Cancer screening

An examination for cancer begins with the collection of complaints and anamnesis. Careful collection of complaints and anamnesis in an individual interview depends on the preparedness of the doctor and his ability to communicate with the patient.

The patient is interviewed according to a certain scheme. Find out changes in the general condition of the patient (weight loss, fever, weakness, edema, headache, etc.), the state of the respiratory, cardiovascular, nervous systems, gastrointestinal tract. Particular attention is paid to "alarm signals", which include hemoptysis, jaundice, enlargement of the lymph nodes, micro- and macrohematuria, admixture of blood in the feces, etc. When "alarms" appear, an in-depth examination should be conducted to exclude the diagnosis of cancer.

It should be remembered that in the early stages of malignant tumor development, the patient may not present certain complaints, except for persons having pre-tumorous diseases. In such cases, suspicion of malignancy should arise when the nature of the sensations that the patient noted before, perhaps for several years, has already changed.

It is important to collect anamnesis not just to find out the symptoms of a disease of any one organ. It is necessary to focus on the previous medical and operational benefits, which can help in diagnosing the present disease as a relapse or metastasis of a distant tumor.

Such an examination for cancer, as an examination and palpation of the patient along with the collection of an anamnesis are an important part of the diagnosis of a malignant tumor. The main rule for physicians should be a complete external oncological examination of the patient, which includes examination and palpation of the skin, visible mucous membranes, all peripheral lymph nodes (occipital, cervical, submaxillary, supra- and subclavian, axillary, cubital, inguinal and popliteal), thyroid, dairy glands, as well as cervix, men - testicles, rectum. Such tactics are explained by the following points. First, local lesions can be secondary signs (distant metastases) of a tumor localized in a completely different place. For example, the supraclavicular lymph nodes to the left may be affected in cancer of the gastrointestinal tract, left lung cancer, lymphogranulomatosis, lymphomas, etc. Secondly, synchronous occurrence of multiple tumors of one (basal cell, skin melanoma) or different localizations is possible. Thirdly, with a full examination of the patient, it is necessary to identify a pronounced concomitant pathology, which may affect the amount of additional examination and the nature of the treatment. After completing the physical examination, the doctor must decide which additional diagnostic methods are shown in this case.

[1], [2], [3], [4], [5]

Instrumental examination for cancer

Instrumental examination for cancer is due to the peculiarities of the spread of the tumor process in the body:

• determination of the spread of the tumor process within the affected organ: specify the tumor size, its location relative to the anatomical structures of the organ, the anatomical growth form, the degree of invasion of the wall of the hollow organ, the germination of adjacent organs and tissues;
• investigation of regional lymphatic drainage zones to detect possible metastatic lymph node involvement;
• the detection of possible distant organ metastases, taking into account the priority of their occurrence in tumors of various localizations.

To this end, modern methods of visualization of internal organs from the arsenal of radiation and endoscopic diagnostics are used.

Radiodiagnosis - this examination for cancer includes several main types.

1. X-ray diagnostics:
   • basic X-ray diagnostics;
   • computed tomography (CT);
   • magnetic resonance imaging (MRI).
2. Radionuclide diagnostics.
3. Ultrasound diagnostics.

Basic X-ray diagnostics

Screening for cancer includes fluoroscopy (X-ray telescoping on apparatus equipped with X-ray image intensifiers), fluorography, radiography and linear tomography, etc.

X-ray radiographic examination is mainly used in contrast studies of the gastrointestinal tract and respiratory system. Moreover, in addition to visual data, the radiologist can obtain roentgenograms, called sighting or survey, depending on the breadth of coverage of the studied object. Also, under X-ray television control, puncture biopsy and endoscopic X-ray procedures can be performed.

X-ray examination for cancer of the upper digestive tract is the main method of diagnosing tumoral formations of the pharynx, esophagus, stomach and duodenum, which are examined simultaneously. First, the first portion of the barium mixture taken by the patient gives a tight filling of the esophagus and an image of the internal relief of the stomach. Then, after taking up to two glasses of barium suspension, a tight filling of the stomach is achieved. With the use of a gas-forming mixture or physiological ingestion of air, a double contrast is obtained, which makes it possible to investigate the relief of the gastric mucosa. The study of the relief of the mucous output of the stomach and duodenum is achieved by dosed compression with a special device (tube) on the X-ray apparatus.

Irrigoscopy is a retrograde contrast enema - this cancer test is used to examine the rectum and large intestine. Under the control of fluoroscopy with the help of Bobrov's apparatus, up to 4.5 liters of contrast mass is injected into the rectum lumen to produce a tight colon filling. After emptying the intestine on the radiographs, the mucosal relief is visible. For double contrast, the large intestine is filled with air, and a picture of the internal relief and all the anatomical features is obtained.

Irrigoscopy is performed after a digital examination of the rectum and sigmoidoscopy performed by a pre-proctologist, as these parts of the large intestine are poorly visible in irrigoscopy. In contrast fluoroscopy of the hollow organs of the gastrointestinal tract, the following symptoms of tumor involvement are revealed:

• defect filling, characteristic for tumors, exophytic-growing inside the lumen of the organ;
• persistent (organic) narrowing of the lumen of the hollow organ with its deformation, which is characteristic of the infiltrative form of cancer with circular lesion;
• Stiffness of the wall in a limited area (determined by tight filling and double contrasting), characteristic of infiltrative cancer growing in the wall of the organ and outwards from it.

By indirect radiographic evidence, if compression is detected from the outside, one can assume the presence of a tumor in adjacent organs.

Radiographic examination for cancer (along with diagnostic fluorography) is widely used in the diagnosis of pulmonary pathology and osteoarticular system.

In the study of pulmonary pathology, changes such as single or multiple foci and foci of lesion, ventilation disorders (hypoventilation, valve emphysema, atelectasis), pathological changes in the lung's root (expansion with loss of structure), expansion of the mediastinum shadow (in the lesion of the mediastinal lymph nodes or with mediastinal tumors), the presence of fluid in the pleural cavity or seals on the paracostal or interstitial pleura (with specific metastatic pleurisy or mesothelioma pleura).

When studying bone-articular pathology, it is possible to detect such signs of malignant lesions as thickening of the bone with its deformation, destruction of the spongy or compact substance, osteoplastic foci.

[6], [7], [8], [9], [10], [11]

CT scan

In the future, to clarify the diagnosis requires a linear or computed tomography.

Linear tomography (LT) is a method for studying sections of internal organs in the study of the lungs, mediastinum and osteoarticular system.

This examination on cancer allows for a peripheral lung cancer or pleural tumor to get a clear image of the pathological focus, to evaluate its contours, structure and relation to surrounding tissues.

With central lung cancer, RT allows to obtain an image of the tumor in the root of the lung, lobar or segmental bronchus with an assessment of its patency.

When diagnosing the root or mediastinal lymphadenopathy, the affected lymph nodes should be detected, as with LT, unlike computed tomography, normal lymph nodes are not visible.

And, finally, in diagnosis of laryngeal tumors, LT can detect additional tissues and deformation of the lumen of the organ.

Special types of radiography, such as cholecystography, mammography and its varieties (cysto- and doktografiya), radiography in conditions of artificial pneumothorax, pneumoperitoneum, parietografiya, fistulography, endoscopic retrograde pancreato cholangiography, as well as angiography, lymphography, excretory urography and other types of research are carried out exclusively in specialized institutions.

Computed tomography (CT), or X-ray computed tomography (CT) is an x-ray examination for cancer, based on computer processing of data on the extent of X-ray absorption at different points in the studied object. The main purpose of CT is the diagnosis of cancer, accompanied by voluminous formations.

The resulting images, in their anatomical nature, are almost analogous to the Pirogov anatomical sections of the human body.

With CT of the brain, orbit, base bone and cranial vault, primary and metastatic tumors are detected starting at 7-8 mm. However, a reliable sign of malignancy is only the destruction of the bone walls of the orbit and the spread of the tumor to the surrounding anatomical structures; in the absence of these signs, it is not possible to determine the degree of malignancy.

With CT of the facial skull, paranasal sinuses, nasal cavity, nasopharynx, additional neoplasms in the soft tissues of the face and paranasal sinuses are easily visualized.

Computer tomography of the neck allows to diagnose well the tumors and cysts of the neck, lymph node involvement. When examining the thyroid gland, difficulties arise in the layering of the bones of the upper humeral girdle. However, large tumor nodes are visible without distortion, while the relationship of the tumor with surrounding tissues and anatomical zones, including the upper mediastinum, is well traced.

In tumors of the laryngopharynx and larynx, CT is used mainly to determine the exorhant spread of the tumor.

The CT of chest organs (mediastinum, lungs, pleura) are almost identical to those for basic X-ray diagnostics. However, CT can provide more accurate information about tumor germination in surrounding structures.

Computer tomography of the abdominal cavity and retroperitoneal space has no significant advantages over the basic radiographic diagnostic methods.

When studying the osteoarticular system, the CT efficiency is superior in its capabilities to basic X-ray diagnostics and is an effective method for assessing the condition of large flat and long tubular bones. In the diagnosis of primary bone tumors, CT can provide an image of the intraosseous and extra-bone soft tissue component of the tumor. With tumors of soft tissues, the main advantage of CT is the possibility of determining their relationship with bones, joints and other anatomical structures.

[12], [13], [14], [15]

MRI

The basis of magnetic resonance imaging (MRI) is the recording of radio waves emitted by magnetized hydrogen atoms after exposure to an external radio wave signal, and computer processing of data. With the help of MRI, one can get an image of organs and tissues containing any amount of water (excitation of hydrogen atoms). Formations that do not contain water or carbon are not displayed on the MRI. Accuracy, sensitivity of MRI exceeds similar CT scores in different areas by 2-40%. CT and MRI have almost equal opportunities in diagnosing the pathology of the brain substance, tracheobronchial tree and lung parenchyma, parenchymal organs of the abdominal cavity and retroperitoneal space, large flat bones, lymph nodes of any groups. However, when studying the stem part of the brain and the entire spinal cord, heart and vascular structures, extremities (especially the joints), the pelvic organs, the advantage belongs to the MRI. In oncological practice, MRI is necessary for differential diagnosis of primary and secondary tumors of the central nervous system (trunk, spinal cord), heart and pericardium, and spine.

Radionuclide Diagnosis (RND)

This is an examination for cancer, based on recording images from objects emitting gamma rays. For this, radiopharmaceuticals (RFP) containing radionuclides are introduced into the human body. Spatial distribution of RFP in internal organs is determined with the help of scanning devices and scintillation gamma cameras. With the help of isotope methods, it is possible to obtain anatomical and topographic images of organs, to evaluate data on their position and size, and also the nature of the distribution of radioactive pharmacological agents in them. Positive scintigraphy is based on intensive absorption of the drug by tumor tissue. The presence of increased accumulation of RND in any part of the organ under examination indicates a pathological focus. This method is used to identify primary and metastatic tumors of the lungs, brain, bones and some other organs. With negative scintigraphy, isotope absorption defects are detected, which also indicates a volumetric pathological process in the organ. This principle is based on the diagnosis of primary and metastatic tumors of the parenchymal organs: liver, kidney, thyroid and pancreas.

Emission computer tomographs are equipped with a rotation system of the built-in gamma camera, which allows reconstructing the sectional image (single-photon emission computer tomography - SPECT). In addition to functional investigations of various organs, it is possible to obtain information on structural disorders. Thus, scintigraphy of the skeleton is widely used, which makes it possible to reveal clinically latent metastases in the osteoarticular system.

Positron emission tomographs (PET) are based on the use of positrons emitted by radionuclides. For the production of radionuclides on PET cyclotrons are used. This type of tomography allows you to study hidden metabolic processes.

Ultrasound diagnosis (ultrasound, sonotomography)

This examination for cancer takes a significant place in radiation diagnosis. The physical basis of this method is to obtain a computer picture from the ultrasound signal reflected by organs and tissues. Used ultrasound methods are divided into screening, basic and specialized. Screening procedures allocate pathological sites on a background of a normal picture (identification "own - another's"). Basic research is limited to studying the organs of the abdominal cavity, retroperitoneal space, small pelvis, thyroid and mammary glands, superficial lymph nodes.

Specialized examination for cancer is performed using intracavitary sensors (rectal, vaginal, esophageal), cardiovascular sensors, with puncture biopsy. Modern devices equipped with a sono-CT function are capable of constructing a cross-section with obtaining a picture similar to a computer tomogram. With the success of ultrasound used for primary and secondary tumors and concomitant pathology of the liver, pancreas, spleen, kidneys, prostate, uterus, extraorganic tumors of the abdominal cavity, retroperitoneal space and small pelvis.

Endoscopic examination for cancer

In modern oncology, one of the leading places in the diagnosis of malignant tumors is endoscopic research methods.

Endoscopy is a visual examination of the cancer of hollow organs and body cavities with the help of special opto-mechanical devices - endoscopes. The latter can be rigid or flexible. The design of endoscopes is based on the use of fiber optics, they are less traumatic and more suitable for instrumental palpation and biopsy. Rigid endoscopes find their application in proctology (sigmoidoscopy), anesthesiology (laryngoscopy).

Endoscopic diagnostic methods allow solving the following tasks in oncology:

• primary diagnosis of malignant tumors of a number of organs of the thoracic and abdominal cavities;
• differential diagnosis of pathological processes of individual organs and cavities of the organism in those cases when a preliminary examination does not allow to exclude the presence of a malignant disease in a patient;
• Specifying diagnostics allowing more accurate determination of localization, size, anatomical shape, internal and external boundaries of the detected tumor;
• morphological diagnostics by targeted biopsy;
• early diagnosis of malignant tumors and detection of precancerous diseases during preventive examinations of the population using endoscopic research methods;
• dispensary observation of patients with benign tumors and chronic diseases, which can serve as a breeding ground for cancer;
• control over the effectiveness of treatment of patients with malignant tumors for the timely diagnosis of relapses and metastases;
• Electrosurgical excision of polyps with specification of their histological structure.

Currently, targeted biopsy and cytological examination are an indispensable component of a complex endoscopic study. The main types of endoscopic biopsy are plaque, brush (brush biopsy) and loop. Morphological examination with gingival biopsy and the use of a loop sends smear-prints (for cytology) and directly pieces of tissue (for histology), with brush-biopsy - the resulting unstructured material is examined only cytologically. When bronchoscopy for cytology, you can use flushing water of the bronchi.

The most widely used among endoscopic methods are fibrogastroduodenoscopy, including in the form of variants fibro-schizophrenia, fibrogastroscopy. Endoscopic examination for esophageal cancer allows to diagnose most tumors of this organ, to obtain indirect signs of neoplasm of mediastinum and defeat of lymph nodes.

In the diagnosis of gastric tumors, the method is effective in recognizing exophytic tumors. Fibroduodenoscopy allows to obtain indirect signs of cancer of the head of the pancreas or obvious signs of its germination into the duodenum.

Fibrocolonoscopy - examination for colon cancer. The study allows to detect organic stenoses caused by endophytic cancer, exophytic tumors, to conduct their biopsy. For therapeutic purposes, they are used for polypectomy.

[16], [17], [18], [19], [20], [21]

Video Endoscopy

Currently, video endofibroscopes are being introduced into endoscopic diagnostics, intended for research of the mucosa of the esophagus, stomach, duodenum and colon with diagnostic and therapeutic purposes. The whole process of endoscopy (ie, the image of the cavity and the walls of the organ) is displayed on the monitor in a color image, with the possibility of simultaneous recording on a videotape for subsequent repeated viewing.

Retrograde pancreatocholangioscopy allows for preoperative visual examination of the pancreatic duct and bile duct system.

Colposcopy (cervical examination) and hysteroscopy (endoscopy of the uterine cavity) are the leading screening for cancer in oncogynecology.

Urethroscopy, cystoscopy serve both for the primary diagnosis of neoplasms of the urinary tract, and for timely recognition of tumor recurrence during dispensary follow-up of patients after radical treatment. Repeated endoscopic studies in the process of chemotherapy and radiation therapy make it possible to follow the reaction of the tumor and normal tissues of the organ to the effect of therapeutic factors.

Laparoscopy - examination of the abdominal cavity and small pelvis in the volume: the lower surface of the liver, parietal and visceral peritoneum, part of the intestine, part of the female sexual sphere. This screening for cancer is used to search for distant metastases, peritoneal or other extraorganic tumors with subsequent biopsy.

Fibroepiipharyngoscopy is an endoscopic examination for upper respiratory tract cancer. With the help of this method, the primary tumor is visualized, the prevalence of it on the pharyngeal wall is assessed, the shape of the growth is determined, and on the basis of endoscopic semiotics and the result of the biopsy, a conclusion is made about the genesis and nature of the neoplasm.

Fibrobronchoscopy allows for a general examination of the bronchi, taking material for cytological examination.

Mediastinoscopy is a method for studying the mediastinal lymph nodes. In this study, the endoscope is drawn through a cut above the jugular breaststroke or in the parasternal region between the I-III ribs. Therefore, only the anterior mediastinum is examined.

Thoracoscopy is performed through a small incision in the intercostal space, through which an endoscope is introduced into the thoracic cavity for examination of the parietal and visceral pleura and the surface of the lung. The method allows to detect and verify tumors and small metastatic nodes on the pleura, to perform an edge biopsy of the lung tissue.

Endoscopic retrograde pancreatoholangiography and bronchography are diagnostic X-ray endoscopic procedures used for endoscopic contrasting of the organs under study.

Endoehography is the use of an ultrasound probe at the distal end of the endoscope, which provides unified information about the wall of the hollow organ and surrounding tissues, catching changes 2-3 mm in diameter. Before the operation, using this method, metastasis of regional lymph nodes in gastric cancer is determined, the degree of invasion.

Endoscopic optical coherence tomography is an optical examination for cancer, consisting in obtaining an image of the body tissues in a cross-section with a high resolution level, which makes it possible to obtain morphological information at a microscopic level.

Laboratory examination for cancer

This examination for cancer is mandatory to determine the overall somatic state of cancer patients at all stages of diagnosis and treatment. However, there are currently no reliable specific laboratory tests for establishing a tumor disease.

Changes in the parameters of peripheral blood, biochemical, immunological data in an oncological patient are due not to the presence of a tumor, but to those disorders of the functions of the organs and systems that it causes by its presence.

Changes in peripheral blood in cancer patients are also nonspecific: there may be an acceleration of ESR above 30 mm / h, leukopenia or leukocytosis, lymphopenia, thrombocytopenia or thrombocytosis, anemia.

Various violations of rheological properties of blood are possible: fluctuations in blood viscosity, aggregation of erythrocytes, which can cause hypercoagulation.

Specific biochemical changes in the body of cancer patients have also not been revealed. Nevertheless, for certain localizations of tumors, some biochemical changes can be noted: in primary liver cancer, an increase in alkaline phosphatase; pancreatic cancer - increased enzymes (lipase, amylase, alkaline phosphatase); mechanical jaundice - increased activity of aldolase, aminotransferases; prostate cancer - a high level of acid phosphatase.

With cancer of the breast, kidney, ovaries, non-small cell lung cancer, hypercalcemia is possible.

With an increase in catabolism and a decrease in detoxification capacity in malignant tumors, there is an accumulation in the body of endotoxins, which have a damaging effect on organs and systems. Metabolic disorders lead to the release of proteolytic enzymes into the blood and the formation of so-called medium-molecular peptides. Hyperfermentation and medium-mass molecules are the main factors of intoxication, which, in particular, causes the development of anemia.

Immunological tests, as a rule, show inhibition of the immune response, and especially of the T-cell link, characterized by a decrease in the total number of T-lymphocytes, active T-lymphocytes and T-helper cells. Oncological disease primarily develops on the background of immunodepression and secondarily aggravates it in the course of progression. All kinds of specific therapeutic measures can contribute to the inhibition of the immune system: surgery, chemoradiotherapy.

Definition of oncomarkers

At present, there is no single test to determine the presence of a specific tumor in the human body, but with the help of oncomarkers it is possible to determine the presence of a tumor in the body in general. Markers of malignant growth include substances of different nature: antigens, hormones, enzymes, glycoproteins, proteins, metabolites. Since the concentration of markers correlates with the mass of the tumor tissue, they are usually used to evaluate the results of treatment. According to the data of the majority of researchers, tumor markers are not informative for early diagnosis of the tumor process.

The most commonly used markers are tumor-associated antigens, including CA 125 (for diagnosis, differential diagnosis and control of the effectiveness of ovarian cancer treatment), CA 19-9 (for pancreas and colon cancer), prostate-specific antigen (PSA) (for diagnosis, evaluation of treatment effectiveness and dynamic control of patients with prostate cancer).

Tocopherol antigens include alpha-fetoprotein (used to diagnose and evaluate the effectiveness of primary liver cancer and testicular cancer), cancer embryonic antigen or carcinoembryonic antigen (CEA) to assess the effectiveness of treatment for colon, stomach, and breast cancer.

Monitoring the level of concentration of oncomarkers in the blood gives an idea of the radical nature of the treatment measures, the possible recurrence of the disease, which makes it possible to apply them in the dynamic observation of the oncological patient during the treatment and in the future - throughout their subsequent life.

[22], [23], [24], [25], [26], [27], [28], [29],

Morphological examination for cancer

In modern oncology, the character of the pathological process is established with the obligatory use of morphological methods. Oncological diagnosis should always be verified morphologically.

Of particular importance at the present time has become a cytological examination for cancer, which makes it possible to quickly and effectively verify the process without surgical intervention.

Since the late 1960's. Cytological diagnosis has become widespread in various fields of medicine and, above all, in oncology and surgery.

Clinical practice has proved the high information value of the cytological method. The coincidence of cytological and histological conclusions in tumors of the main localizations reaches 93 - 99%. Supplementing and enriching the traditional pathohistological study, the cytological method has its own specifics and advantages primarily because the object of the study is not tissues but cells that are easy to obtain without surgical intervention in relatively simple ways: puncture the tissues with a thin needle, take scrapings or prints from the surface of the pathological education and so on. This excludes the danger of damage to organs and makes available almost all anatomical formations for research.

In tumors of external localizations, incision or excision biopsy, diagnostic puncture, scraping, and fingerprints from the surface of ulcers and wounds are used.

Informative material for cytological examination can be obtained with the help of exfoliative biopsy in the study of pathological discharges: sputum, urine, ascitic and pleural fluids, independent discharge from the nipple of the breast and the like.

With the advent of endoscopic techniques, internal organs (stomach, intestines, lungs, genitals, etc.) became available for biopsy during diagnostic procedures (gastroscopy, laparoscopy, bronchoscopy, colonoscopy).

There are five stages of morphological diagnosis in oncology.

The first stage (outpatient) on the basis of cytological research allows to form three groups of patients: 1) with benign processes; 2) with suspected cancer; 3) with malignant neoplasms.

The second stage (clinical diagnosis) is designed to refine the parameters of an already detected tumor (histotype, degree of differentiation, the presence of metastases in regional lymph nodes, the determination of the nature of exudates, etc.). These indications are decisive in choosing the optimal treatment plan (surgery, pre-operative or self-treatment, chemotherapy or hormonal effects).

The third stage (intraoperative) is important in all respects. Express intraoperative cytological research helps to solve several questions:

• determine the anatomical form of tumor growth;
• Verify the spread of the tumor process to neighboring organs;
• to investigate all regional lymph nodes;
• by studying the prints from the edges of the resected organ to make an objective impression of the radical nature of the surgical intervention;
• the study of prints from the bottom and edges of the wound to determine the ablatility of the surgical operation.

Express cytological examination for cancer promotes morphological verification and objective specification of the stage of the disease already during the operation, which ensures timely and adequate volume of surgical treatment.

The fourth stage (postoperative), on which the planned histological examination of the removed drug is performed, allows to establish:

• tumor histotype;
• degree of malignancy and differentiation;
• the degree of organ germination by the tumor;
• defeat of regional lymph nodes;
• the state of immunogenic zones in the lymph nodes;
• degree of pathomorphosis after radiation or drug treatment.

The fifth stage (in the rehabilitation period) uses a cytological examination for cancer, which helps early detection of the progress of the disease in the form of relapses and metastases.

So, if a seal is found in the area of a previous operation or an increase in regional or supraregional lymph nodes, a diagnostic puncture is performed. Morphological control is performed at any visit of an oncological patient to a doctor. Patients undergoing surgery for gastric and intestinal cancer are given an endoscopic examination with a biopsy of suspicious areas.