Transcript TUMORS. CLINICAL SYMPTOMS, DIAGNOSTICS, AND TREATMENT

TUMORS.
CLINICAL SYMPTOMS,
DIAGNOSTICS, AND
TREATMENT
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.
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.
Etiology.
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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 haven’t
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.
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).
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.
The list of conditions in the cancer group
includes:
Cancer type by severity:
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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.
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 patient’s 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.
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. Physician’s 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.
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.
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).
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.
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 overgrowth, i.e. carcinoma).
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).
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 Josef’s metastases);
• tumors of the ovaries (Krukenberg's metastases);
• Virchov’s 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.
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.
To confirm the diagnosis of a malignant
lesion of its metastases special
investigations have to be performed.
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Endoscopy;
Cytology (swabs, aspirates);
Histology (biopsy);
X-ray investigations (roentgenoscopy,
roentgenography, tomography, angiography,
lymphography);
Radioisotope methods (scanning, scintigraphy);
Ultrasonography;
Computerized axial tomography;
Laboratory tests (blood cell morphology).
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.
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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.
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.
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.
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.
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 Hodgkin’s 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.
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
subclaviсuгal, axillary lymph nodes as well as the
pectoralis minor muscles is removed en bloc.
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).
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, intracavitary or interstitial radiation.
External radiation involves g-therapy with
radioisotopes (60Co, 137Cs. etc.).
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.
The following main groups of chemotherapeutic
preparations are used;
1. Cytostatics (novembihin, cyclophosphan, TEPA
[triethylenethiophospharamide], dopan, vinblastin,
vincristin, etc.) hamper the growth of tumor cells,
affecting cellular mitosis.
2. Antimetabolites after the metabolism of cancer cells
by:
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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.
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.