1. Generalities in oncology Dr. Fekete Zsolt

2. Direct signs of cancer Direct signs are attributed to tumor growth either at the level of the primary tumor or at the level of lymph nodes and metastases. 1.The primary tumor- visible or palpable in a)superficial tumors (skin, breast cancer, testicle, soft tissues) b)advanced deep lying tumors 2.Adenopathy=larger than normal lymph node -can be benign or malignant -present in tumors extending through the lymphatics: lung cancer, breast cancer, head and neck cancer, lymphomas 3. Metastasis-visible or palpable only when superficial ! Usually, at early stages, the presence of the primary tumor or adenopathy does not produce pain.

3. Indirect signs/symptoms of cancer More frequent than direct signs 1.Abnormal discharge (vagina, rectum, nasal fossae, nipple) -hemorrhagic -serous 2.Compression syndromes -mediastinal-compression of the superior vena cava or compression of the esophagus -intracranial: intracranial hypertension -abdominal: intestinal occlusion/incomplete occlusion, decreased urinary stream, pollakiuria, mechanical jaundice

4. Indirect signs/symptoms of cancer- cont 3. Neurologic signs: -paralysis -neuralgia -sphincterial incontinence -nerve root compression at the level of spinal cord -cranial nerve (III-XII) paralysis 4. Paraneoplastic syndromes (see Lecture Book for details) 5. General signs and symptoms: -anorexia and weight loss -small grade fever -perspirations- -pruritus 6. Changes in blood test values: -increased ESR (erythrocyte sedimentation rate) -Anemia -thrombocytopenia

5. Diagnosis of cancer history physical examination Non-invasive diagnostic tools: imagery and laboratory tests Invasive diagnostic tools: biopsy and pathological evaluation of tumor tissue; imaging through an incision- thoracoscopy, mediastinoscopy A medical procedure is defined as non-invasive when no break in the skin is created (there is no contact with the an internal body cavity beyond a natural or artificial body orifice).

6. Evaluation of loco-regional and distant extension Evaluation of local extension-tumor size and the rapports with healthy structures Evaluation of extension to regional lymphatic- nodes Evaluation of metastases

7. Evaluation of the biological status of the patient The simplest way to evaluate the detrimental effect of the cancer on the organism as a whole, the performance index is used: -Zubrod index -Karnofsky index

8. Evaluation of the biological status of the patient- the Zubrod scale 0 (Karnofsky 90-100) - Fully active, able to carry on all pre-disease activities without restriction, no weight loss. 1 (Karnofsky 70-80) – Presents symptoms or weight loss, but less than 5% of initial weight or restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work. 2 (Karnofsky 50-60) - Ambulatory and capable of all self-care but unable to carry out any work activities. Up more than 50% of waking hours. OR: weight loss between 5-10% of initial weight. 3 (Karnofsky 30-40) - Capable of only limited self-care; confined to bed or chair 50% or more of waking hours. OR: weight loss more than 10% of initial weight. 4 (Karnofsky 10-20) - Completely disabled. Cannot carry on self-care. Totally confined to bed. 5 – Dead

9. Cancer staging Staging refers to the establishment of the extent of the disease and rendering patients similar in disease features, prognostic and treatment in common groups. Staging thus simplifies treatment decisions, offers prognostic data in the face of an individual patient, helps evaluate treatment results and eases communication between different cancer centers. It can be clinical or surgical, pretherapeutic and after primary treatment (y). Clinical staging (c) is based on clinical evaluation, imaging tests, endoscopy and laboratory data. Surgical (pathologic) staging (p) is obtained during surgical and pathological evaluation of a tumor. There are 4 stages for every cancer (I-II-III-IV) These 4 stages are made up from a varying number of different TNM combinations

10. Cancer staging The TNM staging is based on evaluation of three variables: the primary tumor (T), regional no T0-there is no evidence of a primary tumor Tis-"in situ" cancer T1->T4 describes the tumor size and status of spreading N0-there is no evidence of cancer in the regional lymph nodes N1->N3 describe the status of the spreading into the lymph nodes (for instance, the location, size and number of lymph nodes affected). M0-there is no evidence of distant spreading M1-distant spreading has been found.

11. Cancer epidemiology Western Europe, North America- Romania- Asia- South America-

12. Questions 1.What are the direct signs of cancer? 2.Enumerate some indirect signs of cancer. 3.Which are the non-invasive and invasive diagnostic procedures of a cancer? 4.What is the Zubrod performance index of a patient who is confined to bed or chair 50% or more of waking hours? 5.What is the Zubrod performance index of a patient who lost 20 kg and his initial weight was 100 kg? 6.What is the Zubrod performance index of a patient who is bedridden?