Transcript TUMORS. CLINICAL SYMPTOMS, DIAGNOSTICS, AND TREATMENT

m.d. Shydlovscky. A.V.
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.
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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.
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:
◦ 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 over-growth,
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 nontender. It is sometimes even possible to palpate
separate clear-cut metastatic nodules.
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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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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.
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; interintestinal 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, intra-cavitary 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:
◦ suppressing the synthesis of purins (mercaptopurine);
◦ acting on the enzyme systems (fluoruracil) or on the
transformation of folic acid (methotrexate);
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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.