Neoplasia – in a nutshell

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Causes

Usually chronic or recurrent exposure to:

  • Biological agent e.g. HPV – cervical cancer
  • Radiation e.g.  UV radiation – skin cancer
  • Chemical agent e.g. smoking – lung cancer

Strong genetic component.  FHx malignancy important
Types

  • Solid tumours – managed mainly by oncologists +/- surgeons
  • Haematological malignancy – managed mainly by haematologists

Pathogenesis

  • Initially asymptomatic and indolent
  • Some are slow growing/developing (e.g SCC, chronic leukaemia)
  • Benign neoplasia may not need treatment unless causing symptoms
  • Depending on tumour may enter a rapid growth phase or metastasise early
  • Malignant tumours display locally invasive features (cancer= ‘crab’) i.e. margins not well demarcated and can erode surrounding vessels, capsules, lumens, imaging studies show local destruction e.g. periosteal reaction of bone cancer or ill-defined margins on imaging studies
  • Effects of metastases may be the first symptom to manifest

Clinical manifestations

Unexplained weight loss is a red flag
Neoplastic

  • Vascular involvement – ulceration and bleeding from mucosal/serosal surfaces, bleeding from orifices
  • Luminal obstruction – e.g. bronchial collapse > dyspnoea, renal tract obstruction > prostatism, obstructive renal failure, bowel obstruction > vomiting, distension, obstipation
  • Organ dysfunction – e.g. marrow infiltration > anaemia, thrombocytopenia > pallor, spontaneous bleeding

Paraneoplastic

  • Due to endocrine or humoral effects at a distant site e.g. ACh antibodies > Lambert-Eaton syndrome, SIADH/lung cancer

Haematological malignancies

  • Usually affects marrow components or lymph nodes
  • Diagnosis from FBC, marrow biopsy or node biopsy

Investigations

  • Imaging studies e.g. XR, Ultrasound, CT
  • Endoscopic e.g. bronchoscopy, gastro-dueodenal endoscopy, cystoscopy, laryngoscopy
  • Biopsy
  • Staging investigations are needed at some point to determine treatment

Treatment
Choice of treatment depends on histology (grading including benign/malignant), local spread and presence of metastases and presence of symptoms
Surgery

  • Most useful if no distant metastases
  • De-bulking palliative treatment for severe symptoms
  • Occasionally may be possible to resect solitary mets
  • Stent insertion for luminal obstruction e.g. oesophageal, biliary, ureteric

Chemotherapy

  • Most commonly employed adjuvant therapy
  • Works better for faster dividing tumours
  • Sometimes given pre-operatively to de-bulk tumour
  • Administered by treating physician or oncologist
  • Can be administered systemically to direct organ or injected directly to organ
  • Occasionally may need placement of long-term vascular access e.g. Infusaport
  • Acute complications affects rapidly dividing cells – marrow depression (immunosuppression (beware of febrile neutropenia: PMN count < 0.5), anaemia, thrombocytopenia, N&V&D, oral-pharyngeal mucositis, also organ-specific effects by different agents
  • Late complications – other neoplasia

Radiotherapy

  • Local therapy post-surgery as adjuvant therapy
  • Most often used for palliation to treat symptomatic metastases e.g. bone pain
  • Specifically used to primary tumour if radiosensitive e.g. ENT tumours

Can be administered as

  • External beam (various modalities) – treatments divided into ‘fractions’ to minimise normal tissue damage but maximise tumour regression
  • Brachytherapy – radioactive pellets directly implanted in tumour e.g. prostate cancer
  • Radio-isotopes – labelled isotopes ingested and taken up directly by organ e.g. radioactive iodine/thyroid cancer
  • Acute complications – cutaneous/mucosal damage or irritation, acute inflammation/bleeding, marrow depression (if large areas of body irradiated) > pancytopenia
  • Chronic complications – chronic inflammation/bleeding e.g. radiation proctitis, cystitis, fibrosis/scarring, radiation osteonecrosis, other neoplasia
  • Aside: Rare non-cancer uses e.g. pterygium, Dupuytren’s contracture

Other interventions
Angioembolisation

  • Performed by interventional radiologist
  • Feeding vessels to tumour embolised to induce tumour infarction
  • Maybe performed

Other management issues

  • DVT /PE risk
  • Symptom control
  • Failure to respond to therapy
  • Late recurrence (beware of ‘cancer survivors’ with recurrent symptoms)
  • Palliative care
  • Reconstructive surgery e.g. breast surgery
  • Other cosmesis e.g. wigs
  • Psychosocial (see below)

Psychosocial issues

  • Side effects of treatment e.g. loss of taste, difficulty eating, hair loss
  • Disfiguring surgery or treatments e.g. mastectomy, radiation skin changes
  • Travelling distances for treatment
  • Loss of fertility / Family planning
  • Depression / Anxiety

Prognosis
Largely dictated by

  • Staging (nodal involvement, metastases) – ‘TNM’ system for solid tumours
  • Grading (histological and biochemical characteristics)

Screening

Most effective in high risk groups

  • Behaviour e.g. sexually active females – Pap smear
  • Age e.g. breast cancer – mammography
  • Strong FHx e.g. multiple endocrine neoplasia
  • Pre-malignant conditions e.g. ulcerative colitis, cervical intra-epithelial neoplasia

Acute oncological emergencies

  • Fever: Febrile neutropenia – urgent WCC/diff for confirmation, septic screen and rapid administration of broad spectrum antibiotics to include Pseudomonas
  • Altered mental state / Seizures: Hypercalcaemia – IV hydration, biphosphonate therapy, Cerebral metastases
  • Luminal obstruction: massive lung collapse, bowel obstruction, urinary obstruction/retention
  • Massive bleeding from tumour erosion: haematemesis or malaena, haemoptysis, PR bleeding
  • Dyspnoea: pulmonary embolus
  • Tumour lysis syndrome: sever hyperkalemia/uricaemia post chemotherapy > need IVT hydration and maintain high urine output

Evaluating the possible malignancy

  • Consider the presence or severity of symptoms
  • Clinically evaluate for the likely source and the likelihood of abnormality
  • Monitor asymptomatic or indeterminate imaging studies regularly
  • Commence more extensive investigations and refer if symptoms, signs or tests change significantly
  • Biopsy unexplained, persistent or changing skin lesions or nodes
  • Discuss concerns with a specialist
  • Urgent referral if an acute oncological emergency

The ‘cancer survivor’

  • Beware of recurrent symptoms even if no longer under specialist follow-up.  Consider re-instituting investigations
  • Be aware of late complications of treatment

Summarising/Documenting oncological history

  • Duration of symptoms
  • Date of diagnosis
  • Histological diagnosis and stage (if known)
  • Treatments to date and response
  • Any major complications of disease or treatment
  • Active disease or in remission
  • Any followup ongoing
  • Treating clinician(s)

1 thought on “Neoplasia – in a nutshell

  1. Timothy Mann

    While unintentional weight loss warants investigation. It is grossly over-rated as a sign of malignancy. Only ~25% of people with weight loss will have malignancy. And psychiatric pathology is a more likely explanation. In one study <2% of patients developed cancer after routine history examination and basic bloods were done.

    Reference UpToDate

    Reply

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