Each cancer location has specific revealing symptoms.
Independently of the location however, most revealing factors can be deduced from physiopathology and the particular development characteristics of the tumour.
Once these symptoms have appeared, phsyicians should request a few diagnostic procedures in order to:
Appropriate and rapidly initiated treatment offers the best prospects to patients.
1) Physiopathology of revealing symptoms:
Here are a few examples:
Clinical examination :
Complete clinical examination is the first and most often the best way to obtain a precise diagnosis and cancer staging. (See below the main revealing symptoms for major cancers)
The physician should give himself/herself enough time and should have all the practical facilities available in order to perform a complete and calm examination of his/her patient.
The first step, should involve letting the patient explain with his/her own words his/her disease; the physician listening to and taking into account silences and doubts. Usually, a patient only speaks for about 30 to 60 seconds: calmly listening to the patient will offer the physician a great deal of information on the patient’s psychological state of mind (which will be very important when the subject of cancer diagnosis needs to be broached) and it is also a clear sign of politeness and respect.
Clinical questioning should be precise, well-mannered, discreet and empathetic. When investigating personal and family history, an open dialogue is the first way to establish a mutually confident relationship with the patient. It allows the evaluation of the patient’s thoughts and fears about his/her disease. It also allows (if the patient is willing) improved understanding on his/her personal, family, professional and social situation. All of these aspects are important when the time comes to announce bad news and to propose, always feared and potentially mutilating, treatment.
This initial period should also allow a relaxed, attentive clinical examination, respecting the patient's modesty and avoiding unnecessary painful procedures.
In many cases, the patient will be asked to undress and show a part of his/her body often qualified as disgraceful or shameful by many people. Patient modesty should always be respected, however a precise and careful examination is most necessary: most cultural inhibitions can be relieved by tactful consideration and patience. We also have to overcome our own modesty and our own inhibitions. It is of course easier not to perform a complete clinical examination than to convince the patient of its usefulness. Such ill-placed modesty may inhibit early diagnosis and result in monstrous tumours (breast tumours, gynaecological tumours, urological tumours) because the physician has, at no time, dared to perform a correct clinical examination.
Some cancers are truly monstrous and we may wonder how the patient managed to live with such a tumour. For instance, the following pictures demonstrate how a communication gap can result in abysmal tumours of the lip, the face, the cervical nodes, the breast, the anus, the testis or the penis. The psychological reactions to the discovery of cancer, denial, shame and fear of being examined, the fear of surgery and of the medical world are among the factors which may explain the relative frequency of such monstrous discoveries.
The clinical examination should be performed in the greatest calm: the physician should concentrate on his/her work and ask the patient (and the family) for silence, if necessary. A precise, detailed clinical examination, during which the physician looks for the smallest clinical evidence, even if it somewhat disturbs the patient's intimacy, is most often understood by the patient as a total interest in the disease and, consequently, the patient himself/herself.
Some cancer classifications are carried out by the clinical examination alone: thus learning how to correctly perform an exhaustive examination is a major part of medical student teaching. For a few difficult or unpleasant examinations, a general anaesthesia is recommended (in particular for gynaecological tumours where pelvic examination may be painful due to inflammation: for instance, the required relaxation for a quality clinical evaluation of the invasion of uterine parameters is rarely obtained during the first examination).
In the same manner, discovering metastastic nodes or skin lesions, by a precise clinical examination, renders complex and costly paramedical examinations unnecessary and prevents futile surgery. A poor clinical examination may induce a waste of time and money and unpleasant and unnecessary procedures.
Among the major clinical procedures:
Thus, very often, the clinical examination can enable the precise diagnosis and staging of the cancer. The examination enables a genuine physical contact between the carer and the patient, communication which is essential for quality patient/carer dialogue.
Many psychological mistakes arise from the absence of this contact communication. The intimate dialogue with the other carers (such as nurses and auxiliaries) is the consequence of this type of communication, and how the patient suffers from a distant impersonal dialogue when the physician uses radiographies and scanner as a protective screen.
A quality clinical examination avoids unnecessary paraclinical examinations. Although these paraclinical examinations are useful for other purposes (such as measuring tumour size), they will be accepted all the better if the physician has performed a complete examination and explained why he/she needs such paraclinical exams.
Explaining the necessity of paraclinical examination is lawful. The physician should explain the reasons, the advantages and the risks of any paraclinical examination and obtain the patient's tacit agreement. If the patient knows why such an examination is necessary, he/she will understand the diagnostic protocol and will also be more confident in the therapeutic protocol.
Only necessary complementary examinations should be requested for diagnosis and classification of cancer. Any complementary examination is more or less toilsome for the patient. Certain patients demand many complementary examinations, sometimes because the first clinical examination appeared to them too superficial to convince them of their disease. An examination should offer genuinely useful information: the physician may explain to the patient why an examination is futile, painful or even dangerous, through constructive and direct dialogue.
In the same manner, the physician or the nurse should explain how the complementary examination will be performed in order to avoid unnecessary patient fears. The general practitioner, the oncologist or the internist must know enough of the procedure to be able to explain to the patient precisely what is going to happen (advantages and disadvantages).
Giving detailed and specific documentation (which offers a second explanation) is generally recommended. Drafting of such written information should be coordinated with the specialist (performing the examination), the prescribing physician, the paramedical personnel involved in the examination (nurse, technician) because they are generally the people most likely to be solicited for further simple explanations, and possibly a patient's committee. Giving such a written explanation does not dispense from answering the patient with a reply such as, "It’s all written down in the leaflet!”.
They most often confirm and objectify clinically suspected lesions and reveal new lesions, thus modifying the staging and treatment possibilities.
Main radiological procedures include:
Since it can be performed within a very short timescale (in comparison with CT-Scan or RMI) , this simple examination should be used as often as possible.
X-Ray very often allows a rapid diagnosis, for example when a risk of medullar compression is suspected, through the discovery of irregular vertebral crushes or the disappearance of vertebral pedicles.
A bone scintigraphy may help in requesting the appropriate radiography by localising the lesion.
The following pages demonstrate a few diagrammatic aspects of bone X-Rays for discovering bone metastases:
Technical improvements have been made over the last ten years, and further progress is pending (digitalisation for instance).
Nowadays, tumours as small as 4 mm in diameter can be detected (infraclinical tumours) with the usual typical image of a dense, poorly delineated, star-like opacity harbouring a few microcalcifications.
Biopsies, now performed in stereotaxic conditions, offer pre-operative histological information.
Here are the various chapters you can consult over the following pages:
Lesions (primitive tumour, deeply located nodes, metastases) whose volume is greater than 1 cm are relatively easy to detect.
Enhanced contrast with the use of iodine products is characteristic of increased vascularisation, frequently observed in cancer lesions.
New modern devices (helical and multisclice devices) allow very thin jointive slices, with minimal patient irradiation, performed in a short time thus eliminating artefacts due to respiratory movement which decrease the size of detectable pathological images.
CT scan can detect relatively deep lesions thus enabling biopsies to be performed to obtain the histological proof of cancer.
CT scan has now become the best device to define target volumes for radiotherapy and to calculate preradiotherapy dosimetry.
A few views have been pooled together in a special chapter, most of them borrowed from various sites. We have produced a diagram with comments for each view in order to assist interpretation.
Its actual definition is somewhat lower than scanner definition, however devices are constantly becoming more rapid and effective Indications are therefore ever-increasing and gradually differentiated from those of CT scanners.
In particular, many studies are currently underway to objectivise the initial changes induced by chemotherapy, radiotherapy or new target treatments and to predict clinical responses to treatment.
Another very attractive indication might be the surveillance of irradiated tumours (in particular breast carcinoma).
With no intended pretence, we have pooled together a few RMI views with the same educational tools and goals:
Angiographic procedures are less frequently used than in the past: they enabled viewing of anarchical tumour vascularisation (particularly in renal or brain tumours). They may also be used for therapeutic acts such as chemoembolisation or intraarterial chemotherapy.
Ultrasound is an easy method for differentiating full lesions from cysts and other hollow liquid lesions.
Its major interest is its quickness and the non-invasive nature of the examination for the patient. However, it requires a very well trained radiologist, since image production is obtained by the radiologist's hand and paper reproductions rarely offer the oncologist sufficient and/or tangible clinical information.
Its major indications are for the detection of liver metastases, pancreatic lesions, pelvic tumours (ovary) or superficial tumours (thyroid, testis).
Intracavitary probes are very useful for certain pathologies:
The quality of the ultrasonography examinations is highly operator-dependent and paper reproductions are but a far cry from the actual examination; for this reason, ultrasonography is rarely used to monitor therapeutic trials which impose precise tumour measurements requiring to be verified by independent observers.
Recent progress in this technique has provided knowledge on tumour vascularisation and offers 3D images.
Scintigraphies:
Scintigraphy is a functional exploration: image quality is of less interest than the actual function explored.
However, cancer is not the only pathology which can induce scintigraphic abnormalities. Interpretation should therefore always be made with caution and should take into account the patient's clinical history.
The infused tracer is a diphosphonate labelled with 99Technetium. Like phosphorus, it fixes where bone modelling is observed: fracture callus, active Paget's disease, tumour metastasis.
The total radioactivity is extremely low (740 MBq) with no known danger to patients.
A local punctiform hyperfixation is rather significant of a bone metastasis, however it can also be observed in benign pathologies (such as arthritis, bone infection, post traumatic sequela).
In principle, only cancers bearing an osteoid reaction should fix the tracer, however almost all lytic bone destruction is accompanied by a minor reconstruction process hence provoking hyperfixation.
Main bone metastases detected by scintigraphy are breast cancer metastases, prostate cancer metastases, and thyroid cancer. Scintigraphy enables avoiding radiographies of all bone parts and offers the possibility to limit radiography to enhanced bones. Primary bone lesions are generally highly enhanced (for instance Ewing's sarcoma ).
Hyperscan is a particular aspect used for certain prostatic bone or mammary cancer metastases. The fixation is so high than generalised metabolic radiotherapy may be proposed treating all the bone metastases in one shot.
However, to locally treat a metastasis (by radiotherapy for instance) or refute the exeresis of a primary tumour (in relation to supposed distant metastases), further confirmation is required (such as bone radiography or RMI). Other pathologies provoke hyperfixation, particularly among aged people, and include arthrosis or metabolic bone disease such as Paget's disease).
Radioactive Iodine is the reference physiological tracer: it is a reliable tracer of hormonogenesis and permits a cartography of Iodine fixation. However the use of 131I is complicated by radioprotection issues related to its long half life (8 days) and its major ß emitting characteristics. 99Technetium or 99mTc is generally preferred and provides quality nodule distinction (cold or hot) and the surveillance of a non-toxic goiter.
With thyroid scintigraphy, we can distinguish the following pathologies:
For instance, we can study the ventricular contraction fraction by studying the evolution of radioactivity of the precardiac area after intection of a radioactive tracer.
Pulmonary ventilation is studied by the absorption of xenon, enabling the seperation of each part of the lung: before deciding on pneumonectomy or lobectomy to treat lung cancer, knowledge of the capacity of the remaining lung is essential
Pulmonary perfusion study is an essential step for diagnosing pulmonary embolism, a frequent complication in cancer after lower limb or pelvis thrombophlebitis.
Renal scintigraphy is used toimprove definition of renal clearance.
These techniques are often used for the study of chemotherapy toxicity; however they often need to be compared with other classical functional methods.
The antibody should be specific, and not absorbed by circulating antigens and, if possible, should not disturb further immunological assays of the antigen.
This technique has been used to detect micrometastases which can be treated by localised surgery: choriocarcinoma (β-HCG), digestive metastases (ACE), ovarian carcinoma (Ca-125), and so on.
This latter technique avoids postoperative complications from unnecessary lymphadenectomies.
After chemotherapy, when complete remission seem to be obtained, the X-Ray scanner can still show tumour masses which, however, do not fix 67Gallium. The absence of fixation defines complete remission. Sometimes (thorax or abdominal views), the interpretation may be more delicate due to the digestive elimination of Gallium.
High grade non-Hodgkin lymphoma and most Hodgkin's lymphoma have a very great affinity for 67Gallium, wheras low grade lymphoma has a lesser affinity. Another products used for these latter lymphoma are 201Thallium or MIBI.
This is the principle of PETScan (see linked chapter) which is more and more useful due to the increased availability of positron devices and the possibility of combining them with an X-Ray scanner (PET-CT)
The use of positron emitting isotopes is very promising for the detection of mediastinal or abdominal tumours and for the study of their limits.
However, since they require very expensive devices and costly isotopes, a precise evaluation of the practical value of PETScan (useful modifications of therapeutic schedules) should be carried out within the framework of international studies.
Endoscopy procedures:
The emergence of optic fibres and cold light has revolutionised the endoscopic approach to tumours. Examinations, which in the past were painful, are now easy to perform, well tolerated and allow the clear exploration of airways (laryngoscopy, bronchoscopy), digestive tract (oesophagoscopy, gastroscopy, colonoscopy, rectoscopy), urinary tract (cystoscopy, ureteroscopy), genital apparatus (hysteroscopy), under local or general anaesthesia which can be repeated if necessary.
All of these examinations enable a precise description of the tumour but, more importantly, offer the possibility of performing biopsies to obtain pathological diagnosis before any radical treatment. In combination with an ultrasonographic probe, they study the extent of tumour invasion (which is necessary for most classifications) and look for nearby satellite nodes.
Other more complex examinations require general anaesthesia and are performed to obtain a biopsy sample in a less traumatic manner than via surgical exploration: mediastinoscopy, pleuroscopy, laparoscopy, arthroscopy.
The use of a television camera allows a better description of the lesion and offers the possibility of involving several physicians in the endoscopic exploration.
Abdominal surgery through laparoscopy has not yet totally proved its worth in oncology, except for very limited tumours or in a diagnostic setting (such as lymphadenectomy by coelioscopy). It requires a very well trained surgeon and team. The risk of cancer diffusion along the puncture openings is promoted by intraabdominal hyperpressure and clear, carcinologically satisfactory surgery may be difficult to prove (cf. definition of complete carcinological surgery). The use of a robot could be of great interest for other laparoscopic surgical acts (urology, gynaecology) although its cost-effectiveness has not yet been demonstrated.
Cancer diagnosis always requires a biopsy and a pathological examination (except during terminal phases when therapy is not feasible).
Except in such rare situations, beginning radical treatment without the histological (or at least cytological) proof of malignancy would be verging on malpractice. Some long lasting infections, certain benign tumours and a few rare diseases may mimic cancer; however the erroneous administration of radiotherapy or chemotherapy in such circumstances would be a source of major complications.
In order to ensure a genuine multidisciplinary discussion and concerted therapy decision integrating and combining all available therapeutic facilities (peroperatory radiotherapy, preoperatory chemotherapy), it is essential to try to obtain histological certainty before any operation.
Exploratory laparotomies (”to see what’s going on”) should become an exception in the case of convergent diagnostic arguments (avoiding the multiplication of unnecessary paramedical examinations). Since it is an aggressive act for the patient, it should only be proposed after thorough consideration and preoperative patient preparation in order to perform, in one single operation, both diagnosis and therapy.
Medical students who have never had the opportunity of practical work experience in a pathology unit may find useful information to improve their understanding of histological reports, throughout the following pages.
- standard techniques for pathology
- specific staining techniques,
- cytology techniques,
- extemporaneous examinations,
- immunohistochemistry techniques,
- in situ hybridation techniques,
- PCR technique (polymerase chain reaction),
- cytometry techniques
Preoperative biopsies:Recent clinical progress has resulted in more and more frequent preoperative histological diagnosis with the use of endoscopies which detect the tumour and enable accurate biopsies. Similarly, new interventional radiology techniques enable needle biopsies. A few examples:
The macroscopic study of surgical specimens should:
For instance, breast carcinoma may often present as a very suspicious but small sized image, the exeresis of which should be performed allowing for healthy limits.
For thyroid carcinoma, the arguments in favour of cancer are more or less clear and a peroperative
pathological confirmation is often useful.
Studying the limits of soft tissue sarcoma by an extemporaneous examination has been shown to increase
the number of complete excisions and therefore to obtain a better clinical result.
Such extemporaneous examinations are technically very difficult: the pathologist should be given sufficient time to thoroughly study the specimens.
More and more frequently, tumour specimens are simultaneously conserved in liquid nitrogen for specific studies (markers, oncogenes, in situ hibridisation, abnormal protein studies) as part of tissue banks common to Cancer Centres. The precise correlation between clinical evolution (hence the necessity for a global medical record) and tissue characteristics will allow major studies on prognostic
factors and will modify therapeutic schemes.
In the same manner, it may be useful to use part of the tumour specimen for tissue culture of cancer cells thus enabling specific metabolic studies. The proximity of research laboratories and operating theatres is mandatory for such studies. The study of freshly cultivated cells (primary culture) avoids the use of long-term cultivated cell lines having lost their physiological or pathological clinical characteristics.
Histological classification:
In a deliberately simplified initial approach, we can distinguish:
We can distinguish:
Malignant and benign tumours:
The following table roughly distinguishes malignant from benign tumours:
For many epithelial tumours, there are intermediary forms between typically benign and typically malignant tumours, known as borderline tumours, microinvasive tumours, in situ tumours.
Pathology report :
Precise histological knowledge of the tumour is essential for treatment and prognosis.
It then describes, with the same precision, the histological type and the differentiation grade incuding, if necessary, specific staining and immunohistochemistry studies.
It should also specify the status of the surgical limits (with frankness vis-à-vis the surgeon since further treatment may be possible), the distance between the tumour and the specimen limits, the number and location of pathological nodes.
The surgeon will perform a mastectomy or an amputation according to pathologist's diagnosis following extemporaneous examination. Therefore, there should be mutual trust between the pathologist and the surgeon in order to establish a confident team.
The final report sometimes involves very important details modifying therapy. For instance, histological grading for breast cancer will determine whether adjuvant chemotherapy should be performed or not.
Another example is testicular cancer: if the histology is in favour of seminoma, this is a highly radiosensitive tumour; whereas if histology does not reveal seminoma (non seminomatous tumour), it is chemosensitive. If an atypical subset exists in a seminoma, it should be treated by chemotherapy.
A pathologist should not be ashamed of asking for confirmation from a more specialised colleague: it is in the patient's best interest. Collegiality between pathologists enables trouble-free new slide reading.
The pathologist should therefore be totally integrated within the multidisciplinary team during the discussion on treatment, in order to ensure that physicians correctly interpret his/her findings.
If necessary, the pathologist can himself request complementary examinations or molecular biology on histological slides.
Diagnostic check-up :
The knowledge of the usual development of cancer should provide the basis for the extension check-up necessary for classifying the tumours. These check-ups should be relatively comprehensive, of as little discomfort as possible to the patient and should avoid unnecessary health costs.
Multiplying examinations is not the proof of good medicine: a thorough medical history, provided by a confident patient, together with a well conducted and complete clinical examination (including pelvic examination on a calm patient) will orient the check-up towards the essential paraclinical examinations required for complete and rapid diagnosis. Patients are reassured by a competent and energetic approach. The multiplication of radiographies and endoscopies often translates the weakness of intellectual medical diagnosis or the physician's fear to announce bad news.
For this reason, with a complete preoperative diagnosis, the multidisciplinary team can decide on the best therapeutic association depending on the patient's specific situation (including general status, associated pathologies and the patient's and his/her family's wishes.
Here are a few examples to understand how check-ups are elaborated.
Independently of the location however, most revealing factors can be deduced from physiopathology and the particular development characteristics of the tumour.
Once these symptoms have appeared, phsyicians should request a few diagnostic procedures in order to:
Rigorously defined diagnostic check-up should offer patients optimal efficiency in order to make the quickest and most appropriate therapeutic decision. Delay in diagnosis induces treatment delay and, consequently, a major decline in patient chances and results.
- make diagnosis as soon as possible, with the least disturbing and painful procedures for the patient,
- quickly obtain tumour biopsy offering precise histological knowledge,
- request the necessary clinical and paraclinical check-ups looking for local and remote cancer evolution ,
- precisely define the cancer stage,
- initiate the treatment schedule, decided according to previously defined therapeutic protocols adjusted through a multidisciplinary study of the patient's medical record.
Appropriate and rapidly initiated treatment offers the best prospects to patients.
1) Physiopathology of revealing symptoms:
Mass Syndrome
The presence of a tumour may alone constitute a revealing symptom, either directly or by the disturbances that it induces. As cancer invades the nearby healthy structures, the tumour mass is generallyirregular and hard upon palpation.Here are a few examples:
- a lump in the breast
- brain mass with cerebral oedema (inducing intra cranial hypertension with headache, vomiting and seizures),
- dysphagia provoked by an oesophageal tumour,
- ureteral and/or urethral compression in relation to a prostate cancer
- small bladder syndrome (urgency) in relation to a bulky bladder carcinoma,
- various digestive disorders provoked by colic or ovarian carcinoma,
- bulky indolent testicle typical of testis cancer.
Local invasion
The cancerous tumour locally invades the organ, modifying its aspect or perturbing its functions:When the cancer tumour invades the nearby structures, other symptoms are observed:
- classical 'peau d'orange' (orange peel aspect) when breast cancer invades the skin,
- dysphonia when a vocal chord is invaded by a laryngeal carcinoma,
- deglutition disorders in relation with oesophageal or head and neck tumours,
- dyspepsia in relation to gastric tumours,
- constipation in relation to colic tumours.
- compression oedema (enlargement of the arm provoked by invading breast cancer, frequent phlebitis in relation to pelvic tumours, ascitis from ovarian or gastric or colon tumours, cava superior syndrome in relation to mediastinal tumours)
- dyspnoea and atelectasis during lung cancer or massive lung metastases,
- lung carcinomatous lymphangitis restricting inspiration,
- pain in relation to peripheral nerves (otalgia during advanced laryngeal cancer, sciatica in relation to bone metastases or pelvic invasion),
- navel invasion during ovarian tumours ('syster Mary syndrome').
Haemorrhage
Since larger tumours need to be nourished, a fragile vascularisation system is elaborated by the nearby mesenchymatous structures. Haemorrhaging is therefore frequent in invading tumours:Every incidence of haemorrhaging requires a thorough exploration even if the patient is under anticoagulant medication.
- hemoptysis of bronchial tumours,
- haematemesis and melaena during gastric tumours,
- haematuria during bladder, kidney, ureter or prostate tumours,
- haemospermia during prostate cancer,
- rectal bleeding during rectal cancers,
- metrorrhagia in relation to cervix carcinoma (typically provoked by sexual intercourse) which can involve genuine flooding,
- menorrhagia and metrorrhagia during corpus uteri carcinoma,
- hemorrhagic ascitis during ovarian or digestive tumours,
- hemorrhagic pleurisis in relation to pleural metastases.
Necrosis
Necrosis is due to poor tumour vascularisation. It frequently induces:
- healing delays,
- tumour infection,
- very strong foul-smelling (very characteristic of head and neck tumours or gynaecological tumours),
- spontaneous fistula or fistula occurring after irradiation,
- foul-smelling skin node ulceration or skin satellite nodules.
Remote evolution
Cancer discovery via a revealing metastasis occurs in approximately 15% of cancers.- node metastases with the supraclavicular 'Troisier's' node revealing a digestive or pelvic cancer, inguinal node revealing a pelvic or a leg tumour, cervical massive nodes revealing head and neck cancers,
- skin metastases (in breast cancer, renal carcinoma, umbilicus 'sister Mary syndrome' in ovarian cancer, satellite tumours in melanoma...),
- liver metastases (revealed by jaundice or liver pains),
- lung metastases (rarely revealed by dyspnoea, most often by systematical lung radiography),
- cerebral metastases (revealed for instance by seizure),
- other metastases (may concern any organ).
A few typical revealing syndromes are described below:
- Colon cancer
- Bladder cancer
- Lung cancer
Clinical examination :
Complete clinical examination is the first and most often the best way to obtain a precise diagnosis and cancer staging. (See below the main revealing symptoms for major cancers)
The physician should give himself/herself enough time and should have all the practical facilities available in order to perform a complete and calm examination of his/her patient.
The first step, should involve letting the patient explain with his/her own words his/her disease; the physician listening to and taking into account silences and doubts. Usually, a patient only speaks for about 30 to 60 seconds: calmly listening to the patient will offer the physician a great deal of information on the patient’s psychological state of mind (which will be very important when the subject of cancer diagnosis needs to be broached) and it is also a clear sign of politeness and respect.
Clinical questioning should be precise, well-mannered, discreet and empathetic. When investigating personal and family history, an open dialogue is the first way to establish a mutually confident relationship with the patient. It allows the evaluation of the patient’s thoughts and fears about his/her disease. It also allows (if the patient is willing) improved understanding on his/her personal, family, professional and social situation. All of these aspects are important when the time comes to announce bad news and to propose, always feared and potentially mutilating, treatment.
This initial period should also allow a relaxed, attentive clinical examination, respecting the patient's modesty and avoiding unnecessary painful procedures.
In many cases, the patient will be asked to undress and show a part of his/her body often qualified as disgraceful or shameful by many people. Patient modesty should always be respected, however a precise and careful examination is most necessary: most cultural inhibitions can be relieved by tactful consideration and patience. We also have to overcome our own modesty and our own inhibitions. It is of course easier not to perform a complete clinical examination than to convince the patient of its usefulness. Such ill-placed modesty may inhibit early diagnosis and result in monstrous tumours (breast tumours, gynaecological tumours, urological tumours) because the physician has, at no time, dared to perform a correct clinical examination.
Some cancers are truly monstrous and we may wonder how the patient managed to live with such a tumour. For instance, the following pictures demonstrate how a communication gap can result in abysmal tumours of the lip, the face, the cervical nodes, the breast, the anus, the testis or the penis. The psychological reactions to the discovery of cancer, denial, shame and fear of being examined, the fear of surgery and of the medical world are among the factors which may explain the relative frequency of such monstrous discoveries.
The clinical examination should be performed in the greatest calm: the physician should concentrate on his/her work and ask the patient (and the family) for silence, if necessary. A precise, detailed clinical examination, during which the physician looks for the smallest clinical evidence, even if it somewhat disturbs the patient's intimacy, is most often understood by the patient as a total interest in the disease and, consequently, the patient himself/herself.
Some cancer classifications are carried out by the clinical examination alone: thus learning how to correctly perform an exhaustive examination is a major part of medical student teaching. For a few difficult or unpleasant examinations, a general anaesthesia is recommended (in particular for gynaecological tumours where pelvic examination may be painful due to inflammation: for instance, the required relaxation for a quality clinical evaluation of the invasion of uterine parameters is rarely obtained during the first examination).
In the same manner, discovering metastastic nodes or skin lesions, by a precise clinical examination, renders complex and costly paramedical examinations unnecessary and prevents futile surgery. A poor clinical examination may induce a waste of time and money and unpleasant and unnecessary procedures.
Among the major clinical procedures:
- Inspection and palpation of breasts for the characterization of a mammary tumour, which can be visible, distort the shape of the breast or infiltrate the skin with the classical 'peau d'orange' aspect,
- pulmonary region percussion and auscultation to detect a pleural effusion,
- Mouth cavity examination (comprising palpation) for diagnosis and staging of mouth cancers
- Examination with Clarke's mirror of laryngeal cancers,
- Systematic palpation of every node area, in particular cervical, axillary and inguinal nodes
- Palpation of the hepatic area to detect secondary hepatomegaly,
- Percussion (and palpation) of the splenic area to detect splenomegaly
- Abdomen palpation to detect abdominal or ovarian tumours,
- Vaginal examination with speculum to discover a cervix uteri tumour,
- Vaginal examination with bimanual examination looking for an enlarged uterus or a pelvic mass,
- Rectal examination to study the status of parameters (during cervix carcinoma staging) or looking for a pelvic mass, like ovarian carcinoma,
- For male patients, a rectal examination is necessary for diagnosis and evaluation of a prostate tumour,
- Rectal examination is an important step for diagnosis and evaluation of a rectal tumour,
- Complete skin examination looking for skin metastases,
- Careful and quiet palpation of an enlarged scrotum in order to differentiate a testis tumour (large indolent testis) from an epididymitis (testicular painful adnexa).
- Neurological examination to detect a neurological metastasis
Usual symptoms for some cancers |
| Colon carcinoma |
| Lung carcinoma |
| Bladder carcinoma |
Many psychological mistakes arise from the absence of this contact communication. The intimate dialogue with the other carers (such as nurses and auxiliaries) is the consequence of this type of communication, and how the patient suffers from a distant impersonal dialogue when the physician uses radiographies and scanner as a protective screen.
A quality clinical examination avoids unnecessary paraclinical examinations. Although these paraclinical examinations are useful for other purposes (such as measuring tumour size), they will be accepted all the better if the physician has performed a complete examination and explained why he/she needs such paraclinical exams.
Explaining the necessity of paraclinical examination is lawful. The physician should explain the reasons, the advantages and the risks of any paraclinical examination and obtain the patient's tacit agreement. If the patient knows why such an examination is necessary, he/she will understand the diagnostic protocol and will also be more confident in the therapeutic protocol.
Only necessary complementary examinations should be requested for diagnosis and classification of cancer. Any complementary examination is more or less toilsome for the patient. Certain patients demand many complementary examinations, sometimes because the first clinical examination appeared to them too superficial to convince them of their disease. An examination should offer genuinely useful information: the physician may explain to the patient why an examination is futile, painful or even dangerous, through constructive and direct dialogue.
In the same manner, the physician or the nurse should explain how the complementary examination will be performed in order to avoid unnecessary patient fears. The general practitioner, the oncologist or the internist must know enough of the procedure to be able to explain to the patient precisely what is going to happen (advantages and disadvantages).
Giving detailed and specific documentation (which offers a second explanation) is generally recommended. Drafting of such written information should be coordinated with the specialist (performing the examination), the prescribing physician, the paramedical personnel involved in the examination (nurse, technician) because they are generally the people most likely to be solicited for further simple explanations, and possibly a patient's committee. Giving such a written explanation does not dispense from answering the patient with a reply such as, "It’s all written down in the leaflet!”.
Radiological procedures:
They most often confirm and objectify clinically suspected lesions and reveal new lesions, thus modifying the staging and treatment possibilities.
Main radiological procedures include:
1. Lung X-Ray
This very simple procedure is most useful for the diagnosis of primary lung tumours, pulmonary metastases, pleuritic or parietal localisations, as well as the study of infectious complications or post-therapeutic pulmonary fibrosis.Since it can be performed within a very short timescale (in comparison with CT-Scan or RMI) , this simple examination should be used as often as possible.
- Alveolar syndrome or atelectasia,
- Pulmonary nodules,
- Carcinomatosous lymphangitis,
- Solitary nodule of the lung,
- Pulmonary cavity,
- Mediastinal tumours,
- Pleural effusion,
- Pneumothorax,
- Bone metastases.
- It is very easy to obtain (with a mean delay of a few hours compared to generally more than a week for a CT-Scan),
- It generally offers the necessary information in many cases: except for phase II studies, it is rarely useful to know that the patient has more than 3 or 4 pulmonary metastases, when no real treatment is available.
2. Standard bone X-Rays
Standard bone X-Rays may show either primitive bone tumours, or more often bone metastases which can be of three different aspects:Quickly obtaining a bone X-Ray is mandatory when the patient is suffering from pain evoking a pre-fracture syndrome.
- lytic lesions: local disappearance of the bone structure (metastasis from kidney, lung, head and neck, and many other malignant tumours),
- dense lesions: local densification of the bone structure (metastasis from breast, prostate or thyroïd carcinoma),
- joint lesions (lytic and dense).
X-Ray very often allows a rapid diagnosis, for example when a risk of medullar compression is suspected, through the discovery of irregular vertebral crushes or the disappearance of vertebral pedicles.
A bone scintigraphy may help in requesting the appropriate radiography by localising the lesion.
The following pages demonstrate a few diagrammatic aspects of bone X-Rays for discovering bone metastases:
- Lytic lesions of peripheral bones
- Lytic lesions of pelvic bones
- Lysis of a vertebral segment
- Lytic lesions of the skull
- Dense lesions of the pelvic bones
- Dense bone lesions of vertebrae
- Dense lesions of the skull
3. Mammography
Mammography is the leading examination for diagnosis of breast cancer.Technical improvements have been made over the last ten years, and further progress is pending (digitalisation for instance).
Nowadays, tumours as small as 4 mm in diameter can be detected (infraclinical tumours) with the usual typical image of a dense, poorly delineated, star-like opacity harbouring a few microcalcifications.
Biopsies, now performed in stereotaxic conditions, offer pre-operative histological information.
Here are the various chapters you can consult over the following pages:
- Technical aspects
- Breast anatomy
- Histogenesis of mammary lesions
- Interpreting mammograms
- Asymmetrical densities
- Masses
- Calcifications
- Mammogram analysis with ACR system
- Puncture
- Mammotome procedure
4. Computer tomography (CT-Scan)
Tomodensitometry or computed tomography (scan) is one of the major tools for diagnosing cancer in almost any part of the body.Lesions (primitive tumour, deeply located nodes, metastases) whose volume is greater than 1 cm are relatively easy to detect.
Enhanced contrast with the use of iodine products is characteristic of increased vascularisation, frequently observed in cancer lesions.
New modern devices (helical and multisclice devices) allow very thin jointive slices, with minimal patient irradiation, performed in a short time thus eliminating artefacts due to respiratory movement which decrease the size of detectable pathological images.
CT scan can detect relatively deep lesions thus enabling biopsies to be performed to obtain the histological proof of cancer.
CT scan has now become the best device to define target volumes for radiotherapy and to calculate preradiotherapy dosimetry.
A few views have been pooled together in a special chapter, most of them borrowed from various sites. We have produced a diagram with comments for each view in order to assist interpretation.
- Head and neck scan,
- Thorax scan,
- Upper abdominal scan (liver - pancreas - biliary ducts),
- Lower abdominal scan (retroperitoneal region),
- Pelvis scan.
5. Resonance magnetic imaging
Magnetic resonance imaging initially offered very interesting images in neurological and osseous pathologies.Its actual definition is somewhat lower than scanner definition, however devices are constantly becoming more rapid and effective Indications are therefore ever-increasing and gradually differentiated from those of CT scanners.
In particular, many studies are currently underway to objectivise the initial changes induced by chemotherapy, radiotherapy or new target treatments and to predict clinical responses to treatment.
Another very attractive indication might be the surveillance of irradiated tumours (in particular breast carcinoma).
With no intended pretence, we have pooled together a few RMI views with the same educational tools and goals:
- Brain RMI,
- Thorax RMI,
- Abdominal RMI,
- Pelvis RMI,
- Bone structure RMI.
6. Other radiological procedures
Pedal lymphography is still used for lymphoma and by a few teams in cervix uteri carcinoma.Angiographic procedures are less frequently used than in the past: they enabled viewing of anarchical tumour vascularisation (particularly in renal or brain tumours). They may also be used for therapeutic acts such as chemoembolisation or intraarterial chemotherapy.
Ultrasound procedures:
Its major interest is its quickness and the non-invasive nature of the examination for the patient. However, it requires a very well trained radiologist, since image production is obtained by the radiologist's hand and paper reproductions rarely offer the oncologist sufficient and/or tangible clinical information.
Its major indications are for the detection of liver metastases, pancreatic lesions, pelvic tumours (ovary) or superficial tumours (thyroid, testis).
Intracavitary probes are very useful for certain pathologies:
- endorectal probe for prostate cancer,
- endovaginal probe for gynaecological cancer,
- ultrasound probe within an endoscope for digestive tumours to specify wall invasion: oesophagus, rectum.
The quality of the ultrasonography examinations is highly operator-dependent and paper reproductions are but a far cry from the actual examination; for this reason, ultrasonography is rarely used to monitor therapeutic trials which impose precise tumour measurements requiring to be verified by independent observers.
Recent progress in this technique has provided knowledge on tumour vascularisation and offers 3D images.
Scintigraphies:
Scintigraphy is a functional exploration: image quality is of less interest than the actual function explored.
However, cancer is not the only pathology which can induce scintigraphic abnormalities. Interpretation should therefore always be made with caution and should take into account the patient's clinical history.
1. Bone scintigraphy
Bone scintigraphy detects metastases before any radiological symptoms appear and could be referred to as a 'screening' procedure for bone metastases.The infused tracer is a diphosphonate labelled with 99Technetium. Like phosphorus, it fixes where bone modelling is observed: fracture callus, active Paget's disease, tumour metastasis.
The total radioactivity is extremely low (740 MBq) with no known danger to patients.
A local punctiform hyperfixation is rather significant of a bone metastasis, however it can also be observed in benign pathologies (such as arthritis, bone infection, post traumatic sequela).
In principle, only cancers bearing an osteoid reaction should fix the tracer, however almost all lytic bone destruction is accompanied by a minor reconstruction process hence provoking hyperfixation.
Main bone metastases detected by scintigraphy are breast cancer metastases, prostate cancer metastases, and thyroid cancer. Scintigraphy enables avoiding radiographies of all bone parts and offers the possibility to limit radiography to enhanced bones. Primary bone lesions are generally highly enhanced (for instance Ewing's sarcoma ).
Hyperscan is a particular aspect used for certain prostatic bone or mammary cancer metastases. The fixation is so high than generalised metabolic radiotherapy may be proposed treating all the bone metastases in one shot.
However, to locally treat a metastasis (by radiotherapy for instance) or refute the exeresis of a primary tumour (in relation to supposed distant metastases), further confirmation is required (such as bone radiography or RMI). Other pathologies provoke hyperfixation, particularly among aged people, and include arthrosis or metabolic bone disease such as Paget's disease).
2. Thyroid scintigraphy
Thyroid scintigraphies are very interesting for the delineation of 'cold' nodules and to eliminate other thyroid pathologies which induce increased volume of the gland.Radioactive Iodine is the reference physiological tracer: it is a reliable tracer of hormonogenesis and permits a cartography of Iodine fixation. However the use of 131I is complicated by radioprotection issues related to its long half life (8 days) and its major ß emitting characteristics. 99Technetium or 99mTc is generally preferred and provides quality nodule distinction (cold or hot) and the surveillance of a non-toxic goiter.
With thyroid scintigraphy, we can distinguish the following pathologies:
- cold nodules (which do not fix Technetium and should be further explored),
- hot nodules (hormone producing nodules),
- multinodular goiters,
- thyroiditis,
- and endocrine thyroid pathology (Basedow's hyperthyroidism, hypothyroidism).
3. Functional scintigraphies
The isotopic tracer is used to study the function of an organ.For instance, we can study the ventricular contraction fraction by studying the evolution of radioactivity of the precardiac area after intection of a radioactive tracer.
Pulmonary ventilation is studied by the absorption of xenon, enabling the seperation of each part of the lung: before deciding on pneumonectomy or lobectomy to treat lung cancer, knowledge of the capacity of the remaining lung is essential
Pulmonary perfusion study is an essential step for diagnosing pulmonary embolism, a frequent complication in cancer after lower limb or pelvis thrombophlebitis.
Renal scintigraphy is used toimprove definition of renal clearance.
These techniques are often used for the study of chemotherapy toxicity; however they often need to be compared with other classical functional methods.
4. Radio-immuno-scintigraphy
This technique uses an antibody specific to a particular tissue or antigen which has been labelled with a radioactive tracer.The antibody should be specific, and not absorbed by circulating antigens and, if possible, should not disturb further immunological assays of the antigen.
This technique has been used to detect micrometastases which can be treated by localised surgery: choriocarcinoma (β-HCG), digestive metastases (ACE), ovarian carcinoma (Ca-125), and so on.
5. Peroperatory scintigraphy
With the use of a scintigraphy probe during operation, the surgeon may detect non-visible tumours and perform a complete exeresis (for instance, for local thyroid relapse, microscopic digestive relapse, satellite node study in breast carcinoma.This latter technique avoids postoperative complications from unnecessary lymphadenectomies.
6. 67Gallium scintigraphy
67Gallium is an anolog of iron which is linked to various plasma proteins (transferrin, lactoferrin, ferritin) for which lymphoma cells express surface receptors: study of 67Gallium enables the physiological evaluation of tumour cell viability.After chemotherapy, when complete remission seem to be obtained, the X-Ray scanner can still show tumour masses which, however, do not fix 67Gallium. The absence of fixation defines complete remission. Sometimes (thorax or abdominal views), the interpretation may be more delicate due to the digestive elimination of Gallium.
High grade non-Hodgkin lymphoma and most Hodgkin's lymphoma have a very great affinity for 67Gallium, wheras low grade lymphoma has a lesser affinity. Another products used for these latter lymphoma are 201Thallium or MIBI.
7. Positron scanning or petScan
Some isotopes with a very short half-life emit postrons, allowing precise metabolism studies of pathological tissues. Since they have strong but short radioactivity and since their location can be precisely determined by coincidence study, they can very precisely detect metabolically active tumours (increased glucose consumption).This is the principle of PETScan (see linked chapter) which is more and more useful due to the increased availability of positron devices and the possibility of combining them with an X-Ray scanner (PET-CT)
The use of positron emitting isotopes is very promising for the detection of mediastinal or abdominal tumours and for the study of their limits.
However, since they require very expensive devices and costly isotopes, a precise evaluation of the practical value of PETScan (useful modifications of therapeutic schedules) should be carried out within the framework of international studies.
Endoscopy procedures:
The emergence of optic fibres and cold light has revolutionised the endoscopic approach to tumours. Examinations, which in the past were painful, are now easy to perform, well tolerated and allow the clear exploration of airways (laryngoscopy, bronchoscopy), digestive tract (oesophagoscopy, gastroscopy, colonoscopy, rectoscopy), urinary tract (cystoscopy, ureteroscopy), genital apparatus (hysteroscopy), under local or general anaesthesia which can be repeated if necessary.
All of these examinations enable a precise description of the tumour but, more importantly, offer the possibility of performing biopsies to obtain pathological diagnosis before any radical treatment. In combination with an ultrasonographic probe, they study the extent of tumour invasion (which is necessary for most classifications) and look for nearby satellite nodes.
Other more complex examinations require general anaesthesia and are performed to obtain a biopsy sample in a less traumatic manner than via surgical exploration: mediastinoscopy, pleuroscopy, laparoscopy, arthroscopy.
The use of a television camera allows a better description of the lesion and offers the possibility of involving several physicians in the endoscopic exploration.
Abdominal surgery through laparoscopy has not yet totally proved its worth in oncology, except for very limited tumours or in a diagnostic setting (such as lymphadenectomy by coelioscopy). It requires a very well trained surgeon and team. The risk of cancer diffusion along the puncture openings is promoted by intraabdominal hyperpressure and clear, carcinologically satisfactory surgery may be difficult to prove (cf. definition of complete carcinological surgery). The use of a robot could be of great interest for other laparoscopic surgical acts (urology, gynaecology) although its cost-effectiveness has not yet been demonstrated.
Pathology:Oesophageal endoscopy, Gastric endoscopy, Colic endoscopy,
ORL endoscopy, Urinary endoscopy.
Cancer diagnosis always requires a biopsy and a pathological examination (except during terminal phases when therapy is not feasible).
Except in such rare situations, beginning radical treatment without the histological (or at least cytological) proof of malignancy would be verging on malpractice. Some long lasting infections, certain benign tumours and a few rare diseases may mimic cancer; however the erroneous administration of radiotherapy or chemotherapy in such circumstances would be a source of major complications.
In order to ensure a genuine multidisciplinary discussion and concerted therapy decision integrating and combining all available therapeutic facilities (peroperatory radiotherapy, preoperatory chemotherapy), it is essential to try to obtain histological certainty before any operation.
Exploratory laparotomies (”to see what’s going on”) should become an exception in the case of convergent diagnostic arguments (avoiding the multiplication of unnecessary paramedical examinations). Since it is an aggressive act for the patient, it should only be proposed after thorough consideration and preoperative patient preparation in order to perform, in one single operation, both diagnosis and therapy.
Pathology techniques
With the courtesy of Dr Yves DENOUX, a previous pathologist at the Centre François Baclesse, we have described the various techniques used for pathological diagnosis.Medical students who have never had the opportunity of practical work experience in a pathology unit may find useful information to improve their understanding of histological reports, throughout the following pages.
- standard techniques for pathology
- specific staining techniques,
- cytology techniques,
- extemporaneous examinations,
- immunohistochemistry techniques,
- in situ hybridation techniques,
- PCR technique (polymerase chain reaction),
- cytometry techniques
Cytology
Many cancer types produce fluid extravasation which can be studied by a cytology technique: pleural effusion and ascites, cerebrospinal fluid.
| Normal cytology | Cancer cytology |
- laryngoscopy and biopsies for head and neck tumours,
- bronchoscopy for lung tumours,
- gastrocopy for gastric tumours,
- colonoscopy, rectoscopy for rectocolic tumours,
- colposcopy and hystéroscopy for uterine tumours,
- cystoscopy for bladder and prostate tumours,
- ultrasonography guided biopsies for mammary, liver, renal, prostatic and other tumours,
- stereotaxic guiding for biopsy of mammary tumours.
Operation specimen
For certain tumours, the biopsy approach should be postponed due to the risk of dissemination to the adjacent wall, and a well defined surgical act should be proposed as soon as the probable diagnosis has been seriously contemplated: soft tissue sarcoma, peritoneal carcinomatosis due to ovarian carcinoma or testis tumour, for instance.The macroscopic study of surgical specimens should:
- describe with full detail the various specimen sent by the surgeon
- describe the general macroscopic aspect (size, colour, physical aspect)
- specify the surgical limits,
- detect nodes and prepare systematic slices for histology,
- prepare serial and/or well oriented slices with a clear individualisation of the surgical limits.
Extemporaneous examination
For many tumours, diagnosis of malignancy may remain uncertain until radical surgery.For instance, breast carcinoma may often present as a very suspicious but small sized image, the exeresis of which should be performed allowing for healthy limits.
For thyroid carcinoma, the arguments in favour of cancer are more or less clear and a peroperative
pathological confirmation is often useful.
Studying the limits of soft tissue sarcoma by an extemporaneous examination has been shown to increase
the number of complete excisions and therefore to obtain a better clinical result.
Such extemporaneous examinations are technically very difficult: the pathologist should be given sufficient time to thoroughly study the specimens.
More and more frequently, tumour specimens are simultaneously conserved in liquid nitrogen for specific studies (markers, oncogenes, in situ hibridisation, abnormal protein studies) as part of tissue banks common to Cancer Centres. The precise correlation between clinical evolution (hence the necessity for a global medical record) and tissue characteristics will allow major studies on prognostic
factors and will modify therapeutic schemes.
In the same manner, it may be useful to use part of the tumour specimen for tissue culture of cancer cells thus enabling specific metabolic studies. The proximity of research laboratories and operating theatres is mandatory for such studies. The study of freshly cultivated cells (primary culture) avoids the use of long-term cultivated cell lines having lost their physiological or pathological clinical characteristics.
Microscopic study
Microscopic study should:
- identify the histological tumour type,
- propose a differentiation study according to established grading system,
- precise the exeresis limits of the tumour,
- identify the invasion status of the sampled nodes, particularly capsular disruptions.
Histological classification:
In a deliberately simplified initial approach, we can distinguish:
Solid tumours
Solid tumours can be divided into 4 major categories which can also be combined.Epithelioma
They originate from the epithelium and represent approximately 90% of all cancer types.We can distinguish:
malpighian or epidermoid tumours
- the origin of which is a malpighian epithelium:
- skin, oesophagus, head and neck epithelium, cervix uteri, lung,
 |
Diagram of a malpighian carcinoma: in [a] mucosa, in [b] basal membrane, in [c] submucosa, in [d] muscularis mucosae. By clicking on the numbers, you can obtain the microscopic view of the lesion. In [1], normal epithelium. In [2], in situ carcinoma. In [3], microinvasive cancer. In [4], invasive carcinoma. In [5], abnormal mitosis. In [6], apoptotic cell. In [7], angiogenesis. |
adenocarcinoma,
excreto-urinary cancer or transitional carcinoma
- they originate from an exocrine or endocrine gland,
- breast, prostate, colon (most often mucinous), stomach, thyroid, lung,
Thyroid carcinoma For most epithelioma, well or poorly differentiated forms can be described within a grading system, which endeavours to be as reproducible as possible between two observers.
- excretory urinary epithelium (ureter, bladder, uretra)
Sarcoma
- They originate from mesenchymal structures.
- fibrosarcoma, liposarcoma, leiomyosarcoma, rhabdomyosarcoma, osteosarcoma, chondrosarcoma, synoviolosarcoma,
 |
Neuroectoblastic tumours
- They originate from central nervous system: glioma, ependymoma,
- or from other neurological systems: meninges (meningioma), nervous nodes (synmpathoblastoma), Schwann sheath (schwannoma), melanogenic system (melanoma) or diffuse endocrine system (apudoma).
 |
Embryonic tumours
- Dysembryomas can be more or less mature: neuroblastoma, nephroblastoma, choriocarcinoma (placental, testicular, ovarian or extragonadal), immature teratoma.
Hematopoiesis tumour
They are classified according to the cell type from which they originate: leukaemia, lymphoma, myeloma and so on (see haematology course).
Lymphoma
Malignant and benign tumours:
The following table roughly distinguishes malignant from benign tumours:
| Benign tumour | Malignant tumour |
| Differentiated, Rare mitoses, Slow growth, No local invasion, No destruction of normal tissue, Surrounded by a capsule, No relapse after complete exeresis, No node metastasis, No remote metastasis No or little influence on the host | Well to poorly differentiated, Frequent mitoses, Generally fast growing, Local invasion of neighbouring tissues, Destruction of normal structures, No clear limits, Quick local relapse if no complete exeresis, Node metastases Remote metastasis, Death of the host. |
For many epithelial tumours, there are intermediary forms between typically benign and typically malignant tumours, known as borderline tumours, microinvasive tumours, in situ tumours.
Pathology report :
Precise histological knowledge of the tumour is essential for treatment and prognosis.
Histological report qualities
The histological report should precisely describe the sample specimens received (with potential artefacts such as specimen opened by the surgeon), the possibility of precisely orienting the surgical specimen with respect to its initial in vivo orientation, the number of received nodes.It then describes, with the same precision, the histological type and the differentiation grade incuding, if necessary, specific staining and immunohistochemistry studies.
It should also specify the status of the surgical limits (with frankness vis-à-vis the surgeon since further treatment may be possible), the distance between the tumour and the specimen limits, the number and location of pathological nodes.
Legal value of the histological report
The histological report is a legal part of the medical record.The surgeon will perform a mastectomy or an amputation according to pathologist's diagnosis following extemporaneous examination. Therefore, there should be mutual trust between the pathologist and the surgeon in order to establish a confident team.
The final report sometimes involves very important details modifying therapy. For instance, histological grading for breast cancer will determine whether adjuvant chemotherapy should be performed or not.
Another example is testicular cancer: if the histology is in favour of seminoma, this is a highly radiosensitive tumour; whereas if histology does not reveal seminoma (non seminomatous tumour), it is chemosensitive. If an atypical subset exists in a seminoma, it should be treated by chemotherapy.
Cooperation between pathologists and slide new interpretation
Requests for new slide readings for new interpretation or the execution of specific staining are frequent. Some tumours are difficult to classify and require specific expertise.A pathologist should not be ashamed of asking for confirmation from a more specialised colleague: it is in the patient's best interest. Collegiality between pathologists enables trouble-free new slide reading.
Reading the histological report
It is the physician’s duty to correctly interpret the histological tumour type before beginning treatment.The pathologist should therefore be totally integrated within the multidisciplinary team during the discussion on treatment, in order to ensure that physicians correctly interpret his/her findings.
If necessary, the pathologist can himself request complementary examinations or molecular biology on histological slides.
Diagnostic check-up :
The knowledge of the usual development of cancer should provide the basis for the extension check-up necessary for classifying the tumours. These check-ups should be relatively comprehensive, of as little discomfort as possible to the patient and should avoid unnecessary health costs.
Multiplying examinations is not the proof of good medicine: a thorough medical history, provided by a confident patient, together with a well conducted and complete clinical examination (including pelvic examination on a calm patient) will orient the check-up towards the essential paraclinical examinations required for complete and rapid diagnosis. Patients are reassured by a competent and energetic approach. The multiplication of radiographies and endoscopies often translates the weakness of intellectual medical diagnosis or the physician's fear to announce bad news.
For this reason, with a complete preoperative diagnosis, the multidisciplinary team can decide on the best therapeutic association depending on the patient's specific situation (including general status, associated pathologies and the patient's and his/her family's wishes.
Here are a few examples to understand how check-ups are elaborated.
BREAST
- standard check-up according the usual location of metastases,
- metastasis risk factors in breast carcinoma
- check-up for a non palpable mammary tumour
- check-up for a palpable mammary tumour.
COLON
- check-up for an operable colic tumour
LUNG
Since we only have few therapeutic weapons to endeavour to cure our patients from cancer, we need to be sure to use the right weapons in the right circumstances.
- check-up for an operable bronchial tumour
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