Neoplastic Disorders

NEOPLASTIC DISORDERS

Learning OutcomesAt 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.

Naming of Tumors Tumors derive their names from the types of

the tissues involved. Examples

Parent tissue Benign Tumor Malignant Tumor

EpitheliumSkin and mucous membrane

Glands

Papilloma Polyp

Adenoma

Squamous cell carcinomaBasal cell carcinomaTransitional cell carcinomaAdenocarcinoma

Parent Tissue Benign Tumor Malignant TumorEndotheliumBlood vessels

Lymph VesselsBone Marrow

Hemangioma

Lymphangioma

HemangiosarcomaAngiosarcomaLymphangiosarcomaMultiple MyelomLeukemiaLymphosarcomaLymphatic LeukemiaMalignant Lymphoma

Parent Tissue Benign Tumor Malignant TumorConnective TissueEmbryonic Fibrous Tissue

Myxoma

Myxosarcoma

Fibrous Tissue

Fibroma

Fibrosarcoma

Adipose Tissue

Lipoma

Liposarcoma

Cartilage

Chondroma

Chondrosarcoma

Bone

Osteoma

Osteogenic Sarcoma

Synovial Membrane

Synovioma Synovial Sarcoma

Parent Tissue Benign Tumor Malignant Tumor

Muscle TissueSmooth Muscle

Striated Muscle

Leiomyoma

Rhabdomyoma

Leiomyosarcoma Rhabdomyosarcoma

Parent Tissue Benign Tumor Malignant Tumor

Nerve TissueNerve Fibers &Sheath

NeuromaNeurinoma

Neurogenic Sarcoma

Ganglion Cells Neurofibroma Neurofibroma SarcomaNeuroblastoma

Glial Cells

Meninges

GanglioneuromaGliomaMeningioma

GlioblastomaSpongioblastoma

Parent Tissue Benign Tumor Malignant Tumor

Pigmented NeoplasmsMelanoblasts

Pigmented Nervus

Malignant MelanomaMelanocarcinoma

Parent Tissue Benign Tumor Malignant TumorMiscellaneousPlacenta Hydatidiform

MoleDemoid Cyst

Chorion-epithelioma (choriosarcoma)Embryonal carcinomaEmbryonal sarcomaTeratocarcinoma

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 Hodgkin’s 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 Benign Malignant

Cell characteristics Well-differentiated cells that resemble normal cells of the tissue from which tumor originated

Cells are undifferentiated & often bear little resemblance to the normal cells of the tissue from which they arose

Mode of growth of growth

Tumor grows by expansion and does not infiltrate the surrounding tissues; usually encapsulated

Grows at the periphery & sends out processes that infiltrate & destroy the surrounding tissues

Rate of growth Rate of growth is usually slow Rate of growth is variable & depends on level of differentiation; the more anaplastic the tumor, the faster its growth

Metastasis Does not spread by metastasis Gains access to the blood and lymphatic channels & metastasis to other areas of the body

General effects Is usually a localised phenomenon that does not cause generalised effects unless its location interferes with vital functions

Often causes generalised effects, such as anaemia, weakness, & weight loss

Tissue destruction Does not usually cause tissue damage unless its location interferes with blood flow

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

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

Usually causes death unless growth can be controlled

Benign MalignantLimited growth potential May proliferate rapidly or

grow slowlyLocalized Spread ( metastasize)

throughout the bodyFibrous capsule No enclosing capsule

Rarely recur after removal

May recur even after treatment

Usually regular in shape Irregular shape with poorly defined border

Cells similar to cell of parent tissue ( well differentiated)

Cells much different from parent cells ( poorly differentiated)

Expansive growth 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.

- A wide range of diagnostic procedures may be used to determine the cause of the patients symptoms.

- Radiologic Studies1. Chest X-Ray2. A mammogram, a flat plate of the abdomen, or x-ray films

of the extremities3. Barium studies of the gastrointestinal tract4. Intravenous pyelogram (IVP) to evaluate the urinary tract5. Mylogram to assess the spinal cord 6. Computed Tomography (CT) produces multiple cross

sectional depictions of internal structures7. 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 DefinitionsStage Designation DefinitionT Primary Tumor Size, extent, and depth of

primary tumor

TX Primary tumor cannot be assessed

TO No evidence of primary tumor

Tis Carcinoma in situ

T1-T4 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 No regional lymph node metastasis

N1-N3 Increasing numbers and size of involved regional lymph nodes

Cont…… Stage Designation Definition

M Metastasis Absence or presence of distant spread of diseases

MX Distant disease cannot be assessed

MO No distant spread of disease

M1 Distant spread of disease

Grade StageGrade 0Normal Tissue

Stage 0Cancer in situ

Grade 1Well differentiated with minimal deviation from tissue of origin

Stage ITumor limited to tissue of origin

Grade 2Moderately well differentiated with evidence of structural changes from normal tissue of origin

Stage IILimited local spread

Grade Stage

Grade 3Poorly differentiated with extensive structural changes from normal tissue of origin

Stage IIIExtensive local and regional spread

Grade 4Very anaplastic, with no resemblance to tissue of origin

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 - Breast Cancer and cancer of liver

B - Types of Leukemia

C - Cancer of Brain/ Brain Tumor

D - 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.