
Basic Oncology Frederick
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Contents
Part I The Cancer Problem
1 What Is Malignancy ? 3
1.1 Nature of a Malignancy 5
1.2 What is the Prevalence of Cancer? 6
1.3 Tumours Benign and Malignant? 7
1.4 Dangers of Malignant Tumours 8
1.5 What Causes Cancer 9
1.5.1 Is There a Single Cause Or a Single Common Pathway? 9
1.5.2 Apoptosis 10
1.5.3 Carcinogens 10
1.5.4 Tobacco Smoking 10
1.5.5 Alcohol 11
1.5.6 Betel Nut 11
1.5.7 Sunshine 12
1.5.8 Other Forms of Irradiation: X-rays and Atomic Irradiation ... 12
1.5.9 Industrial Irritants and Carcinogens 13
1.5.10 Chemical Carcinogens 13
1.5.11 Hormones 13
1.5.12 Viruses 14
1.5.13 Bacteria 15
1.5.14 Pre-Existing Abnormalities 15
1.5.15 Nutritional Deficiencies and Food Habits 15
1.5.16 Estimate of Known Risk Factors and Associations
with Cancer 15
2 Epidemiology 17
2.1 Comparative Cancer Incidence 17
2.2 People Most at Risk 18
2.3 Viral and Other Infection Associations 18
2.4 Heredity and Genetic Factors 19
2.4.1 Tumour Suppressors, Proto-Oncogenes and
Cancer-Oncogenes 19
2.4.2 Tumour Suppressor Genes 21
2.4.3 Cell Cycle Regulatory Genes 21
2.5 Molecular Biological Changes in Controlling
Cell Division 22
2.5.1 Inherited Cancer Genes: Inherited and Familial Cancers 23
2.6 Age 24
2.6.1 Infants 24
2.6.2 Children, Adolescents and Young Adults 25
2.6.3 Increasing Age 25
2.7 Predisposing and Pre-Malignant Risk Factors 26
2.7.1 Skin 26
2.7.2 Oesophagus 26
2.7.3 Stomach 26
2.7.4 Bowel 27
2.7.5 Mouth and Throat 27
2.7.6 Stones: Gallstones, Kidney and Bladder Stones 27
2.7.7 Chronic Inflammation 27
2.7.8 Acute Injury 28
2.7.9 Pre-Existing Lumps and Benign Tumours 28
2.7.10 Congenitally Abnormal Tissues 28
2.7.11 Gender 28
2.8 Diet and Cancer: Special Dietary
Preventive Ingredients 29
2.9 Stomach Cancer 31
2.10 Bowel Cancer: Cancers of the Colon and Rectum 32
2.11 Other Cancers 32
2.12 Vegetarian Diets 32
2.13 Special Dietary Ingredients: Phytoestrogens and Lycopene 32
2.14 Vitamins, Anti Oxidants and Trace Elements 33
2.15 Race 33
2.16 Geographic Associations 34
2.17 Environment 35
2.17.1 Sunshine 35
2.17.2 Air Pollution 35
2.17.3 Ionising Irradiation 35
2.17.4 Goitre Belts 35
2.18 Occupation 36
2.19 Habits and Lifestyle 36
2.19.1 Smoking 36
2.19.2 Alcohol 37
2.19.3 Sun-Exposure 37
2.19.4 Betel Nut 37
2.19.5 Pregnancies and Breast Cancer 37
2.19.6 Cultural and Social Customs 37
2.20 Psychological Factors: The Possible Role of
Stress or Emotion in Cancer Development 38
2.21 Cancer Registries 39
3 Summary of Practical Measures to Prevent Cancer 41
3.1 Smoking 41
3.2 Viral and Bacterial Protection 41
3.3 Genetic Protection 42
3.4 Skin Cancers 42
3.5 Diets: Stomach and Bowel Cancer, Breast Cancer 43
3.5.1 Prostate Cancer 43
3.5.2 Thyroid Cancer 43
3.5.3 Dioxins 43
3.5.4 Breast Cancer 43
3.6 Industrial Cancers 44
3.7 Ionising Irradiation 44
3.8 Treatment of Pre-Malignant and Potentially
Malignant Lesions 45
3.8.1 Pre-Malignant Conditions 45
Part II General Features of Cancer-Presentation and Management
4 Symptoms of Cancer: Local and General 49
4.1 Lump 50
4.2 Ulcer 50
4.3 Pain 50
4.4 Bleeding 51
4.5 Weight Loss 51
4.6 Interference with Tissue or Organ Function 52
4.7 Symptoms of Metastatic Spread 52
4.7.1 Lymph Nodes 52
4.7.2 Liver 53
4.7.3 Lungs 53
4.7.4 Bones 53
4.7.5 Fat and Muscles 53
4.7.6 Bowel 53
4.7.7 The Brain 53
4.7.8 The Unknown Primary Syndrome 53
5 Signs of Cancer: Local and General 55
5.1 Lump 55
5.2 Ulcer 56
5.3 Bleeding and Evidence of Blood Loss 56
5.4 Lymph Node Enlargement 56
5.5 Other Swellings 57
5.6 Findings of a General Examination Including
Mouth, Throat, Abdomen, Rectum and Anus 57
5.7 Rare and Seemingly Unrelated Indications of Cancer 58
6 Clinico-Pathology of Cancers 59
6.1 Typing, Grading and Staging of Cancer 60
6.2 Cancer Typing 60
6.3 Cancer Grading 60
6.4 Clinico-Pathological Staging of Cancer 61
6.5 Clinical Decisions Based on Pathology Information 62
7 Investigations That May be Useful in Detecting Cancer 65
7.1 Screening Programs 66
7.2 Screening Tests 66
7.2.1 The Cervical Smear or “Pap” (Papanicolaou) Test 66
7.2.2 Occult Blood Tests 66
7.2.3 Gastro-Oesophageal Screening 67
7.2.4 Breast Screenings: Mammography 68
7.2.5 Skin Cancer Screening: Especially the “Mole Check” 68
7.2.6 PSA Screening Test 69
7.2.7 Genetic Testing 69
7.3 Organ Imaging 69
7.3.1 X-Rays 69
7.3.2 Barium (Baryum) and Iodine Contrast X-Rays 70
7.3.3 Radiographic Screening 72
7.3.4 Mammography 72
7.3.5 Chest X-Ray 73
7.3.6 Skeletal X-Rays 73
7.3.7 Angiography 73
7.3.8 Isotope Scans (Nuclear Scintigraphy) 74
7.3.9 CT Scan or CAT Scan (Computerised Axial Tomography) .... 75
7.3.10 Ultrasound Scans 77
7.3.11 MRI (Magnetic Resonance Imaging) 78
7.3.12 PET (Positron Emission Tomography) Scan 78
7.4 Endoscopic Examinations: Rigid and Flexible Scopes 79
7.4.1 Rigid Scopes 79
7.4.2 Sigmoidoscopy 79
7.4.3 Proctoscopy 80
7.4.4 Vaginal Speculum 80
7.4.5 Laryngoscopy and Bronchoscopy 80
7.4.6 Oesophagoscopy 80
7.4.7 Cystoscopy 80
7.4.8 Echo-Endoscopy 81
7.4.9 Flexible Scopes 81
7.4.10 Gastroscopy or Endoscopy 81
7.4.11 Colonoscopy 81
7.4.12 Laparoscopy (Peritoneoscopy) and Thoracoscopy 82
7.4.13 Culdoscopy 82
7.5 Indirect Evidence of Cancer 82
7.5.1 Blood and Serum Tests 82
7.5.2 White Cell Count (WCC) 82
7.5.3 Erythrocyte Sedimentation Rate (ESR) 83
7.5.4 Serum Biochemistry 83
7.5.5 Tumour Markers 83
7.5.6 The Future 84
7.6 Direct Evidence of Cancer 84
7.6.1 Biopsy 84
7.6.2 Needle Aspiration or “Punch Out” Biopsy 85
7.6.3 Aspiration Cytology 86
7.6.4 Bone Marrow Biopsy 86
7.6.5 Standard Paraffin Section Biopsy and
Frozen Section Biopsy 86
8 Treating Cancer 87
8.1 Can Cancer Be Cured? An Outline of Prognosis 87
8.2 In Western Societies More Cancers are
Cured than Not Cured 88
8.3 Methods of Treatment 89
8.3.1 Principles of Treatment of Potentially Curable
Regional Cancers 89
8.3.2 Surgery 90
8.3.3 Radiotherapy 92
8.3.4 Chemotherapy (Cytotoxic Drug Treatment) 94
8.4 Other Important Treatments 104
8.4.1 Hormone Therapy 104
8.4.2 Immunotherapy 107
8.5 Some Further Treatments Under Study 111
8.5.1 Heat Therapy 111
8.5.2 Gene Therapy 112
8.6 General Care 113
8.6.1 Care of General Health 113
8.6.2 Treatment of Complications 114
8.6.3 Supportive Care and Supportive Care Teams 115
8.6.4 Pain Relief 115
8.6.5 Psychological and Spiritual Help 116
8.6.6 Follow-Up Care 117
8.6.7 The Specialty of Palliative Care 118
8.6.8 Alternative Medicine 118
9 Relationship Between Patients, Their Doctors and the Healthcare Team
Part III Most Common Cancers
10 Skin Cancers 125
10.1 Skin Cancer Prevention 125
10.2 Basal Cell Carcinoma (BCC) 126
10.2.1 Treatment 128
10.3 Squamous Cell Carcinoma (SCC) 128
10.3.1 Treatment 129
10.4 Melanoma 133
10.4.1 Pathology 133
10.4.2 Causes and Incidence 133
10.4.3 Early Features of Melanoma 134
10.4.4 Treatments of Melanoma 137
10.4.5 Investigations to Guide Surgical Treatment 137
10.4.6 Other Treatments 138
10.4.7 Vaccine Studies 139
11 Lung Cancer (Bronchogenic Carcinoma) 143
11.1 Symptoms 144
11.2 Investigations 145
11.3 Significance of Histological Findings 146
11.4 Treatments 146
11.5 Mesothelioma 148
11.6 Metastatic Cancer in the Lung 148
12 Breast Cancer 151
12.1 Hormone Replacement Therapy (HRT) 153
12.2 Symptoms 154
12.3 Inflammatory Breast Cancer 156
12.4 Cancer of the Male Breast 156
12.5 Signs 157
12.6 Investigations 157
12.6.1 Breast Cancer Staging 158
12.7 Treatments 158
12.8 Prevention 158
12.9 Pathology 160
12.10 Early Breast Cancer 161
12.10.1 Surgery and/or Radiotherapy 161
12.10.2 Adjuvant Chemotherapy 163
12.10.3 Hormone Sensitivity Tests 163
12.10.4 Options in Management of Early Breast Cancer 164
12.11 Locally Advanced and Metastatic Breast Cancers 164
12.12 Physical and Emotional Needs 165
12.12.1 Breast Prostheses and Breast Reconstruction 165
12.12.2 Breast Clinics 167
12.12.3 Cancer Societies and Breast Cancer Support Groups 167
13 Cancers of the Digestive System (Alimentary Tract) 171
13.1 Cancer of the Oesophagus 171
13.1.1 Pathology 172
13.1.2 Symptoms 172
13.1.3 Signs 172
13.1.4 Investigations 172
13.1.5 Treatment 173
13.2 Cancer of the Stomach 175
13.2.1 Pathology 175
13.2.2 Symptoms 176
13.2.3 Signs 176
13.2.4 Investigations 176
13.2.5 Treatment 177
13.3 Cancers of the Liver 179
13.3.1 Primary Liver Cancer (Hepatoma or
Hepatocellular Carcinoma) 179
13.3.2 Secondary (Metastatic) Liver Cancer 182
13.4 Cancer of the Gall Bladder and Bile Ducts 186
13.4.1 Symptoms 186
13.4.2 Signs 186
13.4.3 Pathology and Treatment 187
13.5 Cancer of the Pancreas 187
13.5.1 Presentation 187
13.5.2 Investigations 188
13.5.3 Treatment 188
13.6 Cancers of the Small Intestine 190
13.6.1 Carcinoid Tumour 190
13.7 Cancer of the Large Bowel (Colon and Rectum) 191
13.7.1 Clinical Features 193
13.7.2 Investigations 193
13.7.3 Treatment 194
13.7.4 Follow-Up Care 195
13.8 Cancer of the Anus 195
13.8.1 Presentation and Pathology 195
13.8.2 Treatment 197
14 Head and Neck Cancers 199
14.1 Cancers of the Lips 200
14.2 Cancers of the Floor of the Mouth (Under the Tongue),
Anterior Two-Thirds of the Tongue, and Buccal Mucosa
(Inside the Cheek) 200
14.3 Cancer in the Posterior Third of Tongue, Tonsillar
Region and Pharynx 206
14.4 Cancers of the Post-Nasal Space (The Air Passage
at the Back of the Nose) 207
14.4.1 Presentation 208
14.4.2 Treatment 208
14.5 Cancer of the Larynx 208
14.5.1 The Lost Cords Club 210
14.6 Salivary Gland Cancers 210
14.7 Cancers of the Thyroid Gland 213
14.7.1 Causes and Presentation 213
14.7.2 Accidental Irradiation 214
14.7.3 Investigations 214
14.7.4 Types of Thyroid Cancer 214
14.7.5 Papillary Cancer 214
14.7.6 Follicular Cancer 215
14.7.7 Medullary Cancer 215
14.7.8 Anaplastic Cancer 215
14.7.9 Other Types 216
15 Cancers of Female Genital Organs 217
15.1 Cancers of the Uterus 217
15.2 Cancer of the Cervix 217
15.2.1 Presentation and Risk Factors 217
15.2.2 Investigations 218
15.2.3 Treatment 218
15.2.4 Prevention 219
15.3 Cancer of the Body of the Uterus (Endometrial Cancer) 221
15.3.1 Presentation 221
15.3.2 Investigations 221
15.3.3 Treatment 221
15.4