NEOPLASTIC DISORDERS

Learning Outcomes
At the end of the lecture, the student is able to: 1. Define the specified terms 2. Discuss the naming of tumors 3. Outline the general diagnosis of a neoplastic disease 4. Describe the common clinical management regimes currently in use surgical, chemotherapeutic, radiation, and biological modifiers.

Tumors derive their names from the types of the tissues involved. Examples Parent tissue Benign Tumor Malignant Tumor
Epithelium Skin and mucous membrane Papilloma Polyp Squamous cell carcinoma Basal cell carcinoma Transitional cell carcinoma Adenocarcinoma

Naming of Tumors

Glands

Adenoma

Parent Tissue Benign Tumor Malignant Tumor

Endothelium Blood vessels Hemangioma Hemangiosarco ma Angiosarcoma Lymphangiosarc oma Multiple Myelom Leukemia Lymphosarcoma Lymphatic Leukemia Malignant

Lymph Vessels Bone Marrow

Lymphangioma

Parent Tissue Benign Tumor Malignant Tumor

Connective Tissue Embryonic Fibrous Tissue Fibrous Tissue Adipose Tissue Cartilage Bone Synovial Membrane

Myxoma

Myxosarcoma

Fibroma Lipoma Chondroma Osteoma Synovioma

Fibrosarcoma Liposarcoma Chondrosarcoma Osteogenic Sarcoma Synovial Sarcoma

Parent Tissue Benign Tumor Malignant Tumor

Muscle Tissue Smooth Muscle Striated Muscle

Leiomyoma Rhabdomyoma

Leiomyosarcom a Rhabdomyosarc oma

Parent Tissue Benign Tumor Malignant Tumor

Nerve Tissue Nerve Fibers &Sheath Ganglion Cells Neuroma Neurinoma Neurofibroma Neurogenic Sarcoma

Glial Cells Meninges

Neurofibroma Sarcoma Neuroblastoma Ganglioneuroma Glioblastoma Glioma Spongioblastom Meningioma a

Parent Tissue Benign Tumor Malignant Tumor

Pigmented Neoplasms Melanoblasts Pigmented Nervus Malignant Melanoma Melanocarcinom a

Parent Tissue Benign Tumor Malignant Tumor

Miscellaneous Placenta Hydatidiform Mole Demoid Cyst Chorionepithelioma (choriosarcoma) Embryonal carcinoma Embryonal sarcoma Teratocarcinom a

Naming of Tumors
There are two types of tumor- benign and malignant Classification of malignant tumors is difficult because many contain several types of cells and may also have benign tissue incorporated within them. Cancers may be classified according to cell type origin. Two main types are epithelial and connective tissue. The term carcinoma denotes a malignant tumor of the epithelial cells and the term sarcoma denotes a malignant tumor of the connective tissue cells. Tumors are also known by scientists who described them. e.g Hodgkins disease. Some are named after the organs from which they arise. E.g Hepatoma

Grade - Is the classification of the tumor cells based on cellular differentiation, or resemblance to normal cells to structure, function, and maturity. - The degree of malignancy ( grade) is based on microscopic examination of lesion. - Tumors are classified into four grades. Grade 1 tumor is the most differentiated which means the tumor mostly looks like the normal cells or the tissue of origin and therefore are the least malignant whereas a grade 4 tumor is the least differentiated which means that there is no resemblance to the normal cells or the tissue of the origin and there is a greater chance of malignancy

Characteristics of Benign & Malignant tumors

Characteristics Cell characteristics Benign Well-differentiated cells that resemble normal cells of the tissue from which tumor originated Tumor grows by expansion and does not infiltrate the surrounding tissues; usually encapsulated Rate of growth is usually slow Malignant Cells are undifferentiated & often bear little resemblance to the normal cells of the tissue from which they arose Grows at the periphery & sends out processes that infiltrate & destroy the surrounding tissues Rate of growth is variable & depends on level of differentiation; the more anaplastic the tumor, the faster its growth Gains access to the blood and lymphatic channels & metastasis to other areas of the body Often causes generalised effects, such as anaemia, weakness, & weight loss

Mode of growth of growth Rate of growth

Metastasis

Does not spread by metastasis

General effects

Is usually a localised phenomenon that does not cause generalised effects unless its location interferes with vital functions Does not usually cause tissue damage unless its location interferes with blood flow

Tissue destruction

Often causes extensive tissue damage as the tumor outgrows its blood supply or encroaches on blood flow to the area; may also produce substances that cause cell damage Usually causes death unless growth can be controlled

Ability to cause death

Does not usually cause death unless its location interferes with vital functions

Benign
Limited growth potential Localized Fibrous capsule Rarely recur after removal Usually regular in shape Cells similar to cell of parent tissue ( well differentiated) Expansive growth

Malignant
May proliferate rapidly or grow slowly Spread ( metastasize) throughout the body No enclosing capsule May recur even after treatment Irregular shape with poorly defined border Cells much different from parent cells ( poorly differentiated) Infiltrative growth

Diagnosis of a Neoplastic Disease

- Patients past medical history and physical examination and presenting signs and symptoms provide important data towards diagnosing a malignancy - Nurses also play a important role in history taking and physical examination. - In addition to the physical examination and health history, diagnosis must be confirmed through histological and cytological examination.

1. 2. 3. 4. 5. 6. 7.

A wide range of diagnostic procedures may be used to determine the cause of the patients symptoms. Radiologic Studies Chest X-Ray A mammogram, a flat plate of the abdomen, or x-ray films of the extremities Barium studies of the gastrointestinal tract Intravenous pyelogram (IVP) to evaluate the urinary tract Mylogram to assess the spinal cord Computed Tomography (CT) produces multiple cross sectional depictions of internal structures Magnetic resonance imaging provides sensitive images of soft tissues without interference from bone.

Laboratory Studies - Bone Marrow Aspiration - Chemistry Profile- Bilirubin, Uric Acid, Blood urea nitrogen (BUN), creatinine, electrolytes, lactate dehydrogenase (LDH),AST, ALT,magnesium

Cytology - is the examination of cells obtained from the tissue scrapping, body fluids, secretions or washings Biopsy - is the only definite way that cancer can be diagnosed - incisional biopsy is the surgical removal of a section of a neoplasm - a portion of the tissue is obtained by surgical procedure and is examined - often done as a part of the endoscopic procedures or under the guidance of CT to ensure that suspicious areas are sampled - bone marrow biopsy uses a special needle to aspirate bone marrow tissue.

Staging
- Staging is a form of classification that describes the gross extent of the tumor and its spread (metastasis). Grading and staging are useful to the physician in predicting whether the tumor may be expected to respond to the treatment. - Once the cancer diagnosis is confirmed by pathology, the information's from the tests and scan results are combined to determine the stage of malignancy. - The TNM system is used to determine the stage of malignancy. T the size of the primary tumor N the absence or presence of the regional lymph node M the absence or presence of distant metastatic disease

TNM Definitions
Stage Designation
T Primary Tumor TX TO Tis T1-T4

Definition
Size, extent, and depth of primary tumor Primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ Increasing size or extent of primary tumor

Cont.
Stage Designation Definition
N Nodal Metastasis Extent and location of involved regional lymph nodes NX Regional lymph nodes cannot be assessed No regional lymph node metastasis Increasing numbers and size of involved regional lymph nodes

NO

N1-N3

Cont
Stage Designation
M Metastasis

Definition
Absence or presence of distant spread of diseases Distant disease cannot be assessed No distant spread of disease Distant spread of disease

MX

MO

M1

Grade
Grade 0 Normal Tissue Grade 1 Well differentiated with minimal deviation from tissue of origin Grade 2 Moderately well differentiated with evidence of structural changes from normal tissue of origin

Stage
Stage 0 Cancer in situ Stage I Tumor limited to tissue of origin Stage II Limited local spread

Grade
Grade 3 Poorly differentiated with extensive structural changes from normal tissue of origin Grade 4 Very anaplastic, with no resemblance to tissue of origin

Stage
Stage III Extensive local and regional spread

Stage IV Widespread metastasis

Clinical Management
1. Surgery Surgery serves as a diagnostic treatment modality. Surgical intervention provides tissue sampling for histology, decreases the tumor burden for further treatment and can provide cure for the low grade tumors. There are different types of surgical procedures for various cancers.

2. Chemotherapy - is the use of strong drugs to destroy cancer. - The drugs are often called anticancer drugs - These drugs can be given in the form of tablets, injections into the muscles or by intravenous injections - Treatment is usually over 3-12 months and can be more.

- Normally cells grow and die in a controlled way. But cancer occurs when cells become abnormal and keep dividing and forming more cells without control or order. - Anti cancer drugs destroy cancer cells by stopping them from growing or multiplying at one or more points in their life cycle. - Because some drugs work together rather than alone, chemotherapy may often consist of more than one drug. This is called a combination chemotherapy.

- Depending on the type of cancer and the stage of development, chemotherapy can be used: To cure cancer To keep the cancer from spreading To slow the cancers growth To kill cancer cells that may have spread to other parts of the body from the original tumor To relieve symptoms that may have been caused by cancer Can also help people live more comfortably- this is known as palliative care.

- Chemotherapy is also used in addition to surgery and radiation therapy. When it is used like this, it is called Adjuvant Therapy - There are several reasons why chemotherapy may be given in addition to other treatment methods. For instance, chemotherapy may be used to shrink a tumor before surgery or radiation

Side Effects of Chemotherapy

Nausea and vomiting Hair loss and thinning Mouth, gum and throat problems Bowel problems ( constipation and diarrhea) Fatigue/anemia Infection Blood clotting Nerve and muscle effects Effects on skin and nails Kidney and bladder effects Flu like symptoms Fluid retention

3. Radiation Therapy - Radiation Therapy or radiotherapy has been used a part of cancer treatment to control malignant cells. - Radiotherapy is used for the treatment of malignant tumors ( cancer) and may be used as the primary therapy. Usually radiotherapy is combined with chemotherapy and hormone therapy. This is called adjuvant therapy and will depend on the tumor type, location and stage as well as well as the general health of the patient

- Radiation therapy is commonly applied to the cancerous tumor. The radiation fields may also include the draining lymph nodes if they are clinically involved with tumor. - Radiation therapy works by damaging the DNA of the cells.

Side Effects
- Radiation therapy is painless. Many low-dose palliative treatments ( for example, radiotherapy to bone metastases) causes minimal or no side effects, although short term pain can be experienced in the days following treatment due to edema compressing nerves in the treated area. - However, treatment to higher doses causes varying side effects during treatment (acute side effects) in the months or years following treatment ( long term side effects) or after

re treatment (cumulative side effect). - The nature,severity,and length of side effects depends on the organs that receive the radiation, the treatment itself ( type of radiation, dose, concurrent chemotherapy) and the patient. - The main side effects are fatigue and skin irritation, like mild to moderate sun burn. Patient will experience fatigue often during the middle of a course of treatment and can last for weeks after treatment ends.

Hormonal Therapy
- Hormonal therapy is one of the major modalities of medical treatment for cancer. - It involves the manipulation of the endocrine system through exogenous administration of specific hormones, particularly steroid hormones or drugs which inhibit the production or activity of such hormones. - Because steroid hormones are are powerful drivers of gene expression in certain cancer cells, cahnging the levels or activity of certain hormones can cause certain cancers

to cease growing, or even undergo cell death. - Hormonal therapy is used for several types of cancers including breast, prostate, and endometrium For example, the use of estrogen response modulator Tamoxifen used for the treatment of breast cancer.

Group Discussions
A B C D Breast Cancer and cancer of liver Types of Leukemia Cancer of Brain/ Brain Tumor Cancer of the throat/ Multiple Myeloma

Work on your various groups and discuss in detail the pathophysiology, diagnosis and staging, signs and symptoms and clinical management of the above cancers.