Syllabus of the subject cancer 2002 Introduction In the large majority of cases, the treatment of malignant tumours is complex

and highly specialised. It can be guided only by a specialist-oncologist. The training of medical students in the subject Cancer is not aimed at making such specialists, only teaching of basic knowledge and practice of oncology, strictly relevant for other areas in medicine. The teaching will be based on pathophysiological, pathological and clinical features of a particular malignant disease. After having successfully finished the subject, the student must know well the symptomatology of malignant diseases. Logical approach to the relevant investigations and treatment strategy will be required. One of the main problems in oncology is a late diagnosis of a malignancy, causing delay in instituting an appropriate treatment. It will be repeatedly stressed that tumors must not be forgotten in the differential analysis of most symptoms. The teaching should go along following baselines: terminology and nomenclature of malignant diseases, symptomatology of malignancies, rational indication of additional investigation procedures including the assessment of their results, principles of treatment modalities in oncology, indication, timing and sequence of treatment modalities in a particular malignant disease explaining the necessity of a complex treatment, basic follow-up guidelines, possible side-efects of oncological therapy, their early diagnosis and treatment, ways and possibilities of cancer prevention. In view of the introduced concept of study in the 3 rd Medical Faculty, there is a substantial overlap between oncology and other medical specialities. Clinical importance. Malignant diseases are the second cause of death in the Czech population. At present, approximately one in three persons will be diagnosed having a malignant tumour and every fifth one will die of it. Definitions of malignant and benign tumours (characteristics). Epidemiology. Risk assessment and methods of risk definition. Incidence and prevalence. Most common malignancies (acc. to age and sex). Molecular biology (onkogenes), physical and chemical cancerogenes Common cancerogenes. Onkogenes divided according to the mechanism of action. Mechanism of action of chemical and physical cancerogenes. Ways of elimination and decreasing the risk of cancerogenes. Principles of treatment of malignant tumours Intent Radical therapy. Palliation. Symptomatic treatment. Sequencing and timing. Neoadjuvant, basic, adjuvant. Induction, maintenance, consolidation, salvage. Concomitant, sequential.

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Modalities of the treatment. Surgery. Oncological surgery is part of training in general surgery Radiotherapy. Basic definitions.Types of ionizing radiation and examples of clinical use. Absorption of ionizing radiation in the matter. Possibilities how to influence the dose distribution. Mechanism of action in malignant and healthy tissues. Teleradiotherapy vs brachyradiotherapy. Radiotherapy planning. Definition of the target volume. Basic radiobiology. Kinetics of cell killing by ionizing radiation. Differences between healthy and malignant cells and possibilities of its positive exploration. Total dose, dose per fraction. Overall reatment time. Hyperfractionation, hypofractionation, acceleration of radiotherapy. Dose rate and its influence on therapeutic index. Acute, chronic and late radiation toxicity. Integration of radiotherapy into a complex oncological treatment. Chemotherapy. Basic definitions. Kinetics of tumour growth, response to cytostatic drugs. Grouping of cytostatic drugs according to their mechnism of action and chemical structure. Principles of combining cytostatic drugs. Means of administration, dosage, intensity of chemotherapy, total length of chemotherapy. Resistence to chemotherapy, and ways how to influence it. Acute, chronic and late toxicity of chemotherapy. Integration of chemotherapy into a complex oncological treatment. Hormonal treatment. Mechanism of hormonal manipulation. Examples of malignant tumors in which hormonal treatment plays an important role. Immunotherapy. Principles of immunotherapy. Basic clinical application of immunotherapy. Supportive treatment. Pain. Causes and sorts of pain in oncological patients. Full assessment of pain. Treatment (treatment modalities and combinations). Infection in oncological patients. Most common infection causes in oncology.Prevention and treatment. Nutrition, disorders of metabolism. Causes. Therapy. Psychological support. Research in oncology. Phases of clinical research. Basic statistical terms, used in oncology. Special oncology. CNS tumours. Definition and clinics- also part of the subjects Disorders of the nervous system. Incidence. Anatomy of the central nervous system. Risk factors. Genetic. Physical. Other. Basic grouping. Primary vs secondary. Most common malignancies, metastasizing into the CNS.

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According to histopathology - astrocytoma, ependymoma, oligodendroglioma, spongioblastoma, meningeoma, craniopharyngeoma, pipuitary adenoma, neurinoma, medulloblastoma, germinal tumours, hemangioma. According to localisation - brain hemispheres, cerebellum, brain stem, optic nerve, cerebellopontine angle, pituitary and adjacent area, epiphysis, spinal cord, meninges. Natural history and symptoms (according to the localization and tumour type) - headache, vertigo, visual disturbances, disturbances of speech, increased intracranial pressure, motor, sensory a sensitive deffects, signs of compression or destruction of surrounding structures, epileptic fits and further neurological symptoms Diagnosis a differential diagnosis. History a physical examination. Additional investigations CT, NMR, biopsy if possible. Further investigations (acc. to localisation and histology) Therapy. Basic aim- radical and palliative treatment in particular tumours. Indication of radical neurosurgery in particular tumours, radiotherapy, cytostatic chemotherapy, side-effects of therapy, supportive treatment, rehabilitation, results and prognosis, prognosis in particular tumour types, importance of careful follow-up, difference in prognosis between adults and children. Head and neck tumours. Incidence. Anatomy a physiology - grouping according to anatomy (oral cavity, naso-, oro- and hypopharynx, larynx, nasal cavity and sinuses, salivary glands, ear). Risk factors smoking, alcohol abuse. Clinical picture - pain in the neck, dysphagia and odynophagia, bleeding, voice change, neck lymphadenopathy. Symptoms according to the localisation of primary lesion Histopathology of malignant ENT tumours (variants) - epidermoid carcinoma, malignant lymphoma, adenocarcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma. Diagnosis a differential diagnosis. History. Physical examination - incl. endoscopy (direct and indirect laryngoskopy, epipharyngoscopy, rhinoskopy). Additional investigations - CT, MRI, ultrasonography of the neck. Biopsy. Indication and types Treatment - surgery, radiotherapy, chemotherapy, combination of radiotherapy and surgery and/or chemotherapy with regard to organ and function saving procedures. Prevention- see risk factors. Results and prognosis, scheme of follow-up Skin cancer. Clinical picture- also part of the subject Skin changes. Anatomy of the skin. Etiology a patophysiology. Risk factors. Genetic. Non-familial. Exposition to the ionizing and non-ionizing radiation. Chemical cancerogens. Malignant transformation of a pigmented nevus.

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Histopathology precanceroses, melanoblastoma, spinocellular carcinoma and basalioma, skin lymphoma. Diagnosis and differential diagnosis. History. Physical examination. Treatment. Surgery. Basic principles of radical treatment of melanoma and non-melanoma. Radiotherapy. Adjuvant treatment of melanoma. Results and prognosis Tumours of the thyroid gland. Anatomy a physiology of the thyroid gland. Risk factors. Hereditary. Non-familial. Histopathology - adenoma and carcinoma, tumours from the follicular cells, medullary carcinoma, lymphoma. Diagnosis and differential diagnosis. History. Clinical examination. Laboratory investigation, ultrasonography, CT... Differential diagnosis of a thyroid mass. Treatment - surgical treatment. Rational approach- parcial vs subtotal thyreoidectomy. Indication of adjuvant treatment. Radiotherapy (teletherapy and metabolic brachytherapy)rational. Suplementation of thyroid hormones / TSH suppression. Complications surgery, adiotherapy. Results and prognosis. Prevention. Tumours of the mediastinum. Also part of subjects Dyspnoe and pain on the chest and Abdominal symptomatology dysphagia, nausea, vomiting, regurgitation... Anatomy of the mediastinum, topography. Symptomatology - dysphagia, odynophagia, loss of weight, pain on the chest, recurrent pneumonia. Special problematics (e.g. thymoma hypogamaglobulinemia, collagenosis) myasthenia gravis, aplastic anemia,

Basic groups - carcinoma of the oesophagus, thymoma, a eurogenic tumours, germinal tumours, lymphomas, (tumours of the thyroid gland- if thyroid localised in the mediastinum). Ethiology. Histopathology of mediastinal tumours - adenocarcinoma and epidermoid carcinoma, malignant lymphomay, adenoma, thymoma, neurogenic tumours, germinal tumours.

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Diagnosis and differential diagnosis. History. Physical examination. Additional investigations - chest X-ray, MRI, CT of the mediastinum, esophagoscopy, mediastinoscopy, liver sonography. Differential diagnosis of enlarged mediastinum. Treatment. Indication of radical and palliative treatment- in general. Surgery. Basic surgical procedures in oesophageal carcinoma. Radiotherapy- indication of radical and adjuvant radiotherapy Brachytherapy and teletherapy. Indication of chemotherapy. Results and prognosis Lung carcinoma, mesothelioma. Definition and clinics- also part of the subject Dyspnea and pain on the chest. Lung anatomy, physiology of gas exchange, interpretation of lung function tests Etiology and patophysiology. Histopathology. Benign lung tumours. Small-cell and non-small-cell lung carcinoma. Mesothelioma. General and chest symptoms. Loss of weight, cough, dyspnea, pain on the chest, hemoptysis, stridor, superior vena cava syndrome, dysphagia, Horners syndrome, Pancoast syndrome. Extrathoracic symptomatology caused by metastases. Paraneoplastic symptoms. Also part of the subject Endocrine and metabolic disorders. Diagnosis and differential diagnosis. History. Physical examination. Additional investigations - chest X-Ray, CT, bronchoscopy, mediastinoscopy and thoracoscopy, biopsy. Differential diagnossis of pleural effusion. Treatment. Indication and basic thoracosurgical approaches. Radiotherapy (indication, techniques). Chemotherapy (indication, basic drugs and combinations). Indication of prophylactic cranial irradiation in small-cell lung carcinoma. Results and prognosis Prevention Tobacco abuse. Mesothelioma as a result of occupational hazard Breast carcinoma. Incidence, risk factors.

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Genetic. Non-familial, especially relationship to estrogens. Anatomy of the breast. Histopathology - non-invasive and invasive carcinoma, basic subgroups. Special categoryPagets disease, phyllodes tumour. Inflammatory breast carcinoma. Characteristics and natural course of the disease. Diagnosis and differential diagnosis. History. Physical examination. Technics of the breast and lymphatic areas examination. Additional investigations- basic risk features in mammography, ultrasonography. Biopsy. Additional staging examinations (Chest X-Ray, bone scintigraphy, liver sonography, tumour markers). Treatment - surgery. Indication of mastectomy and breast conserving surgery. Radiotherapy. Basic indications- basic, adjuvant, salvage, palliative. Possible treatment complications. Chemotherapy. Neoadjuvant, adjuvant, palliative. High-dose chemotherapy. Hormonal treatment. Follow-up. Rationale indications. Results and prognosis. Screening. Recommended procedures in standard and high-risk population. Tumours of the abdomen and pelvis. Basic grouping. Carcinoma of the stomach. Tumours of the liver and subhepatic region, carcinoma of the pancreas and biliary ducts. Tumours of the small intestine. Colorectal carcinoma. Ovarian carcinoma. Anatomy of the organs of the abdomen - portal system, lymphatic drainage of particular abdominal organs. Definition and clinics- also part of the subject Pain in the abdomen. Symptomatology pain, loss of appetite, loss of weight, cachexia. Nausea, vomiting, disorders of the passage up to the acute ileus. Changes in the stools habits, changes of the stools colour and consistency. Obstructive icterus. Hematemesis, melaena, hypochromic anemia, fatigue. Enlargement of the abdomen. Bleeding. Symptoms due to hormone overproduction (carcinoid, islet-cell tumours of the pancreas, steroid hormones in endocrine active ovarian tumours). Risk factors. Genetic. Other. Patology of GIT tumours and ovarian carcinoma - adenocarcinoma, malignant lymphoma, carcinoid. Islet-cell tumours of the pancreas. Histopathology of ovarian tumours incl. germinal and gonadal tumours.

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Diagnosis and differential diagnosis. History. Physical examination incl. per rectum examination. Additional investigations: X-Ray of the stomach (double contrast method), gastroscopy, ultrasonography and CT of the abdomen, ERCP, i.v. urography, cystoscopy, colonoscopy, rectoscopy, irrigography Importance of tumour markers in the diagnostics and follow-up of GIT and ovarian carcinoma Treatment - surgery of the stomach, intestine, ovarectomy and adnexectomy. Pelvic and paraaortic lymphadenectomy. Chemotherapy - basic indication. Radiotherapy - basic indication. Possibilties of screening and prevention. Ovarian cancer. Colorectal carcinoma. Prognosis. Urogenital tract tumours except testicular carcinoma (tumours of the kidney, ureter, urinary bladder, urethra and prostate). Anatomy of the urogenital tract. Definition and clinical picture. Hematuria and dysuria- part of the subject Bleeding. Etiology and patophysiology. Risk factors. Histopathology - adenocarcinoma of the kidney, urinary bladder and prostate. Transitional cell carcinoma, epidermoid carcinoma. Wilms tumour and sarcomas- see Childhood tumours. Diagnosis and differential diagnosis. History and physical examination. Examination per rectum, bimanual examination under anaesthesia. Additional investigations- IVU, CT of the abdomen, ultrasonography, cystoscopy and endoscopic biopsy, tumour markers (PSA), transrectal endosonography. Characteristic and natural course of the disease. Influence on the treatment strategy. Treatment - surgery- radical nephrectomy, radical cystectomy, radical prostatectomy. Indication and basic procedure. Palliative nephrectomy. Transuretral resection of the prostate. Radiotherapy. Basic indication and technique. Acute and chronic treatment toxicity. Chemotherapy. Basic indication, choice of drugs. Hormonal manipulation. Mehanism of action. Basic indications and contraindications. Imunotherapy. Indications and treatment toxicity. Results and prognosis Follow-up. Rational indication of procedures Tumours of the testis. Clinical picture- also part of the subject Reproduction and developmental disorders. Anatomy and embryology.

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Lymphatic drainage. Development of the sperm, hormonal production. Etiology and patophysiology, risk factors. Histopathology - germinal tumours (seminomas and non-seminomas). Gonadal tumours. Other. Diagnosis and differential diagnosis. History. Physical examination. Additional investigations - ultrasonography, staging procedures (CT of the pelvis and retroperitoneum, bipedal lymphography, CT of the mediastinum, chest X-Ray), tumour markers Differential diagnostis of testicular tumours. Treatment - surgery: High transinguinal orchiectomy as diagnostic and therapeutic procedure. Retroperitoneal lymphadenectomy. Radiotherapy. Basic indication and technique. Chemotherapy. Indication and drugs. Unsolved issues of adjuvant treatment. Results and prognosis. Follow-up. Importance of tumour markers.

Gynecologic tumours (except carcinoma of the ovary and Fallopian tube)- carcinoma of the uterus, uterine cervix, vagina and vulva. Clinical picture- bleeding in the menopause, post-coital bleeding, vaginal discharge- also part of the subjectBleeding. Ethiology and patophysiology. Risk factors. Estrogens. HPV, HIV. Anatomy of the female pelvis. Histopathology - precanceroses of the uterine cervix and endometrium. Epidermoid carcinoma, adenocarcinoma. Diagnosis and differential diagnosis. History. Physical examination. Additional investigations - colposcopy, cytology, fractionated curretage of the uterus, lung Xray, cystoscopy and rectoscopy, renal ultrasonography, CT of retroperitoneum and pelvis, i.v. urography, bipedal lymphography. Treatment - surgery. Indication and procedures. Radiotherapy (teletherapy and brachytherapy). Rational of the combination. Acute and chronic side-effects. Role of chemotherapy.

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Results and prognosis. Sex education. Hormonal manipulation. Screening- cytology. Carcinoma of the anus. Clinical picture. Anatomy of the anus and anal region, lymphatic drainage. Risk factors. Diagnosis. History. Physical examination. Additional investigations - CT, bipedal lymphography, lung X-ray. Treatment radiotherapy, radio-chemotherapy. Surgery. Indication of particular treatment modalities, especially from the point of an organ and function preservation. Results and prognosis. Bone and soft tissue sarcoma. Also part of the subjectDisorders of the locomotive system. Etiology and patophysiology. Histopathology - liposarcoma, leiomyosarcoma, rhabdomyosarcoma, angiosarcoma, fibrosarcoma, osteo- and chondrosarcoma, epithelial sarcoma, Ewing sarcoma, PNET, other sarcomas. Diagnosis and differential diagnosis. History. Physical examination. Additional investigations - X-ray, CT, bone scintigraphy, NMR, lung X-ray, biopsy, angiography. Differential diagnosis of bone lesions. Importance of early diagnosis. Treatment. Complex treatment - basic principles of sarcoma surgery including appropriate biopsy. Radiotherapy. Indication and technique. Chemotherapy. Indication and choice of drugs. Unsolved issues of neoadjuvant and adjuvant chemotherapy. Results and prognosis. Prosthetics . Tumours of the eye and orbit. Clinical picture - also part of the subject Sensory disorders.

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Anatomy of the eye and orbit, physiology of seeing, disorders of the visus, scotomas. Risk factors. Hereditary retinoblastoma, Knudsens model. Histology - primary tumours of the orbit (malignant melanoma, retinoblastoma, malignant lymphoma, epidermoid carcinoma, adenocarcinoma, glioma and meningeoma). Secondary tumours (neuroblastoma...). Diagnosis and differential diagnosis. History. Physical examination. Additional investigations. Treatment - surgical treatment. Radiotherapy (teletherapy and brachytherapy). Organ and function preserving treatment. Role of chemotherapy in retinoblastoma. Acute and chronic treatment toxicity - xerophtalmia. Catarrhact. Retinopathy. Neuropathy of the optic nerve. Screening of familial retinoblastoma. Malignant lymphoma and leukemiaperipheral lyphadenopathy, anemia. Leukemias and malignant lymphomas. Definition and clinical picture- also part of the subjects Horenat stavy and Bleeding. Anatomy and patophysiology. Anatomy of the lymphatic system, hematopoesis and its disorders. Histopathology Histopatologic classification of lymphoma and leukemia Diagnosis and differential diagnosis. History (fatigue, fewer, sweating, itching, bleeding...) Physical examination. Additional investigations - interpretation of the blood count, bone marrow and trephine, staging investigations. Emphasis on the rational approach Characteristic and natural course of particular types of leukemia and lymphoma. Appropriate choice and sequence of treatment modalities Treatment - cytostotoxic chemotherapy- induction, consolidation and maintenance chemotherapy, prophylaxis of the CNS involvement. Position of the high-dose chemotherapy with peripheral progenitor cells or bone marrow transplant. Indication of radiotherapy. Toxicity of chemo- and radiotherapy including late effects. Results and prognosis. According to leukemia or lymphoma type. Childs age tumours. Epidemiology Clinical characteristics of common pediatric tumours.

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CNS tumours. Acute lymphoblastic leukemia. Malignant lymphoma. Wilms tumour. Neuroblastoma. Ewing sarcoma, rhabdomyosarcoma. Diagnosis and differential diagnosis. Physical examination. Additional investigations. Treatment. Basic treatment strategy. Acute, chronic and late side-effects of treatment. Prognosis. Choriocarcinoma. Etiology and patophysiology. Normal pregnancy. Mola hydatidosa, mola prolipherans (destruens), choriocarcinoma. Diagnosis and differential diagnosis. History. Physical examination. Additional investigations- especially -HCG. Treatment surgery, chemotherapy. Prognosis. Metastatic tumour of unknown primary site. Most common localisation of primary tumour (on the basis of post-mortem examinations). Diagnostic procedures (emphasis on rational approach). History. Clinical examination. Basic imaging. Laboratory. Helpful features in histopathology Basics of rational therapy. Rare tumours- can be added as required

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