Mario Brown Arnold
Cancer today is a global diagnosis that encompasses numerous diseases characterized by commonly presenting a pathological proliferation of one or multiple cell clones, which does not respond to the usual regulatory mechanisms (suppressor genes, apoptosis, etc.). This cell proliferation is capable of invading organs neighboring the site in which it initially develops and also spills into the bloodstream to generate cell nests in other organs that will become future clinical metastases over time.
The symptoms present at the time of the consultation will largely depend on the growth and local invasion as well as the development of metastases in distant organs.
If cancer is a disease of multiple organs, it is forced to accept as a conclusion that the symptoms and signs can be varied many times but coincident in others. Emerging as a second conclusion that the cancer does not produce specific symptoms; since for example dyspnea and chest pain that are frequently present in lung cancer are also symptoms of pulmonary thromboembolism or bacterial pneumonia. What may vary is the context in which these symptoms occur and this is a valuable fact to keep in mind for a correct interpretation of the clinical picture. That is, if the cough and dyspnea occur in the context of a young adult, non-smoker and with a fever of 39º in the last 24 hours. It will have more right to think of bacterial pneumonia than cancer.
Based on this criterion of association between symptoms-signs and context, a list of neoplastic diseases will be seen based on their location by organs and the most frequent symptoms and signs that they can produce and how or when to suspect based on these symptoms a possible Cancer.
Malignant tumors of the oropharynx and larynx
They usually manifest as space-occupying lesions in the oral cavity, with infiltrative symptoms of the organ such as enlargement of the lingual or palatine tonsils, macroglossia or dysfunction of the tongue in cases of infiltration of the floor of the mouth. It usually presents as a frequently bleeding and exudative ulcerative lesion that does not heal, with associated halitosis. These injuries are strongly linked to cigarette and alcohol abuse in middle-aged or older men.
Laryngeal cancer has its cardinal symptom in dysphonia very frequently of long term evolution which makes one suspect a long-standing injury. Early diagnosis is very important because in these instances it is highly curable with surgery or radiation therapy. This is a neoplasm with a strong incidence regarding smoking and alcohol abuse moreover when these addictions coexists with low income social status.. Chronic inflammatory dysphonia caused by professional activity (teachers, announcers, singers) can be a predisposing factor. Computed Thomography (CT) is an essential element to define the extension of the local tumor and to assess the presence of metastases, the most common being the lungs.
Malignant Chest Tumors
The criterion of precocity in the diagnosis must always be kept in mind to have the opportunity to cure lung cancer.
The most frequent tumor of the chest is carcinoma of the lung, strongly linked to smoking.
It is not possible to speak of early symptoms in this disease, so the clinical follow-up of smokers and their control with regular imaging (at least with Chest Radiographs) is reasonable.
However, if the tumor is small (less than 3 cm in diameter and no additional lesions are documented in the metastatic check-up by contrast-enhance Chest Tomography ( CT ) or Magnética Resonance ( MRI) of the Central Nervous Sistem (CNS) and/or PET-CT, it can be cured with surgery. So in this case, the tumor size is related to the possibility of cure.
The frequent symptoms of lung carcinoma are irritative dry cough, but it can be productive predominantly mucous in cases of adenocarcinoma or alveolar bronchiole carcinoma. Hemoptoic sputum, chest pain, and dyspnea are also common. The latter is very common and intense in cases of alveolar bronchiolae adenocarcinoma and in cases of carcinomatous lymphangitis, which is a form of invasion through the intra-pulmonary lymphatics and is usually fatal as it leads to acute respiratory failure.
Tumors located in the right pulmonary vertex can produce the stellate ganglion injury that is initially stimulated with lagoftalmos, mydriasis, and exophthalmia known as Porfour de Petit Syndrome and its subsequent infiltration and depression of lymph node function with ptosis. palpebral, enophthalmia and miosis. (Claude Bernard-Horner syndrome).
Mediastinal lymphadenopathies or the same compression of the tumor mass over the superior vena cava usually evolve to a syndrome consisting of facial and cervical bloating, cutaneous redness, headache and venous congestion secondary to obstruction to flow that returns through the superior cava; This condition is called Superior Vena Cava Syndrome.
Digestive Tube Tumors
- The esophageal cancer (squamous cell carcinoma or adenocarcinoma) is a tumor that gradually installs its cardinal symptom, dysphagia. This usually begins as dysphagia to solid food, at a variable onset but ends up progressing to liquid dysphagia and eventually aphagia.
These alterations depend entirely on the progressive restriction of the esophageal lumen, therefore, when the dysphagia is installed, you already have a tumor that has progressed enough to limit the lumen of the organ.
Weight loss is a sign that is inexorably associated with dysphagia and is a consequence of the metabolic disorder that causes the disease.
The evolution of esophageal carcinoma leads to rapid lymphatic dissemination to periesophageal and subdiaphragmatic nodes and systemic metastases, with lung metastases being the most frequent.
- The stomach cancer (adenocarcinoma ) is subreptitious in their development, thereby compromising the chance of cure as often discovered as an advanced tumor.
Abdominal pain, vomiting, anorexia, and weight loss are frequent symptoms of advanced disease. When the lesion is located in or involves the pyloric antrum, vomiting is from retention, with food that is almost undigested and intense halitosis is perceived.
Since it is a predominantly loco-regional behavioral disease,early metastases to the lymphatics nodes compromise the surgical chance of cure. Metastases to the liver and invasion of the abdominal cavity with ascites and abdominal pain are frequent.
- The pancreatic adenocarcinoma has a predominant location at the head of the organ infiltrating it and spreading rapidly to the nerves of the plexus and pancreatic lymph nodes in the retoperitoneum. This causes pain very frequently manifest on the back, in a bar, of increasing intensity and that calms initially with non-steroidal analgesics.
The enlargement of the pancreatic head produces compression of the common bile duct at its mouth in the Wirsung with subsequent cholestatic jaundice. Weight loss is common and pronounced. Abdominal ultrasonography and Computed Tomography (CT) of the abdomen with contrast are useful for detecting the lesion and, above all, contrasted tomography, allows showing its links with arterial and venous vessels. CA 19.9 can act as a monitor of the evolution of the disease after treatment is instituted.
Colon and Rectal Cancer: are diseases related in part to certain genetic alterations such as Familial Multiple Polyposis (FAP) and Hereditary Familial Colon Cancer Non-Polyposis (HNPFCC).
They are also associated with poor diets or with the absence of green grains and vegetables and a sedentary lifestyle.
Adenocarcinoma of the right colon occurs more frequently with anemia, decay, vague abdominal pain, weight loss, and a palpable abdominal mass but these usually are late symptoms.
Cancer of the left colon presents alternation with constipation and diarrhea and usually manifests intestinal obstructive symptoms with pain, nausea and vomiting.
Rectal cancer patients may present with proctorrhagia, pushing, and rectal tenesmus. Pelvic pain is a late symptom and indicator of the extension of the rectal tumor to nerve structures in the pelvis.
Digital rectal examination is suitable for diagnosis of rectal tumor in the vast majority of cases. Video rectoscopy is a suitable means for evaluating the tumor and for taking samples for biopsy purposes.Magnetic resonance imagen (MRI) of the pelvis using diffusion may be very helpful for to define invasion to the pelvic lymph nodes and allows evaluation of ded rectal wall.
In the case of colon cancer, video colonoscopy allows evaluating the mucosa of the organ and removing material for biopsy.
Computed axial tomography is very useful to define if there are extracolonic lesions, organ perforation and to evaluate the extension in those patients where the obstructive phenomenon does not allow the colonoscope to pass.
Carcino embryonic antigen (CEA) allows monitoring response to the treatment and must be done at the initial evaluation
Urinary Tract Tumores
The most common tumour is clear cell carcinoma (85% of kidney tumors), it predominates in middle-aged adults and its accidental diagnosis is not uncommon thanks to an imaging study due to other reasons.
Low back pain and hematuria are characteristic, and a syndrome composed of these two symptoms plus polyglobulia is described.
The most frequent metastatic sites are the lungs, skeleton, and central nervous system.
These tumors are easily detectable by ultrasound, although Computed Tomography provides more accurate data regarding capsular invasion, regional node involvement, perirenal fat and is the choice to define if there were distant metastases.
Transitional cell carcinoma of the bladder is the most common in the organ (85% - 90%) and predominates in men. Its link with the deleterious effect of various substances has been known for a long time, but above all anilines commonly used in the textile industry.
Hematuria is a common symptom and, in advanced stages, it may appear urinary frequency due to a compromised bladder lumen with or without dysuria. It can metastasize to the pelvic, lumbar lymph nodes, both lungs, and bone system.
Edema of the lower limbs due to lymph node block is a late symptom as is rectal obstruction and pelvic pain due to neural invasion.
The most common prostate tumor is adenocarcinoma. Its incidence begins around the age of 50, although it increases decade after decade, reaching almost 70% of men aged 80 and over.
Early prostate cancer is essentially asymptomatic but can be detected by a simple maneuver such as digital rectal examination. This is possible because most of the organ cancers are located in peripheral areas (80%) while 15% are in the transitional zone around the prostatic urethra being inaccessible to touch.
The progression of cancer within the prostate leads to increased volume of the gland, presenting the patient with dysuria and frequency.
The infiltration of the periprostatic nerves leads the neoplastic cells to the seminal vesicles and the neck of the bladder, and blood may appear in the ejaculation and eventually dysuria and hematuria. Distant metastases predominate in the skeleton and then in the lungs and are less frequent in the liver and CNS.
The dominant symptom of bone metastases is pain, which is usually capricious in behavior, varying from injury to injury. It is described in the case of multiple bone metastases that at least 1/3 of them do not hurt. These bone lesions, when located on the dorsum of the vertebra or in the laminae, usually develop towards the dorsal canal with the consequent risk of spinal compression, which usually evolves from sensory disorders (hypoaesthesia-anesthesia) in the lower limbs to paresis and plegia when the picture evolves completely. In the latter case it is usually irreversible.
Bone metastases are predominantly blastic and images that tend to be rounded with blastic appearance are observed in conventional radiology.
Multislice Computed Tomography and Nuclear Magnétic Resonance are useful to define nerve root compromise and dural canal invasion
Prostatic Serum Antigen (PSA)is useful as specific marker of the disease and as a monitor of the response to the treatment.
Tumors of the Male Genital Apparatus
The vast majority of testicular tumors are malignant and originate in the germ cells of the organ (more than 90%). They are the most frequent tumors in men aged 15 to 35 years.
Although there are several histological types, the most common and comprehensive way to group them is in a) Seminoma, b) Non-Seminoma tumors.
The cardinal sign is testicular enlargement, usually unilateral and painless. In about 30% of patients there may be pain due to bleeding or intratumoral infarction. In cases of young men with severe and acute abdominal pain, with a history of cryptorchid, this could be due to the torsion of a hidden mass in the undescended testicle. Low back pain in a young male may be caused by metastasis to the lumbo-aortic nodes from a testicular tumor. Other less frequent signs are gynecomastia (about 10%) and also infertility (3%).
Nonseminomatous carcinomas, variety choriocarcinoma, can metastasize to the bone and central nervous system. Lung and liver metastases are also seen without distinction of histological type.
These tumors produce hormones and enzymes (HCG beta subunite,, alpha fetus protein, LDH) serving their serum levels as diagnostic elements and as monitors of response to treatment.
Testicular ultrasound is a very useful diagnostic element to demonstrate the presence of a solid or cystic intratesticular mass, to define whether there is intratesticular fluid and if there is infiltration of the layers that cover the organ.
Computed axial tomography is of choice for the search for distant lesions in lymph node regions, liver and lungs.
Tumors of the Female Genital Apparatus
Malignant tumors of epithelial origin are 85%, they occur in women older than 60 years and the predominant subtype is papillary and serous adenocarcinoma.
It occurs more frequently as a pelvic tumor mass that can exceed 10 cm in diameter for a long time, ascites is a frequent sign and means involvement of the peritoneal serosa.
Ovarian cancer is a disease of frank evolution within the pelvic abdomen, so even in its advanced stages, they usually pass within said limits with the development of peritoneal carcinomatosis manifested by ascites, abdominal pain, and sub-occlusive symptoms due to invasion of intestinal loops. Nodular-appearing lung metastases, retroperitoneal lymphadenopathy, and liver metastases may also occur.
CA 125 is a serum protein that is valuable when it rises above the normal range in the diagnosis of pelvic masses and as a monitor of response to treatment (surgery, chemotherapy).
- Ovarian Cancer
Infiltrating ductal carcinoma is the most common type. The age of presentation in women has decreased from close to 50 years to 40 years, being frequent to diagnose breast carcinoma in women in the 30's.
Population studies carried out by the National Cancer Institute (USA) suggest that obesity and a high-fat diet may have a role in the genesis of these tumors.
The cardinal sign is the breast nodule, commonly asymptomatic and discovered on a routine clinical examination or by means of a control mammography.
Since the frequent route of dissemination is trough axillary lymphatics chains, palpable lymphadenopathy in the unilateral armpit should warn of the possibility of a ipsilateral breast tumor. A small percentage of mammary tumors, those of the internal quadrants drain towards the internal mammary chain making these lymph nodes inaccessible to the physical examination. Of all breast cancers that metastasize about 30% do so directly through the bloodstream without passing through the axillary nodes.
Bone, lung, and liver metastases are common, in combination but not necessarily simultaneously. About 10% of patients can present metastases in the central nervous system, although this percentage can escalate in patients called triple negative, to 40%. These triple negative breast cancers are named based on the negativity of immunohistochemical examination of estrogen, progestin receptors and the Her 2-Neu (or C-ERB2) oncogene.
They are more aggressive tumors, affect younger women, and although they usually have response rates to chemotherapy similar to other mammary carcinomas, relapses are faster and more frequent, with high percentages of brain metastases.
Laboratory tests are not specific, but bone metastases, when multiple, can be accompanied by anemia, elevation of alkaline phosphatase and hypercalcemia.
Liver metastases when they involve large volumes of parenchyma are usually accompanied by anorexia, poor tolerance to food intake, jaundice and coluria, the latter two already due to liver function failure.
Total bone scintigraphy is useful to define skeletal lesions suspected of metastasis.
CT of the chest and abdomen is indicated to evaluate pulmonary, hepatic parenchyma, retroperitoneal and mediastinal ganglionary chains. PET-CT is very helpful to define bone metastases in difficult to interpret Bone Scan lesions and as a ,marker of neoplastic activity in lung, liver ,bone and lumps nodes.
Ultrasonography is useful for differential diagnosis of solid lesions vs. cysts in liver and to assess pelvic masses that could suggest carcinomatosis of gynecological organs.