PRINCIPLES OF ONCOLOGY

Dr. Ganesh.T
Oncology is the study, diagnosis, and treatment of tumors (neoplasms).

Neoplasms

• Growths made up of cells that reproduce abnormally

• Tumor cells lack the mechanism to stop producing and they lack the ability to die
after a certain period
• Apoptosis is the death of normal cells in a normal time cycle
• Tumors can be either benign or malignant
Benign Malignant

•encapsulated •not capsulated

• not life-threatening •categorized by the types of
•made up of differentiated tissue from which they develop
cells • can be life-threatening
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Carcinoma Sarcoma

•Originates from epithelial tissue • Originates in muscle or connective

and is the most common type of tissue and lymph
cancer
• A fairly rare form of cancer
• Also called solid tumors
• Certain leukemias are sarcomas
• Common sites for carcinomas:
-skin
-lungs - stomach
-breasts - mouth
-colon - uterus

•Spread by way of the lymphatic

system
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Mixed-Tissue Tumor

•Derives from tissue that is capable of separating into either epithelial or connective
tissue because it is composed of several types of cells

• Can be teratomas, which are growths containing bone, muscle, skin, glandular
tissue and other cells

NOTE: A class of cancer such as leukemia arises from blood, lymph or

nervous system cells

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Malignant Tumors

•Made up of cells that lack the

normal orderly arrangement of
the cells from which they arise

•Lack a defined mature cell

structure referred to as
anaplasia

•Any abnormal tissue

development is known as
dysplasia

• Metastasis may occur

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 Causes of Cancer DNA

•Inherited defect transmitted to the

child in DNA
• Exposure to carcinogens

Types of Carcinogens

• Environmental agents Other Cancer Causing

Agents
• Chemicals
• Radiation
• Viruses • tobacco
• smoke
• asbestos
• insecticides
• certain dyes
• certain hormones
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 Cancer Terms - Recap
• Neoplasia
– Development of an abnormal growth of new cells
that is unresponsive to normal growth control
mechanisms
• Neoplasm
– Any abnormal growth of new tissue that serves
no useful purpose
– Neoplasm = tumor
 Cancer Terms
• Differentiation
– Cells become specialized and differentiated both
physically and functionally
• Cells look and act like the parent cell, or tissue of origin
• Anaplasia
– Loss of cellular differentiation and reversion to a
more primitive form
• Anaplasia = dedifferentiation
 Cancer Terms
• Malignant
– Tending to become worse and cause death
• Metastasis
– Process by which malignant cells spread to other
parts of the body
 Benign versus Malignant Tumors
• Benign
– Usually encapsulated
– Cells similar in structure to cells from which they
originate
– Well-defined borders
– Slow growing and limited to one area
– Possible growth displacement (but not invasion)
to adjacent tissue
 Benign versus Malignant Tumors
• Malignant
– Not encapsulated; not cohesive, and irregular
pattern of growth
– No resemblance to cell of origin
– No well-defined borders
– Growth into adjacent cells rather than displacing
or pushing them aside
– Rapid growth through rapid cell division and
multiplication
 Classification of Neoplasms
• System for naming neoplasms
– Root word to indicate type of body tissue that
gives rise to neoplasm
– Suffix to indicate whether tumor is benign or
malignant
• Benign tumor suffix = oma
• Malignant tumor suffix = carcinoma or sarcoma
 Classification of Neoplasms
• Carcinomas
– Solid tumors that originate from epithelial tissue
• Tissue that covers external and internal body surfaces,
lining of vessels, body cavities, glands, and organs
• Sarcomas
– Originate from supportive and connective tissue
• Bone, fat, muscle, and cartilage
 Grading of Neoplasms
• Grading
– Measures extent to which tumor cells differ from
their parent tissue
– Grade 1 = well-differentiated cells, function most
like the parent tissue
• Least malignant
– Grade 4 = least differentiated cells, not like the
parent tissue
• Most rapidly increasing in number
 Staging of Neoplasms
• Staging
– Extent of disease and relative size of tumor
– TNM staging classification system
• Internationally recognized system used for staging
neoplasms
• T: (0-4) = tumor size (primary)
• N: (0-3) = degree of regional lymph node involvement
• M: (0-3) = presence or absence of distant metastases
 Risk Factors
• Lifestyle and environmental risk factors
– Tobacco
– Alcohol
– Diet
– Sunlight
– Radiation
– Industrial agents and chemicals
– Hormones
 Risk Factors
• Lifetime risk
– Probability that an individual, over the course of
his or her lifetime, will develop cancer or will die
from cancer
• Relative risk
– Measures the strength of the relationship
between risk factors and particular types of cancer
 Warning Signs of Cancer
• Need for immediate follow-up
– C = Change in bowel or bladder habits
– A = A sore that does not heal
– U = Unusual bleeding or discharge
– T = Thickening or lump in breast or
elsewhere
– I = Indigestion or difficulty in swallowing
– O = Obvious change in a wart or mole
– N = Nagging cough or hoarseness
 TREATMENT
TECHNIQUES
AND PROCEDURES
 Pre-operative imaging and TNM
staging
• Most solid tumours require adequate and site-
specific imaging.
• This facilitates diagnosis and staging of the
primary tumour and staging for distal metastases.
• For example mammography using the BIRADS
system and ultrasound are used in breast cancers
to assess a primary breast cancer.
• Meanwhile, an oesophageal cancer requires a CT
and a low rectal cancer will be best assessed with
MRI or endorectal ultrasound, whilst a thyroid
cancer is best evaluated with neck ultrasound.
The goals of imaging the primary tumour are to
assess tumour size,
invasion into surrounding structures and
operability.
Imaging to stage a tumour aims at assessing
nodal involvement and distal metastases.
 TNM STAGING
The TNM staging system (American Joint Commission on
Cancer AJCC) is devised for cancers to allow an
assessment of
• T- tumour,
• N- nodal metastases and
• M- distal metastases.
The goal of having a site-specific staging system is to
estimate prognosis,
facilitate treatment planning including the sequence of
treatments and
allow comparisons of treatment for different stages.
• Generally, a combination of different ‘T’, ‘N’, and
‘M’ allows the cancer to be grouped into stages.
• Stages I-IV usually depict a tumour in the
following state:
Stage 1- early and superficial cancer,
Stage 2- locally advanced,
Stage 3- regionally advanced with lymph node
metastases and
Stage 4- distant metastatic disease.
 Contents
5. Cancer spread page
Routine Medical Examination

• Pap smear • Testicular exam

- test for cervical and uterine - palpate for tumors in testes
cancer

• Breast exam
- palpate for lumps in the breast

• Digital rectal exam

-screening for prostate cancer

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Blood Tests

• Carcinoembryonic antigens (CEA)

- detects gastrointestinal tumors

• Human chorionic gonadotropin

• Prostate-specific antigen (PSA) (HCG)
- detects prostate cancer - present with testicular cancer

• Alphafetoprotein test (AFP) • Cancer antigen 125 (CA-125)

- detects liver or testicular cancer - protein produced by ovarian cancer
cells

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Categorizing Tumors

Tumors are categorized by:

•grade (the maturity of the tumor)

• stage (the degree the tumor has spread)

• appearance (using a microscope and by visual observations)

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Microscopic Examination

Determines if a tumor is:

• alveolar
- forming small sacs shaped like alveoli

• anaplastic • dysplastic
- reverting to a more immature - abnormal in cell appearance
form

• carcinoma in situ
- contained at a site without • diffuse
spreading - spreading evenly
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 Microscopic Examination (cont’d)
• hyperplastic
- excessive development of
cells
• epidermoid
- resembling epithelial cells
• pleomorphic
- having many types of cells
• follicular
- containing glandlike sacs
• undifferentiated
- lacking a defined cell
• hyperchromatic structure
- intensely colored

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Visual Examination

• cystic • necrotic
- filled with fluid - containing dead tissue

• fungating
• polypoid
-projecting in a mushroom-
- containing polyps
like pattern

• medullary • verrucous
- large and fleshy - having wart-like, irregular growths

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 Pathological biopsy

• Despite suggestive imaging, a cancer is not

diagnosed until histopathological biopsy.
• Biopsies where tissue (as opposed to cells) are
provided to the pathologist increase the accuracy
of the pre-operative diagnosis but may not
always be feasible.
• Biopsies may be undertaken percutaneously -- for
example, a core biopsy of the breast, fine needle
aspiration of thyroid or endoscopically such as in
gastric cancer or colon cancer.
•A biopsy should confirm
the tumour type, grade,
may show lymphovascular invasion and in some
cases,
special immunohistochemical stains may be
performed to assess hormone receptor status
such as in breast cancer or flow cytometry may
be performed to assess subtypes such as in
lymphoma.
• Staging may also require a biopsy of draining
lymph nodes.
• The goals of a biopsy should be to provide a
diagnosis without excessive morbidity to the
patient.
• Needle biopsy is not always adequate to aid
treatment and occasionally incisional or
excisional biopsies may be required.
• Lymphoma is a common tumour that may
require a larger tissue sample to make the
diagnosis.
 Diagnosis - RECAP

Early detection of asymptomatic cases

(screening)
Mammography PSA colonoscopy for APC

Diagnosis of symptomatic cases

Clinical Imaging Endoscopy
Tumour sampling
Tumour markers
Diagnosis
 Diagnosis

Tumour sampling
Types

• Tissue biopsy – cytology

• Image-guided – unguided
• Frozen section – paraffin sections
 Diagnosis

Tumour sampling
Tissue biopsy
• Needle, endoscopic or operative biopsies
• Obtains a piece of tissue
• Diagnosis depends on cellular morphology &
tissue architecture (orientation and invasion)
Cytology
• e.g., FNAC & exfoliative cytology
• Obtains cells
• Diagnosis depends on cellular morphology only
• Requires an expert cytologist
 Diagnosis

Incision
Site & direction
Diagnosis
 Diagnosis

Healthy

Cancer
 Diagnosis

Tumours markers

Help in the diagnosis of certain tumours and in the

follow-up of the patients after treatment.

•Alpha-feto protein HCC & testicular teratoma

•CEA GIT, pancreas and breast CA.
•PSA Prostate CA.
•CA 15-3 Breast CA.
•CA 19-9 GIT & pancreas CA.
•Thyroglobulin Thyroid CA.
 Patient-selection and timing of
surgery
• One of the biggest challenges for the surgeon is
to choose the correct surgery for the correct
patient and with the tumour type and biology in
mind.
• Although surgery removes a tumour and provides
further pathological information to estimate
prognosis and influence adjuvant therapies, the
surgery cannot cause more morbidity than the
cancer and must achieve surgical goals without
compromising tumour biology.
• When tumours are locally advanced, a
neoadjuvant approach with chemotherapy,
radiotherapy or targeted therapies may be
important to ‘control’ the growth of a tumour,
down-stage a tumour to render it operable, or
because the impact of systemic disease risk may
outweigh those of local control.
• Similarly, patients with metastatic disease may
still require surgery to prevent complications of
the primary tumour, such as bowel obstruction
from a colon cancer.
 MULTIDISCIPLINARY APPROACH
• The pre-operative multidisciplinary team
including anaesthetists, cardiologists,
dieticians, psychologists and social workers,
and tumour-specific specialist nurses often
assesses fitness for cancer surgery and the
psychosocial impact of surgery.
Incisional biopsy Excisional biopsy

•Removal of part of a •Removal of the

tumor for examination tumor and
surrounding tissue
Surgical
Procedures
Resectioning Exenteration

•Removal of the •Removal of an organ,

tumor and a large tumor, and surrounding
amount of the tissue
surrounding tissue

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Other Surgical Procedures

• Cryosurgery
- destruction by freezing

• Electrocauterization
- destruction by burning

• Fulguration
- destruction by high-frequency current

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Chemotherapy Biological Therapy

• Use of drugs to treat •Use of agents that enhance

cancer the body’s own immune
response in fighting tumor
growth

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 Treatment
Techniques and Procedures
• Chemotherapy
– Use of cytotoxic drugs and chemicals to achieve a
cure, decrease tumor size, provide relief of pain, or
slow metastasis
 Treatment
Techniques and Procedures
• Immunotherapy
– Agents capable of changing the relationship
between a tumor and the host are known as
biological response modifiers (BRMs)
• Agents are used to strengthen individual’s immune
responses
 Treatment
Techniques and Procedures
• Mohs Surgery
– Surgical procedure in which the cancerous tumor
is removed in stages
– Tissue is examined for evidence of cancer
– Additional tissue is removed until negative
boundaries are confirmed
• Advanced treatment procedure for skin cancer
 Treatment
Techniques and Procedures
• Radiation therapy
– Delivery of ionizing radiation to accomplish one or
more of the following:
• Destruction of tumor cells
• Reduction of tumor size
• Decrease in pain
• Relief of obstruction
• To slow or stop spread of cancer cells
 Treatment
Techniques and Procedures
• Radiation therapy
– Destroys rapidly multiplying cells regardless of
whether they are cancerous
– Goal is to reach maximum tumor control with no,
or minimum, normal tissue damage
– May be delivered by teletherapy (external)
– May be delivered by brachytherapy (internal)
 Treatment
Techniques and Procedures
• Surgery
– Tumor removal through surgery
– In more than 90 percent of all cancers, surgery is
used for diagnosing and staging
– In more than 60 percent of all cancers, surgery is
the primary treatment
• When feasible, the primary tumor is excised in its
entirety
 Treatment
Techniques and Procedures
• Common surgical procedures
– Incisional biopsies
• Used to remove a piece of a tumor for examination and
diagnosing
– Excisional biopsies
• Used to remove the tumor and a portion of normal
tissue
– En block resection
• Removal of a tumor and a large area of surrounding
tissue that contains lymph nodes
 Treatment
Techniques and Procedures
• Common surgical procedures
– Fulguration
• Destruction of tissue with electric sparks
– Electrocauterization
• Destruction of tissue by burning
 Treatment
Techniques and Procedures
• Common surgical procedures
– Cryosurgery
• Destruction of tissue by freezing the malignant tissue
– Exenteration
• Wide resection that removes the organ or origin and
surrounding tissue
 Treatment - RECAP

Standard modalities

A. Surgery
B. RT
C. Chemotherapy
D. Hormone therapy
E. Immunotherapy
 Treatment A. Surgery

Definition of radical surgery

Primary tumour Safety margin

Lymph nodes
•GIT CA Routinely resected
•Breast CA Excision or irradiation
•Head & neck & skin Treated only if involved

Whenever possible lymph nodes are removed in

continuity with the primary tumour = block excision.
 Treatment A. Surgery

Precautions
Avoid spillage of malignant cells, local & blood

Advantages
•Quick
•Effective
•The largest number of cures
•Confirms full ablation of a tumour (clear safety margin).

Disadvantages and Limitations

•Functional and cosmetic disabilities
•Not applied if fixed to a vital structure or with mets.
 Treatment B. Radiotherapy

May replace surgery or may be given in addition

Common indications
1. Cancer of the larynx so as to preserve the voice
2. Early Hodgkin's disease
3. Early prostate cancer
4. As part of conservative therapy for early breast
cancer (after surgery)
 Treatment B. Radiotherapy

Methods
Powerful X-rays, gamma rays, electrons, or heavy
particles are directed to the tumour by one of two
main methods
1. Teletherapy (cobalt & linear accelerator)
2. Brachytherapy (implanted needle)
 Treatment B. Radiotherapy

Advantages
• Preserves surrounding structures
• Can destroy microscopic extensions around a
tumour that a scalpel might miss
• Safer option for old frail patients
• Usually does not require hospitalization
• SCC is sensitive

Disadvantages
• Adenocarcinoma is much less sensitive
• Burns of the skin or enteritis - difficult to treat
• Compared to surgery, radiotherapy is slower
• Like surgery, it is not suitable for mets
 Treatment C. Chemotherapy

Common indications

• Blood & lymphoid CA

• For solid tumours
-Main modality in case of detected metastases
-Adjuvant to surgery in early cases where
microscopic metastases are possibly present

Better results are obtained from

combination chemotherapy
 Treatment C. Chemotherapy

Advantages
1. Can reach malignant cells anywhere in the body
2. Leukaemias, lymphomas and testicular cancer are
successfully treated by new combination drugs.

Disadvantages
1. Chemotherapy kills the rapidly growing cells of the
bone marrow, causes anemia, leucopenia and
thrombocytopenia.
2. Other side effects of chemotherapy include
diarrhoea, nausea vomiting and hair loss.
 Treatment D. Hormone therapy

Examples
• Anti-oestrogens for with ER +ve breast CA
• Androgen blockade for men with prostate cancer
• Thyroxin to suppress TSH for papillary thyroid CA

Advantages
Mild side effects

Disadvantages
Limited to tissues with hormone receptors
 Treatment E. Immune therapy

Non-specific
BCG TCC of urinary bladder

Specific
Monoclonal antibodies from a single clone of
lymphocytes that have been stimulated by a
specific protein of the cancer cells
 Treatment

Bone marrow transplantation

Not a therapy in itself

Indications
To strengthen depleted bone marrow that is weakened
by high, potentially curative doses of RT or
chemotherapy

Sources
•Allogeneic donations
•Autologous donations
 Surgery of the primary tumour

• The aims of any cancer surgery are to remove

the cancer with an adequate margin of normal
tissue with minimal morbidity.
• Clear margins have an impact on local control.
• Margin requirements differ according to the
origin of the tumour and the functional
impact must be considered.
Two examples of margins versus function/cosmesis include
rectal cancer and breast cancer.
A low rectal cancer requires an adequate margin above the
anal sphincters to enable a primary anastomosis (anterior
resection) that is not under tension and therefore at risk of
anastomotic leak. As a cancer encroaches on the level of
the sphincter muscles, the sphincters must be sacrificed in
order achieve an adequate margin (abdominoperineal
resection).
In breast cancer, a wide local excision may be adequate for
many breast cancers but if the result is poor cosmesis/
shape, a mastectomy may be a better operation to achieve
a clear margin.
SURGERY OF THE LYMPH NODAL BASIN

• Many solid tumours require removal of the

draining lymph nodes for the purpose of
staging and/or to achieve local control.
• Levels of prophylactic lymph nodes dissection
vary according to tumour type and may
increase surgical morbidity.
 SENTINEL NODE BIOPSY
• Surgery in some tumours has become more
conservative with the advent of sentinel node
biopsy when lymph node metastases are not
evident pre-operatively.
• Sentinel node biopsy is frequently used in breast
cancer and melanoma.
• The aim of the sentinel node biopsy is to provide
an assessment as a staging tool to predict
prognosis and influence use of adjuvant
therapies.
 Surgery in metastatic disease and
emergencies
• Local control may become an issue in some patients
with metastatic disease.
• Surgery may be undertaken in an elective or
emergency setting in colorectal cancer to prevent or
manage a bowel obstruction, to bypass a segment of
small bowel involved with peritoneal disease or to
place an endoscopic stent, for example in a metastatic
cholangiocarcinoma or oesophageal cancer.
• In addition, in some tumour types, such as breast
cancer, colorectal cancer or liver metastases, removal
of the primary in a patient who has stable metastatic
disease may improve prognosis and survival.