1)Introduction

What is Cancer?
Cancer is one of the most feared diseases in the world and it affects
over 11 lakh people every year in India alone. Worldwide, more than 10
million people succumb to this disease every year. Let us explore what is
cancer, the causes of cancer, symptoms, diagnosis, and treatment of
cancer.

In humans, cell differentiation and proliferation are highly manipulated

and regularized by the cell division mechanism. Uncontrolled cell
division occurs when a process called contact inhibition fails. In
healthy organisms, during this process, when cells come in contact with
other cells, the process of cell replication ceases.

As a result, contact inhibition becomes a powerful anti-cancer

mechanism, but it is lost in cancer cells. Hence, most types of cancer
have tumours (except for cancers of the blood).

Cancer is a serious disease in which the cells start dividing abnormally in

an uncontrolled manner. 

Most cancer cells are found in the shape of tumours, with a few notable
exceptions such as leukaemia. All tumours are not cancerous. Some
tumours, such as moles, stop growing and are not malignant. 

Let us have a detailed look at the different types of cancer.

Types of Cancer
There are more than a hundred different types of cancer that
are characterized by abnormal cell growth. Listed here are a few types of
cancer:

Carcinoma
It is the most common form of cancer that affects the epithelial cells
which form the lining of internal organs or the skin.

Lung cancer, skin cancer, pancreatic cancer and ovarian cancer are

some of its common manifestations. Carcinomas can be identified by the
different cells that they affect:

 Adenocarcinoma – A form of carcinoma that affects mucus or fluid-forming

epithelial cells. Common examples of adenocarcinoma are breast cancer,
colon cancer, and prostate cancer.
 Squamous Carcinoma- A carcinoma that affects the epithelial cells which
are present beneath the outermost surface of the skin. These cells also form
the lining of many vital organs in the human body such as the stomach,
kidneys, lungs, intestines, and bladder.
 Basal Cell Carcinoma– A type of carcinoma that affects the basal cells found
in the deepest layer of the epidermis. It is a form of skin cancer which appears
as a lump or ulcer in the affected areas.
 Transitional cell carcinoma – It affects cells of transitional epithelium found
in the lining of the bladder, ureters and certain parts of the kidney.

Sarcoma
These cancer cells develop in the bones and soft tissues such as fat
tissues, cartilages, blood vessels, lymph and other supporting tissues
of tendons and ligaments.

The most common form of sarcoma in the bone is osteosarcoma, and in

soft tissues include Kaposi sarcoma, liposarcoma, malignant fibrous
histiocytoma, leiomyosarcoma, and dermatofibrosarcoma protuberan.
Leukaemia
Commonly known as blood cancer, leukaemia affects the tissues of the
bone marrow which is responsible for blood production. It is one of the
fatal forms of cancer.
Leukaemia is completely different from other types of cancer. It is
caused by the uncontrolled production of white blood cells (Lymphoid
cells and myeloid cells). These abnormal white blood cells damage
the tissues of the bone marrow and crowd the normal blood
cells. These abnormal white blood cells continue to divide and damage
the complete normal blood cells. As a result, the Leukemia patient fails
to provide adequate red blood cells to supply oxygen, adequate normal
white blood cells to fight infections and adequate platelets for blood
coagulation.

Lymphoma
Lymphoma is a form of cancer that affects the lymphocytes in the lymph
nodes, which are a part of the immune system. There are two kinds of
lymphoma:

 Hodgkin lymphoma – originates in the B cells

 Non-Hodgkin lymphoma, – originates in B or T cells.

Melanoma
It is a form of skin cancer that targets melanin – the pigment responsible
for skin colour. In this form of cancer, the melanocytes are affected
resulting in the abnormal formation of melanin. It may also affect other
tissues that are pigmented, such as the eyes.

Myeloma
Myeloma targets another part of the immune system- the plasma cells.
The affected plasma cells, called myeloma cells divide in the bone
marrow causing multiple tumours in the bones (Multiple Myeloma also
called Kahler disease)
CNS Cancers
CNS (Central Nervous System) cancers originate from the brain and the
spinal cord. Gliomas, vestibular schwannomas, meningiomas, primary
CNS lymphomas, pituitary adenomas, and primitive neuroectodermal
tumours are a few CNS cancers

2)History of disease
The earliest known descriptions of cancer appear in several papyri from
Ancient Egypt. The Edwin Smith Papyrus was written around 1600 BC
(possibly a fragmentary copy of a text from 2500 BC) and contains a
description of cancer, as well as a procedure to remove breast tumours
by cauterization, stating that the disease has no treatment. [1] However,
incidents of cancer were rare. In a study by the University of
Manchester, only one case was found "in the investigation of hundreds
of Egyptian mummies, with few references to cancer in literary
evidence."[2]
Hippocrates (c. 460 BC – c. 370 BC) described several kinds of cancer,
referring to them by the term καρκινος (carcinos), the Greek word for
crab or crayfish, as well as carcinoma.[3] This comes from the
appearance of the cut surface of a solid malignant tumour, with "the
veins stretched on all sides as the animal the crab has its feet, whence it
derives its name".[4] Since it was against Greek tradition to open the
body, Hippocrates only described and made drawings of outwardly
visible tumors on the skin, nose, and breasts. Treatment was based on
the humor theory of four bodily fluids (black and yellow bile, blood, and
phlegm). According to the patient's humor, treatment consisted of diet,
blood-letting, and/or laxatives. Celsus (c. 25 BC - 50 AD)
translated karkinos into cancer, the Latin word for crab or crayfish.
In the 2nd century AD, the Greek physician Galen used oncos (Greek for
swelling) to describe all tumours, reserving Hippocrates'
term carcinos for malignant tumours. Galen also used the suffix -oma to
indicate cancerous lesions. It is from Galen's usage that we derive the
modern word oncology.
Through the centuries it was discovered that cancer could occur
anywhere in the body, but Hippocrates' humor-theory based treatment
remained popular until the 19th century with the discovery of cells.

16th–19th centuryedit

A surgical operation to remove a malignant tumor, 1817

In the 16th and 17th centuries, it became more acceptable for doctors
to dissect bodies to discover the cause of death. The German
professor Wilhelm Fabry believed that breast cancer was caused by a
milk clot in a mammary duct. The Dutch professor Francois de la Boe
Sylvius, a follower of Descartes, believed that all disease was the
outcome of chemical processes, and that acidic lymph fluid was the
cause of cancer. His contemporary Nicolaes Tulp believed that cancer
was a poison that slowly spreads, and concluded that it was contagious.
[6]

The first cause of cancer was identified by British surgeon Percivall Pott,

who discovered in 1775 that cancer of the scrotum was a common
disease among chimney sweeps. The work of other individual physicians
led to various insights, but when physicians started working together
they could draw firmer conclusions.
3)Causes of Cancer
Like symptoms, there is no conclusive evidence for its causes. However,
scientists have found certain things which aggravate the occurrence of
this disease. Some of the common factors are:

1. Genetics
2. Tobacco and other related narcotics
3. Alcohol
4. Exposure to unnatural radiation (such as UV rays) for an extended
period of time
5. Diet and lifestyle
6. Exposure to certain chemicals for a long time
7. Infections
8. Unhealthy environment

4) Mode of transmission
 cancer is not a contagious disease. There is nothing that will cause a
cancer to be passed from one person to another, except for extremely
rare circumstances. Some genes can lead certain families to develop
certain kinds of cancers, but one does not inherit cancer; one inherits
genes. You cannot “catch” cancer from someone else. Close contact or
things like sex, kissing, touching, sharing meals, or breathing the same
air cannot spread cancer. Cancer cells from someone with cancer are
not able to live in the body of another healthy person
5) Symptoms of Cancer
Cancer can be identified by a variety of symptoms. In some cases, symptoms could
vary or may not show any signs and symptoms. There are a few general symptoms:

1. Irregular loss of weight

2. Recurrent fever
3. Continuous pain in a certain area
4. Fatigue
5. Irregular changes in the skin (pigmentation, unusual hair growth,
red or yellow skin, blotches etc.)
Apart from these, women should watch out for certain symptoms of the
cancers that are unique to them:

1. Change in the shape or color of the breast

2. Bleeding out of the menstrual cycle period
3. Bloating
4. Blood in stool
6) DIAGNOSIS
Diagnosis begins with a thorough Physicalexa mination and a complete medical
history. The doctor will observe, feel and palpate (applypre ssure by touch)
different parts of the body in order to identify any variations from the normal si
ze, feel, and texture of the organ or tissue. Different methods are used for the
diagnosis of cancer those are

Histological Methods
These methods are based on microscopic examination of properly fixed
tissues ,supported with complete clinical and investigative data. These methods
are most valuable in arriving at the accurate diagnosis. These diagnosis by
either of these methods is made on the basis of that cytological features of
benign tumours resemble those of normal tissues and that they are unable to
invade and metastasise,while malignant tumours are identified by lack of
differentiation in cancer cell termed an aplasia( a condition whereby cells lose
the morphological characteristics of mature cells and their orientation with
respect to each other and to endothelial cells.)or cellular atypia(itis a pathologic
term for a structural abnormality in a cell) and may invade as well as metastasis.

Cytological Methods
These methods for diagnosis consist of study of cells shed off into body cavities
and study of cell by putting a fine needle introduced under vacuum into the
lesion(fine needle aspiration cytology FNAC).

Fine Needle Aspiration Cytology

Fine Needle Aspiration Cytology (FNAC) is a diagnostic procedure where a
needle is inserted into your body, and a small amount of tissue is sucked out for
examination under a microscope. It is a quicker and less painful procedure than
a Biopsy, but doctors still prefer a biopsy for lymphomas as it gives surer
results.
Application
This type of sampling is performed for one of two reasons 1. A biopsy is
performed on a lump or a tissue mass when its nature is in question. 2. For
known tumors, this biopsy is performed to assess the effect of treatment or to
obtain tissue for special studies. When the lump can be felt, the biopsy is
usually performed by a Cytopathologisticor a Surgeon. In this case, the
procedure is usually short and simple. Otherwise, it may be performed by an
interventional radiologistic, a doctor with training in performing such biopsies
under X-ray or ultrasoundguidance. In this case, the procedure may require
more extensive preparation and take more time to perform.

Histochemistry and Cytochemistry

These are additional diagnosis tools which helps the pathologist in identifying
the chemical composition of cell.Their constituents and their products by
special staining methods. Though immunohistochemical techniques are more
useful for tumourdiagnosis, histochemical and cytochemical methods are still
employed for this purpose.

Immunohistochemistry
This is an immunological method of recognizing a cell by one or more of its
specific components in the cytoplasm,cell membrane or nucleus . These cell
components are combine with specific antibodies on the formaline fixed
paraffinesection.the complex of antigen and antibody on the slide is made
visible for light microscopic identification by either fluorescent dyes or by
enzymes, as shown in Fig 3. The list of immunochemical stains is ever
increasing; one important group of such antibody stains is directed against
various classes ofintermediate filaments which is useful in classification of
poorly-differentiated tumours of epithelial or mesenchymal origin.
1. Electron Microscopy
Ultra structural examination of tumour call offers selective role in diagnostic
pathology

1.Cell junctions-their presence and type

. 2.Cell surface eg: presence of microvilli.
3. Cell shape and cytoplasmic extinction.
4.Shape of the nucleus and features of nuclear memberane.
5. nucleoli-size and density.
6.cytoplasmicorgenelles-their number is generally reduced.
7. Dense bodies in the cytoplasm.
8 any other secretory products in the cytoplasameg:melanosomesin melanoma
and memberane bound granules in endocraintumours
7)Treatment of Cancer
Medical science has advanced greatly in the last few decades and found
the treatment for most forms of cancers. The process of treatment
depends on the type and stages of cancer. Some of the common
treatment includes surgery, chemotherapy, hormonal therapy,
immunotherapy, and radiation therapy

Ablation Therapy
Ablation therapy is a minimally invasive method used by doctors to eliminate aberrant
tissue found in a variety of illnesses. Ablation treatment can be used to destroy (ablate) a
small amount of heart tissue producing irregular heart rhythms or to treat cancers in the
lung, breast, thyroid, liver, or other parts of the body. 

Who Needs Ablation Treatment? 

Ablation therapy offers a wide range of applications. Ablation is a procedure
that is used to treat cardiac disorders including atrial fibrillation and improve
quality of life. Some other types of ablation therapy are used instead of open
surgery to preserve good tissue and reduce surgical risks, such as in the
removal of thyroid nodules or breast cancers. 

Ablation is a procedure that can be used to treat a variety of medical issues.  

 To treat a heart arrhythmia 

 To control heavy bleeding during menstruation 

 To cure tumors in the kidney, liver, and other organs

What Are The Different Types Of Ablation Therapy? 
1.Ablation of atrial fibrillation 

Atrial fibrillation ablation is a treatment for atrial fibrillation, a type of

irregular and chaotic heartbeat (A-fib). It creates microscopic scars in the
heart. 

When the catheter is pushed into the heart, the dye is injected, and energy is
provided. Inform the doctor if any discomfort or shortness of breath is
experienced. It normally takes three to six hours to complete the
surgery. More complicated procedures take longer time.

2. Cardiac Ablation 

Cardiac ablation creates microscopic scars in the heart using heat or cold

energy to block faulty electrical signals and restore a regular heartbeat. The
treatment is used to treat irregular heartbeats (arrhythmias). 

The catheter is inserted into the heart through a blood artery by the doctor.

Frequently, more than one catheter is used. Catheters can be put into a blood
vessel in the groin, shoulder, or neck

Sensors on the catheter's tip send electrical impulses and record the electrical
activity of the heart. This information helps the doctor pinpoint the source
of the arrhythmia and determine where the ablation should be performed. An
electrophysiology (EP) study is the name for this type of operation. 

3. Cryoablation for cancer 

A thin, wand-like needle (cryoprobe) is introduced through the skin and

directly into the malignant tumor during cryoablation. Gas is fed into the
cryoprobe to freeze the tissue. The tissue is then allowed to defrost. The
freezing and thawing process is also performed numerous times during this
treatment. 
 4. Laser PVP Surgery 

An enlarged prostate can be treated using laser PVP surgery, which is a

minimally invasive procedure. The method involves performing photo
selective vaporization of the prostate with a laser (PVP). 

A tube with an imaging device (cystoscope) is introduced into the penis

during laser PVP surgery. Through the cystoscope, a surgeon uses a laser to
burn away extra tissue that is obstructing urine flow through the prostate.

5. Radiofrequency neurotomy 

Radiofrequency neurotomy targets specific nerves and temporarily disables

their capacity to send pain signals using heat created by radio waves. This
process is also called as radiofrequency ablation. 

An intravenous (IV) line will be inserted into the arm or hand to give

medication to make the patient comfortable while the surgery is performed.
Before the radiofrequency needles are implanted, numbing medicine will
be injected into the skin. The radiofrequency needles will be guided to the
precise spot by the doctor using a special X-ray machine (fluoroscope),
ensuring that only the targeted nerve tissue is treated. 

What Are The Possible Side Effects Of Ablation

Therapy? 
Ablation therapy has different hazards depending on the
procedure utilized and the severity of the underlying disease. Ablation
therapy is generally considered to be quite safe, with very little risk.
Ablation complications can include: 

 Bleeding puncture wound  

 Infections 

 Scarring 
  Damaged blood vessels  

 A stroke or a heart attack  

8) PREVENTION
a) Eating a healthy diet

b) Exercisung regularly

c) Limit alcohol

d) Maintain a healthy weight

e) Minimise your exposure to radiation and toxic chemicals

f) Not smoking or chewing tobacco

g) reduce sun exposure, especially if you burn easily

9)CURRENT SCIENARIO IN INDIA

The estimated number of incident cases of cancer in India for the

year 2022 was found to be 14,61,427 (crude rate:100.4 per
100,000). In India, one in nine people are likely to develop cancer in
his/her lifetime.

Based on the cancer registry data it is estimated that there will be about
800,000 new cancers cases in India every year. At any given point there
is likely to be 3 times this load that about 240,000 cases. Cancer sites
associated with tobacco form 35 to 50% of all cancers in men and about
17% of cancers in women.

According to an ICMR study, one in nine Indians will develop

cancer during their lifetime. One in 68 men will develop lung cancer
and one in 29 women will develop breast cancer.

 
10) CASE STUDY

50/M Mr SK was diagnosed with advanced cancer lung (stage4)

(adenocarcinoma - never smoker) and started on chemotherapy at
outside hospital. After 6 weekly dose he worsened and came to Apollo
for second opinion were he met Dr Manish Singhal.

He was rendered second opinion however the treating oncologist

declined to follow.

He spent more time doing another biopsy as his 1st biopsy was
inadequate to do complete mutation testing. His EGFR mutations testing
which is very important to conduct in lung cancer especially in never
smokers had failed due to technical reasons. However, his condition
kept worsening.

He finally decided to take treatment with Dr Singhal.

When he came he was breathless and required oxygen support and had
to be optimized.

CT Chest showed lymphangitis carcinomatosis with large lung mass

/tumor on right side and pleural effusion.

Xray chest on 07.11.2020 showed fluid in the lung (Red arrow), Large
opaque lung mass(blue arrow), multiple numerous small lung nodules
(lymphangitis carcinomatosis – miliary shadows in both lung fields), best
appreciated in red circle.

He was started on Bevacizumab + pemetrexed + carboplatin (triple drug

combination) after optimizing his general condition. This protocol is
tested in Point break study and Avaperl international studies.

With in 10 days his Xray was better and on day 21st just before his
second cycle he was oxygen independent, walking and climbing stairs
comfortably. His X ray showed miraculous improvement – effusion
disappeared, lung mass almost dissolved away and lung fields were
clear off miliary nodules.
11) REFERENCES
1. Malati T. Tumour markers: an overview. Indian Journal of Clinical
Biochemistry. 2007;22(2): 17-31
2. . Tumor Markers. http://www.patient.co.uk/doctor/Tu mour-
Markers.htm.
3. Perkins GL, Slater ED, Sanders GK and Prichard JG. Serum tumor
markers.American family physician. 2003;68(6):1075-1088.
4. . Novaković S. Tumor markers in clinical oncology.Radiology and
Oncology. 2004;38(2).
5. Harsh Mohan’s. Text book of pathology fifth edition fore word
Ivan damjanoy. Basics of pathology.
6. Mischel PS, Cloughesy TF and Nelson SF. DNA-microarray
analysis of brain cancer: molecular classification for therapy.
Nature Reviews Neuroscience. 2004;5(10):782-792
7. Green ED, Guyer MS. Institute N. H. G. R. Charting a course for
genomic medicine from base pairs to bedside. Nature.
2011;470(7333):204-213.
8. Tang YW, Procop GW and Persing DH. Molecular diagnostics of
infectious diseases.Clinical Chemistry. 1997;43(11):2021-2038.