TUMORS. CLINICAL SYMPTOMS, DIAGNOSTICS, AND TREATMENT

1
TUMORS.CLINICAL SYMPTOMS, DIAGNOSTICS, AND
TREATMENT
2

• Tumors are nonconformist cellular populations no
  longer dedicated to the purposes of the organism
  as a whole. In contrast with normal cellular
  populations, ontogenetically grouped to form
  organs that remain fixedly related to one related
  to one another and are integratively functional,
  neoplastic cells do not form organs, are not
  fixedly related to other cells, and function
  physiologically as relatively independent
  uncontrolled elements. They are separated
  behavioristically into the benign and the
  malignant types.

3

• A benign tumour is one that does not spread or
  "metastasize" to other parts of the body a
  "malignant tumour" is one that does. A benign
  tumour is caused by cell overgrowth, and thus is
  different from a cyst or an abscess.
• Although benign is better news than malignant for
  biopsy, it does not always mean "harmless",
  though many are almost harmless. A benign tumour
  may still grow, and this growth may cause damage
  to any organs, tissues, or nerves in its
  vicinity. Hence, a benign tumour can still cause
  serious illness if it presses on important areas.

4
Etiology.

• The primary etiologic factors involved in the
  inception of tumors in man are still unknown.
  Presumptively, something happens to the
  constitution of nuclear material of a cell,
  rendering it no longer obeisant to regulation of
  its growth. Although the primary cellular genesis
  of neoplasia is unknown, it can be induced by a
  variety of agents, these may be classified as
  mechanical, infectious, chemical and physical
  (chiefly, ionizing radiation).
• The anthropogenous pollution of external medium
  in Ukraine is connected to a motor transports
  (cars in the country havent catalysts),
  metallurgical, power, chemical industry and
  nuclear power. Ukraine was on 110 place among 122
  countries of the world in 2001 behind an index of
  ecological stability. In northern areas of the
  country is close six millions population lives in
  conditions of the raised level of radiation - as
  result of consequences of failure on Chornobul
  atomic power station (1986). By the highest
  oncology case rate Southern and East regions of
  Ukraine differ, in which there are basic
  metallurgical, coal and power complexes.

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GENERAL EVALUATION OF THE ONCOLOGICAL PATIENT

• Early detection of a malignant tumor is a prefer
  for its successful treatment. History of the
  patient usually offers clues that may be
  suggestive of a malignant process
• the living conditions and habits (e.g. such
  carcinogenic factors as smoking)
• the area of living (e.g. skin cancer is much more
  common in those living in the South lung cancer
  predominates in industrialized areas with
  excessive air pollution).

6

• Cancer is a group of more than 100 different
  diseases. Cancer occurs when cells become
  abnormal and keep dividing and forming more cells
  without order or control. All organs of the body
  are made up of cells. Normally, cells divide to
  produce more cells only when the body needs them.
  If cells divide when new ones are not needed,
  they form a mass of excess tissue called a
  tumour. Tumours can be benign (not cancer) or
  malignant (cancer). The cells in malignant
  tumours can invade and damage nearby tissues and
  organs. Cancer cells can also break away from a
  malignant tumour and travel through the
  bloodstream or the lymphatic system to form new
  tumours in other parts of the body. The spread of
  cancer is called metastasis.

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• The list of conditions in the cancer group
  includes
• Cancer type by severity
• Benign tumour.
• Malignant tumour.
• Metastatic cancer - spreading of cancer beyond
  its initial site to lymph nodes and/or other body
  areas.
• Cancer type by type of tumour sarcoma,
  leukaemia, lymphoma, myeloma, melanoma.
• Cancer type by common locations lung cancer,
  colorectal cancer, brain cancer, throat cancer,
  oral cancer, liver cancer, bone cancer,
  pancreatic cancer.

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• At its initial stages a tumor is unlikely to
  produce any complaints, as the suspicion of a
  malignancy is sometimes based only on a few
  indistinct symptoms, the meticulous questioning
  is mandated. It is therefore necessary to inquire
  whether there is been any minor change in the
  patients well-being. Of great importance is what
  is referred to as the syndrome of minor symptoms
  and signs, i.e. the state of discomfort that may
  be indicative of a malignancy
• fatigability without apparent cause and a
  reduction in working capability
• rejection or unwillingness to eat certain foods
• drowsiness
• apathy to what used to be of interest
• a foreign body sensation
• abdominal discomfort rather than pain (i.e. a
  feeling of heaviness)
• lack of satisfaction after nicturition or
  defecation, etc.

9

• The earlier diagnosis of the malignant tumor has
  better prognosis. The oncological alertness
  implies
• 1. Physician's knowledge of early and/or atypical
  symptoms and signs of malignancy and its
  complications.
• 2. Physicians knowledge of the clinical pictures
  of premalignant conditions and their treatment.
• 3. The timely referral of patients with
  supposedly malignant conditions to specialized
  medical centers.
• 4. The adequacy of the patient's examination by
  the physician who was the first to suspect the
  malignancy irrespective of their specialty.

10

• Premalignant conditions include diffuse and focal
  overgrowth of the epithelium of the skin and
  mucous membranes, which can be recognized through
  inspection and endoscopy.
• The examples might be as follows
• - leukoplakia, or white spots, i.e. vegetations
  of the epithelium covering mucous membranes, the
  changes being undetectable on palpation
• - certain benign cutaneous lesions (e.g.
  papillomas, polyps, birth marks)
• - different forms of senile dyskeratosis.

11

• Pain is not a characteristic feature of tumor,
  with the exception of tumors arising from blood
  vessels and neural tissues, which exert pressure
  on the tissues. Usually, the pain is related to
  the distention of the adjacent tissues,
  infiltration of the nerves or organ
  insufficiency. Hence, intestinal obstruction
  resulting from the adluminal growth of a tumor
  causes spastic pains. In addition, persistent
  pain suggests either serous involvement or
  tumorous infiltration of the organ (e.g. tenesmus
  is a symptom of a rectal tumor).

12

• Palpation is one of the major methods used in the
  physical examination as it provides the physician
  with vital information of the tumor. The
  palpation of the tumor is to be gentle and with
  appropriate pressure, the finger lips being used
  to feel first the intact adjacent tissue while
  approaching the tumor itself. It is sometimes
  performed with both hands, as is the case with
  feeling the lymph nodes, breast tumors.
• The size of a tumor measures from millimeters to
  centimeters. The tumor shape is accounted for by
  its nature (benign vs. malignant). Modularity of
  the surface and adherence to the neighboring
  tissues, coupled with firm consistency, is
  characteristic of a malignancy, in contrast to a
  benign overgrowth or a cyst, which has smooth
  surface and is often round and mobile. It is
  noted that metastatic nodules on the surface of a
  malignant tumor are likely to be smooth.

13

• The consistency of a tumor appreciably depends on
  its type
• - soft (normally implies a benign nature of the
  tumor, e.g. lipomas or polyps of mucous
  membranes in some cases, however, this can be a
  finding of an undifferentiated tumor
• - hard (associated with an overgrowth of the
  connective tissue, e.g. fibroma)
• - firm (firm consistency, together with
  elasticity without fluctuation, is typical of an
  encapsulated tumor filled with fluid)
• - wooden-like without demarcation (provides
  substantial evidence of a malignant over-growth,
  i.e. carcinoma).

14

• The mobility of a tumor can be either spontaneous
  (active) or induced (passive). Of special
  importance is the tumor motility in relationship
  to the skin or muscles.
• The tumor can move spontaneously
• - when it originates from a mobile organ in the
  abdominal cavity
• - on changing the body position
• - on swallowing (goitre)
• - on muscular contraction (muscle tumor).

15

• It is noteworthy that in numerous cases it is the
  metastases that are identified first. To confirm
  the diagnosis of a malignant lesion or its
  metastases, special investigations have to be
  performed. The following are the examples
• tumors of the umbilicus (sister Josefs
  metastases)
• tumors of the ovaries (Krukenberg's
  metastases)
• Virchovs metastases (the metastases to the
  supraclavicular lymph nodes) suggesting gastric
  carcinoma with distant metastases
• hepatic enlargement with nodules on its surface
  in an ascitic patient requires ruling out an
  abdominal malignant tumor.

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• Similarly, all the lymph nodes have to be
  thoroughly palpated. Metastatic lymph nodes
  differ from intact ones in that they are
  enlarged, round, firm and occasionally nodular
  and adhered to the surrounding tissues and other
  lymph nodes. However, unlike inflamed nodes, they
  commonly lack tenderness.
• Because the malignancies of numerous organs (e.g.
  the lung, prostate, breast) produce osseous
  metastases, a meticulous skeletal investigation
  is required.
• The liver may also harbour metastases from
  various types of tumors, which necessitates its
  thorough examination. The metastatic liver is
  enlarged the edges being nodular, firm and
  non-tender. It is sometimes even possible to
  palpate separate clear-cut metastatic nodules.

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To confirm the diagnosis of a malignant lesion of
its metastases special investigations have to be
performed.

1. Endoscopy
2. Cytology (swabs, aspirates)
3. Histology (biopsy)
4. X-ray investigations (roentgenoscopy,
   roentgenography, tomography, angiography,
   lymphography)
5. Radioisotope methods (scanning, scintigraphy)
6. Ultrasonography
7. Computerized axial tomography
8. Laboratory tests (blood cell morphology).

18

• According to the clinical classification, the
  four types of pathological overgrowth are
  identified (in general)
• Stage I - tumor is localized, occupies a limited
  area does not infiltrate into the wall of the
  organ, metastases are absent.
• Stage II - tumor is of a big size, can infiltrate
  into the organ wall but does not spread beyond
  the organ, there can be solitary metastases to
  the regional lymph nodes.
• Stage III - tumor is of a big size with
  degeneration, infiltration into the hollow organ
  wall multiple metastases to the regional lymph
  nodes are present.
• Stage IV - is tumor with distant metastases to
  organs and lymph nodes and with infiltration of
  surrounding organs.

19
The TNMGP classification may read as follows
T1-4 N0-3 M0-1 G1-4 P1-4.

• For vast majority tumors the world classification
  behind system TNM are used
• T - primary tumor.
• T0 - primary tumor not indicated.
• Tis - is preinvasive carcinoma (cancer in situ).
• T1 - is tumor to 2 cm in diameter, not spreading
  on surrounding tissues.
• T2 - is tumor to 5 cm in diameter, is spreading
  on surrounding tissues insignificantly.
• T3 - is tumor more then 5 cm in diameter and
  spreading on surrounding tissues.
• T4 - is tumor, which spreading of surrounding
  structures or skin, with restricted mobility.

20

• N - regional lymph nodes.
• N0 - the lymph nodes stab are absent.
• N1 - the metastases in solitary mobility lymph
  nodes are present.
• N2 - the metastases in regional lymph nodes,
  which fixed between it-selves (packet) and
  neighboring structures are present.
• N3 - the metastases in more distant lymph nodes
  are present.
• Nx - estimation of regional lymph nodes is not
  enough.
• M - are distant metastases.
• M1 - the distant metastases are present.
• M0 - the distant metastases are absent.
• Mx - estimation of distant metastases is not
  enough.

21

• G - is level of differentiation.
• G1 - is high level of differentiation.
• G2 - is middle level of differentiation.
• G3 - is low level of differentiation.
• G4 - is notdiffential tumor.
• P - penetration.
• P1 - is tumor in mucous membrane.
• P2 - the tumor to grow in sub mucous membrane.
• P3 - the tumor to grow in layer of muscles.
• P4 - the tumor to grow through serous membrane
  and to leave of organ.

22
GENERAL PRINCIPLES OF TUMOUR TREATMENT

• The malignant diseases call for immediate
  therapy, whereas benign masses require treatment
  if they
• cause dysfunction of the organ affected
• result in cosmetic defects
• are found premalignant
• are suspected of transforming into malignant
  ones.

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• The therapeutic methods for malignant disease
  include surgery, radiation, chemo- and/or hormone
  therapy.
• Surgery is the main method of treatment of
  malignant tumors and it is often combined with
  radiation or chemotherapy. This is referred to as
  combined therapy (for example, in breast cancer,
  cancer of the uterus, ovaries, etc.). The
  radiation therapy can be either employed pre- or
  postoperatively. This can also accompany
  chemotherapy, as is the case, for example, in
  myeloma or Hodgkins lymphoma.
• When the tumor has advanced so far that
  successful surgery in view of a metastatic spread
  is very unlikely, the case is considered
  inoperable.
• Operating on patients with malignant tumors, the
  surgeon should follow the principle of ablasty,
  which implies the prevention of spread of tumor
  cells during the surgery by means of removing the
  mass within the intact tissues. To avoid damaging
  the tumor, it is necessary to ligate the veins as
  early and excise the tumor, fat tissues and lymph
  nodes en bloc.

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• The principle of antiblasty involves
• 1) the measures aimed at destroying the cancer
  cells in the operation site (in the wound, in the
  lymph vessels and veins using electrocautery,
  laser or plasmatic scalpels
• 2) cleansing the wound after excision of the
  tumor with 70 alcohol solution
• 3) infusions of chemotherapeutic drugs.
• As the tumor cells can spread beyond the organ
  affected to the lymphatic vessels, lymph nodes
  and surrounding tissues, it is recommended that a
  large portion or the entire organ involved be
  removed together with the surrounding tissues and
  fasciae. This is known as the principle of vines.
  An operation for breast cancer serves as an
  illustration, in which case the breast with the
  fatty tissues, fasciae and the subclavi?u?al,
  axillary lymph nodes as well as the pectoralis
  minor muscles is removed en bloc.

25

• The radical operation involves the removal of the
  entire organ (e.g. the breast, uterus) or its
  large portion (the stomach, bowel) together with
  the regional lymph nodes.
• The combined surgery during which the organ
  affected is excised with part of or the entire
  organ into which the tumor has spread is also
  regarded radical.
• Palliative operations are performed to remove
  part or the entire organ if the metastases are
  not liable to ablation. They are indicated when
  complications of the malignancy are found (e.g.
  tumor decay with bleeding, perforation of gastric
  or colon cancer).
• Symptomatic operations are aimed at eliminating
  complications caused by the enlarged tumor
  without removing the tumor itself (e. g.
  gastrostomy in oesophageal cancer
  inter-intestinal anastomosis in bowel cancers
  complicated by intestinal obstruction,
  tracheostomy in cancer of the larynx).

26

• Radiation therapy. Above half of the patients
  with malignant tumors are exposed to
  radiotherapy. It can either be used as an
  independent method for early stages of the
  disease (e.g. cancer of the lower lip, cervix of
  the uterus and the skin) or is included in the
  combined therapy. Radiation therapy commonly
  coupled with surgery and undertaken either pre-
  or postoperatively. In addition, radiotherapy can
  be combined with chemo- or hormone therapy.
• The curative effect on the tumor and its
  metastases is achieved through external,
  intra-cavitary or interstitial radiation.
• External radiation involves g-therapy with
  radioisotopes (60Co, 137Cs. etc.).

27

• Chemotherapy. Chemotherapy this is using of
  drugs by synthetic or natural origin with purpose
  of firm to stop of malignant cells development.
  Chemotherapy uses chemical agents to destroy
  cancer cells throughout the body Hence, the use
  of chemotherapy in combination with other methods
  of treatment.
• If combined with surgery, chemotherapy is
  employed to treat, for instance, ovarian cancer.
  Also, it is of great importance for the treatment
  of systemic oncological diseases (e.g. leukaemia,
  Hodgkin's lymphoma). At the early stage of
  malignancy, i.e. when the tumor can be removed
  surgically, chemotherapy alone should not be
  attempted.

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• The following main groups of chemotherapeutic
  preparations are used
• Cytostatics (novembihin, cyclophosphan, TEPA
  triethylenethiophospharamide, dopan,
  vinblastin, vincristin, etc.) hamper the growth
  of tumor cells, affecting cellular mitosis.
• Antimetabolites after the metabolism of cancer
  cells by
• suppressing the synthesis of purins
  (mercaptopurine)
• acting on the enzyme systems (fluoruracil) or on
  the transformation of folic acid (methotrexate)
• Anti-cancer antibiotics are a group of commands
  produced by fungi or microorganisms actynomycine
  D, bruneomycin, mytomycin.

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• Hormone therapy. Hormones are the treatment of
  hormone receptor-positive tumors. These
  medications supplement the combined therapeutic
  methods of surgery, radiotherapy and
  chemotherapy. The preparations of the male sex
  hormone - androgen (testosterone propionate.
  methyltestosterone) are indicated in breast
  cancer, whereas those of female sex steroid -
  estradiol (synestrol and diethylstilboestrol) are
  known to be effective in cancer of the prostate.
• Hormone therapy of tumors also includes surgeries
  on the endocrine glands e.g. surgical castration
  of women with breast cancer.