Management of malignant disease

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CHAPTER 7 Management of malignant disease

Screening 114
Premalignant conditions 115
General symptoms and signs of malignant disease 115
Diagnostic procedures 116
Staging and grading of cancer 117
The multidisciplinary team (MDT) meeting 117
Tumour markers 118
Treatment of cancer 119
Terminal care 124

Patients with malignant disease form a major part of the workload of a surgical unit. They are assessed and decisions on management are made as part of a multidisciplinary team of surgeons, oncologists, specialist radiologists and pathologists, nurses, dieticians, etc. The total number of patients with malignant disease is rising owing to increased life expectancy. Where possible, the aims should be to prevent malignancy, e.g. cessation of smoking in the prevention of lung cancer, and the avoidance of excessive ultraviolet light in the prevention of skin cancer. Screening programmes should be instituted to make earlier diagnoses of the common forms of cancer and hopefully maximize the cure rate.

Screening

This is the examination of an asymptomatic population at risk of a particular condition, with a view to early diagnosis and consequent increase in cure rate. The basis for screening a normal population is to diagnose cancer at an asymptomatic stage, treatment at which point results in greater survival than cancers diagnosed at a symptomatic stage. For a screening programme to be successful it must adhere to certain principles:

• The cancer being detected must be common enough to represent an important health problem.
• The natural history of the cancer should be established, i.e. its development from a latent phase to symptomatic disease.
• A test should be available to detect the latent stage; the test should be sensitive and specific to the cancer and be acceptable and safe to the patient.
• Early detection of the cancer should lead to a benefit in terms of cost of treatment and survival of the patient.

Examples of screening programmes being carried out at present are:

• Cervical smears for cervical carcinoma
• Mammography for carcinoma of the breast
• Faecal occult bloods for carcinoma of the colon.

Premalignant conditions

It is important that these conditions are recognized and appropriate action taken.

Examples of premalignant conditions include:

• Skin: actinic keratoses, Bowen’s disease, erythroplasia of Queyrat (penis).
• GI tract: leukoplakia (mouth and tongue), Plummer–Vinson syndrome, Barrett’s oesophagus, villous adenoma, familial polyposis coli, ulcerative colitis, Crohn’s disease, Ménétrièr’s syndrome.
• GU tract: leukoplakia of the bladder, bilharzia.

General symptoms and signs of malignant disease

These may relate to the primary tumour, metastases, or generalized systemic manifestations.

They may be broadly classified as follows:

Primary tumour

Palpable swelling

This is usually painless unless invading other structures. Common examples include the palpable masses of the primary tumour in carcinoma of the breast, carcinoma of the thyroid, carcinoma of the caecum.

Obstruction

Examples include dysphagia in carcinoma of the oesophagus, obstructive jaundice in carcinoma of head of pancreas, large bowel obstruction in carcinoma of the colon, vomiting in gastric outlet obstruction from carcinoma of the gastric antrum.

Bleeding

• Overt: haemoptysis, haematemesis, haematuria, rectal bleeding
• Occult: carcinoma of the stomach or carcinoma of the caecum. Anaemia occurs.

Symptoms due to compression or invasion of local structures

SVC obstruction with bronchial carcinoma; back pain with retroperitoneal invasion with pancreatic cancer; invasion of nerves, e.g. facial paralysis with carcinoma of the parotid gland, recurrent laryngeal nerve palsy with anaplastic carcinoma of the thyroid.

Metastases

• Enlarged lymph nodes: may be discrete or hard, irregular and matted
• Hepatomegaly: primary in stomach, colon, bronchus, or breast
• Jaundice: from nodes in the porta hepatis, with primary in the stomach, pancreas, or colon
• Ascites: ovarian or any GI malignancy
• Abdominal mass due to omental secondaries – often in association with ascites
• Pathological fractures from bony metastases, e.g. breast, bronchus, thyroid, prostate, kidney
• Pleural effusion, e.g. from breast cancer
• Fits, confusion, personality change from cerebral metastases, e.g. breast, bronchus, malignant melanoma.

Generalized manifestations

Examples include cachexia, PUO (lymphoma, hypernephroma), hypertrophic pulmonary osteoarthropathy (carcinoma of the bronchus), thrombophlebitis migrans (carcinoma of the pancreas), neuropathies and myopathies (carcinoma of the bronchus), endocrine manifestations, e.g. ADH or ACTH production in bronchial carcinoma.

Asymptomatic incidental findings

Axillary lymphadenopathy on routine examination, e.g. with small impalpable carcinoma of the breast. Silent pulmonary primary or metastases on routine CXR.

Diagnostic procedures

Biopsy

This is mandatory, and may be carried out in a variety of ways:

• Fine-needle aspiration using a 22G needle: smear produced on slide; read by experienced cytologist
• Core biopsy, e.g. Tru-Cut: core of tissue removed for histological examination
• Incisional biopsy: removes a small accessible piece of the lesion for histological examination
• Excisional biopsy: the complete removal of a discrete lesion without a wide margin and without it being considered curative of the malignancy
• Evaluation under anaesthetic: to assess presence or extent of disease, e.g. staging laparotomy (largely superseded by CT scanning), panendoscopy, mediastinoscopy, bronchoscopy with biopsy of suspicious or high-risk areas.

Imaging (e.g. ultrasound, CT or MRI)

This is used for confirming a suspected diagnosis and assessing spread. A negative study does not exclude microscopic disease.

Positron emission tomography (PET)

This is complementary to other imaging modalities but differs from them as the scanner detects the metabolic activity of cancer cells via their increased uptake of a radioactive tracer (fluorodeoxyglucose) and subsequent emission of positrons. It can be used to detect the site of an unknown primary malignancy in the patient who presents with metastatic disease that cannot be identified by conventional clinical, radiological or histological means (e.g. SCC of the head and neck); for identification of metastases, e.g. lung cancer or non-Hodgkin’s lymphoma; or for monitoring of response to therapy, and evaluation of recurrence. Further evidence is required to evaluate the roles for this relatively new modality.

Staging and grading of cancer

The extent of the malignancy of a tumour may be established clinically to provide an indication of the prognosis and to act as a guide for the type of treatment. It is also necessary for comparing the efficacies of different treatments in clinical trials. Three methods may be used – clinical, pathological and histological. Pathological staging is very subjective and there is a degree of observer variation. A tumour’s apparent growth rate may be graded according to its histological appearance and its resemblance to mature cells of its lineage (degree of differentiation) can be commented on to indicate aggression.

Clinical staging

An example of this is the Manchester Classification of carcinoma of the breast (→ Ch. 10). This is based purely on clinical findings but is somewhat imprecise.

Clinical and pathological staging

The TNM Classification is recommended by the International Union Against Cancer. This method uses both clinical and laboratory results to grade the tumour. The clinician assesses three factors:

• Extent of the tumour (T)
• Node status (N)
• Presence of metastases (M).

(→ Ch. 10).

A method that is based on pathological staging only is Dukes’ Classification for colorectal carcinoma (→ Ch. 14).

Grading of tumours

The histological appearance of specimens are graded according to various criteria such as the proportions of cells undergoing mitosis, the degree of differentiation, the degree of nuclear pleomorphism, etc. This represents the ‘aggressive’ nature of the cancer. Examples include Broder’s grading of squamous cell carcinoma or the Bloom-Richardson grading of breast carcinoma.

The multidisciplinary team (MDT) meeting

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