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TUMORS. CLINICAL SYMPTOMS, DIAGNOSTICS, AND TREATMENT

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Title: 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.

5
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.

7
  • 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.

8
  • 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.

16
  • 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.

17
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.

23
  • 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.

24
  • 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.

28
  • 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.

29
  • 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.
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