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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 3rd 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.
Modalities of the treatment.
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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.
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Etiology a patophysiology. Risk factors. Genetic. Non-familial. Exposition to the ionizing and
non-ionizing radiation. Chemical cancerogens. Malignant transformation of a pigmented
nevus.
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)
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myasthenia
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gravis,
aplastic
anemia,
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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.
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, Horner´s 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.
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Results and prognosis
Prevention
Tobacco abuse. Mesothelioma as a result of occupational hazard
Breast carcinoma.
Incidence, risk factors.
Genetic.
Non-familial, especially relationship to estrogens.
Anatomy of the breast.
Histopathology - non-invasive and invasive carcinoma, basic subgroups. Special categoryPaget´s 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
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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.
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.
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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.
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 subject“Bleeding”.
Ethiology and patophysiology.
Risk factors.
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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.
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 subject“Disorders 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.
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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”.
Anatomy of the eye and orbit, physiology of seeing, disorders of the visus, scotomas.
Risk factors.
Hereditary retinoblastoma, Knudsen´s 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 “Hore─Źnaté 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...)
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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.
Child´s age tumours.
Epidemiology
Clinical characteristics of common pediatric tumours.
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 ß-HCG.
Treatment – surgery, chemotherapy.
Prognosis.
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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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