The diagnosis of malignancy

The diagnosis of cancer may be suspected by both doctor and patient but obviously needs to be confirmed. Patients with cancer and their families are likely to be frightened; the very word cancer, often avoided by doctors and patients alike, is, often incorrectly, assumed to imply certain death. Reassurance and advice on therapy can only be given on the basis of a tissue diagnosis obtained via a needle biopsy or at surgery. Alternatively a fine needle aspiration can be obtained for cytological diagnosis. This has the advantage of being simple and quick to perform but an experienced cytologist is necessary.
Malignant lesions can be distinguished by the pleomorphism of the cells, increased numbers of mitoses, nuclear aberration and evidence of invasion into surrounding tissues. The degree of differentiation or anaplasia of the tumour is a factor in deciding the treatment and determining the prognosis.
Immunohistochemistry using monoclonal antibodies against tumour antigens is being used to differentiate cell types.


Before a decision about treatment can be made, it is important to establish not only the type of tumour but also its extent, i.e. which other organs are involved. Various staging investigations will therefore be performed before a treatment decision is made.
Staging systems vary according to the type of tumour. One widely used system is the TNM classification (T, tumour; N, node; M, metastasis) which can be applied to most cancers. T describes the size of the tumour (where in TO there is no evidence of tumour and Tl-3 indicates a progressive increase in size); N describes the increasing involvement of nodes (N1-N3) and M describes the absence (MO) or presence (M1) of metastases. Specific tumours, e.g. Hodgkin’s disease, are classified according to more specific classifications.
In addition to anatomical staging, the person’s general state of health obviously needs to be taken into account when planning treatment. This has been ascribed a ‘performance scale’ which is also of important prognostic significance.

Tumour markers

These can be useful in diagnosis and in following the response to treatment. Relatively specific markers include a-fetoprotein, {3-human chorionic gonadotrophin (~-HCG) and prostate-specific antigen (PSA). Other less disease-specific antigens can be useful particularly in following up treatment, e.g. carcinoembryonic antigen (CEA) in gastrointestinal adenocarcinomas and Ca 125 in ovarian or other epithelial cancers.

Karnowsky performance status.
Karnowsky performance status.

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