INTRODUCTION TO

ONCOLOGY
& TREATMENT MODALITIES

Radiotherapy Deptt. AIIMS Bhopal

Objectives
 What is Cancer ?.

 Branches of Oncology.

 Diagnostics & Treatment modalities.

 Classification of Cancer.

 Difference between Malignant & Benign tumours.

 Advances in Oncology.

 Various treatment modalities in Oncology.

 DEFINITION
• Neoplasia means ‘new growth’
• Cancer is a non-specific term meaning lump or swelling, often a
synonym for neoplasm.

• Neoplasm means ‘tumor / cancer’ abnormal mass of tissue whose growth

exceeds and is uncoordinated with that of normal tissues and persists in
the same excessive manner even after cessation of the stimuli which
evoked the change.

• It can be benign or malignant.

• Benign: Cells grow as a compact

mass and remain at their site of origin.

• Malignant:
Growth of cells is uncontrolled
Cells can spread into surrounding
tissue and spread to distant sites.
 ONCOLOGY

Oncology is a branch of medicine that deals with the

prevention, diagnosis, and treatment of cancer.

Branches of Oncology :-

1. Surgical Oncology
2. Radiation Oncology
3. Medical Oncology
 Differences between benign and
malignant neoplasms
BENIGN MALIGNANT
Nuclear variation in Nuclear variation in size and
size and shape shape minimal to marked,
minimal often variable
Diploid Range of ploidy
Low mitotic count, Low to high mitotic count,
normal mitosis abnormal mitosis

Retention of Loss of specialisation

specialisation
Structural
differentiation Structural differentiation shows
wide range of changes
retained
Organised Not organised
Functional Functional differentiation often
differentiation lost
usually
 HALLMARKS OF CANCER.
cancers display eight fundamental
changes in cell physiology,
Which are as following:
1. Self-sufficiency in growth signals
2. Insensitivity to growth-inhibitory
signals
3. Altered cellular metabolism
4. Evasion of apoptosis
5. Limitless replicative potential
(immortality)
6. Sustained angiogenesis
7. Invasion and metastasis
8. Evasion of immune surveillance
 NOMENCLATURE OF NEOPLASM

Benign Tumor's :
MESENCHYMAL EPITHELIAL
- Suffix - oma to cell of origin
Lipoma Adenoma
- Name of Origin cell +
Fibroma Papilloma
morphologic character + -oma
Chondroma Cystadenoma

 Misnomers - Hematoma, Osteoma Papillary

Granuloma Cystadenoma
Choriostoma,
Rhabdomyoma Polyps
 Exceptions - Hepatoma, Leiomyoma
Mesothelioma,
Lymphoma, Hemangioma
Seminoma Lymphangioma
 NOMENCLATURE
Malignant tumors:
Name of origin cell + morphologic character + carcinoma/
sarcoma

Solid Mesenchymal Tissues

Derived from Mesoderm; are suffixed with -sarcoma
Liposarcoma
Fibrosarcoma
Chondrosarcoma
Osteosarcoma
Blood vessels - ?
Lymph vessels – ?

Epithelial Tissue tumours are suffixed with - carcinoma

May be derived from any germ cell layer
Squamous cell Carcinoma
Renal cell carcinoma
Mesothelioma
 SPECIAL NOMENCLATURE
• Blastoma: tumors arising in immature tissue or nervous tissue,
most of them are malignant

– E.g.: medulloblastoma, retinoblastoma, nephroblastoma

• Some tumors ataching the suffix- oma, but they are malignant

• Malignant tumor of the liver: Hepatoma

• Melanoma of the skin: Melanoma
• Lymphoproliferative tumor: Lymphoma (Hodgkin’s and Non Hodgkin’s)
• Malignant proliferation of leukocytes: Leukemia
MIXED TUMORS
A. Derived from 1 germ layer –

 These undergo Divergent Differentiation

eg. Pleomorphic Adenoma of salivary glands

B. Derived from all 3 germ layers –

Teratoma
i. Benign (mature) (e.g. benign dermoid cyst)
ii. Malignant (Immature) (e.g. malignant teratocarcinoma)
COMPARISON BETWEEN A BENIGN TUMOR
OF THE MYOMETRIUM (LEIOMYOMA) AND A
MALIGNANT TUMOR OF THE SAME ORIGIN
(LEIOMYOSARCOMA)
CHARACTERISTICS OF BENIGN &
MALIGNANT TUMORS
 CANCER SCREENING SIGNS AND
SYMPTOMS
As simple as…..The Seven Danger Signals
The American Cancer Society uses the word C-A-U-T-I-O-N to
help recognize the seven early signs of cancer:
1. Change in bowel or bladder habits.
2. A sore that does not heal.
3. Unusual bleeding or discharge.
4. Thickening or lump in the breast, testicles, or elsewhere.
5. Indigestion or difficulty swallowing.
6. Obvious change in the size, color, shape, or thickness of a
wart, mole, or mouth sore.
7. Nagging cough or hoarseness.
These signs don't necessarily mean you have cancer, but
it's important to have them checked out

• Persistent coughing or hoarseness

 CAN SCREENING FOR CANCER BE
USEFUL?
Definition: Screening is defined as the presumptive identification of
unrecognized disease in an apparently healthy, asymptomatic population by
means of tests, examinations or other procedures that can be applied rapidly
and easily to the target population.

Primary prevention: Finding and removing adenoma thus reducing Colorectal

cancer burden

Screening to Prevent Cancer:

 The WHO defines screening as the identification of unrecognized disease by
the application of a rapid test.
 Four cancers commonly screened are:
 cervical cancer by a Pap smear using Acetic Acid
 breast cancer by mammogram and/or self breast examination
 colon cancer by colonoscopy
 prostate cancer by a PSA test and digital rectal examination
SCREENING
There are two requirements for usefulness of screening:
 Test must detect cancer early
 There should be evidence that early treatment results in improved outcome
 To screen the right population.
Ideal screening test • Cheap • Sensitive • Specific • Accessible • Safe • Acceptable

Other important aspects of Cancer Screening:

 The best types of cancer for screening are those with a reasonably high
incidence of a population at risk
 Reliability and Validity
 There should be a long preclinical phase where treatment can begin
 Test should easily done,at a modest non-prohibitive cost.
 Acceptability of a test: Will the patient show up for the test?
Detection methods for screening include
 palpation (breast, prostate)
 internal methods (endoscopy, mammogram)
 biochemical markers (PSA for prostate).
Pitfalls of screening :

● False-positive test result: Lead to anxiety and unnecessary invasive diagnostic

procedures.

● Over diagnosis: Diagnosis of a condition that would not have become

clinically significant had it not been detected by screening.

● False-negative test result: Falsely reassure an individual with subsequent

clinical signs or symptoms of cancer and thereby actually delay diagnosis and effective
treatment.

The key of therapy is to practice Personalized Medicine as much as possible and in

cancer, we're working toward that at the molecular level-targeting DNA Mutations.

Clinical trials are used to evaluate cancer treatment protocols and maybe Interventional
(two competing protocols) or Observational (people are given treatment and observed).
 DIAGNOSIS
• Screening

• Self examinations

• Biopsy

• X-rays, CT scans, MRI scans, PET scans, and ultrasound scans

• Molecular diagnostic test

• More than 90 percent of all cancers are diagnosed by some form of

biopsy: needle aspiration, core needle biopsy, incisional biopsy(piece of
tumor), or excisional biopsy (entire tumor—e.g., mole)
 Causes of cancer
Three major type of carcinogens

Chemical carcinogenesis
• Mutagens
• Chemical carcinogenesis and their metabolism

Physical carcinogenesis (radiation)

• Ultraviolet radiation, Asbestos

Infectious Pathogens (Viral)

• Human T-cell leukemia viruses, DNA
viruses, Human papillomaviruses
• Epstein-Barr virus, Hepatitis B virus
 CAUSES OF CANCER

Environmental factors

 Tobacco Genetic
 Alcohol E.g.

 Dietary Factors
• Retinoblastoma in
Children
 Occupational exposures
• Leukaemia in Mongols
 Viruses

 Parasites

 Customs ,habits, Lifestyles

 Others – sunlight, pollution, drugs

CANCER BURDEN GLOBOCAN 2018 :
INDIA
TREATMENTS
• Surgery

• Radiotherapy

• Chemotherapy

• Immunotherapy

• Hormone therapy

• Gene therapy

• Cancer-specific immune system cells to treat cancer

 TREATMENT OF CANCER

It’s a multidisciplinary treatment for cancer that includes surgery,

radiation, and chemotherapy.

Importance of Consent(most elaborate!).

Surgery is most effective for localized cancers.

If the cancer has spread at diagnosis, which unfortunately is the case
at least half of the time, then regional radiation can be used, and
chemotherapy has to be used.

Clinical trials are conducted to evaluate treatments. Clinical trials are

used to evaluate cancer treatment protocols and maybe Interventional
(two competing protocols) or Observational (people are given
treatment and observed).
 TREATMENT OF CANCER

Human clinical trials go through three phases to study maximum tolerated dose:
safety, side effects and effectiveness compared to current standard therapies —
referred to as phases I, II, and III, respectively.

It is a long and expensive process, costing in the range of hundreds of millions

of dollars.

Preventive Surgeries:
 Surgical procedures are sometimes used to prevent cancer. For example, an
operation to descend an infant’s undescended testis may prevent later
testicular cancer; or, where a mutated BRCA1 gene is present, surgical
removal of breasts and ovaries may be indicated
 SURGICAL TREATMENT
Advantages of surgery
 Tumor has no biological resistance to it;
 Unlike radiation and chemotherapy, there are no carcinogenic side effects;
 Tumor heterogeneity is not an issue; and
 If the cancer is localized, surgery can affect a total cure.

Disadvantages
 Unintended removal or damage of normal tissues
 loss of normal function; and
 Increased growth of metastases if the tumor is not localized.
 TREATING CANCER WITH RADIATION

Radiation is one of the most common treatments for cancer. Other names for
radiation treatment are radiation therapy, radiotherapy, irradiation,or x-ray
therapy.

Radiation therapy uses high-energy particles or waves, such as x-rays,

gamma rays, electron beams, or protons, to destroy or damage cancer cells.

There are two main types of radiation therapy,LINAC external beam(EBRT)

and internal(Brachytherapy).

Radiation treatment is planned to damage cancer cells, with as little harm as

possible to nearby healthy cells.

Radiation, like surgery, can cure a localized cancer, and it is also used as an
adjunct to other treatment methods as Neo-adjuvant, Concurrent and Adjuvant
therapy
TREATING
CANCER WITH
RADIATION

Radiation works by
making small breaks
in the DNA inside
cells. These breaks
keep cancer cells
from growing and
dividing and cause
them to die.
Radiation acts through
DIRECT and INDIRECT
effect.
TREATING CANCER WITH CHEMOTHERAPY

•The modern era of cancer chemotherapy can be traced in part to the discovery of
nitrogen mustard, a chemical warfare agent, as an effective treatment for cancer in
the 1940s.

•Neo-adjuvant Chemotherapy and Adjuvant Chemotherapy

•The effectiveness of chemotherapy against cancer depends on several factors: the

biology of the tumor (sensitivity to chemotherapy), the pharmacology of the drug,
and the patient’s condition and tolerance for side effects.

•As with radiation, the therapeutic index is critical. Tumor sensitivity to a drug may
be increased
• if the tumor DNA is already damaged;

• if it is rapidly dividing;
• if the tumor produces new proteins, they may be targeted by a drug.
 TREATING CANCER WITH CHEMOTHERAPY

For drugs to be effective, the blood supply to the tumor

(angiogenesis) must be enough; the drug must be able to cross
the cell membrane and, in some cases, get into the nucleus of the
cell itself.
Rationale for Combination Chemotherapy:
 There are new mutations that happen in a tumor as the tumor
grows, thereby leading to Resistance;
 Heterogeneity of the tumor—the idea that different cells respond to
different agents
 Different drugs treat different phases of the cell cycle

Remission vs Cure vs Tumor Control

SIDE EFFECTS AND RECENT ADVANCES

Side effects to chemotherapy can be very debilitating and limit patient tolerance
to treatment. Drugs that interfere with tumor cell division will also affect gut,
bone marrow, skin, and hair causing Diarrhea, Hair loss ,Nausea and Fatigue

Mechanisms of resistance
 through additional mutations

 through selective growth of previously resistant cells

 decreased drug uptake by cells

 decreased drug activation and/or increased drug deactivation

 increased repair of tumor cell damage

 alteration of the target by mutation

 TARGETED THERAPY
•Targeted therapy is a cancer treatment that uses drugs. But it is different from
traditional chemotherapy, which also uses drugs to treat cancer. Targeted therapy
works by targeting the cancer’s specific genes, proteins, or the tissue environment
that contributes to cancer growth and survival. These genes and proteins are found
in cancer cells or in cells related to cancer growth, like blood vessel cells.

•There are two main types of targeted therapy 1. small molecule drugs, which are
small enough to enter cells. 2. monoclonal antibodies, which are too large to enter
cells.

Examples : 1. Imatinib (Gleevec) is approved for chronic myelogenous

leukemia, gastrointestinal stromal tumor and some other types of cancer.

2.Rituximab targets CD20 found on B cells. It is used in non Hodgkin lymphoma.

IMMUNOTHERAPY AND GENE THERAPY
Immunotherapy is treatment that uses certain parts of a person’s immune
system to fight diseases such as cancer. This can be done in a couple of ways:
• Stimulating your own immune system to work harder or smarter to attack
cancer cells
• Giving you immune system components, such as man-made immune system
proteins.
Types of Immunotherapy :
Monoclonal antibodies: These are man-made versions of immune system
proteins.
Immune checkpoint inhibitors: These drugs basically take the ‘brakes’ off the
immune system, which helps it recognize and attack cancer cells.
Cancer vaccines: Sipuleucel-T is a vaccine- for prostate cancer .
intravesical BCG immunotherapy for superficial bladder cancer.
IMMUNOTHERAPY AND GENE THERAPY
• CTLA-4
Another way to stimulate the immune system is, essentially, to stop it from
getting tired
CTLA-4 acts as brakes on the immune system. A drug called Yervoy
(ipilimumab) has been developed that stops the CTLA-4 from acting, and as a
result, the immune system keeps fighting the cancer
• Herceptin
In the context of immune therapy, one targeted therapy involves a drug called
that attacks breast cancer cells that have too much of a certain protein, HER2,
with an antibody protein that binds to the HER2 antigen on the cell surface and
destroys the cancer cell.
 GENE THERAPY

 Cancer gene therapy is still in its very early and primitive stages and is used

chiefly on very sick patients who have not benefited from standard therapies.

There are three types of gene therapy:

 Mutation compensation,

 RNA interference, and

 tumor-specific viruses.
 ACKNOWLEDGMENT

1. De Vita, Hellman, and Rosenberg's Cancer, Principles and

Practice of Oncology 11th edition

2. (Robbins Pathology) Vinay Kumar, Abul K. Abbas, Jon C.

Aster - Robbins and Cotran Pathologic Basis of Disease,
Professional Edition-Saunders (2014).

3. Cancer Nursing-Principle and Practice- 7th edition by Connie

Henke Yarbro, Debra Wujcik.

4. Principles and Practice of Radiation Oncology – 7th edition

Perez & Braddy.
THANK YOU