GENERAL PRINCIPLES OF TUMOUR TREATMENT

The malignant diseases call for immediate therapy, whereas benign masses require treatment if they

• cause dysfunction of the organ affected;

• result in cosmetic defects;

• are found premalignant;

• are suspected of transforming into malignant ones.

Abbreviation	Stands for	Characteristics to be considered	Stages
T	Tumour	Size of the primary tumour	T1-T4
N	Nodes	Involvement of the lymph nodes	NO - nodes are not palpable N1 - metastases to the regional nodes N2 - metastases to the second level nodes N3 - metastases to distant nodes
M	Metastases	Presence of organ metastases	MO - no metastases M1 - metastases present
G	Grade	Tumour differentiation	G1 - low level of malignancy (highly differentiated tumour) G2 - moderate level of malignancy (low differentiated tumour) G3 - high level of malignancy (undifferentiated tumour)
P	Penetration	Depth of the tumourous infiltration into the walls of a hollow organ (histological criteria)	P1 - cancer infiltrating into the mucous membrane P2 - cancer infiltrating into the submucosal layer P3 - cancer infiltrating ito as deep as the serous layer P4 - cancer infiltrating into the serous layer or extending beyond the organ wall

The therapeutic methods for malignant disease include surgery, radiation, chemo- and/or hormone therapy.

Surgery is the main method of treatment of malignant tumours and it is often combined with radiation or chemotherapy. This is referred to as combined therapy (for example, in breast cancer, cancer of the uterus, ovaries, etc.). The radiation therapy can be either employed preor postoperatively. This can also accompany chemotherapy, as is the case, for example, in myeloma or Hodgkin's lymphoma.

Surgery is not applied if the condition can be treated by radiation or drug therapy alone (e.g. cancer of the lip).

When the tumour has advanced so far that successful surgery in view of a metastatic spread is very unlikely, the case is considered inoperable.

Operating on patients with malignant tumours, the surgeon should follow the principle of ablasty, which implies the prevention of spread of tumour cells during the surgery by means of removing the mass within the intact tissues. To avoid damaging the tumour, it is necessary to ligate the veins as early and excise the tumour, fat tissues and lymph nodes en bloc.

The principle of antiblasty involves:

1) the measures aimed at destroying the cancer cells in the operation site (in the wound, in the lymph vessels and veins using electrocautery, laser or plasmatic scalpels;

2) cleansing the wound after excision of the tumour with 70% alcohol solution;

3) regional infusions of chemotherapeutic drugs.

As the tumour cells can spread beyond the organ affected to the lymphatic vessels, lymph nodes and surrounding tissues, it is recommended that a large portion or the entire organ involved be removed together with the surrounding tissues and fasciae. This is known as the principle of zones. An operation for breast cancer serves as an illustration, in which case the breast with the fatty tissues, fasciae and the sub-clavial, axillary lymph nodes as well as the pectoralis major muscles is removed en bloc.

The radical operation involves the removal of the entire organ (e.g. the breast, uterus) or its large portion (the stomach, bowel) together with the regional lymph nodes.

The combined surgery during which the organ affected is excised with part of or the entire organ into which the tumour has spread is also regarded radical.

Palliative operations are performed to remove part or the entire organ if the metastases are not liable to ablation. They are indicated when complications of the malignancy are found (e.g. tumour decay with bleeding, perforation of gastric or colonic cancer).

Symptomatic operations are aimed at eliminating complications caused by the enlarged tumour without removing the tumour itself (e.g. gastrostomy in oesophageal cancer; inter-intestinal anastomosis in bowel cancers complicated by intestinal obstruction, tracheostomy in cancer of the larynx).

Radiation therapy. Above half of the patients with malignant tumours are exposed to radiotherapy. It can either be used as an independent method for early stages of the disease (e.g. cancer of the lower lip, cervix of the uterus and the skin) or is included in the combined therapy. Radiation therapy is commonly coupled with surgery and undertaken either preor postoperatively. In addition, radiotherapy can be combined with chemoor hormone therapy.

The curative effect on the tumour and its metastases is achieved through external, intra-cavitary or interstitial radiation.

External radiation involves g-therapy with radioisotopes (⁶⁰Co, ¹³⁷Cs, etc.).

In intracavitary radiation therapy the source of radiation is introduced into a natural cavity (e.g. the oral cavity or uterine cavity, urinary bladder, maxillary antrum etc.). To perform interstitial radiation, isotopes are inserted directly into the tissues using needles or capsules after the removal of the tumour (e.g. postmastectomy). Staying in the tissues for long periods the isotopes act on the residual tumour cells and their metastases to the lymph nodes.

Chemotherapy. The most common malignant tumours (e.g. cancers of the lung, breast, stomach and intestines) are known to respond poorly to drug therapy as compared to surgical and radiation therapy. Hence, the use of chemotherapy in combination with other methods of treatment.

If combined with surgery, chemotherapy is employed to treat, for instance, ovarian cancer. Also, it is of great importance for the treatment of systemic oncological diseases (e.g. leukaemia, Hodgkin's lymphoma). At the early stage of malignancy, i.e. when the tumour can be removed surgically, chemotherapy alone should not be attempted.

The following groups of chemotherapeutic preparations are used:

1. Cytostatics (novembihin, cyclophosphan, TEPA [triethylenethiophospharamide], dopan, vinblastin, vincristin, etc.) hamper the growth of tumour cells, affecting cellular mitosis.

2. Antimetabolites alter the metabolism of cancer cells by

— suppressing the synthesis of purins (mercaptopurin);

— acting on the enzyme systems (fluoruracil, phthorafur) or on the transformation of folic acid (metotrexate).

3. Anti-cancer antibiotics are a group of compounds produced by fungi or microorganisms: actinomycin D, bruneomycin, mytomycin.

Hormone therapy. Hormones are a treatment of choice for hormone receptor-positive tumours.

These medications supplement the combined therapeutic methods of surgery, radiotherapy and chemotherapy. The preparations of the male sex hormone - androgen (testosterone propionate, methyl testosterone) are indicated in breast cancer, whereas those of female sex steroid - estradiol (synestrol and diethylstilboestrol) are known to be effective in cancer of the prostate.

Hormone therapy of tumours also includes surgeries on the endocrine glands e.g. surgical or radiation castration of women with breast cancer.

TESTS

Chapter XIV. TUMOURS

1. The absolute indications for removal of benign tumours are as follows:

1. Functional disorders of the affected organ.

2. Persistent injury to superficial benign tumours with clothes and footwear.

3. Progressive tumour growth.

4. Persistence of tumour.

5. Suspicion of malignant degeneration.

Choose the right combination of answers:

A. 1, 2, 3, 4. B. 1, 3, 4, 5. C. 1, 2, 3, 5. D. 2, 3, 4, 5. E. 1, 2, 3, 4, 5.

2. Malignant tumour is characterized by:

1. Expansive growth.

2. Lymphogenous spreading.

3. Inclination to recurrence.

4. Infiltrative growth.

5. Incapsulation.

Choose the right combination of answers:

A. 1, 2, 3. B. 3, 4, 5. C. 2, 3, 4. D. 2, 3, 5. E. 2, 3, 4, 5.

3. GI endoscopy helps:

1. Identify the localization of the tumour.

2. Recognise the colour of the tumour.

3. Stage the tumour.

4. Assess regional lymphadenopathy.

5. Identify the decay of the tumour.

Choose the right combination of answers:

A. 1, 2, 3. B. 1, 3, 4. C. 1, 4, 5. D. 2, 3, 4. E. 1, 2, 5.

4. During surgery, the gastric tumour with regional metastases was found to have penetrated all the layers of the stomach. The tumour was mobile. Stage the tumour:

A. Stage I.

B. Stage II.

C. Stage III.

D. Stage IV.

E. The malignant character of the tumour is doubtful.

Choose the correct answer.

5. The antiblastics includes:

1. Careful, non-traumatic removal of tumour.

2. Removal of visible metastases.

3. The use of electrotomes and laser scalpels.

4. Ligation of hollow organs above and below the tumour.

5. Cleansing of the wound with alcohol.

Choose the right combination of answers:

A. 1, 2. B. 1, 3. C. 3, 5. D. 1, 4, 5. E. 2, 4.

6. The ablastics includes the following:

1. The cleansing of surgical wound with alcohol.

2. Preoperative radiotherapy.

3. Frequent change of instruments and linen.

4. Preliminary ligation of blood vessels.

5. Surgery within intact tissues.

Choose the right combination of answers:

A. 1, 2. B. 2, 3. C. 1, 4. D. 3, 5. E. 4, 5.

7. The examples of palliative surgeries for malignant tumours involve the following:

1. Removal of metastasis together with the tumour.

2. Internal bypass anastomosis in obstruction of the affected organ's lumen.

3. Arrest of haemorrhage from the tumour.

4. Removal of the primary tumour with metastases left intact.

5. Major radical surgery.

Choose the right combination of answers:

A. 1, 2, 3. B. 2, 3, 4. C. 2, 3, 4, 5. D. 1, 5. E. 2, 3, 5.

8. The patient who has had the malignant tumour removed is considered cured:

A. When the initially small tumour was removed completely.

B. If metastases were not found during surgery.

C. If signs of recurrence have not been found for at least 5 years postoperatively.

D. If the surgery was performed with all oncological rules observed.

E. All of the above are correct.

Choose the correct answer.

9. Usually, superficial benign tumour:

1. Is round.

2. Is not attached to the neighbouring tissues.

3. Is attached to the neighbouring tissues.

4. Is tender on palpation.

5. Has regional lymphadenopathy.

Choose the right combination of answers:

A. 1, 2. B. 1, 3, 4. C. 1, 2, 3. D. 2, 4, 5. E. 1, 2, 5.

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