Neoplasia IV Past Paper 2024-2025 PDF

Session 12 Neoplasia IV Incidence, prognosis & Treatment Dr Israa A. Kadhim References Robbins Basic Pathology, 10th edition. 2018 Muir’s Textbook of Pathology. 15th edition. 2014  Objectives To understand: 1. Staging of malignant tumours. -Rectu...

Session 12 Neoplasia IV Incidence, prognosis & Treatment Dr Israa A. Kadhim References Robbins Basic Pathology, 10th edition. 2018 Muir’s Textbook of Pathology. 15th edition. 2014  Objectives To understand: 1. Staging of malignant tumours. -Rectum, Breast, Prostate, Bladder, Hodgkin’s disease 2. Grading of malignant tumours. -Squamous cell carcinoma, Breast carncer, Colon cancer 3. The biological basis for the use of different cancer treatments. -Radiotherapy, Chemotherapy, Hormone therapy, Newer agents eg. Herceptin Objectives 4. The use of tumour markers in diagnosis and monitoring of disease. -Carcinoembryonic antigen -Human chorionic gonadotrophin -Alpha fetoprotein 5. The value of screening -Cervix -Breast Cancer incidence and mortality by site and sex 5 PREDICTING TUMOUR BEHAVIOUR Staging (TNM) – Size of tumour – Node status – Distant metastasis Grade – Receptors/Molecular alterations STAGING Stage is the extent of the tumor based upon both objective pathologic and objective clinical criteria. The most common system used is TNM (T tumor size, N=lymph node status, and M metastases). The stage of the tumor gives good prognostic value. STAGING TNM T = tumour N = node M = metastasis breast, lung T1 = 90% 5 yr survival B Extending through muscularis propria 70% 5 yr survival C Lymph nodes involved 30% 5 yr survival STAGING Hodgkin’s Disease (Ann Arbor) I one group of nodes involved II two separate groups, same side of diaphragm III nodes involved both sides of diaphragm, plus spleen IV bone marrow, lung, other sites A- no symptoms B- fever with sweats, itching, weight loss Ann Arbor staging GRADE Grade is the differentiation of a tumour Differentiation is how similar the tumour cells look when compared with the cell type of origin. e.g, well-differentiated squamous cell carcinoma looks very similar to stratum corneum, and poorly differentiated squamous cell carcinoma may be difficult to determine without immunohistochemical stains directed against squamous cell-specific proteins  Grade I – well differentiated adenocarcinoma Grade II-moderately Grade I-squamous cell differentiated adenocarcinoma carcinoma 15 GRADING Breast Degree of differentiation depends on: 1. degree of tubule formation 2. extent of nuclear variation 3. number of mitoses Breast cancer GRADING Prostate Gleason Scale of 1 to 5 Degree of gland formation and the architectural pattern Grade 1- well formed glands Grade 5 – sheets of cells, poorly formed TREATMENT Surgery Radiotherapy Chemotherapy Hormone therapy TREATMENT Primary Depends on of nature of tumour Stage Adjuvant Recurrent/metastases RADIOTHERAPY Factors Type of radiation Cumulative dose Rate of delivery Target tissues  RADIOTHERAPY Cells and tissues of the body and their tumours vary in their capacity to sustain injury. Phase of cell cycle Repair mechanisms Oxygenation RADIOTHERAPY SENSITIVITY High – Lymphoma – Leukaemia – Seminoma Fairly high – Squamous carcinomas Moderate – GI, breast Low – sarcoma CHEMOTHERAPY Drugs used have effects at particular stages of the cell cycle. Effects depend on tumour cells being in cell cycle Also have an effect on rapidly dividing cells e.g. bone marrow CHEMOTHERAPY Cyclophosphamide- can act on cells in G1, S phase and mitosis. Vincristine - can block cells entering cell cycle and act on mitosis Methotrexate - acts on cells in S phase PREDICTING RESPONSE HORMONE THERAPY Detection of hormone (oestrogen) receptor Herceptin ® Detection of amplification/overexpression of HER-2 High estrogen receptors Low ER ER Negative ER 27 c-erbB-2/neu/HER-2 antibodies made and modified for use in humans if HER-2 present as detected by Hercep- Test, then can use Herceptin for treatment 28 TUMOR MARKERS Products liberated from tumour into blood stream. May aid diagnosis and can be used to gauge response to therapy and for follow up. 29  TUMOR MARKERS Alpha fetoprotein – – Hepatocellular carcinoma – Germ cell tumours Human chorionic gonadotrophin – Trophoblastic tumours 30 TUMOR MARKERS Acid phosphatase, Prostate specific antigen – Prostatic carcinoma Carcinoembryonic antigen – GI tract Hormone products – Endocrine tumours 31  SCREENING Aims to detect pre-malignant, non invasive and early invasive cancers to improve prognosis. Cervix Breast Large Intestine Prostate 32 SCREENING Cervical Relies on cytological examination of smears to detect “early” changes - dysplasia Factors include – - age range screened - population at risk - adequate smear - cytological examination 33 SCREENING Breast Aims to identify invasive cancers before they can be felt (10-15 mm in size ) and DCIS Relies on mammography Factors – › frequency of screening › age range 34  How can we improve prognosis Identify ‘‘at risk’’ group -Familial -Occupational Detect at an earlier stage -Breast -Cervix  Small Group Questions Case 1: A 18 year old man presented with swelling of his right testis. You are shown a photograph of the specimen which contains a tumour in picture 1. What sort of tumour could it be? 2. Which markers are of value in the diagnosis of testicular tumours and why? 3. The patient received further treatment after his surgery. How can the tumour markers be of help at this time and in the subsequent follow-up? Testicular Teratoma Case 2: A 40 year old man complains of a swelling in the left side of his neck. On questioning he has had intermittent fever and itching. At surgery he is found to have an enlarged lymph node. Histology shows the characteristic features of Hodgkin‟s disease. 1- What is the name of the cell seen in picture 2a labeled A? 2- What is the name of the cell seen in picture 2a labeled B and seen at higher magnification in picture 2b labeled C? 3- Scans of the patient show a mass at the side of the abdominal aorta. What could this be? Hodgkin‟s disease Case 3: A 55 year old women presents with a lump in her breast. On examination there is evidence of retraction of the nipple. A diagnosis is made after mammography and cytology. After discussion with the patient it is decided that mastectomy (removal of the breast) will be performed. You are shown the gross specimen in picture 1. What feature might have been seen clinically that would have helped in staging the extent of disease? 2. What other features relating to the nature of the tumour helps in assessing the stage of disease? 3. Oestrogen receptor analysis of the tumour is performed and it is decided to treat the patient with tamoxifen, an anti-oestrogen. What effects can this have on the tumour? 4. What other parts of the body may be affected by tamoxifen? Breast carcinoma Case 4: A 70 year old woman sees her G.P. because she has noticed bright red blood in her stools. She has no other symptoms. She is referred for investigation and at sigmoidoscopy is found to have a polypoid ulcerated lesion in her rectum. The diagnosis is carcinoma. You are shown a histological section of the rectal lesion. It contains ill-formed glands which are packed together. 1. What features will help you assess the differentiation of the lesion?  Colorectal carcinoma 3. Are there any tumour markers of value in moni toring cancers of the large intestine? Case 5 A 65 year old man attends his GP with haemorrhoids. The GP performs a Per Rectum (PR) examination and incidentally discovers a craggy enlarged prostate. The GP refers the man to a urology consultant who finds that the man's serum Prostate Specific Antigen (PSA) level is elevated. 1. The Urologist performs a prostate needle biopsy. The appearance of benign prostate is shown for comparison in picture 5a. The histological appearance of the patient's biopsy is shown in picture 5b. What is seen in picture 5b and what grading system is used?. 2. Back pain may be a common problem with this condition – why? Prostatic carcinoma Thank you