TUMORS.TUMORS.CLINICAL SYMPTOMS, CLINICAL SYMPTOMS, DIAGNOSTICS, AND DIAGNOSTICS, AND

TREATMENTTREATMENT

Tumors are nonconformist cellular populations Tumors are nonconformist cellular populations no longer dedicated to the purposes of the no longer dedicated to the purposes of the organism as a whole. In contrast with normal organism as a whole. In contrast with normal cellular populations, ontogenetically grouped cellular populations, ontogenetically grouped to form organs that remain fixedly related to to form organs that remain fixedly related to one related to one another and are one related to one another and are integratively functional, neoplastic cells do integratively functional, neoplastic cells do not form organs, are not fixedly related to not form organs, are not fixedly related to other cells, and function physiologically as other cells, and function physiologically as relatively independent uncontrolled relatively independent uncontrolled elements. They are separated elements. They are separated behavioristically into the benign and the behavioristically into the benign and the malignant types.malignant types.

A benign tumour is one that does not spread A benign tumour is one that does not spread or "metastasize" to other parts of the body; or "metastasize" to other parts of the body; a "malignant tumour" is one that does. A a "malignant tumour" is one that does. A benign tumour is caused by cell overgrowth, benign tumour is caused by cell overgrowth, and thus is different from a cyst or an and thus is different from a cyst or an abscess.abscess.

Although benign is better news than malignant Although benign is better news than malignant for biopsy, it does not always mean for biopsy, it does not always mean "harmless", though many are almost "harmless", though many are almost harmless. A benign tumour may still grow, harmless. A benign tumour may still grow, and this growth may cause damage to any and this growth may cause damage to any organs, tissues, or nerves in its vicinity. organs, tissues, or nerves in its vicinity. Hence, a benign tumour can still cause Hence, a benign tumour can still cause serious illness if it presses on important serious illness if it presses on important areas.areas.

Etiology.Etiology. The primary etiologic factors involved in the inception of The primary etiologic factors involved in the inception of

tumors in man are still unknown. Presumptively, tumors in man are still unknown. Presumptively, something happens to the constitution of nuclear something happens to the constitution of nuclear material of a cell, rendering it no longer obeisant to material of a cell, rendering it no longer obeisant to regulation of its growth. Although the primary cellular regulation of its growth. Although the primary cellular genesis of neoplasia is unknown, it can be induced by a genesis of neoplasia is unknown, it can be induced by a variety of agents, these may be classified as mechanical, variety of agents, these may be classified as mechanical, infectious, chemical and physical (chiefly, ionizing infectious, chemical and physical (chiefly, ionizing radiation).radiation).

The anthropogenous pollution of external medium in The anthropogenous pollution of external medium in Ukraine is connected to a motor transports (cars in the Ukraine is connected to a motor transports (cars in the country haven’t catalysts), metallurgical, power, country haven’t catalysts), metallurgical, power, chemical industry and nuclear power. Ukraine was on chemical industry and nuclear power. Ukraine was on 110 place among 122 countries of the world in 2001 110 place among 122 countries of the world in 2001 behind an index of ecological stability. In northern areas behind an index of ecological stability. In northern areas of the country is close six millions population lives in of the country is close six millions population lives in conditions of the raised level of radiation - as result of conditions of the raised level of radiation - as result of consequences of failure on Chornobul atomic power consequences of failure on Chornobul atomic power station (1986). By the highest oncology case rate station (1986). By the highest oncology case rate Southern and East regions of Ukraine differ, in which Southern and East regions of Ukraine differ, in which there are basic metallurgical, coal and power complexes.there are basic metallurgical, coal and power complexes.

GENERAL EVALUATION OF THE GENERAL EVALUATION OF THE ONCOLOGICAL PATIENTONCOLOGICAL PATIENT

Early detection of a malignant tumor is a Early detection of a malignant tumor is a prefer for its successful treatment. History prefer for its successful treatment. History of the patient usually offers clues that may of the patient usually offers clues that may be suggestive of a malignant process:be suggestive of a malignant process:

the living conditions and habits (e.g. such the living conditions and habits (e.g. such carcinogenic factors as smoking) carcinogenic factors as smoking)

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

Cancer is a group of more than 100 different Cancer is a group of more than 100 different diseases. Cancer occurs when cells become diseases. Cancer occurs when cells become abnormal and keep dividing and forming more abnormal and keep dividing and forming more cells without order or control. All organs of the cells without order or control. All organs of the body are made up of cells. Normally, cells divide body are made up of cells. Normally, cells divide to produce more cells only when the body needs to produce more cells only when the body needs them. If cells divide when new ones are not them. If cells divide when new ones are not needed, they form a mass of excess tissue called needed, they form a mass of excess tissue called a tumour. Tumours can be benign (not cancer) or a tumour. Tumours can be benign (not cancer) or malignant (cancer). The cells in malignant malignant (cancer). The cells in malignant tumours can invade and damage nearby tissues tumours can invade and damage nearby tissues and organs. Cancer cells can also break away and organs. Cancer cells can also break away from a malignant tumour and travel through the from a malignant tumour and travel through the bloodstream or the lymphatic system to form bloodstream or the lymphatic system to form new tumours in other parts of the body. The new tumours in other parts of the body. The spread of cancer is called metastasis.spread of cancer is called metastasis.

The list of conditions in the cancer group The list of conditions in the cancer group includes: includes:

Cancer type by severity: Cancer type by severity: Benign tumour. Benign tumour. Malignant tumour. Malignant tumour. Metastatic cancer - spreading of cancer beyond Metastatic cancer - spreading of cancer beyond

its initial site to lymph nodes and/or other body its initial site to lymph nodes and/or other body areas.areas.

Cancer type by type of tumour: sarcoma, Cancer type by type of tumour: sarcoma, leukaemia, lymphoma, myeloma, melanoma.leukaemia, lymphoma, myeloma, melanoma.

Cancer type by common locations: lung Cancer type by common locations: lung cancer, colorectal cancer, brain cancer, cancer, colorectal cancer, brain cancer, throat cancer, oral cancer, liver cancer, bone throat cancer, oral cancer, liver cancer, bone cancer, pancreatic cancer.cancer, pancreatic cancer.

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

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

rejection or unwillingness to eat certain foods;rejection or unwillingness to eat certain foods;drowsiness;drowsiness;apathy to what used to be of interest;apathy to what used to be of interest;““a foreign body” sensation;a foreign body” sensation;abdominal discomfort rather than pain (i.e. a feeling abdominal discomfort rather than pain (i.e. a feeling

of heaviness);of heaviness);lack of satisfaction after nicturition or defecation, lack of satisfaction after nicturition or defecation,

etc.etc.

The earlier diagnosis of the malignant tumor The earlier diagnosis of the malignant tumor has better prognosis. The oncological has better prognosis. The oncological alertness implies:alertness implies:

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

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

3. The timely referral of patients with 3. The timely referral of patients with supposedly malignant conditions to supposedly malignant conditions to specialized medical centers.specialized medical centers.

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

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

The examples might be as follows:The examples might be as follows:

- leukoplakia, or “white spots”, i.e. - leukoplakia, or “white spots”, i.e. vegetations of the epithelium covering vegetations of the epithelium covering mucous membranes, the changes being mucous membranes, the changes being undetectable on palpation;undetectable on palpation;

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

- different forms of senile dyskeratosis.- different forms of senile dyskeratosis.

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

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

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

The consistency of a tumor appreciably The consistency of a tumor appreciably depends on its type:depends on its type:

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

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

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

- wooden-like without demarcation - wooden-like without demarcation (provides substantial evidence of a (provides substantial evidence of a malignant over-growth, i.e. carcinoma).malignant over-growth, i.e. carcinoma).

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

The tumor can move spontaneously:The tumor can move spontaneously:

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

- on changing the body position;- on changing the body position;

- on swallowing (goitre);- on swallowing (goitre);

- on muscular contraction (muscle tumor).- on muscular contraction (muscle tumor).

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

• • tumors of the umbilicus (sister Josef’s tumors of the umbilicus (sister Josef’s metastases);metastases);

• • tumors of the ovaries (Krukenberg's tumors of the ovaries (Krukenberg's metastases);metastases);

• • Virchov’s metastases (the metastases to the Virchov’s metastases (the metastases to the supraclavicular lymph nodes) suggesting supraclavicular lymph nodes) suggesting gastric carcinoma with distant metastases;gastric carcinoma with distant metastases;

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

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

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

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

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

1.1. Endoscopy;Endoscopy;2.2. Cytology (swabs, aspirates);Cytology (swabs, aspirates);3.3. Histology (biopsy);Histology (biopsy);4.4. X-ray investigations (roentgenoscopy, X-ray investigations (roentgenoscopy,

roentgenography, tomography, roentgenography, tomography, angiography, lymphography);angiography, lymphography);

5.5. Radioisotope methods (scanning, Radioisotope methods (scanning, scintigraphy);scintigraphy);

6.6. Ultrasonography;Ultrasonography;7.7. Computerized axial tomography;Computerized axial tomography;8.8. Laboratory tests (blood cell morphology). Laboratory tests (blood cell morphology).

According to the clinical classification, the four types According to the clinical classification, the four types of pathological overgrowth are identified (in of pathological overgrowth are identified (in general): general):

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

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

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

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

The TNMGP classification may The TNMGP classification may read as follows: T1-4 N0-3 M0-1 read as follows: T1-4 N0-3 M0-1 G1-4 P1-4.G1-4 P1-4. For vast majority tumors the world classification For vast majority tumors the world classification

behind system TNM are used:behind system TNM are used: T - primary tumor.T - primary tumor. T0 - primary tumor not indicated.T0 - primary tumor not indicated. Tis - is preinvasive carcinoma (cancer in situ).Tis - is preinvasive carcinoma (cancer in situ). T1 - is tumor to 2 cm in diameter, not spreading T1 - is tumor to 2 cm in diameter, not spreading

on surrounding tissues.on surrounding tissues. T2 - is tumor to 5 cm in diameter, is spreading T2 - is tumor to 5 cm in diameter, is spreading

on surrounding tissues insignificantly.on surrounding tissues insignificantly. T3 - is tumor more then 5 cm in diameter and T3 - is tumor more then 5 cm in diameter and

spreading on surrounding tissues.spreading on surrounding tissues. T4 - is tumor, which spreading of surrounding T4 - is tumor, which spreading of surrounding

structures or skin, with restricted mobility.structures or skin, with restricted mobility.

N - regional lymph nodes.N - regional lymph nodes.N0 - the lymph nodes’ stab are absent.N0 - the lymph nodes’ stab are absent.N1 - the metastases in solitary mobility lymph N1 - the metastases in solitary mobility lymph

nodes are present.nodes are present.N2 - the metastases in regional lymph nodes, N2 - the metastases in regional lymph nodes,

which fixed between it-selves (packet) and which fixed between it-selves (packet) and neighboring structures are present.neighboring structures are present.

N3 - the metastases in more distant lymph nodes N3 - the metastases in more distant lymph nodes are present.are present.

Nx - estimation of regional lymph nodes is not Nx - estimation of regional lymph nodes is not enough.enough.

M - are distant metastases.M - are distant metastases.M1 - the distant metastases are present.M1 - the distant metastases are present.M0 - the distant metastases are absent.M0 - the distant metastases are absent.Mx - estimation of distant metastases is not Mx - estimation of distant metastases is not

enough.enough.

G - is level of differentiation.G - is level of differentiation.

G1 - is high level of differentiation.G1 - is high level of differentiation.

G2 - is middle level of differentiation.G2 - is middle level of differentiation.

G3 - is low level of differentiation.G3 - is low level of differentiation.

G4 - is notdiffential tumor.G4 - is notdiffential tumor.

P - penetration.P - penetration.

P1 - is tumor in mucous membrane.P1 - is tumor in mucous membrane.

P2 - the tumor to grow in sub mucous P2 - the tumor to grow in sub mucous membrane.membrane.

P3 - the tumor to grow in layer of muscles.P3 - the tumor to grow in layer of muscles.

P4 - the tumor to grow through serous P4 - the tumor to grow through serous membrane and to leave of organ.membrane and to leave of organ.

GENERAL PRINCIPLES OF TUMOUR GENERAL PRINCIPLES OF TUMOUR TREATMENTTREATMENT

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

• • cause dysfunction of the organ affected;cause dysfunction of the organ affected;

• • result in cosmetic defects;result in cosmetic defects;

• • are found premalignant;are found premalignant;

• • are suspected of transforming into are suspected of transforming into malignant ones.malignant ones.

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

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

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

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

The principle of antiblastyThe principle of antiblasty involves: involves: 1) the measures aimed at destroying the cancer 1) the measures aimed at destroying the cancer

cells in the operation site (in the wound, in the cells in the operation site (in the wound, in the lymph vessels and veins using electrocautery, lymph vessels and veins using electrocautery, laser or plasmatic scalpels; laser or plasmatic scalpels;

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

3) infusions of chemotherapeutic drugs. 3) infusions of chemotherapeutic drugs. As the tumor cells can spread beyond the organ As the tumor cells can spread beyond the organ

affected to the lymphatic vessels, lymph nodes affected to the lymphatic vessels, lymph nodes and surrounding tissues, it is recommended that and surrounding tissues, it is recommended that a large portion or the entire organ involved be a large portion or the entire organ involved be removed together with the surrounding tissues removed together with the surrounding tissues and fasciae. This is known as and fasciae. This is known as the principle of the principle of vines.vines. An operation for breast cancer serves as An operation for breast cancer serves as an illustration, in which case the breast with the an illustration, in which case the breast with the fatty tissues, fasciae and the subclaviсuгal, fatty tissues, fasciae and the subclaviсuгal, axillary lymph nodes as well as the pectoralis axillary lymph nodes as well as the pectoralis minor muscles is removed en bloc.minor muscles is removed en bloc.

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

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

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

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

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

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

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

Chemotherapy.Chemotherapy. Chemotherapy – this is using Chemotherapy – this is using of drugs by synthetic or natural origin with of drugs by synthetic or natural origin with purpose of firm to stop of malignant cells’ purpose of firm to stop of malignant cells’ development. Chemotherapy uses chemical development. Chemotherapy uses chemical agents to destroy cancer cells throughout agents to destroy cancer cells throughout the body Hence, the use of chemotherapy in the body Hence, the use of chemotherapy in combination with other methods of combination with other methods of treatment. treatment.

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

The following main groups of chemotherapeutic The following main groups of chemotherapeutic preparations are used; preparations are used;

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

2.2. Antimetabolites after the metabolism of cancer Antimetabolites after the metabolism of cancer cells by:cells by: suppressing the synthesis of purins suppressing the synthesis of purins

(mercaptopurine);(mercaptopurine); acting on the enzyme systems (fluoruracil) or on the acting on the enzyme systems (fluoruracil) or on the

transformation of folic acid (methotrexate); transformation of folic acid (methotrexate);

3.3. Anti-cancer antibiotics are a group of Anti-cancer antibiotics are a group of commands produced by fungi or commands produced by fungi or microorganisms: actynomycine D, microorganisms: actynomycine D, bruneomycin, mytomycin.bruneomycin, mytomycin.

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

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