GENERAL EVALUATION OF THE ONCOLOGICAL PATIENT

Early detection of a malignant tumour is a prerequisite for its successful treatment.

History of the patient usually offers clues that may be suggestive of a malignant process:

• the living conditions and habits (e. g. such carcinogenic factors as smoking or chewing of tobacco);

• the area of living (e.g. skin cancer is much more common in those living in the South; lung cancer predominates in industrialised areas with an excessive air pollution).

At its initial stages a tumour is unlikely to produce any complaints. As the suspicion of a malignancy is sometimes based only on a few indistinct symptoms, the meticulous questioning is mandatory. It is therefore necessary to inquire whether there has been any minor change in the patient's well-being. Of great importance is what is referred to as the syndrome of minor symptoms and signs, i.e. the state of discomfort that may be indicative of a malignancy:

• fatigability without apparent cause and a reduction in working capability;

• rejection or unwillingness to eat certain foods

• drowsiness;

• apathy to what used to be of interest;

• «a foreign body» sensation;

• abdominal discomfort rather than pain (e.g. a feeling of heaviness);

• lack of satisfaction after micturition or defecation, etc.

Furthermore, a change in size, colour or consistency of a pre-existing lesion (e.g. a birthmark) is not infrequently of a diagnostic value.

It has to be, however, noted that such symptoms do not necessarily suggest a malignant tumour.

The earlier the diagnosis of the malignant tumour, the better the prognosis. As the patient with malignancy may first report to a physician of whatever speciality, the oncological alertness is important for each health care professional. The oncological alertness implies:

1. Physician's knowledge of early and/or atypical symptoms and signs of malignancy and its complications.

2. Physician's knowledge of the clinical pictures of premalignant conditions and their treatment.

3. The timely referral of patients with supposedly malignant conditions to specialised medical centres.

4. The adequacy of the patient's examination by the physician who was the first to suspect the malignancy irrespective of their speciality.

Persistent progression of symptoms is often a hallmark of a malignant condition. The history of the disease is often short in duration; on the other hand, a long-standing chronic inflammation or benign tumour may precede a malignant process. The physical examination is invariably based on routine methods: inspection, palpation and auscultation.

Historically, physicians were inclined to emphasise the patient's appearance in their seeking for the cause of the disease and even the location of the tumour, which was relevant to advanced forms of cancer. In fact, at the initial stages patients with malignancy do not show any clinical signs of the disease. Moreover, some may look virtually healthy and even gain body weight.

Premalignant conditions include diffuse and focal overgrowth of the epithelium of the skin and mucous membranes, which can be recognised through inspection and endoscopy.

The examples might be as follows:

• leukoplakia, or «white spots», i.e. vegetations of the epithelium covering mucous membranes, the changes being undetectable on palpation;

• certain benign cutaneous lesions (e.g. papillomas, polyps, birth marks);

• different forms of senile dyskeratosis.

The syndrome of pathological discharge (bloodstained discharge or bleeding) can be encountered in advanced stages of carcinoma. Diagnostically, blood-stained discharge is a common sign of malignancy, which is not the case with bleeding.

The syndrome of malfunction is due to structural and functional disorders of the organ involved. Tumours that grow inside, especially those of smaller organs, tend to cause early symptoms of obstruction (e.g. the tumour of the Vater's papilla leads to early development of jaundice). In contrast, when the tumour affects the lumen of a larger organ (e.g. the large intestine) intestinal obstruction is typical of an advanced malignancy.

Assessing the functional state of the organ affected the physician has to consider both the functional disorder of the organ and the functional presentation of the tumour itself. Most often, the competence of the organ involved is reduced (e.g. a decrease in the acid output as a result of gastric carcinoma), while the clinical signs of intoxication can be associated with hormonal overactivity of the tumour itself.

Pain is not a characteristic feature of tumour, with the exception of tumours arising from blood vessels and neural tissues, which exert pressure on the tissues. Usually, the pain is related to the distention of the adjacent tissues, infiltration of the nerves or organ insufficiency. Hence, intestinal obstruction resulting from the adluminal growth of a tumour causes spastic pains. In addition, persistent pain suggests either serous involvement or tumourous infiltration of the organ (e.g. tenesmus is a symptom of a rectal tumour)

Palpation is one of the major methods used in the physical examination as it provides the physician with vital information of the tumour. The palpation of the tumour is to be gentle and with appropriate pressure, the finger tips being used to feel first the intact adjacent tissue while approaching the tumour itself. It is sometimes performed with both hands, as is the case with feeling the lymph nodes, breast tumours.

The size of a tumour measures from millimetres to centimetres. The tumour shape is accounted for by its nature (benign vs. malignant). Nodularity of the surface and adherence to the neighbouring tissues, coupled with firm consistency, is characteristic of a malignancy, in contrast to a benign overgrowth or a cyst which has smooth surface and is often round and mobile. It is noted that metastatic nodules on the surface of a malignant tumour are likely to be smooth.

The consistency of a tumour appreciably depends on its type:

• soft (normally implies a benign nature of the tumour, e.g. lipomas or polyps of mucous membranes; in some cases, however, this can be a finding of an undifferentiated tumour (e.g. sarcoma);

• hard (associated with an overgrowth of the connective tissue, e.g. fibroma);

• firm (firm consistency, together with elasticity without fluctuation, is typical of an encapsulated tumour filled with fluid);

• wooden-like without demarcation (providessubstantial evidence of a malignant overgrowth, i. e. carcinoma).

The mobility of a tumour can be either spontaneous (active) or induced (passive). Of special importance is the tumour motility in relationship to the skin or muscles.

The tumour can move spontaneously:

• when it originates from a mobile organ in the abdominal cavity;

• on changing the body position;

• on swallowing (goitre);

• on muscular contraction (muscle tumour).

The physician has to evaluate the tumour's mobility. It is of particular significance in infiltrating immobile tumours, which most commonly appear malignant by nature.

It is noteworthy that in numerous cases it is the metastases that are identified first. To confirm the diagnosis of a malignant lesion or its metastases, special investigations have to be performed. The following are the examples:

• tumours of the umbilicus;

• tumours of the ovaries (Krukenberg's tumour);

• Wirchow's metastasis (the metastasis to the supraclavicular lymph nodes) suggesting gastric carcinoma with distant metastases;

• hepatic enlargement with nodules on its surface in an ascitic patient requires ruling out an abdominal malignant tumour.

In confirmed cases these signs invariably serve as the evidence of a stage IV malignant tumour.

Similarly, all the lymph nodes have to be thoroughly palpated. Metastatic lymph nodes differ from intact ones in that they are enlarged, round, firm and occasionally nodular and adhered to the surrounding tissues and other lymph nodes. However, unlike inflamed nodes, they commonly lack tenderness.

Because the malignancies of numerous organs (e.g. the lung, prostate, breast) produce osseous metastases, a meticulous skeletal investigation is required.

The liver may also harbour metastases from various types of tumours, which necessitates its thorough examination. The metastatic liver is enlarged, the edges being nodular, firm and non-tender. It is sometimes even possible to palpate separate clear-cut metastatic nodules.

Also, rectal, oral and pharyngeal tumours have to be examined by way of palpation. The digital examination of these tumours yields additional information about their size, form, mobility and consistency.

All the women suspected of having a malignant tumour are to undergo bimanual gynaecological examination.

Percussion and auscultation are performed within the routine physical examination.

To confirm the diagnosis of a malignant lesion or its metastases special investigations have to be performed:

1. Endoscopy.

2. Cytology (swabs, aspirates).

3. Histology (biopsy).

4. X-ray investigations (roentgenoscopy, roentgenography, tomography, angiography, lymphography).

5. Radioisotope methods (scanning, scintigraphy).

6. Ultrasonography.

7. Computerised axial tomography.

8. Laboratory tests (blood cell morphology, enzyme activity etc, as indicated).

One of the crucial points in evaluating the patient suspected of having a malignant disease is the staging of the tumour, for this helps decide on the appropriate management.

According to the clinical classification, the four stages of pathological overgrowth are identified:

Stage I - tumour is localised, occupies a limited area, does not infiltrate into the wall of the organ, metastases are absent.

Stage II - tumour is of a big size, can infiltrate into the organ wall but does not spread beyond the organ, there can be solitary metastases to the regional lymph nodes.

Stage III - tumour is of a big size with degeneration, infiltration into the hollow organ wall; multiple metastases to the regional lymph nodes are present.

The TNMGP classification

Stage IV - tumour with distant metastases to organs and lymph nodes and with infiltration of surrounding organs.

The TNMGP classification may read as follows: T1-4 N0-3 M0-1 G1-3 P1-4.

The T criteria vary with the organ affected:

Colonic cancers

• T1 - tumour occupying part of the bowel wall;

• T2 - tumour occupying half the circumference of the bowel;

• T3 - tumour occupies the whole circumference of the bowel, constricting the lumen and causing symptoms of intestinal obstruction;

• T4 - tumour circularly narrows the bowel lumen or completely obstructs the lumen of the bowel, leading to intestinal obstruction.

Breast tumours

T1 - tumour measures less than 2 cm.

T2 - tumour measures 2 to 5 cm with skin and nipple involvement.

T3 - tumour, measuring more than 5 to 10 cm, is adherent to the skin or fixed to chest wall as well as fungating tumours.

T4 - tumour measures more than 10 cm with skin and chest wall involvement or fungating tumour.

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