q\FK PLNUR51$ NWÏUH XPR OLZLDM UÏ QLFRZDQLH UDND ] SU]HZOHN \PL FKRUR EDPL WU]XVWNL RUD] ]GURZ\PL WNDQNDPL WHJR QDU] GX ,FK QDGPLHUQD HNVSUHVMD GRW\F]\ Z\ F]QLH NRPÏUHN QRZRWZRURZ\FK L QLH Z\VWÆSXMH Z NRPÏUNDFK ]GUR Z\FK &] VWHF]NDPL NWÏU\FK ]ZLÆNV]RQ HNVSUHVMÆ Z SRUÏZQDQLX ] JUXS NRQWUROQ REVHUZXMH VLÆ Z UDNX WU]XVWNL V P LQ PL5 PL5 PL5 PL5 D PL5 E PL5 D DQG PL5 &]X Ry L VZR LVWRy PLNUR51$ PL5 D S PL5 PL5 PL5 PL5 PL5 S PL5 S DQG PL5 S Z Z\NU\ZDQLX UDND WU]XVWNL L GUÏJ Ï FLRZ\FK Z\QRVL RGSRZLHGQLR L 'RN DG QRy WHVWX GLDJQRVW\F]QHJR MHVW ]QDF] FR Z\ V]D QL Z SU]\SDGNX &D RUD] &($ L RVL JDM F QLHPDO
7DEHOD =HVWDZLHQLH UÏ Q\FK PDUNHUÏZ QRZRWZRURZ\FK Z\NRU]\VW\ZDQ\FK Z SUDNW\FH NOLQLF]QHM
412
7HVW
1RZRWZÏU
0DWHULD
&HO
$QW\JHQ NDUF\QRHPEULRQDOQ\ &($
5DN MHOLWD JUXEHJR
.UHZ
0RQLWRURZDQLH VNXWHF]QRyFL OHF]HQLD L UR]SR]QDZDQLH QDZURWX FKRURE\
&$
5DN WU]XVWNL UDN SÆFKHU]\ND Ï FLRZHJR UDN GUÏJ Ï FLRZ\FK UDN R GND
.UHZ
2FHQD VNXWHF]QRyFL OHF]HQLD
II. Diagnostyka
FG WDEHOL
7HVW
1RZRWZÏU
0DWHULD
&HO
&$
5DN MDMQLND
.UHZ
3RPRF Z UR]SR]QDZDQLX RFHQLH RGSRZLHG]L QD OHF]HQLH L QDZURWX FKRURE\
&$ &$
5DN SLHUVL
.UHZ
2FHQD VNXWHF]QRyFL OHF]HQLD L QDZURWX FKRURE\
$QW\JHQ JUXF]R X NURNRZHJR 36$
5DN JUXF]R X NURNRZHJR
.UHZ
3RPRF Z UR]SR]QDZDQLX RFHQD RGSRZLHG]L QD OHF]HQLH L SRV]XNLZDQLH QDZURWX FKRURE\
α IHWRSURWHLQD $)3
5DN Z WURERZR NRPÏUNRZ\ QRZRWZÏU ]DURGNRZ\
.UHZ
3RPRF Z UR]SR]QDQLX UDND Z WURERZRNRPÏUNRZHJR RUD] PRQLWRURZDQLH RGSRZLHG]L QD OHF]HQLH RFHQD VWRSQLD ]DDZDQVRZDQLD URNRZDQLD L RGSRZLHG]L QD OHF]HQLH JX]ÏZ ]DURGNRZ\FK
/XG]ND JRQDGRWURSLQD NRVPÏZNRZD β β K&*
5DN NRVPÏZNL JX]\ ]DURGNRZH
.UHZ PRF]
2FHQD VWRSQLD ]DDZDQVRZDQLD URNRZDQLD L RGSRZLHG]L QD OHF]HQLH
&KURPRJUDQLQD $ &J$
*X]\ QHXURHQGRNU\QQH
.UHZ
3RPRF Z UR]SR]QDZDQLX RFHQD RGSRZLHG]L QD OHF]HQLH L QDZURWX FKRURE\
7\UHRJOREXOLQD
5DN WDUF]\F\
.UHZ
2FHQD RGSRZLHG]L QD OHF]HQLH L SRV]XNLZDQLH QDZURWX FKRURE\
.DOF\WRQLQD
5DN UG]HQLDVW\ WDUF]\F\
.UHZ
3RPRF Z UR]SR]QDZDQLX RFHQLH RGSRZLHG]L QD OHF]HQLH L QDZURWX FKRURE\
6ZRLVWD HQROD]D QHXURQRZD 16(
'UREQRNRPÏUNRZ\ UDN S XFD QHXUREODVWRPD
.UHZ
3RPRF Z UR]SR]QDZDQLX L RFHQD RGSRZLHG]L QD OHF]HQLH
β PLNURJOREXOLQD β 0
6]SLF]DN PQRJL SU]HZOHN D ELD DF]ND V]SLNRZD FK RQLDNL
.UHZ PRF]
2FHQD URNRZDQLD L PRQLWRURZDQLH RGSRZLHG]L QD OHF]HQLH
'HK\GURJHQD]D POHF]DQRZD
1RZRWZRU\ ]DURGNRZH FK RQLDN ELD DF]ND QHXUREODVWRPD
.UHZ
2FHQD VWRSQLD ]DDZDQVRZDQLD URNRZDQLD L RGSRZLHG]L QD OHF]HQLH
,PPXQRJOREXOLQ\
6]SLF]DN PQRJL PDNURJOREXOLQHPLD :DOGHQVWUÒPD
.UHZ PRF]
3RPRF Z UR]SR]QDZDQLX RFHQD RGSRZLHG]L QD OHF]HQLH SRV]XNLZDQLH QDZURWX FKRURE\
5R]SXV]F]DOQ\ IUDJPHQW F\WRNHUDW\Q\ &<)5$
5DN S XFD
.UHZ
0RQLWRURZDQLH QDZURWX FKRURE\
.U FH NRPÏUNL QRZRWZRURZH &HOO6HDUFK
5R]VLDQ\ UDN SLHUVL JUXF]R X NURNRZHJR MHOLWD JUXEHJR
.UHZ
3RPRF Z SRGHMPRZDQLX GHF\]ML NOLQLF]Q\FK L RFHQD URNRZDQLD
:\EUDQH ZVNDěQLNL EDGDñ ODERUDWRU\MQ\FK XbFKRU\FK QD QRZRWZöU
413