Symptomatology and classification (Cancer specific syndromes (Lung cancer,…
Symptomatology and classification
Histopatological examination cornerstone of diagnosis and treatment.
Cancer syndroms according to frequent occurrence
pain > weakness > constipation > depression > anorexia > nausea > vomiting > dyspnoea > dysphagia > diarrhoea > sore mouth
General cancer signs and symptoms
Unexplained weight loss
Loss of apetite
Related to the tumor site
Related to the treatment
Systemic effects of tumors
Progressive weakness, malaise, anorexia and muscle wasting associated with the presence of a malignancy
May pre-date diagnosis of malignancy
TNF-a released by tumor cells and macrophages has been implicated
No universally effective therapeutic modalities appear to be able to reverse cachexia
Additional causes of anemia:
Rapid tumor proliferation which uses up existing stores of folate (macrocytic anemia)
Autoimmune hemolytic anemia frequently associated with chronic lymphocytic leukemia
Mielosuppresion of bone marrow after treatment (use of iron)
Leukoerythroblastic peripheral blood
Immature myeloid cells and nucleated RBCs due to bone marrow invasion by tumor- usually in breast cancer
Increased fibrinogen, factors V and VIII with subsequent venous thrombosis
Potential for pulmonary embolization
Migratory superficial thrombophlebitis
accompanies pancreatic cancer
Due to impared humoral or cell-mediated immunity
Opportunistic infections; common in malignancy
Fever unassociated with infections: Hodgkin’s disease, Renal adenocarcinoma, Osteogenic sarcomas
seen in advanced disease
Almost all patients will have fever at some time, particularly if the cancer affects the immune system
Less often fever may be an early sign of cancer
Usually is a
symptom of advanced disease
May be an early sign (e.g. bone, testicular)
Production of hormones or hormone- like substances by a tumor causing remote symptoms not directly to tumor invasion
Occur in 10% of patients with malignant neoplasms
May be the first indication of the presence of an underlying cancer
The only way to cure paraneoplastic syndromes is to treat the cause- malignancy.
Most common paraneoplastic syndrome
more likely due to malignancy than hyperparathyroidism
Pulmonary squamous cell carcinoma, breast, renal, ovarian carcinoma, adult T- cell leukemia/lymphoma
Secretion of PTH-like substances (PTHrP)- normally produced in low quantities by several tissues (keratinocytes, breast, bone, muscle, ovary)
IL-1, TGF-a, TNF-a, dihydroxy vitamin D
Non Paraneoplastic- bone metastasis or primary bone tumors with lysis of bone- osteosarcoma, multiple myeloma, prostate, breast cancer
Most common paraneoplastic endocrinopathy
Excessive production of ACTH, ACTH-like peptides
50% of patients have pulmonary small cell cancer
Pulmonary small cell cancer,
pancreatic carcinoma, neural tumors
Eaton- Lambert syndrome
Myasthenia gravis- like features
commonly associated with small cell carcinoma of the lung
Differs from myasthenia is that: Muscle strength increases with exercise,There is poor response to Tensilon (edrophonium)
Skin; grey- black itching patches of hyperkeratosis usually in skin folds
Gastric, lung, uterine carcinoma
, pain and hypertrophy of proximal muscles
Purple lesions on the face and palms
nodules- over small joints
Patients need cancer screening for 3 years after diagnossi
Ovarian cancer, lymphomas, lung, gatric cancer
Periosteal new bone formation, fingers and toes
Distal ends of long bones, metatarsals, metacarpals, proximal phalanges
Arthritis adjacent joints
Clubbing of digits
Hippocratic fingers = drumstick fingers = watch-glass nails
Trousseau’s signs, Anemia, Thrombocytosis, Thrombocytopenia, Hypercoagulable state, DIC
Cancer specific syndromes
Weight loss, Loss of apetite, Anaemia, Fever, Paraneoplasitc syndromes (hypertrophic osteoarthropathy, Cushing’s syndrome, hiperpigmentation, ginecomastia, Eaton- Lambert syndrome, enecephalopathy...)
Symptoms related to the tumor site
Cough, Haemoptysis, Pain in the chest, Dyspnoea, Dysphagia, Recurrent pneumonia, Pleural effusion, Hoarseness (paralysis of the recurrent laryngeal nerve), Paralysis of the phrenic nerve (one- sided elevation of diaphram in chest X- ray)
Syndromes related to the lung cancer
SVCS- superior vena cava syndrome
80% due to lung cancer
Indication for immediate oncological treatment
Symptoms: Dyspnea, headache, swelling of the face, arms and the upper chest, skin reddness, venous distention in the neck, upper chest and arms, cough, symptoms of cerebral edema
Pancoast’s- superior sulcus tumor
Symptoms: Shoulder and arm pain,
Horner’s syndrome, Weakness and atrophy of hand muscles
Causes: Non- small cell lung cancer,Other neoplasms (thoracic, hematologic), Infectious diseases
ipsilateral ptosis, miosis, anhidrosis, enophthalmos
Infiltration of cervical sympathetic nerves
Small cell lung cancer
Cough, Dyspnea, Wheezing, Hemoptysis, Chest pain, Postobstructive pneumonitis
Regional: SVCS, hoarseness, dysphagia
Distant: bone pain, CNS symptoms (headache, double vision...)
Related to the primary tumor:
Tumor, Deformation of the nipple, Nipple discharge, Skin deformation, erythema, edema (peel of an orange = peau d’orange), Inflammatory cancer, Paget’s disease, Automastectomy
Related to enlarged axillary lymph nodes
Related to distant metastasis
to metastatic lymph nodes: Tumor,
Arm edema, Ulcerations
Related to the treatment
Head & neck cancer
Pain, Tumor, ulceration, Disturbed breathing, dyspnea, Disturbed food intake, Dysarthria, Hoarseness, Limited mobility of tongue, immobilisation, Face deformation, Stiff nose, Sore ear, Epistaxis
General symptoms (B symptoms)
Weight loss (>10%/6 months)
Skin itching – not included in B symptoms!!!
Symptoms related to tumor’s location
Lymphadenopathy (axilla, neck, groins)
Dyspnoea – mediastinal lymphadenopathy
Early:Postcoital bleeding, Discharge
Late: Bleeding, Pain, Swelling of limbs, Dysuric symptoms, hydronephrosis, Infiltration of the lower part of the digestive tract
Abdominal pain, Blood in stool, Change in frequency: chronic constipation, diarrhoea, Change in the size of the stool, Weight loss, Intestinal occlusion- ileus, perforation
Symptoms related to localization
Rectum, left side of the colon: Bleeding, Change in bowel habits: constipation, diarhoea, Abdominal pain, Ileus
Right side of the colon: Abdominal pain, Fatique, Anemia, Tumor in abdomen, Change in bowel habits, Ileus
Similar to those seen in non- malignant diseases:
Pain in the upper abdomen, Loss of apetite, Nausea, vomiting, Melena (anemia !), Weight loss, Chainges to digestion (feeling full after small meal, indigestion)
Tumor, ascites, hepatomegaly, jaundice
tumor (metastatic lump on the
shelf: Metastatic tumor in
pouch of Douglas
, felt in rectal examination
left supraclavicular lymph node
, indicating cancer in
Sister Mary Joseph
sign: Palpable nodule bulging into umbilicus – metastasis of
Focal symptoms: Paresis, Aphasia, Vision disturbances, Seizures, Cranial nerve palsy
Elevated ICP: Headache, Vomiting, Blurred vision, Quantitative impairment of consciousness, Seizures
Personality disorders, mood disorders, psychosis
Each tumour type has a stage grouping, which is the categorisation of malignancies into stages from I to IV.
A single stage grouping may have multiple TNM stages assigned within it, generally those with a similar prognosis.
TNM staging system*
c: clinical stage, meaning the stage has been determined by clinical examination and imaging
p: pathologic stage, meaning the stage has been confirmed via histology or cytology.
y: indicates the TNM stage has been determined after completion of neoadjuvant therapy.
For example, ypT3N1M0 rectal cancer is one that has been resected after neoadjuvant therapy, with histology showing invasion through the full thickness of the rectal wall and involvement of 1-3 regional lymph nodes.
Female reproductive system cancers (cervix, uterus, ovary, vagina)
The FIGO (International Federation of Gynaecology and Obstetrics) system is used. The stage is determined by features such as degree of invasion, ureteric obstruction, lymphadenopathy and peritoneal seeding. It ranges from Stage I to IV.
classification is used to describe
how many lymph node regions are involved and whether the nodes are on one or both sides of the diaphragm
. The presence or absence of “B symptoms” (night sweats, fevers, weight loss of >10%) is an important prognostic factor and this has been incorporated into the staging system as a suffix after the stage descriptor.
For example, Stage IIIB Hodgkin’s lymphoma indicates the presence of B symptoms and involvement of nodal stations on both sides of the diaphragm.
Small cell lung cancer
This does utilise TNM staging, however more commonly it is simply divided into limited and extensive disease, based on whether it is intrathoracic and can be encompassed within a radiation portal.
Other (non staging) parameters
Disease parameters which play a very important role in determining treatment and prognosis.
The important variables differ depending on the tumour site but include:
tumor grade, hormone receptor status, specific serum markers (eg PSA, LDH, hCG, AFP), chromosomal abnormalities (eg 1p19q co-deletion in oligodendroglioma),
Clark level (melanoma)
0 – Asymptomatic (Fully active, able to carry on all predisease activities without restriction)
1 – Symptomatic but completely ambulatory (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 – Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours)
3 – Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours)
4 – Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)
5 – Death
100 –Normal; no complaints; no evidence of disease.
90– Able to carry on normal activity; minor signs or symptoms of disease.
80– Normal activity with effort; some signs or symptoms of disease.
70– Cares for self; unable to carry on normal activity or to do active work.
60– Requires occasional assistance, but is able to care for most of their personal needs.
50– Requires considerable assistance and frequent medical care.
40– Disabled; requires special care and assistance.
30– Severely disabled; hospital admission is indicated although death not imminent.
20– Very sick; hospital admission necessary; active supportive treatment necessary.
10– Moribund; fatal processes progressing rapidly.