CASE 1

History:

A 44-year-old woman comes to you because of irregular spotting of blood, but not a heavy volume, between menstrual periods. She tells you that she had an abnormal Pap smear "about 10 years ago" but did not return to the clinic to follow up on it. Further history reveals that she has had multiple sexual partners over the last 30 years. On physical examination, you find a large fungating area with erosion on the cervix. You take a Pap smear. The results of the Pap smear confirm your suspicions, and you refer the patient to a gynecologist, who finds only the cervical lesion. The uterus and adnexae appear normal in size. The patient has no abdominal or pelvic pain. There is no lymphadenopathy palpable. A cervical biopsy is taken.

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Questions for discussion:

1. Why do you think the Pap smear showed 10 years ago? What natural history of neoplasia could be represented here?

2. What factor or factors may have played a role in the development of the neoplasm?

3. What are the pathologic features that provide clues to the diagnosis?

4. How would you grade and stage this neoplasm?

CASE 2

History:

A 56-year-old man has had a chronic cough for many years, but in the past few days has noticed that the sputum contains streaks of blood. You discover that he has an 85 pack/year smoking history. He has also gained about 10 kg in the past two months, mostly evident as truncal obesity. His vital signs show T 36.6 C, P 73, R 16, and BP 155/95 mm Hg. On physical examination, you palpate firm, enlarged lymph nodes in the cervical region bilaterally. His liver span also seems to be increased. Abdominal striae are present and the abdomen is enlarged, but without a fluid wave. He has a few small bruises on his arms.

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Questions for discussion:

1. What procedures can you do to further discover the cause of his problems?

2. What environmental cause(s) could have contributed to his disease? What neoplasms are associated with what environmental etiologies?

3. How do you explain his weight gain along with the physical findings? What usually happens to persons with a malignant neoplasm?

4. How do you explain the lymph node findings? Name the ways that tumors can spread.

CASE 3

History:

A 21-year-old man is found to have a stool specimen positive for occult blood, taken with rectal examination during a routine physical. He tells you that several relatives died from "cancer of the bowel" at an early age.

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Questions for discussion:

1. What further procedure(s) can be done to determine what his problem is?

2. What are the genetics of neoplasia? Discuss oncogenes and tumor suppressor genes. What is happening in this case? What produces cell transformation?

3. What are tumor markers? Is such a marker useful in this case?

CASE 4

History:

A 49-year-old woman has been bothered by headaches for several months. She also has difficulty hearing on the left. She blames it on the teenagers at the house next door playing loud rock music.

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Question for discussion:

1. What further procedure(s) can be done to determine what her problem is?

2. How do you tell a benign from a malignant neoplasm?

3. How can a histologically benign neoplasm still cause problems for the patient?

CASE 5

History:

A 61-year-old man has noted lower back pain for about a year accompanied by an 18 kg weight loss. You can find nothing notable on physical examination.

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Questions for discussion:

1. What further procedure(s) can be done to determine what his problem is?

2. What are some reasons for such a profound weight loss?

3. What use can be made of immunohistochemistry to determine the nature of the neoplasm?

4. What features distinguish a carcinoma from a sarcoma? How are tumors classified on the basis of their embryologic origin?

5. What determines the prognosis with neoplasia?