Malignant tumor
Malignant tumor definition
The diagnosis of “tumor” or “tumor suspect” is for everyone concerned a serious cut in his past life dar. Already in the first phase of personal confrontation with his disease, which can be characterized by anxiety, insecurity and despair, calls the disease a strong cooperation of the patient, because the person is facing directly to the position of the presumptive diagnosis of “tumor” may require a large number of clinical and instrumental investigations, surveys and interviews, so rapid an accurate diagnosis can be made.
All tests have to answer the following questions to the goal:
- If the tumor is benign or malignant (dignity)?
- What type of tumor is it?
- What is the extent of the tumor?
- If it is a tumor that occurs primarily in the bone or a metastasis (metastases of tumor tissue) of a tumor that is located outside of the spine?
- Lie metastases in other organs (liver, lung, lymph nodes)?
- What lies before tumor stage (staging)?
- As the treatment of the tumor (surgery, radiotherapy, chemotherapy)?
Only when the investigations have shown results to answer these important questions, it is possible to give the patient a thorough description of its clinical picture and to discuss with the parties concerned the consequences of his illness, possible treatments, risks and complications.
Since a tumor is always a very complex disease that affects mostly different disciplines of medicine, diagnostic and therapeutic treatment goals are discussed in general by a team of specialists from different medical areas and set out. The collaboration of these specialists in the so-called tumor conference guarantees to the affected patients the highest level of competence, quality and safety in the definition and implementation of diagnostics and therapy.
Which means “tumor”?
The term “cancer” comes from Latin and means “swelling or tumor” value-neutral and is used in medicine. Each mass is determined without knowledge of the dignity (“benign / malignant”) tumor called. On the spine is found, as well as the other bones of the skeleton, benign (benign) or malignant (malignant) tumors and malignant tumor metastases (metastases) of malignant tumors, which have their primary office outside the spine.
Such tumors can be classified?
The classification of tumors on the basis of cell groups from which they are formed and most likely also descended.
The assignment, if a tumor is benign or malignant and what histological type of tumor it is done by histological (tissue), histochemical and immunohistochemical studies. In these studies, proteins (proteins) of tissues to be visualized with the aid of antibodies, which will allow a conclusion that there is tissue specific (for example, what type of tumor tissue).
The benign tumors can be easily determined, as a rule, since they exhibit a highly differentiated cell morphology, ie, the cell structure is constructed from the same cells and acts homogeneously. The less differentiated one group of cells, the more difficult it can be precisely determine what dignity (benign / malignant), the tissue has to be examined, as can be in an undifferentiated tumor cells in various stages of cell differentiation.
The malignant bone tumors can, as well as benign tumors, their point of origin accordingly, in osteogenic (from bone outgoing), chondrogenic (from cartilage outgoing), vasogenic (of the vessels outbound), fibro-histiocytic (from the connective tissue outgoing) and hematopoietic (emanating from the bone marrow) tumors can be divided.
What are malignant bone tumors of the spine, it?
• Malignant tumors of osteogenic
Osteosarcoma
Osteosarcoma occurs due between the 10th and 20 Years on. Male children and adolescents are affected more often than females, adults are much less affected. Osteosarcomas in adults can be at the spine and pelvis irradiation of a tumor or other at a pre-existing Paget’s disease (disease of bone, which is characterized by the breakdown of bone) may arise. The cause of the origin of this tumor is not yet entirely clear, and growth-related hormonal factors are discussed as a trigger. The osteosarcomas arise in the metaphysis (growth plate) of long bones or in the cancellous bone (young bones) of the smaller bones. The main sites are the knee area, jaw bone, humerus, pelvis, hip, vertebral, and rarely small bones of hands and feet. Osteosarcoma tends to be very fast hematogenous metastases (Remote tumor Absiedelungen that are scattered through the bloodstream) are rare in the lungs, other bones or sections of the skeleton in the lymph nodes. The treatment of osteosarcoma consists of high-dose chemotherapy and resection of the tumor.
Aggressive osteoblastoma
The aggressive osteoblastoma is a rare, slow growing, malignant tumor that affects the spine, the vertebral arches and pedicles, and the long bones (humerus, femur).
• Malignant tumors chondrogenic
Chondrosarcoma / Chondromyxoidsarkom
Highly differentiated chondrosarcomas grow slowly, undifferentiated tumors can form in a few months large tumors, which form a vessel-poor, cartilaginous tumor tissue. This tumor frequently occurs between the 30th and 60 Years ago, men are more frequently affected. Chondrosarcomas occur frequently in the ribs, pelvis and long bones, more rarely in the spine. Metastasis occurs in the lungs and surrounding lymph nodes. Chondrosarcomas are less radiosensitive and respond to radiation therapy and chemotherapy, only a little. Therefore, the 1st choice of therapy is the most radical surgical removal of tumor tissue.
- Malignant tumors vasogenic
Hemangiosarcoma / Angioasarkom / hemangioendothelioma
These rare cancers begin in the blood vessels and occur mainly in the skin, liver, female breast in front, but also in the bone. Treatment consists of surgical removal of the tumor, chemotherapy or radiation therapy.
- Malignant fibrous histiocytic tumors
Fibrosarcoma
The proceeds from the fibrosarcoma tumor tissue, forming associations of collagenous fibers without bone or cartilage growth, dissolve the bone (osteolysis). The therapy consists of surgical removal of the tumor, because it responds poorly to chemotherapy or radiation treatment.
Malignant fibrous histiocytoma
This tumor has accumulated a wide histological appearance and appears to pre-existing damage to the bone (such as Paget’s disease or after high-dose irradiation). The tumor leads to an extensive osteolysis of the affected bone. Treatment consists of surgical removal and chemotherapy.
- Malignant tumors of hematopoietic
Plasmacytoma (multiple myeloma, multiple myeloma)
Plasmacytoma is the most common malignant tumor of the spine. The majority of cases occur after age 50 Years on, men are more frequently affected than women.
In multiple myeloma there is an uncontrolled proliferation of plasma cells in bone marrow, thus the formation of blood is disrupted. Plasma cells are part of the immune system and are formed in the bone marrow. The degenerate plasma cells lead to a resolution of the affected bone (osteolysis). With this reduction in bone calcium is released, causing the calcium in the blood is markedly increased (hypercalcemia). The proliferating plasma cells crowd out healthy red and white blood cells, so it comes to anemia (anemia) and susceptibility to infection and immune suppression. The gamma globulins are increased, there are paraproteins in urine (Bence Jones proteins).
The diagnosis is confirmed by a bone marrow biopsy. The most common sites are the vertebrae, ribs, clavicle, skull, pelvis and Oberschenkelknochen.Das myeloma is treated with chemotherapy and irradiation. In the presence of a single finding, myeloma of the spine, vertebral collapses existing or impending paraplegia, a surgical procedure may be necessary.
Ewing sarcoma:
Ewing sarcoma occurs in children and adolescents and is the most aggressive of all bone tumors. Ewing sarcoma is found mainly in the long bones, pelvis and vertebrae. This type of tumor grows very quickly and starts very early metastases in the skeleton and the lungs to scatter. Ewing sarcoma is radiosensitive and it speaks well of a chemotherapeutic treatment. Depending on the existing local findings a surgical tumor removal may be necessary.
Non-Hodgkin’s lymphoma (NHL):
In malignant lymphomas are malignant tumors of the lymphatic system. When it comes to this type of tumor degeneration and proliferation of lymphocytes, which can actually responsible for the immune defense of the non Hodgkin lymphomas arise sind.Da from lymphocytes at different developmental stages, they are divided into different groups (B-and T-cell lymphoma, low and high grade NHL). Because the tumor cells spread in the lymphatic system, they can occur almost anywhere in the body. The treatment of these lymphomas is the radiation, chemotherapy and radioimmunotherapy. Depending on the type of lymphoma, a bone marrow transplant or stem cell transplantation may be useful. Depending on the type of lymphoma, the location and stage of disease, surgical removal of lymphoma may be useful.
- Malignant tumors of other origin
Giant cell tumor (osteoclastoma, brown tumor)
Giant cell tumors are a group of semi-malignant tumors because they can deteriorate rapidly during benign to malignant form of deposits. This tumor occurs between the 15th and 40 Years on, women are slightly more affected than men.
Giant cell tumors occur in the connective tissue in the bone, the osteoclasts break down the existing healthy bone leading to osteolysis. The osteoclastoma tends to distance to the fault occurs again (relapse) and is difficult to differentiate cellular level, since it can change the image of its tissue structure. This tumor usually shows itself in the long bones, rarely in the spine, a metastasis in the lung is possible.
Chordoma
The chordoma is a potentially malignant tumor originating from the remnants of the notochord (the notochord arise during embryonic development of the vertebrae). This tumor is found almost exclusively in the area of ??the skull base, the Cross tailbone region and the cervical spine.
It occurs in middle age, leading to extensive osteolysis at the bone. The chordoma speaks to radiotherapy and chemotherapy to hard to see why a surgical procedure may be necessary depending on the local findings.
What symptoms can cause malignant tumors of the spine?
The type and severity of symptoms depend on the extent and location of the tumor. Since the presence of a tumor causes no specific symptoms, a differentiation of a tumor is suffering back pain from other causes, such as diseases of the spine due to wear, difficult, because there are similar symptoms.
>General symptoms such as
- Fever
- Weight loss
- Night sweats
- Fatigue
- Reduced performance
>pain with different causes and quality
Dull persistent pain in the level of infestation tumor
Periostschmerzen (periosteum) by raising and stretching of the periosteum as a result of the destruction of the cortical (outer wall of the vertebra) by the tumor
- Local pressure or percussion pain
- Pain at rest
- Load-independent pain
- Night pain
- Painful restricted movement of the spine
- lymph node enlargement
- Neurological disorders due to compression of the spinal cord or spinal nerves
Radicular symptoms resulting from pressure of the tumor on the spinal nerve roots.
Compression of the posterior spinal nerve root in the corresponding area-sensitive to precipitation with painful sensations. Pressure on the anterior spinal nerve root causes motor deficits with paralysis and atrophy of the muscles in the corresponding areas of distribution.
Paraplegia
With rapid tumor growth may lead to an acute complete paraplegia. Pressure on the posterior columns of the spinal cord results in disorders of depth perception and gait, and altered pain and temperature sensation. When damage to the pyramidal tracts by tumor pressure on the spinal cord may lead to the formation of a muscular weakness of the legs with a feeling of fatigue and temporary paralysis.
Disturbance of bladder and bowel function, sexual dysfunction
Changes in reflexes (increased, reduced, absent)
- instability of the affected motion segment by
Increasing destruction of tumorous vertebra affected
Pathological fracture of the vertebra destabilized
- symptoms emanating from the organ systems, in which sits the primary tumor and metastases spread into the spine. (Gynecological symptoms, discomfort in the gastrointestinal tract, genitourinary abnormalities in, lung, thyroid and prostate)
Such as malignant tumors of the spine diagnosed?
Malignant primary tumors of the spine are often found as an incidental finding during a radiographic examination of the spine because of “back pain”.
For each additional therapeutic approach, it is absolutely important to perform a consistent diagnosis, to the dignity (benign / malignant), the type of primary tumor of the observed vortex finding, and a possibly already existing Metastatic distant metastases in other organ systems (lungs, liver, lymph nodes) clearly is proved.
The following investigation procedures can be used for accurate diagnosis:
- Medical history and clinical examination
When and how the complaints have occurred (acute gradual onset)?
Did the symptoms occur without any apparent cause?
If an accident happens in the background?
Any history of spinal and back problems?
Is spinal mobility restricted?
Where is the pain?
How is the pain? (Dull, burning, continuous, intermittent, depending on load or posture)
Any soft tissue swelling?
Lymphadenopathy are detected?
It was unintentional weight loss?
Are there any abnormalities on clinical examination of the organ systems?
- Neurological examination
Are there any sensory or motor disorders?
Shows a limp through conservation, paralysis, or a shortening of the leg?
Are there any signs of bladder, rectal, or sexual function?
The muscle is normal or is an atrophy (muscle loss) before?
Are the reflexes changed?
- Apparative diagnostic imaging
Conventional X-ray
Plain radiographs in two planes with oblique or direct images as initial diagnosis can provide valuable clues. Location and extent of the tumor, the nature of the bony structure of the vortex and the height of the intervertebral space can be assessed. The location of the tumor within the vertebra, initial conclusions about the dignity (benign / malignant) of the tumor, since benign processes with the exception of hemangioma and eosinophilic granuloma, mostly in the posterior portions of the vertebrae and malignant tumors, mostly in the anterior portions of are found.
Computed tomography (CT)
With this layered imaging process can be represented tumor changes in the bony vertebral structure. Different sectional image slices, three-dimensional reconstructions of the local findings. Computed tomography is used to puncture a suspect targeted tissues or for presentation by narrowed spinal canal with the aid of used contrast agents (CT myelography).
Magnetic resonance imaging (MRI, magnetic resonance)
Magnetic resonance imaging is well suited to assess the positional relationship of the tumor to the spinal cord and spinal nerves, possible infiltration into the adjacent soft tissues and the displacement or the ingrowth of the tumor vessels in fine layers. This technique is now in the diagnosis of malignancy and their differential diagnostic differentiation from other diseases of the spine of the utmost importance. Another important application of MRI is the follow-up after surgery, radiation or chemotherapy, a vertebral tumor.
Nuclear medicine examination procedures
3-Phasenskelettszintigraphie
In this method the patient is injected with a radioactive marker (technetium-99m methylene diphosphonate), which then accumulates in bone where an increased metabolic activity. The entire bony skeleton is mapped, the areas with elevated bone metabolism are clearly distinguishable from the normal structures, so that all districts will be made visible simultaneously with increased metabolism. This method is nonspecific, that is, each district with increased bone metabolism are shown. A differentiation between benign and malignant tumor, osteoarthritis, or an infection of a vortex is feasible only with the help of other diagnostic procedures.
Positron emission tomography (PET)
With this method, after administration of a radiolabeled study drug increased metabolic processes (eg, the increased metabolism of a tumor) may be made in the body. Modern PET devices are combined with a CT scanner. This so-called “two-in-one scanner” creates images using both CT as performed in PET technology and the computer then combines into a meaningful picture.
Single-photon emission computed tomography
(SPECT) This nuclear medicine examination method, in combination with spiral computed tomography, after administration of different level radioactivity altered metabolic processes in the body to visualize the molecular level. By combining the two methods, the data obtained with the SPECT images are combined data of the layer of spiral computed tomography, so that an exact localization of the abnormal regions of the body.
Myelography
Myelography, the administration of contrast medium into the spinal canal changes that narrow the spinal canal or to compress the spinal nerves (eg, tumor compression, herniated disc) made visible. By changing the position of the patient on the examining table, the contrast medium over the entire spinal canal is distributed, dynamic analysis is possible in motion under fluoroscopy. The myelogram is usually combined with a CT scan.
- Biopsy and histological examination
In a biopsy, various methods of tissue taken from a suspicious area, which can then be examined microscopically. This investigation method allows reliable assessment of a tumor is benign or malignant, and that further therapeutic steps must be taken.
There are several different biopsy methods:
Closed methods
In fine needle biopsy or punch biopsy, a small amount of the suspected tissue is removed under general anesthesia. Under microscopic evaluation then the exact histological (histological) diagnosis. (Type of tumor, benign / malignant) These punctures are gentle and are carried out usually under control with computed tomography.
Open procedures
By excision or incision are altered by tumor under general anesthesia either completely or partially removed and histological examined.
- laboratory diagnostics
Laboratory diagnostics are usually no clearly positive proof of the existence of a tumor, some laboratory parameters are nonspecific, ie, they can be changed by other diseases.
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- White blood cells (WBCs)
The increase in this so-called inflammatory markers may be present in tumors, but may occur in other kind of infection.
Tumor markers are proteins that are found in low concentrations in blood plasma and tumor cells, sometimes can be made and determined by normal cells. Increasing the concentration of various tumor markers may be an indication of the presence of a particular tumor, but it is not conclusive. Known tumor marker include:
alpha-fetoprotein (AFP) as an indicator for carcinoma of the liver
Neuron-specific enolase (NSE) as a reference to a small cell lung cancer or neuroendocrine tumors
Prostate-specific phosphatase (PSA) as an indicator for prostate cancer
Monoclonal antibodies from the group of cancer antigens (CA) can provide depending on the existing CA type, on tumors of the mammary gland, pancreas or stomach.
Carcinoembryonic antigen (CEA) as an indicator for tumors of the gastro-intestinal tract
How is the procedure in the diagnosis of bone tumors or bone metastases (staging)?
If a tumor on the bone or other body established by the treating physician must quickly form an overall picture of the following factors in order to group the newly identified tumor in a particular stage:
Dignity, which means the tumor is benign or malignant?
An exact statement as may be made through a biopsy and the histological microscopic examination (histology).
In this investigation, and the extent of differentiation of the tumor cell aggregates are determined, ie how much different the tumor cell groups of healthy, differentiated cells. This process is known as tumor grading, and provides valuable information on the aggressiveness, the growth and metastasis tendency of the tumor.
The Gradingsstufen by G1 (well differentiated) to G4 (undifferentiated) divided. The less differentiated tumor tissue, the more pronounced is the malignancy.
Tumor location and spread
By computer and magnetic resonance imaging, the location and extent of the tumor and its relationship to adjacent tissue structures are detected.
Lie Absiedelungen of the tumor (metastases) in other organ systems before (lungs, liver, bone)?
Whole-body scintigraphy cytoskeleton, MRI and CT show whether and where distant metastases.
The exact knowledge of the above factors are crucial to an individual prognosis and treatment strategy to create the gradient.
Is there a system by which malignant bone tumors or bone metastases are classified (TNM classification)?
For all malignant tumors, with the exception of leukemia and malignant lymphoma, there is the so-called TNM – system that can be used to assess the existing individual tumor disease.
The TNM system is internationally standardized and supported by the attending physicians in the diagnosis and in the course of the disease through a common “language”. The three letters stand for:
T (tumor), tumor size or extent of the primary tumor
N (Node, Node) If there are lymph node metastases?
M (metastasis) Where from the primary tumor?
G (grading) What degree of differentiation of the tumor tissue is present?
The letters T, N, M and G are additionally provided with numbers, then a statement about the size of the tumor (T1-T4), the existence and number of Lymhknotenmetastasen (N0-N3), the absence or presence of distant metastases in other organ systems (M0 or M1) and the degree of differentiation of tumor tissue (G1-G4) permit.
, No definitive statement can be made at diagnosis to one of the three factors of the TNM system and grading, it is called with the additional letter X. “MX” for example, would mean that can be made about the presence of distant metastases, no reliable statements.