CONFIRMING DIAGNOSIS The confirming test for liver cancer is liver biopsy by needle or open biopsy.
Liver cancer is difficult to diagnose in the presence of cirrhosis, but several tests can help identify it:
❑Serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, alkaline phosphatase, lactic dehydrogenase, and bilirubin all show abnormal liver function.
❑ Alpha-fetoprotein rises to a level above 500 mcg/ml.
❑ Chest X-ray may rule out metastasis.
❑ Liver scan may show filling defects.
❑Arteriography may define large tumors.
❑ Electrolyte studies may indicate an increased retention of sodium (resulting in functional renal failure) and hypoglycemia, leukocytosis, hypercalcemia, or hypocholesterolemia.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Lung cancer:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Typical clinical findings may strongly suggest lung cancer, but firm diagnosis requires further evidence.
❑Chest X-ray usually shows an advanced lesion, but it can detect a lesion up to 2 years before symptoms appear. It also indicates tumor size and location.
❑ Sputum cytology, which is 75% reliable, requires a specimen coughed up from the lungs and tracheobronchial tree, not postnasal secretions or saliva.
❑ Computed tomography (CT) scan of the chest may help to delineate the tumor's size and its relationship to surrounding structures.
❑ Bronchoscopy can locate the tumor site. Bronchoscopic washings provide material for cytologic and histologic examination. The flexible fiber-optic bronchoscope increases the test's effectiveness.
❑ Needle biopsy of the lungs uses biplane fluoroscopic visual control to detect peripherally located tumors. This allows firm diagnosis in 80% of patients.
❑ Tissue biopsy of accessible metastatic sites includes supraclavicular and mediastinal node and pleural biopsy. Directed needle biopsy may be performed in conjunction with CT scan.
❑Thoracentesis allows chemical and cytologic examination of pleural fluid.
Additional studies include preoperative mediastinoscopy or mediastinotomy to rule out involvement of mediastinal lymph nodes (which would preclude curative pulmonary resection).
Other tests to detect metastasis include bone scan, bone marrow biopsy (recommended in small cell carcinoma), CT scan of the brain or abdomen, and positron emission tomography.
After histologic confirmation, staging determines the extent of the disease and helps in planning the treatment and predicting the prognosis. (See Staging lung cancer.)
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Breast cancer:
Diagnosis
(Handbook of Diseases)
Diagnostic measures for breast cancer include the following.
Breast self-examination
Although not proven to lower mortality rates, breast self-examination may detect palpable breast lumps, allowing the woman to contact her physician for early evaluation.
Mammography and biopsies
Other diagnostic measures include mammography, a needle biopsy, and a surgical biopsy. Mammography is indicated for any woman whose physical examination might suggest breast cancer. It should be done as a baseline on women ages 35 to 39, every 1 to 2 years for women ages 40 to 49, and annually for women older than age 50, women who have a family history of breast cancer, and women who have had unilateral breast cancer, to check for new disease. However, the value of mammography is questionable for women younger than age 35 (because of the density of the breasts), except those who are strongly suspected of having breast cancer.
False-negative results can occur in as many as 30% of all tests. Consequently, with a suspicious mass, a normal mammogram result should be disregarded, and a fine-needle aspiration or surgical biopsy should be done. Ultrasonography, which can distinguish a fluid-filled cyst from a tumor, can also be used instead of an invasive surgical biopsy.
Other tests
Bone scan, computed tomography scan, measurement of alkaline phosphatase levels, liver function studies, and a liver biopsy can detect distant metastasis. A hormonal receptor assay done on the tumor can determine if the tumor is estrogen- or progesterone-dependent. (This test guides decisions to use therapy that blocks the action of the estrogen hormone that supports tumor growth.)
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Source: Handbook of Diseases, 2003
Spinal neoplasms:
Diagnosis
(Handbook of Diseases)
❑ Spinal computed tomography scan or magnetic resonance imaging shows the location and size of the tumor, or evidence of compression.
❑ Spinal tap shows clear yellow cerebrospinal fluid (CSF) as a result of increased protein levels if the flow is completely blocked. If the flow is partially blocked, protein levels rise, but the fluid is only slightly yellow in proportion to the CSF protein level. A CSF smear may show malignant cells of metastatic carcinoma.
❑ X-rays show distortions of the intervertebral foramina, changes in the vertebrae, collapsed areas in the vertebral body, and localized enlargement of the spinal canal, indicating an adjacent block.
❑ Myelography identifies the level of the lesion by outlining it if the tumor is causing partial obstruction; it shows the anatomic relationship of the tumor to the cord and the dura. If the obstruction is complete, the injected dye can’t flow past the tumor.
Note: This study is dangerous if cord compression is nearly complete because withdrawal or escape of CSF will actually allow the tumor to exert greater pressure against the cord.
❑ Radioisotope bone scan demonstrates metastatic invasion of the vertebrae by showing a characteristic increase in osteoblastic activity.
❑ Frozen section biopsy at surgery identifies the tissue type.
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Source: Handbook of Diseases, 2003
Bladder cancer:
Diagnosis
(Handbook of Diseases)
Only cystoscopy and a biopsy can confirm bladder cancer. Cystoscopy should be performed when hematuria first appears. When it’s performed under anesthesia, a bimanual examination is usually done to determine if the bladder is fixed to the pelvic wall. A thorough history and physical examination may help determine whether the tumor has invaded the prostate or the lymph nodes.
The following tests can provide essential information about the tumor:
❑ Urinalysis can detect blood in the urine and malignant cytology.
❑ Excretory urography can identify a large, early-stage tumor or an infiltrating tumor, delineate functional problems in the upper urinary tract, assess hydronephrosis, and detect rigid deformity of the bladder wall.
❑ Retrograde cystography evaluates bladder structure and integrity. Test results help to confirm the diagnosis.
❑ Pelvic arteriography can reveal tumor invasion into the bladder wall.
❑ Computed tomography scan reveals the thickness of the involved bladder wall and detects enlarged retroperitoneal lymph nodes.
❑ Ultrasonography can detect metastasis beyond the bladder and can distinguish a bladder cyst from a tumor.
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Source: Handbook of Diseases, 2003
Cervical cancer:
Diagnosis
(Handbook of Diseases)
A cytologic examination (Papanicolaou [Pap] test) can be used to detect cervical cancer before symptoms appear. Abnormal cervical cytology generally calls for colposcopy, which can detect the presence and extent of preclinical lesions requiring a biopsy and histologic examination.
Staining with Lugol’s solution (strong iodine) or Schiller’s solution (iodine, potassium iodide, and purified water) may identify areas for a biopsy when the smear shows abnormal cells but there is no obvious lesion. Although the tests are nonspecific and have a high rate of false-positives, they do distinguish between normal and abnormal tissues: Normal tissues absorb the iodine and turn brown; abnormal tissues are devoid of glycogen and don’t change color.
Additional studies — such as cystography, magnetic resonance imaging, computed tomography and bone scans — can be used to detect metastasis.
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Source: Handbook of Diseases, 2003
Colorectal cancer:
Diagnosis
(Handbook of Diseases)
Only a tumor biopsy can verify colorectal cancer, but the following tests help detect it:
❑ Digital examination can help detect almost 15% of colorectal cancers.
❑ Hemoccult test (guaiac) may show blood in the stool.
❑ Proctoscopy or sigmoidoscopy can help detect up to 66% of colorectal cancers.
❑ Colonoscopy permits visual inspection (and photographs) of the colon up to the ileocecal valve and gives access for polypectomies and biopsies of suspected lesions.
❑ Computed tomography scan helps detect areas affected by metastasis.
❑ Barium X-ray, using a dual contrast with air, can locate lesions that are undetectable manually or visually. Barium examination should follow endoscopy or excretory urography because the barium sulfate interferes with these tests.
❑ Carcinoembryonic antigen, although not specific or sensitive enough for an early diagnosis, is helpful in monitoring patients before and after treatment to detect metastasis or recurrence.
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Source: Handbook of Diseases, 2003
Esophageal cancer:
Diagnosis
(Handbook of Diseases)
X-rays of the esophagus, with barium swallow and motility studies, reveal structural and filling defects and reduced peristalsis. Endoscopic examination of the esophagus, punch and brush biopsies, and an exfoliative cytologic tests confirm esophageal tumors.
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Source: Handbook of Diseases, 2003
Gallbladder and bile duct cancers:
Diagnosis
(Handbook of Diseases)
No test or procedure is in itself diagnostic of gallbladder cancer. However, the following laboratory tests support this diagnosis when they suggest hepatic dysfunction and extrahepatic biliary obstruction:
❑ baseline studies (complete blood count, routine urinalysis, electrolyte studies, enzymes)
❑ liver function tests (typically reveal elevated serum bilirubin, urine bile and bilirubin, and urobilinogen levels in more than 50% of patients as well as consistently elevated serum alkaline phosphatase levels)
❑ occult blood in stools (linked to the associated anemia)
❑ cholecystography (may show stones or calcification)
❑ cholangiography (may locate the site of common duct obstruction)
❑ magnetic resonance imaging (detects tumors).
The following tests help compile data that confirm extrahepatic bile duct cancer:
❑ liver function tests (indicate biliary obstruction: elevated levels of bilirubin [5 to 30 mg/dl], alkaline phosphatase, and blood cholesterol as well as prolonged prothrombin time)
❑ endoscopic retrograde pancreatography (identifies the tumor site and allows access for obtaining a biopsy specimen).
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Source: Handbook of Diseases, 2003
Gastric cancer:
Diagnosis
(Handbook of Diseases)
Diagnosis depends primarily on reinvestigations of persistent or recurring GI changes and complaints. To rule out other conditions that produce similar symptoms, a diagnostic evaluation must include the testing of blood, stools, and stomach fluid specimens.
Gastric cancer commonly requires the following studies for diagnosis:
❑ Barium X-rays of the GI tract, with fluoroscopy, show changes (a tumor or filling defect in the outline of the stomach, loss of flexibility and distensibility, and abnormal gastric mucosa with or without ulceration).
❑ Gastroscopy with fiber-optic endoscopy helps rule out other diffuse gastric mucosal abnormalities by allowing direct visualization and gastroscopic biopsy to evaluate gastric mucosal lesions.
❑ Endoscopy for biopsy and cytologic washings and photography with fiber-optic endoscopy provide a permanent record of gastric lesions that can later be used to determine the progress of the disease and the effect of treatment.
The following studies may rule out metastasis to specific organs: computed tomography scans, chest X-rays, liver and bone scans, and a liver biopsy.
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Source: Handbook of Diseases, 2003
Kidney cancer:
Diagnosis
(Handbook of Diseases)
Studies to identify kidney cancer usually include computed tomography scans, excretory urography and retrograde pyelography, ultrasound, cystoscopy (to rule out associated bladder cancer), and nephrotomography or renal angiography to distinguish a kidney cyst from a tumor.
Related tests include liver function studies showing increased levels of alkaline phosphatase, bilirubin, alanine aminotransferase, and aspartate aminotransferase as well as prolonged prothrombin time. Such results may point to liver metastasis, but if metastasis hasn’t occurred, these abnormalities reverse after the tumor has been resected.
Routine laboratory findings of hematuria, anemia (unrelated to blood loss), polycythemia, hypercalcemia, and increased erythrocyte sedimentation rate call for more testing to rule out kidney cancer. A bone scan should also be performed to rule out skeletal metastasis.
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Source: Handbook of Diseases, 2003
Laryngeal cancer:
Diagnosis
(Handbook of Diseases)
Any hoarseness that lasts longer than 2 weeks requires visualization of the larynx by laryngoscopy.
A firm diagnosis also requires xeroradiography, a biopsy, laryngeal tomography, computed tomography scan, or laryngography to define the borders of the lesion, and a chest X-ray to detect metastasis.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Liver cancer:
Diagnosis
(Handbook of Diseases)
The confirming test for liver cancer is a needle or open biopsy of the liver. Liver cancer is difficult to diagnose in the presence of cirrhosis, but several tests can help identify it:
❑ Liver function studies (aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, lactate dehydrogenase, and bilirubin) show abnormal liver function.
❑ Alpha-fetoprotein level increases above 500 µg/ml.
❑ Chest X-ray may rule out metastasis.
❑ Liver scan may show filling defects.
❑ Arteriography may define large tumors.
❑ Electrolyte studies may indicate increased sodium retention (resulting in functional renal failure) and hypoglycemia, leukocytosis, hypercalcemia, or hypocholesterolemia.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Lung cancer:
Diagnosis
(Handbook of Diseases)
Typical signs and symptoms may strongly suggest lung cancer, but a firm diagnosis requires further evidence, including the following:
❑ Chest X-ray usually shows an advanced lesion, but it can detect a lesion up to 2 years before symptoms appear. It also indicates tumor size and location.
❑ Sputum cytology is marginally helpful in obtaining a diagnosis. It requires a specimen coughed up from the lungs and tracheobronchial tree, not postnasal secretions or saliva.
❑ Computed tomography (CT) scan of the chest may help to delineate the tumor’s size and its relationship to surrounding structures.
❑ Bronchoscopy can locate the tumor site. Bronchoscopic washings provide material for cytologic and histologic examination. The flexible fiber-optic bronchoscope increases the test’s effectiveness.
❑ A needle biopsy of the lungs uses biplane fluoroscopic visual control or CT guidance to detect peripherally located tumors. This allows a firm diagnosis in 80% of patients.
❑ Tissue biopsy of accessible metastatic sites includes supraclavicular and mediastinal node and pleural biopsies.
❑ Thoracentesis allows chemical and cytologic examination of pleural fluid.
Additional studies include preoperative mediastinoscopy or mediastinotomy to rule out involvement of mediastinal lymph nodes (which would preclude curative pulmonary resection).
Other tests to detect metastasis include a bone scan, positron emission tomography scan, bone marrow biopsy (recommended in small cell carcinoma), and a CT scan of the brain or abdomen.
After histologic confirmation, staging determines the extent of the disease and helps in planning treatment and predicting the prognosis. (See Staging lung cancer.)
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Ovarian cancer:
Diagnosis
(Handbook of Diseases)
With ovarian cancer, diagnosis requires clinical evaluation, a complete patient history, surgical exploration, and histologic studies. Preoperative evaluation includes a complete physical examination, including pelvic examination with Papanicolaou smear (not clinically useful for ovarian cancer but helpful in diagnosing cervical dysplasia, cervical cancer, and some endometrial cancers) and the following special tests:
❑ abdominal ultrasonography, computed tomography scan, or magnetic resonance imaging (may delineate tumor size)
❑ complete blood count and blood chemistries
❑ chest X-ray for distant metastasis and pleural effusions
❑ barium enema (especially in patients with GI symptoms) to reveal obstruction and size of tumor
❑ mammography to rule out primary breast cancer
❑ liver function studies or a liver scan in patients with ascites
❑ laboratory tumor marker studies, such as CA-125, carcinoembryonic antigen, and human chorionic gonadotropin (the last two are mainly for suspected germ cell tumors).
Despite extensive testing, accurate diagnosis and staging are impossible without exploratory laparotomy, including lymph node evaluation and tumor resection.
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Source: Handbook of Diseases, 2003
Pancreatic cancer:
Diagnosis
(Handbook of Diseases)
Definitive diagnosis requires a laparotomy with a biopsy. Other tests used to detect pancreatic cancer include:
❑ ultrasound — can identify a mass but not its histology
❑ computed tomography scan — similar to ultrasound but shows greater detail
❑ angiography — shows vascular supply of tumor
❑ endoscopic retrograde cholangiopancreatography — allows visualization, instillation of contrast medium, and specimen biopsy
❑ magnetic resonance imaging — shows tumor size and location in great detail.
Laboratory tests that can help support this diagnosis include serum bilirubin level (increased), serum amylase and serum lipase levels (sometimes elevated), prothrombin time (prolonged), and aspartate aminotransferase and alanine aminotransferase levels (elevations indicate necrosis of liver cells).
Additional pertinent studies include alkaline phosphatase level (marked elevation occurs with biliary obstruction), plasma insulin immunoassay (shows measurable serum insulin in the presence of islet cell tumors), hemoglobin level and hematocrit (may show mild anemia), fasting blood glucose level (may indicate hypoglycemia or hyperglycemia), and stool analysis (occult blood may signal ulceration in the GI tract or ampulla of Vater).
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Source: Handbook of Diseases, 2003
Prostatic cancer:
Diagnosis
(Handbook of Diseases)
A digital rectal examination that reveals a small, hard nodule may help diagnose prostatic cancer. The American Cancer Society advises a yearly digital examination for men older than age 40, a yearly blood test to detect prostate-specific antigen (PSA) in men older than age 50, and ultrasonography if abnormal results are found.
Biopsy confirms the diagnosis. PSA is produced by the normal neoplastic ductal epithelium of the prostate and secreted into the lumen; its concentration in the blood is proportional to the total prostate mass. PSA levels will be elevated in all patients with prostatic cancer, and serum acid phosphatase levels will be elevated in two-thirds of men with metastatic prostatic cancer. Therapy aims to return the serum acid phosphatase level to normal; a subsequent rise points to recurrence. Magnetic resonance imaging, computed tomography scan, and excretory urography may also aid the diagnosis.
CLINICAL TIP: Elevated alkaline phosphatase levels and a positive bone scan point to bone metastasis.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
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