General presentation of malignancy, investigation and staging

Question 1

What are the clinical manifestations of primary tumours?

Answer 1

Symptoms depend on the location of the tumour
Often don’t present until there is metastases
Lung cancer - haemoptesis, cough, dyspnoea, recurrent penumonia (obstructive), wheeze

Question 2

What are some signs of metastases?

Answer 2

Local lymphadenopathy
Bone pain, hypercalacemia, pathological fractures (bony mets)
Jaundice
seizures
Cachexia = weight loss, anorexia, muscle weakness from inflammatory cytokines (TNF-alpha, IL-1) from the tumour or the cells in the microenvironment

Question 3

What are paraneoplastic effects?

Answer 3

Unexplained symptom complexes that are associated with 5-10% of malignant neoplasm but not benign

Commonly endocrine symptoms - cushing’s syndrome (autonomous secretion of ACHT or cortisol), hypercalcaemia

Can also be clubbing, vascular thrombosis or immunological symptoms

Commonly occur in lung carcinomas

Question 4

What are important diagnostic differences between biopsy and cytology tissue sampling?

Answer 4

Biopsy is a sampling of cells - allows determination of relationship of the malignant cells to each other and to the stroma –> important in diagnosis of metastasis

Cytology is fine needle aspiration of cells. Only determines presence of malignant cells, can’t determine relationship with stroma, therefore can’t tell if invaded or not

Question 5

What is the difference between grading and staging of tumours?

Answer 5

Grading = degree of differentiation
Staging = degree of invasion/metastisis

Question 6

What are the general principles of the TNM staging system?

Answer 6

T = extent of primary tumor = size/local extent 
N = Metastasis to local LNs
M = Presence or absence of distant metastasis 

These are combined to give 4 stages, with stage 4 indicating distant metastasis

Question 7

What factors are important to know for prognosis of neoplasia?

Answer 7

The type of tumour and sub-type (i.e. cell lineage)
The stage and grade
Presence of lymphovascular invasion
The specific genetic mutation - can predict the likely response to treatment i.e. HER2 amplification & oestrogen receptors in breast cancer
Pattern of inflammation

Question 8

How does the grade affect prognosis?

Answer 8

Poorly differentiated tumours and thus high grade tumours are more aggressive - usually associated with poorer prognosis