Cancer

Overview:

Although cancer is a very serious disease, but survival rates daily improve because of great medical achievement in treatment, screening and prevention

Cancer is a wide spectrum of diseases characterized by abnormal cells that multiply uncontrollably, as these cells destroy normal cells and spread to different areas of the body

Etiology:

• Cancer cells are normal cells in origin, but have undergone changes or mutations in their DNA
• The changes caused an imbalance in how they grow and divide and a disorder in their functions

Symptoms:

• General symptoms:
• fatigue
• weakness
• pallor
• loss weight
• fever and night sweating
• pain
• Symptoms depending on the affected organ: breast, colon, prostate …

Causes:

• The formation of mutations is:
• genetic
• non genetic
• risk factors for cancer:
• smoking
• alcohol
• radiation
• viruses
• intense sun exposure
• carcinogenic food or exposure to environmental carcinogens
• obesity
• some diseases such as ulcerative colitis
• age (although we’re starting notice cancer at relatively younger population)

Diagnosis:

Early detection of cancer is key of successful treatment

• diagnosis is based on a comprehensive clinical examination in collaboration with various other investigations to diagnose cancer, determine its type and stage, and investigate metastases to nearby lymph nodes or to distant organs. cancer is classified into four stages based on its invasion of tissues and its spread to lymph nodes and other organs
• Other surveys include:

laboratory test: to assess the general clinical condition and screening tumor markers that rise in specific cancers

• Radiological investigations: CT, MRI, bone scan and PET scan

Treatment:

• Cancer cases require organized teamwork to find best treatment options for each case, so the treatment is built up by a medical committee composed of: surgeon-Oncologist-Radiologist-pathologist
• Treatment patterns:
• curative treatment: aims to remove or kill cancer cells completely, and is often surgical
• adjuvant therapy: it supports the primary treatment where it aims to kill any cancer cells that may be left after initial treatment to reduce the chance of cancer recurrence, and is often radiation
• palliative treatment: aims to alleviate symptoms of disease and control its spread when full recovery is not possible
• Types of treatment:
• surgical treatment: aims to remove cancer completely or remove as much of it as possible
• chemotherapy: it is based on intravenous infusion of chemical medications killing cancer cells

this type of treatment is responsible for hair loss and dry skin in patients (do not worry: the hair will reappear after end of chemotherapy cycles)

• radiotherapy: it is based on application of high-energy beams of radiation from outside body to kill any cancer cells remaining

 this type of treatment may cause skin burns in some patients (do not worry: the skin can be treated with ointments and massage.

• biological immunotherapy: helps the patient’s autoimmune system from cancer cells attacks
• hormonal therapy: aims to remove hormones that feed on some cancers such as prostate and breast cancer
• targeted drug therapy: which only targets cancer cells
• psychological and social support: one of the most important pillars of treatment where it helps patient dealing with disease.

 this support includes taking care of patient and his emotions and listening well to his fears and hopes and help him in the duties in home and work.

Breast cancer

Overview:

• It is growing of some breast cells in an abnormal way that cannot be controlled, which leads to formation of a non-functional mass in the breast grows over time and then spread to near lymph nodes and may give local or distant metastasis later
• Breast cancer happens in both males and females , but is much more common in women
• Breast cancer is second most common cancer in women
• Survival rates in breast cancer patients have recently improved significantly due to :
• screening campaigns that led to early detection of breast cancer
• updated technologies in diagnostics
• ongoing Pharmaceutical Research
• Types of breast cancer:
• In situ tumor: ductal DCIS or lobular LCIS
• Invasive tumor: intraductal carcinoma IDC (which is the most common) and intralobular carcinoma ILC
• inflammatory cancer
• Paget’s disease
• phyllodes tumor is essentially benign but may develop into cancer
• angiosarcoma

Etiology:

cancer happened when some breast cells begin to grow out abnormally under influence of hormonal and lifestyle factors.

Cancer usually happens at milk-producing ducts (ductal carcinoma), but sometimes it develops at lobules (lobular carcinoma) or at other tissues such as angiosarcoma

Symptoms:

• A lump in breast that causes pressure or pain
• Change in breast size and shape
• Changes in the skin of breast:

Dimpling, puckering, bulging, redness, soreness, rash, or swelling

• Changes in nipple
• Nipple discharge
• armpit node
• general systemic symptoms of cancer (weakness, fatigue, pallor, fever and night sweating)

Causes:

 predisposing factors of breast cancer are:

• Gender: breast cancer is much more common in women
• Getting older: mammograms are recommended every year after age 45
• Family history: 5-10% of breast cancer is genetic
• BRCA1 and BRCA2 are responsible genetic mutations of breast and ovarian cancer, so these mutations should be investigated when there is a family history of breast cancer
• breast cancer in corresponding breast
• Obesity
• radiation
• Reproductive history: Starting menstrual periods before age 12 and starting menopause after age 55 expose women to hormones longer, raising their risk of getting breast cancer.
• Having the first pregnancy after age 30, not breastfeeding, and never having a full-term pregnancy can raise breast cancer risk
• Hormone replacement therapy
• Alcohol

Diagnosis:

• Breast self-examination and mammogram annually after age 45 (or younger when there is a family history) is cornerstone of early diagnosis and therefore treatment it quickly before develops
• clinical examination with detailed history
• A comprehensive laboratory test to assess blood counts, liver and kidney function
• Mammogram: reveals lumps and calcifications in breast tissue
• Breast ultrasound is a primary diagnostic procedure in young ages, revealing breast lumps and cysts
• MRI
• DEXA scan and PET scan to investigate metastases
• Breast cancer is finally diagnosed by breast biopsy (biopsy can be done by fine needle aspiration FNA, but core biopsy better)

Treatment:

As in most tumors, breast cancer is classified into four stages depending on type, size, involved lymph nodes and its metastasis

In breast cancer, additional factors affecting treatment plan must also be considered:

• is the tumor positive or negative Estrogen receptor ER
• is the tumor positive or negative Progesterone receptor PR
• is the tumor positive or negative human epidermal growth factor receptor 2 (HER2)

treatment depends on comprehensive doctors discussion to approach best treatment plan for each case ( oncologist, surgeon , radiologist , pathologist, geneticist and plastic surgeon )

• Breast cancer surgery includes:
• conservative surgery: lumpectomy with safe margins of normal breast tissue
• sentinel lymph node biopsy (sentinel node is first lymph node to which lymph comes from site of injury)
• total mastectomy:

nipple can be preserved in some cases

skin can be preserved in many cases

• axillary lymph nodes clearance: when tumor arrived axilla lymph nodes, we have to dissect all lymph nodes groups in the armpit.

arm lymphedema is common after this procedure, so you should pay close attention not to injure hand, and wear appropriate braces with regular lymph massages.

• Bilateral mastectomy: we perform this procedure when have a breast cancer with a large genetic cancerous factor.
• breast reconstruction: usually done by artificial implants or by free abdominal flap
• Chemotherapy: there are many chemotherapy protocols.

Pre surgery to decrease tumor size in large tumors

post-surgery to kill any cancer cells remaining as adjuvant treatment

• Radiotherapy:
• Post conservative lumpectomy: radiation of lump site
• Post mastectomy in large or metastatic cancer: radiation of chest wall

• Hormone therapy: Tamoxifen

treatment of hormone-sensitive cancers (ER and PR)

Can be started before or after surgery

• Aromatase inhibitors: Femara

To stop Estrogen producing in body (Oophorectomy may be done in some cases)

• Herceptin: in HER2 positive cases
• stem cell therapy: in triple-negative cases (ER – , PR – , HER2 -)

THYROID CANCER

Overview:

• It is abnormal cells that multiply in an uncontrollable way in thyroid tissue

Etiology:

• Cancer cells are normal cells in origin, but have undergone changes or mutations in their DNA
• The changes caused an imbalance in how they grow and divide and a disorder in their functions

Symptoms:

small tumor does not give clear symptoms

 symptoms begin to appear as the tumor increases in size and it is included:

• neck pain
• neck mass
• neck swelling
• Cervical lymphadenopathy
• Difficulty swallowing
• Changes in voice
• general systemic symptoms of cancer (weakness, fatigue, pallor, weight loss, fever and night sweating)

Causes:

causes of thyroid cancer are unknown, but there are several risk factors:

• Gender: where it is most common in females
• radiation
• Genetic disorders

Types:

• Papillary carcinoma: arises from follicular cells that produce hormones, it is more common in the third and fourth decades
• Medullary carcinoma: arises from cells that produce Calcitonin hormone
• Follicular carcinoma: arises from follicular cells also, it happens among people over fifty
• Hertel cell carcinoma: a rare and dangerous type
• Anaplastic carcinoma: arises from follicular cells also, it happens among people over sixty

Diagnosis:

• Clinical examination with detailed history (radiation exposure, family history)
• Laboratory tests to assess thyroid function
• Neck ultrasound
• Radioactive Iodine scan
• FNA: Ultrasound guided biopsy to confirm the diagnosis

Treatment:

Surgical treatment:

• Total or subtotal thyroidectomy
• total thyroidectomy with neck lymph nodes dissection.

gastric cancer

Overview:

• It is abnormal cells grow out in uncontrollable way at stomach wall cells, which leads bulging within lumen of stomach causing obstructive symptoms, and may extend to outside of stomach wall giving pressure symptoms over another organs.
• Gastric cancer occurs in any part of stomach (40% in distal third, 40%in middle third, 10% in proximal third, 10% involving more than one section)

Etiology:

• Cancer cells are normal cells in origin, but have undergone changes or mutations in their DNA
• The changes caused an imbalance in how they grow and divide and a disorder in their functions

Symptoms:

• Abdominal pain
• Weight loss
• Nausea and vomiting
• Heartburn
• Bloating
• Feeling full just by eating a small amount of food
• Difficulty swallowing
• general systemic symptoms of cancer (weakness, fatigue, pallor, fever and night sweating )

Causes:

risk factors for stomach cancer are:

• Family history
• Chronic gastritis
• gastric polyps
• Smoking
• Obesity
• Gastroesophageal reflux
• Helicobacter pylori (H. pylori) infection
• Unbalanced diet: salted and smoked foods , less vegetables and fruits.

Diagnosis:

• Careful clinical examination
• Laboratory tests: to assess anemia, liver and pancreas function, and screening tumor markers
• Upper gastrointestinal endoscopy with biopsy
• Barium swallow evaluates gastric cavity
• Endoscopic ultrasound evaluates invasion of stomach wall
• CT abdominal, pelvic and chest, MRI evaluates tumor stage
• diagnostic laparoscopy may be required with biopsies in some cases

Treatment:

• A very early tumor in the gastric mucosa can be treated with endoscopic upper gastrointestinal resection with close monitoring
• Other options include:
• Partial gastrectomy with adjacent lymph nodes (usually cancer is in distal part of the stomach)
• total gastrectomy with adjacent lymph nodes and esophageal anastomosis procedure.
• Chemotherapy:
• Pre surgery: to decrease tumor size
• Post-surgery: as a supportive adjuvant therapy to kill any remaining cancer cells
• Radiotherapy:
• Pre surgery: to decrease tumor size
• Post-surgery: as a supportive adjuvant therapy to kill any remaining cancer cells
• Radiotherapy and chemotherapy are often both involved in gastric cancer.

Small bowel cancer

 Overview:

• It is an uncommon disease characterized by abnormal cells that multiply uncontrollably, as these cells destroy normal cells in the small intestine and spread to different areas of the body
• Tumor types:
• adenocarcinoma
• neuroendocrine tumors
• lymphoma
• gastrointestinal stromal tumor (GIST)
• sarcoma

Etiology:

• Cancer cells are normal cells in origin, but have undergone changes or mutations in their DNA
• The changes caused an imbalance in how they grow and divide and a disorder in their functions

Symptoms:

• Abdominal pain
• Nausea and vomiting
• Jaundice
• Dark blood in the stool
• Watery diarrhea
• Redness of the skin
• general systemic symptoms of cancer (weakness, fatigue, pallor, fever and night sweating)

Causes:

risk factors include:

• immune system disorder
• Inflammatory bowel disease
• genetic diseases such as:
• Lynch syndrome
• Peutz-jeghers syndrome
• familial adenomatous polyposis

Diagnosis:

• clinical examination
• Laboratory test to assess liver and kidney function
• Upper gastrointestinal endoscopy
• Imaging of the small intestine using the capsule
• CT and MRI to determine stage of tumor

Treatment:

• The treatment for small bowel cancer is usually surgical removal, where involved bowel is removed by laparoscopic surgery and reconnect both edges of healthy intestine
• Chemotherapy can be used as an adjuvant treatment after surgery to kill any remaining cancer cells.

Colorectal cancer

Overview:

• It is abnormal cells multiply in an uncontrollable way at colon wall cells, which bulging inside lumen of colon causing obstructive symptoms and may extend to outside of colon wall giving pressure symptoms over another organs.

cancer cells may give distant metastasis (mainly liver metastasis)

• Colon cancer does not cause any symptoms in early stages (due to large size of colon lumen), it requires a long time until becomes big enough that leads to obstructive or compressive symptoms

 so, it is necessary to screen early for colon and rectal cancer.

Etiology:

• Cancer cells are normal cells in origin, but have undergone changes or mutations in their DNA
• The changes caused an imbalance in how they grow and divide and a disorder in their functions

Symptoms:

• Abdominal pain
• Abdominal distension
• Change in bowel frequency: constipation , diarrhea
• Rectal bleeding
• Bloody stools
• Thin stools
• Feeling of a lump in the rectum
• general systemic symptoms of cancer (weight loss, fatigue, weakness, pallor, fever and night sweating).

Causes:

risk factors include:

• Unbalanced diet: fatty, red meat, processed meat, poor in fiber.
• Poor physical activity
• Age: over fifty
• African origin
• Smoking
• Inflammatory bowel disease: (Crohn’s, ulcerative colitis)
• Obesity
• Diabetes mellitus
• Radiation therapy
• Family history of colorectal cancer
• Family history of familial polyposis
• Excessive alcohol intake
• genetic syndromes:
• Lynch syndrome: hereditary nonpolyposis colorectal cancer
• Familial adenomatous polyposis (FAP): where there are thousands of polyps and are predisposed to cancer

Diagnosis:

• clinical examination
• Laboratory test to assess anemia, liver function and screening for tumor marker CEA
• colonoscopy with biopsy for cancer diagnosis
• CT and MRI of abdomen, pelvis and chest to determine tumor stage.

Treatment:

• Do not forget regular colonoscopy after fifty to detect any colon tumor in its early stages
• colonoscopy should be performed less than fifty in case of a risky family history
• A very early tumor in colon mucosa can be treated with endoscopic removal with close monitoring
• malignancy at tip of polyp can be treated with a polypectomy during colonoscopy

• Other options include:
• Laparoscopic partial colectomy: Colon tumor is removed with mesenteric lymph nodes, and reconnection of colon edges
• Laparoscopic lower anterior resection: in upper rectum tumor, rectum is resected with mesenteric lymph nodes and reconnect colon to anus.
• Abdominal perineal amputation: in low rectal tumors, rectum and anus are excised with its mesenteric lymph nodes and permanent colostomy is performed
• emergency surgery in colon tumors: it is to treat bowel obstruction, perforation or bleeding

 usually, colon tumor is removed and temporary colostomy is performed

colostomy closure can be done after a few weeks

• Chemotherapy:
• Pre surgery: to decrease tumor size
• Post-surgery: as a supportive adjuvant therapy to kill any remaining cancer cells
• palliative treatment when unable to perform surgery
• Radiotherapy:
• Pre surgery: to decrease tumor size
• Post-surgery: as a supportive adjuvant therapy to kill any remaining cancer cells
• palliative treatment when unable to perform surgery
• Radiotherapy and chemotherapy are often both involved in colorectal cancer.

Liver cancer

Overview:

• it is abnormal cells that multiply in an uncontrollable way, as these cells destroy normal cells.
• Liver cell cancer is primary cancer in the liver (arises of hepatic cells), while secondary cancer is metastases transfer to liver cells from other organs and settle in liver as in tumors of the colon and breast
• Frequency of liver metastases is more common than primary liver cancer
• Types of primary liver cancer:
• Hepatocellular carcinoma (HCC): This is the most common form of liver cancer in adults.
• Intrahepatic cholangiocarcinoma (bile duct cancer)
• Angiosarcoma and hemangiosarcoma.
•  

Etiology:

• Cancer cells are normal cells in origin, but have undergone changes or mutations in their DNA

The changes caused an imbalance in how they grow and divide and a disorder in their functions

Symptoms:

• Liver cancer does not give symptoms in its early stages
• In following stages begins the appearance of symptoms that include:
• Abdominal pain usually in the right upper part of the abdomen
• Nausea and vomiting
• Jaundice
• Chalky white stool
• Abdominal distension
• general systemic symptoms of cancer (weight loss , fatigue , weakness, pallor, fever and night sweating )

Causes:

Liver diseases are the most important risk factor for primary liver cancer incidence, it includes:

• Chronic hepatitis B
• Hepatitis C
• Liver cirrhosis
• Hereditary liver diseases such as Wilson’s disease
• Diabetes mellitus
• Excessive drinking alcohol

Diagnosis:

• clinical examination with detailed diseases history
• Laboratory tests to assess liver function
• Abdominal ultrasound to detect any liver mass, diagnosis is confirmed by ultrasound guided biopsy
• CT and MRI to determine tumor stage

Treatment:

• Partial hepatectomy with safe margins if tumor is small and liver function is good
• Advanced liver transplantation with reduced liver function

• Chemotherapy:

in advanced stages as palliative treatment to control symptoms

• Radiotherapy:

In advanced stages as palliative therapy to control symptoms

• There are other techniques include: radiofrequency ablation, embolization, targeted therapy, immunotherapy, intra hepatic artery chemotherapy infusion.

Pancreatic cancer

Overview:

• it is abnormal cells that multiply in an uncontrollable way, as these cells destroy normal cells, which leads to disorder in pancreatic functions
• may occur disorder in secretion of digestive enzymes and may occur disorder in secretion of pancreatic hormones.
• Unfortunately, pancreatic cancer does not give symptoms in its early stages, symptoms begin to appear when the tumor becomes large and spreads to abdominal organs
• Types:
• pancreatic adenocarcinoma:
• most common
• neuroendocrine cancer

Etiology:

• Cancer cells are normal cells in origin, but have undergone changes or mutations in their DNA
• The changes caused an imbalance in how they grow and divide and a disorder in their functions
• When cancer arises from pancreatic cells secreting digestive enzymes, it forms adenocarcinoma
• When cancer arises from hormone-secreting pancreatic cells, it forms endocrine cancer

Symptoms:

• Severe abdominal pain radiating to the back
• Nausea and vomiting
• Jaundice
• Light colored stools
• Dark urine
• Skin itching
• Blood clotting disorder
• general systemic symptoms of cancer (weakness, fatigue, pallor, fever and night sweating )
• Pancreatic cancer may lead to bowel obstruction

Causes:

risk factors of pancreatic cancer include:

• Chronic pancreatitis
• Diabetes mellitus
• Obesity
• Smoking
• Excessive drinking alcohol
• Family history
• Age: pancreatic cancer is most common at older ages (over 65)
• Genetic mutations:
• Lynch syndrome
• BRCA2 mutation which responsible for breast cancer
• Familial atypical multiple mole melanoma (FAMMM) syndrome

Diagnosis:

• clinical examination with detailed diseases history
• Laboratory tests to assess pancreatic function, bilirubin elevation, and screening for tumor markers1 19-9
• Upper gastrointestinal endoscopy
• Endoscopic ultrasound to assess the degree of tumor invasion
• CT, MRI and PET scan to determine stage of the tumor
• Biopsies and samples are taken through the skin under ultrasound guidance or during diagnostic laparoscopy

Treatment:

Pancreatic cancer treatment varies according to cancer stage and location:

• In pancreatic head cancer, Whipple surgery is performed: excision of pancreatic head, duodenum, gallbladder, part of bile duct and adjacent lymph nodes
• In cancer of the body and tail of pancreas, distal pancreatectomy is done (with or without splenectomy)
• Total pancreatectomy in overall injuries
• If surgery is not possible (extensive tumor spread, vascular invasion), some palliative treatments can be performed (nerve blockade to relieve pain, stent insertion in bile duct to treat jaundice)
• Chemotherapy:
• Pre surgery: to decrease tumor size
• post-surgery: as a supportive adjuvant therapy to kill any remaining cancer cells
• Radiotherapy:
• Pre surgery: to decrease tumor size
• post-surgery: as a supportive adjuvant therapy to kill any remaining cancer cells
• Radiotherapy and chemotherapy are often both involved in pancreatic cancer.