How we can diagnosed the cancer

How we can diagnosed the cancer

Cancer diagnosis can be done by the following methods such as laboratory diagnosis and clinical diagnosis such as the features or pictures of the cancers such as it is symptoms which means what the patient complaining and by it is signs which means what the doctor see or notice in the patient by the general and local examination of the whole body of the patient
 
what are the symptoms and signs of malignancy

Malignancy or cancer it is a neoplasm or tumor which can be represented by the following criteria

 Local features of the tumours
 Distant clinical features
 Systemic or general clinical features


Local features of the neoplasm or tumours
This cancer can be present either in the form of mass the patient complaining from abnormal something in his body like mass he felt it by his hand or the patient may complaining from pain which it is very rare in case of malignancy in the site of the tumor or the patient may complaining from change in the function of the organ which have the malignancy such as cancer intestine the patient may come with obstructive manifestations such as inability to pass stool ,abdominal distension,bleeding from rectum and may be vomiting

So that the local features of the cancer can be divided as follow
mass, pain ,changes in organ function obstruction in a hollow viscus ,bleeding or infarction
 

Mass

• Mass may be palpable

• Mass may be a primary tumour or lymph nodes enlarged or secondary lymphadenopathy

• Mass may be painful or more commonly, painless (eg breast lump, testicular lump cancer most commonly come without pain and very rare to become painful such as in some certain conditions

• May cause a mass effect
 Compression of surrounding structures such as cancer thyroid may compress on the trachea and esophagus o Raised ICP in intracranial lesions

Pain
What are the causes of pain in cancer
The pain in case of cancer may be a feature of

• Local mass compression on other structures or nerves

• Capsular stretch eg hepatic, renal carcinoma  may stretch the capsule overlying these organs producing pain
• Infiltration of regional nerves by the tumou or cancer cells which produce neurological pain

• Obstruction of a hollow lumen any structures have a lumen such as intestine ,colon,rectum,esophagus,larynx and pharynx the cancer can causes obstruction of the lumen of these structures because the tumor occupying the lumen by itself may causes pain  

Metastasis cancer spread to other organs such as the bone can produce bone pain which may be severe boring pain and may not respond to usual analgesia and may need for narcotic to relieve it

Changes in organ function
The cancer can produce changes in the function of that organ have a cancer such as when cancer spread or metastasis to the liver produce jaundice which mean yellowish discolouration of the sclera of the eye and skin of the patient and ascitis which mean accumluation of the fluid inside the abdominal cavity and the patient may complaining from abdominal distension or the cancer spread to the lungs and the patient complaining from shortening of breathing and pleural effusion which mean accumulation of malignant fluid in the pleural cavity or the cancer spread to the brain and the patient may complaining from headache blurring of vision and neurological deficits or to the bone and the patient may complaining from bone pain as above or from repeated bone fractures or pathological fractures

Obstruction in a hollow viscus

• The cancer may arising from inside the lumen of the structures( intraluminally) (eg embolism of tumour invading large vessel

• The cancer may arising from the vessel or lumen wall (eg annular circumferential rectal tumour

• The cancer may arising extraluminally (eg peritoneal deposits obstructing ureters


Bleeding

The cancer may causes bleeding which may be due to
May be effect of local tumour ulceration eg rectal carcinoma
May be result of erosion into large vessel eg gastric cancer
Acute bleed into tumour mass may provoke pain eg hepatoma
Infarction torsion and infarction of ovarian masses

GENERAL CLINICAL FEATURES OF NEOPLASMS


General features of neoplasms include
Anaemia

Metabolic effects

Exudates

Paraneoplastic syndromes

Cancer cachexia

Ectopic hormone secretion

Distant clinical features of the tumours

Anaemia

• Occult or overt bleeding

Poor nutritional state

• Low erythropoietin production

Metabolic effects

Weight loss
Anorexia
Pyrexia
Altered sensation eg taste

Specific effects of metastasis
.Exudates eg ascites pleural effusion
Bone metastasis and pathological fractures

Discussions of paraneoplastic syndrome
Paraneoplastic syndromes refer to non-metastatic systemic symptom complexes accompany malignant disease. Symptoms may affect any system of the body and occur
remotely from the site of the primary tumour of secondary deposits. They may be due to
the release of cytokines or autoimmunity generated by cross-reactivity against antibodies
produced against the tumour

Types of paraneoplastic syndrome

Approximately 10% of patients with advanced malignancies have paraneoplastic syndromes. These syndromes are divided into the following categories: miscellaneous(non-specific), rheumatological, renal, gastrointestinal, haematological, cutaneous endocrine, and neuromuscular.

Paraneoplastic syndromes

Rheumatological

Arthropathies, Scleroderma

SLE

. Amyloidosis

Renal

Tumours that can produce ACTH, antidiuretic hormone (ADH), and gut hormones. may cause hypokalaemia, hyponatraemia or hypernatraemia, hyperphosphoramia and alkalosis/acidosis

Nephrotic syndrome

Gastrointestinal

Malabsorption (especially with tumours that produce prostaglandins eg medullary thyroid
Diarrhoea

Haematological Anaemia Thrombocytosis

Disseminated intravascular coagulation (DIC) Migrating vascular thrombosis (Trousseau syndrom
Cutaneous
Itching  Herpes zoster Alopecia Hypertrichosis   Acanthosis migricans (blackish pigmentation of the skin occurring in patients with
metastatic melanomas or pancreatic tumours
Endocrine Cushing syndrome (excessive ACTH or ACTH-like peptides

- Hypercalcaemia (osteolysis or calcaemic humoral substances

Neuromuscular

.Neuromyopathic syndromes such as myasthenia gravis

;management of paraneoplastic syndromes
 respond to resection of the primary tumour. In some cases, where there are clearly identifiable autoantibodies, immunosuppression is considered

Cancer cachexia


 Cachexia is a wasting syndrome with progressive loss of body fat and severe weakness. is unclear but it may be related to the secretion of cytokines by the tumour or response to the tumour. It does not occur in proportion to tumour size (eg can occur dramatically in small oesophageal tumours

Ectopic hormone secretion and neoplasia

 Many tumors that arise from endocrine tissue continue to secrete functional hormones. some tumors that have no basis in endocrine tissue also secrete peptide molecules that are very similar in structure to active hormones or hormone fragments and these molecules acts as analogues
 mostly commonly these peptides mimic the CRF-ACTH axis and result in Cushing syndrome
sometimes ADH may be released and the syndrome of inappropriate ADH is produced

 Laboratory diagnosis

The definitive diagnosis of solid tumors is usually obtained with a biopsy of the lesion
 Biopsy determines the tumor histology and grade and thus assists in definitive therapeutic planning
When a biopsy has been obtained at an outside institution, the slides should be reviewed to confirm the outside diagnosis
Biopsies of mucosal lesions usually are obtained endoscopically e.g., via colonoscope in case of cancer colon or rectum bronchoscope in case of cancer bronchus, or cystoscope in case of cancer urinary bladder


Lesions that are easily palpable, such as those of the skin, can either be excised or sampled by punch biopsy

 Deep-seated lesions can be localized
with CT scan or ultrasound guidance for biopsy

A sample of a lesion can be obtained with

  •  Fine-needle aspiration
  •    Open incisional biopsy
  •  core-needle biopsy
  • excisional biopsy 
 Fine-needle aspiration is easy and relatively safe, but has
the disadvantage of not giving information on tissue architecture
. For example, fine-needle aspiration biopsy of a breast mass can make the diagnosis of malignancy, but cannot differentiate between an invasive and non invasive tumor
  Core-needle biopsy is more advantageous when the histology will affect the recommended therapy
Core biopsy like fine-needle as­piration, is relatively safe and  can be performed either by direct palpation (e.g a breast mass or a soft-tissue mass) or can be guided by an imaging stady (e.g., stereotactic core biopsy of the breast
 Core biopsies, like fine-needle aspirations, have the disadvantage of introducing sampling error
For example, some patients with a diagnosis of atypical ductal hyperplasia on core biopsy of a mam­mographic abnormality are found to have carcinoma upon excision of the lesion it is crucial to ensure that the histologic findings are
consistent with the clinical scenario, and to know the appropriate interpretation of each histologic finding 
, Open biopsies have the advantage of providing more tissue for
histologic evaluation and the disadvantage of being an operative procedure
lncisional biopsies are reserved for very large lesions in which a definitive diagnosis cannot be made with needle biopsy
 Ex­cisional biopsies are performed for lesions in which core biopsy is either not possible or is non diagnostic
Excisional biopsies should be performed with curative intent, that is, by obtaining adequate tissue around the lesion to ensure negative surgical margins
 Orien­tation of the margins by sutures or clips by the surgeon and inking of the specimen margins by the pathologist will allow for determi­nation of the surgical margins and will guide surgical re-excision
If one or more of the margins are positive for microscopic tumor or close
The biopsy incision should be oriented to allow for excision­ of the biopsy scar if repeat operation is necessary
The biopsy incision should directly overlie the area to be removed rather than tunneling from another site, which runs the risk of con­taminating a larger field
Finally, meticulous hemostasis during a biopsy is essential since a hematoma can lead to contamination of the tissue planes and can make subsequent follow-up with physical examinations much more challenging
What are the techniques of tumours cytology 
These including the following cytology techniques

Bruchings eg oesophagus and cervix
FNAC , Fluids either physiological eg cells in urine or sputum or pathological eg cells in ascites or pleural effusion
 The cytological features of malignancy are
  • loss of cellular cohesiveness: nuclei oriented in different directions and are irregularly­
    spaced
  • Cells become detached from one another
  •   Pleomorphism: variation in size, shape and number of nucleoli
  •  moulding of nuclei: nuclei appear pushed into one another or stacked together like a vertebral column
  •  Nuclear to cytoplasmic ratio increased
  •  Chromatin shows irregular clumping and hyperchromasia nuclear membrane is irregular with angular bites
  • Abnormal mitoses may be present
what are the difference between cytology and histology in the diagnosis of malignancy

• Fine nuclear detail may be lost in formalin fixed histology
  •  Cohesiveness of cells is more easily evaluated on cytologic material
  • Histologic sections provide added information on tissue architecture and relation­ ship of cancer cells to normal structures depth of invasion, presence of vascular invasion, etc
What are the histological features or architectural of malignant tumours 
invasion of the underlying or surrounding tissue: extension of tumour beyond the basement membrane for carcinomas and an irregular front penetrating the surrounding tissue
for mesenchymal tumour

stromal changes: the change that occurs in the stroma as tumour invades is called desmoplasia it is a response to invasion of tissue by malignant tumour cells
Loss of normal structure: as tumours become less and less differentiated, they resemble the tissue of origin less and less­

new structures: some tumours will create structures such as glandular structures colon, endometrium cancers or papillary structures thyroid, bladder cancers

Necrosis: may indicate areas of tumour that have insufficient blood supply Angiogenesis and neovasculature

 Inflammation: tumours often cause inflammation and the inflammatory infiltrate is visible immunostaining: an antibody is raised against a protein of particular prognostic significance­
the distribution and concentration of which can then be identified


It can be used for
 
• Identifying poorly differentiated tumours

• Sub-typing tumours

• Identifying an unknown primary from a metastatic deposit

• Assessing tumour microvessel density and angiogenesis


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