TUMORS

The word "tumor" scares many people who are not medically knowledgeable. They mistakenly equate this word with "cancer." That's not true! The Latin word "tumor" simply means "swelling," nothing more. This means that initially, the doctor only knows that there is something "swollen or thickened."
Further circumstances and characteristics of the medical examination narrow down the diagnosis:

• Besides the swelling, is there also redness (Latin "rubor")? Could it possibly be an abscess (encapsulation of pus)?
• Is the tumor warmer than its surrounding tissue (warmth, Latin "calor")?
• Is the swelling diffuse or encapsulated, well-defined?
• Is the tumor overall movable?
• Is there mobility of the tumor against the skin?
• Is there mobility of the tumor against the underlying tissue or the tissue on which the growth sits?
• Is the growth spontaneously painful or painful under pressure (Latin "dolor"), or is it painless?
• Is the tumor soft, semi-firm, or hard, compressible, or rigid in its consistency?
• Does the growth bleed spontaneously or in response to mechanical stimuli, such as friction?

Due to his professional experience, a conscientious doctor can often reasonably narrow down the diagnosis with these visible and palpable characteristics in most cases. Further examinations may be useful for confirmation.

Most commonly, a -harmless- ultrasound examination (also called "sonography") takes precedence, providing additional information about the tissue characteristics and thus the origin of the tumor. More complex additional examinations may be necessary, especially for tumors that are difficult to delineate or located deep inside the body. Computerized Tomography (CT), which is based on X-rays, or Magnetic Resonance Imaging (MRI), also known as Nuclear Magnetic Resonance (NMR), which is based on magnetic waves, are often employed. These examinations require highly complex, large equipment and are therefore more expensive. It is often necessary to combine CT or MRI with contrast agents, which are injected into the veins and accumulate in the tumor. This allows for the discovery of specific tissue properties of the tumor, such as increased or decreased blood flow in the tumor tissue or the retention of certain contrast substances.

Furthermore, special X-ray examinations can be applied, such as mammography for the breast. This technique allows the detection and further analysis of tumors in both female and male breasts, depicting the breast gland, and often precisely identifying changes in the breast gland (e.g., microcalcifications as signs of breast cancer). Mammography is never fully replaceable by breast ultrasound; it is significantly diagnostically safer and more informative. However, both examination techniques complement each other optimally.

While once more common, angiography is now less frequent but still meaningful and necessary for certain tumors. In this procedure, an injection catheter is advanced through a vein or artery into the bloodstream to the site of the tumor. Under X-ray fluoroscopy (mild continuous X-rays similar to a film), contrast agent is injected to observe how it distributes in the blood vessels of the tumor. This allows for a more precise delineation of which blood vessels supply the tumor and whether it is relatively low or rich in blood vessels. These are important distinguishing features in assessing the nature of the tumor. From this, crucial insights for choosing the surgical approach may arise, sometimes even the decision to refrain from intervention if the procedure would be too risky, for example, in the midst of a brain center.

Histology and PE

PE, or Probe-Excision, is the same as Biopsy

Medical professionals often abbreviate typical terms in the course of their work. Thus, the term "Probe-Exzision" was simply shortened to "PE." This term is synonymous with the word "biopsy." It essentially means "sample excision," i.e., the removal of a small, sometimes tiny piece of tissue, for example, from a suspicious growth. This tissue is sent to a pathologist for further assessment. It can also happen that an internal organ, such as the liver or kidney, exhibits pathological changes, and a PE is performed to secure the diagnosis without the presence of a "tumor" or growth. The treating physician sends the PE, along with a detailed description of its origin, to a pathological institute for histological examination.

Histology, Histological Findings, Pathologist

The term "histology" refers to the specialized examination of a tissue sample taken from the body by a pathologist, involving both visual inspection and microscopic examination. The pathologist begins by using a process called "fixation" to harden the tissue into a solid tissue block, which can then be sliced into many very thin sections, sometimes just a few thousandths of a millimeter thick. These ultra-thin sections are stained using various special methods, allowing for better differentiation of the individual microscopic structures. For example, tumor cell nuclei can be specifically stained. If these nuclei are large and thick with many cell divisions, it is more likely to be a malignant tumor that grows rapidly and uncontrollably. Conversely, very few cell divisions would indicate the benign and harmless nature of the tissue sample.

Of course, this is a simplified overview, but you now have a general idea of how such a histological examination takes place. You understand that it involves many steps (fixation, hardening, cutting, staining, evaluation, diagnosis, written documentation) until a histological examination is completed. Until then, everyone involved must exercise patience, and eventually, one hopefully knows exactly what the examined growth is.

Reference Histology and Reference Pathologist

Sometimes the precise assessment of tissue is challenging, or a pathologist may not be entirely certain due to a difficult-to-interpret finding. In such cases, there are so-called "reference institutes" distributed across Germany, featuring highly specialized pathologists, often university professors, who are experts in a particular type of tumor and are intimately familiar with it. These reference pathologists make decisions in such cases, determining, for example, whether chemotherapy is necessary, whether surgery needs to be expanded, and other critical decisions. These are weighty decisions that no responsible pathologist takes lightly. Hence, the burden of making such decisions is often distributed among several competent professionals. In the end, a final, accurate decision is usually reached, shaping the course of follow-up therapy as determined by the treating physicians.

Frozen Section Examination

The so-called "Frozen Section Examination" is a popular measure when the doctor or surgeon is unsure during surgery about the nature of the tissue, whether the tumor is benign or malignant. In this procedure, an unclear tissue sample taken during the operation is rushed to the pathologist for immediate analysis. To ensure the pathologist is ready, frozen sections usually need to be pre-notified. However, due to time constraints, the pathologist cannot apply the necessary processing procedures to observe everything precisely; they must rely on their specialized experience and assess such tissue samples in their natural form. As a result, these frozen section examinations are generally imprecise and uncertain, providing only a preliminary, initial assessment. A definitive statement from the pathologist is only possible after the tissue sample has undergone all processing procedures. Nevertheless, the surgeon receives an initial evaluation and assessment from the pathologist via telephone during the operation.

Sentinel Lymph Node Biopsy or Sentinel Lymph Node Removal

Cancer is a malicious disease, a fact known to everyone. However, doctors can become cunning adversaries when dealing with such cancer that ruins their entire day. Hence, they attempt to outsmart cancer by first understanding its pathways of spread and determining how far it has already spread within the body.
It's important to know that cancers, such as breast cancer or melanoma (a type of skin cancer), often utilize the lymphatic pathways, the fluid pathways outside the blood vessels, for their spread. They essentially "hitch a ride" on the lymphatic system to transport their cancer cells.

Within this lymphatic system, there are specific filtering stations, similar to toll booths on some European highways. These stations are called lymph nodes. Cancer cells get caught in these lymph nodes first (like cars waiting at toll booths) and linger there for a while before continuing to migrate through the body. If one could identify and histologically examine the very first lymph node draining from such a cancer, then one would have a pretty good idea of how far the cancer has already spread or if it is still locally confined. If the cancer hasn't reached the sentinel lymph node yet, the prospects for cure are particularly good.

Around a cancer growth, there are various lymph nodes in different directions, but only one of them is the specific lymph node where any carried cancer cells will initially land. This node is particularly sensitive, hence its technical name "Sentinel Lymph Node." It earns the name "Wächter-Lymphknoten" (“Guardian Lymph Node”) due to its role in guarding against immediate further migration of potential cancer cells. They get caught in it like a filter and are initially "arrested." Only after some time do they break through its "net" and are carried further into other lymph node stations with the lymph flow, similar to a bus taking passengers waiting at the bus stop (in the sentinel lymph node) to the neighboring town and subsequently to the next town.

The trick is to inject a weakly radioactive element into the vicinity of the cancerous growth before a cancer operation. The radioactive components (elements) are transported with the lymphatic flow just like cancer cells and get caught in the sentinel lymph node in the same way. There, they can be precisely located in images and with a Geiger counter, and the sentinel lymph node can be removed for histological examination. If the sentinel lymph node carries cancer cells, it indicates that the cancer has spread beyond its original location. However, it may also mean that it hasn't progressed further than this point. If the sentinel lymph node does not carry cancer cells, it's a positive sign, suggesting that the cancer, at least through the lymphatic system, has not spread. However, this test does not provide information about potential spread through the bloodstream.

The significant advantage of sentinel lymph node biopsy is that only a single lymph node is removed during cancer surgery, as opposed to the previous practice of removing 20-30 lymph nodes. In the past, women who underwent breast cancer surgery with the removal of many lymph nodes from the armpit often experienced severe lymphatic drainage disruptions in the arm. This led to sometimes monstrous, persistent swelling of the affected arm, which often did not improve for a lifetime. Since the introduction of sentinel lymph node biopsy, these "disasters" have become almost forgotten and rarely occur. It's a tremendous advancement that is unfortunately taken for granted today, although it represents a significant achievement in modern medicine.

The „Character“ of Tumors:

Benign, Semimalignant and Malignant

Every growth, every tumor has a kind of "character." Accordingly, it grows and spreads, or it doesn't. One can infer the character of the tumor based on its mode of spread, as revealed by various examinations (ultrasound, X-rays, CT scans, or MRI), and by observing its growth over time.

However, the final assessment of the tumor and its character typically falls under the expertise of the pathologist, who compiles the histological (fine tissue) findings. Only the pathologist can discern how active the cell nuclei of the tumor cells are, how many cell divisions are represented in each microscopic field, and what type the tumor cells are. Based on these observations, the pathologist makes decisions regarding the benign, semimalignant, or malignant nature of the tumor, as well as the degree of malignancy and the specific type of tumor.

Benign Tumors

Benign tumors are growths that respect the boundaries and rules of the body. They can be clearly and distinctly demarcated from the surrounding tissue and do not invade the tissue like a cancerous growth. In all cases, they are encapsulated by a membrane or covering known as the tumor capsule. Typically, these tumors can be easily peeled off their surrounding tissue, strictly on top of the surface of this capsule unless they are too rugged or intricately fused with the surrounding tissue due to inflammation (e.g., in sebaceous cysts).

If benign tumors are carefully excised along with their capsule in the original location, there is a high likelihood that they will not recur at that site. Examples include lipomas (fatty tissue tumors). Unfortunately, due to cost considerations, they are often approached more aggressively. Taking time for meticulous excision is not commonly favored by modern health insurance plans. Since the tumor capsule may tear during removal, small portions of the growth may be left behind, leading to the formation of a new tumor over time, known as a “recurrence”. Recurrences generally exhibit the same growth qualities as the original tumor.

Furthermore, a lipoma, for instance, can form so-called satellite lipomas, which are smaller daughter tumors confined to the original site. These should not be confused with metastases. If the surgeon does not notice them during tumor removal, a new growth, again referred to as a recurrence, may develop, even if the tumor capsule has been completely and without damage removed. Detecting satellite lipomas is challenging since they appear identical to normal fatty tissue and are often mistaken for it during surgery. Nevertheless, they remain benign.

Semimalignant (Half-Malignant) Tumors

Semimalignant means that the tumor possesses characteristics of both a benign and a malignant formation. The word "semi" means nothing other than "half," indicating a kind of "half-and-half tumor."

Such semimalignant tumors can occur in the breast; they are benign in some aspects but can grow very rapidly and have a strong tendency for recurrences, even if removed radically through surgical means. However, these tumors are rare.

Another commonly encountered semimalignant tumor is the so-called basal cell carcinoma (BCC) or “White Skin Cancer”. These tumors are primarily triggered by exposure to the sun and predominantly develop in areas that have been exposed to the sun the most throughout life (face, arms). They exhibit the characteristic that, unlike benign tumors, they no longer adhere to the body's regulation and do not have a solid demarcation (tumor capsule). They grow limitlessly into their surroundings, destroying any tissue in their path, similar to any other malignant cancer such as colorectal or breast cancer. This is their malignant characteristic.

The benign nature of basal cell carcinomas lies in the fact that they never form daughter tumors (metastases) and do not spread throughout the body. When they are surgically removed radically and with a safety margin at the site of origin, the patient is considered cured. This is a characteristic of benign tumors.

Malignant Tumors

Malignant tumors encompass all malignant characteristics: they grow relentlessly and uncontrollably, invading adjacent tissues without respecting boundaries. Like an octopus, they extend their tentacles into neighboring organs, bones, and blood vessels, gradually destroying their host, the patient. Tumor invasions into blood and lymph vessels are responsible for the dissemination of tumor cells through the bloodstream and lymphatic system to other distant locations in the body, where they settle and continue to grow unchecked. These disseminations are called "metastases" (daughter tumors).

In this way, malignant tumors gradually destroy the body of their host until the patient ultimately succumbs. Physicians strive to counteract this by attempting to detect and remove the cancer in a timely manner before it forms metastases. This is successful, for example, in colorectal cancer, which can be discovered early through colonoscopy during preventive screenings and subsequently surgically removed. However, if the cancer is already too advanced and has formed metastases, the only option is to combat the tumor and its daughter disseminations in the body with medication, chemotherapy. This can lead to complete cure, but sometimes it only slows down tumor growth, providing an extension of life.

Malignant tumors can vary in their degree of malignancy. Their "dispositions" can be described as somewhat "gentle," or more "decisive," "aggressive," or "violent." Accordingly, there is a grading system for their malignancy, called "grading". There is a grading classification ("G") of tumor malignancy from G1 ("gentle") to G4 ("violent"). G1 cancers tend to grow relatively slowly, while G4 cancers generally grow very quickly. The only advantage of G4 tumors is their higher sensitivity to chemotherapy. They open the gates in their cell nuclei to grow faster, making them more accessible to chemotherapy drugs. This means that patients suffering from a G4 tumor can still have hope.

Note the following Topics to this Tumor Chapter:

• Lipomas (Fatty Tissue Groths)
• Atheromas (Sebaceous Cysts)