Cancer Treatment & Information

If a person has swelling or symptoms described in the Symptoms section, his or her health care provider will ask many questions about the symptoms (when they began, recent illnesses, past or current medical problems, any medications, workplace, health history, family history, and habits and lifestyle). These questions are followed by a thorough examination.

If, after an initial interview and examination, the health care provider suspects that a patient may have lymphoma, the patient will undergo a series of tests designed to provide further clarification. At some point in this workup, the patient will likely be referred to a specialist in cancer (oncologist).

Blood tests

Blood is drawn for various tests.

• Some of these tests evaluate the function and performance of blood cells and important organs, such as the liver and kidneys.
• Certain blood chemicals or enzymes (lactate dehydrogenase [LDH]) may be determined. High levels of LDH in cases in which NHL is suspected may indicate a more aggressive form of the disorder.
• Other tests may be done to learn more about lymphoma subtypes.

Biopsy

If there is a swelling (also called lump or mass), a sample of tissue from the swelling will be removed for examination. This is called a biopsy. Any of several methods can be used to obtain a biopsy of a mass.

• Masses that can be seen and felt under the skin are relatively easy to biopsy. A hollow needle can be inserted into the mass and a small sample removed with the needle (called a core-needle biopsy). This is usually done in the health care provider’s office with a local anesthetic.
• Core-needle biopsy does not always obtain a good-quality sample. For that reason, many health care providers prefer a surgical biopsy. This involves removal of the entire swollen lymph node through a small incision in the skin. This procedure often is done with a local anesthetic, but it sometimes requires a general anesthetic.
• If the mass is not immediately under the skin but is instead deep inside the body, access is somewhat more complicated. The specimen is usually obtained via laparoscopy. This means making a tiny incision in the skin and inserting a thin tube with a light and a camera on the end (a laparoscope). The camera sends pictures of the inside of the body to a video monitor, and the surgeon can see the mass. A small cutting tool on the end of the laparoscope can remove all or part of the mass. This tissue is withdrawn from the body with the laparoscope.
• A pathologist (a physician who specializes in diagnosing diseases by looking at cells and tissues) examines the tissue sample with a microscope. The pathologist’s report will specify whether the tissue is lymphoma and, with the use of appropriate biologic tools, the type and subset of lymphoma.

Imaging studies

If there is no palpable mass in the presence of persistent symptoms, imaging studies will likely be carried out in order to determine whether a mass is present and, if so, how then to direct a biopsy.

• X-rays: In certain parts of the body, such as the chest, a simple x-ray can sometimes detect lymphoma.
• CT scan: This test provides a 3-dimensional view and much greater detail and may detect enlarged lymph nodes and other masses anywhere in the body.
• MRI scan: This test uses differences in magnetic fields among different types of tissue to create pictures of the inside of the body. Similar to the CT scan, MRI gives 3-dimensional images with excellent detail. MRI provides better definition than CT scan in certain parts of the body, especially the brain and the spinal cord.
• Lymphangiogram: This approach, which provides an image of the lymphatic system by tracing a dye that moves though the system, has essentially been replaced by either CT scan, MRI, or PET (see below).
• Gallium scan: Lymphomas tend to collect a substance called gallium. For this test, a tiny amount of radioactive gallium is injected into the body. A scan is then done to find areas where the gallium has collected. Collections of gallium suggest a tumor.
• Positron-emission tomographic (PET) scan: PET scan is a newer alternative to lymphangiogram and gallium scan for detecting areas in the body that are affected by lymphoma. A tiny amount of a radioactive substance is injected into the body and then traced on the PET scan. Sites of radioactivity on the scan indicate areas of increased metabolic activity, which implies a tumor.

Bone marrow examination

Most of the time, an examination of the bone marrow is necessary to see if the marrow is affected by the lymphoma. This is done by collecting a biopsy of the bone marrow.

• Samples of both liquid (aspirate) and solid bone marrow (biopsy) are taken, usually from a hip bone.
• A pathologist examines the bone marrow under a microscope.
• Bone marrow containing certain types of abnormal B or T lymphocytes confirms lymphoma.
• Bone marrow biopsy can be an uncomfortable procedure, but it can usually be performed in a medical office. Most people receive pain medication prior to the procedure to make them more comfortable.

Other tests

• Lumbar puncture: This test, sometimes called a spinal tap, is a method for collecting a sample of the fluid surrounding the brain and spinal cord. This fluid is called cerebrospinal fluid. If the lymphoma has affected the central nervous system, the cerebrospinal fluid will likely contain lymphoma cells.
• Organ function tests: These tests are usually done before starting treatment to make sure that one’s organs are healthy enough to withstand the side effects of therapy. Examples include an echocardiogram or MUGA scan for the heart and pulmonary function tests for the lungs.

Staging

Staging is the classification of a cancer type by its size and whether and how much it has spread around the body. Determining a cancer’s stage is very important because it tells the oncologist which treatment is most likely to work and what are the chances of remission or a cure (prognosis).

Staging of lymphomas, as in all cancers, is based on the microscopic examination and on the results of imaging studies and related tests that reveal the extent of the cancer involvement. HL is often described as being “bulky” or “nonbulky.” Nonbulky means the tumor is small; bulky means the tumor is large. Nonbulky disease has a better prognosis than bulky disease.

NHL is a complicated set of diseases with a complex classification system. In fact, the classification system is continuously evolving as we learn more about these cancers. The newest classification system takes into account not only the microscopic appearance of the lymphoma but also its location in the body and genetic and molecular features.

Grade is also an important component of the NHL classification.

• Low grade: These are often called “indolent” lymphomas because they grow slowly. Low-grade lymphomas are often widespread when discovered, but because they grow slowly, they usually do not require immediate treatment unless organ function is compromised. They are rarely cured and can transform over time to a combination of indolent and aggressive types.
• Intermediate grade: These are rapidly growing (aggressive) lymphomas that usually require immediate treatment, but they are often curable.
• High grade: These are very rapidly growing and aggressive lymphomas that require immediate, intensive treatment and are much less often curable.

The “staging,” or evaluation of extent of disease, for both HL and NHL, are similar.

• Stage I (early disease) - Lymphoma located in a single lymph node region or in one area or organ outside the lymph node
• Stage II (locally advanced disease) - Lymphoma located in two or more lymph node regions all located on the same side of the diaphragm or in one lymph node region and a nearby tissue or organ. (The diaphragm is a flat muscle that separates the chest from the abdomen.)
• Stage III (advanced disease) - Lymphoma affecting two or more lymph node regions, or one lymph node region and one organ, on opposite sides of the diaphragm
• Stage IV (widespread or disseminated disease) - Lymphoma outside the lymph nodes and spleen that has spread to another area or organ such as the bone marrow, bone, or central nervous system

Both HL and NHL are further classified with letters.

• An “A” or “B” designation indicates whether the person with lymphoma had symptoms such as fevers and/or weight loss at the time of diagnosis. “A” indicates no such symptoms, and “B” indicates symptoms.
• An “E” designation indicates that the tumor spread directly from a lymph node into an organ or that a single organ outside the lymphatic system is affected with no apparent lymphatic involvement.

Prognostic factors

Several risk factors have been extensively evaluated and shown to play a role in treatment outcome. For HL, the International Prognostic Index includes the following 7 risk factors:

1. Male sex
2. Age 45 years or older
3. Stage IV disease
4. Albumin (blood test) less then 4.0 g/dL
5. Hemoglobin (red blood cell level) less than 10.5 g/dL
6. Elevated white blood cell (WBC) count of 15,000/mL
7. Low lymphocyte count less than 600/mL or less than 8% of total WBC

The absence of any of the above risk factors is associated with an 84% rate of control of Hodgkin disease, whereas the presence of a risk factor is associated with a 77% rate of disease control. The presence of 5 or more risk factors was associated with a disease control rate of only 42%.The outcomes for these patients were also determined by the treatment they received, which occurred primarily in the 1980s. Newer treatments for Hodgkin lymphoma may improve these predicted outcomes. Furthermore, new treatments are being developed for patients with greater risk factors. The International Prognostic Index for NHL includes 5 risk factors:

1. Age older than 60 years
2. Stage III or IV disease
3. High LDH
4. More than one extranodal site
5. Poor performance status (as a measure of general health) - From these factors, the following risk groups were identified: 
   • Low risk: 0-1 risk factor, 5-year lymphoma-free survival (LFS) of 70%
   • Intermediate risk: 2-3 risk factors, 5-year LFS of 49-50%
   • Poor risk: 4-5 risk factors, 5-year LFS of 26%

A T-cell NHL subtype is usually considered an additional risk factor. However, a T-cell anaplastic large cell NHL has a lower risk than B-cell NHL. The prognostic models were developed to evaluate groups of patients and are useful in developing therapeutic strategies.

Because the symptoms of leukemia are nonspecific and the causes are not clearly defined, one’s health care provider will carry out extensive interviews and any appropriate tests in order to identify the underlying cause.

• The health care provider will ask many questions about symptoms, current medical situations, medications, medical and surgical history, family history, work history, and habits and life style.
• The physical examination includes a thorough evaluation of all symptoms, not merely lymph nodes and/or possible enlargements of the liver and spleen.

Blood tests: Blood is drawn from a vein in order to check the blood cell counts. In most cases of leukemia, the white blood cell count is very high (although it is not uncommon for the white cell count to be normal in many of the childhood acute lymphocytic leukemias) and the platelet and red cell counts are low. This makes the health care provider consider leukemia as the diagnosis. Other tests are performed to check liver and kidney functions and the possible presence of leukemic cells in the spinal fluid.Biopsy: Because other conditions may give rise to atypical white cell counts, the only way to confirm the diagnosis of leukemia is via an aspirate and biopsy of the bone marrow.

• Biopsy means to take a small sample of the relevant tissue to check for abnormal cells. In leukemia, a biopsy of the bone marrow must be taken and examined.
• This procedure is usually performed in the medical office, usually by a specialist trained in the treatment of blood disorders, that is, a hematologist or a hematologist-oncologist. The procedure is brief (less than a few minutes) and preceded by a local injection for relief of pain.
• Samples of both liquid (aspirate) and solid bone marrow (biopsy) are taken, usually from a hip bone.
• The bone marrow is examined under a microscope, where the presence of leukemic cells confirms the suspected diagnosis.

Genetic studies: The chromosomes of the abnormal cells are examined to look for irregularities. This helps in classifying the various types of leukemia.Lumbar puncture (spinal tap): Because the collection of leukemia cells in the central nervous system can affect mental processes, it is extremely important to know whether the fluid surrounding the brain and spinal cord (cerebrospinal fluid) is affected.

• This procedure is referred to as a lumbar puncture or spinal tap and is usually carried out by the blood specialist in the office. After the procedure, the person needs to lie flat for 1-2 hours.
• A small amount of the fluid is removed from the area around the spinal cord by inserting a hollow needle in the back at around the waist level. The needle is inserted in between the bones in the spine following a small injection into the skin over the injection site in order to minimize discomfort.
• The fluid is examined for the presence of leukemia cells.

Lymph node excision: If the lymph nodes are enlarged, a node may require a biopsy if the bone marrow is difficult to interpret for some obscure reason. This is exceedingly uncommon.  Chest x-ray: A chest x-ray film is frequently taken to look for signs of infection or lymph node involvement by leukemia.Staging

Staging is the way cancers are classified. Staging indicates the size or extent of the cancer, the degree to which other parts of the body are affected, and other important details. In general, leukemias are classified rather than staged in order to determine the most appropriate therapy.

All leukemias are classified according to their genotypes, or their unique chromosomal arrangements, which also enables the physicians to determine risk factors. In addiction, chronic myelogenous leukemia is classified by phase. The 3 phases are chronic phase, accelerated phase, and blast phase (or “blast crisis”) and are defined by the number of blasts (leukemia cells) in the blood and bone marrow.

Chronic lymphocytic leukemia is classified by 2 different staging systems, both based on the parts of the body affected by the leukemia.

If you are having rectal bleeding or changes in your bowel movements, you will undergo tests to determine the cause of the symptoms.

• Your health care provider may insert a gloved finger into your rectum through your anus.
• This test, called a digital rectal exam, is a quick screen to make sure that any bleeding is actually coming from your rectum.
• This is not painful, but it is mildly uncomfortable for some people. It takes only a few seconds.

You may have a test called a colonoscopy.

• This is a test that allows a specialist in digestive diseases (a gastroenterologist) to look at the inside of your colon.
• This test looks for polyps, tumors, or other abnormalities.
• Colonoscopy is an endoscopic test. This means that a thin, flexible plastic tube with a tiny camera on the end will be inserted into your colon via your anus. As the tube is advanced further into your colon, the camera sends images of the inside of your colon to a video monitor.
• Colonoscopy is an uncomfortable test for most people. You will first be given a laxative solution to drink that will clear most of the fecal matter from your bowel. You will be allowed nothing to eat before the test. Whenever possible, you will be given medication before the procedure to relax you and relieve the discomfort.
• Flexible sigmoidoscopy is similar to colonoscopy but does not go as far into the colon. It uses a shorter endoscope to examine the rectum, sigmoid (lower) colon, and most of the left colon.

Air-contrast barium enema is a type of x-ray that can show tumors.

• Before the x-ray is taken, a liquid is introduced into your colon and rectum via your anus. The liquid contains barium, which shows up solid on x-rays.
• This test highlights tumors and certain other abnormalities in the colon and rectum.
• Other types of contrast enemas are available.
• Air-contrast barium enema frequently detects malignant tumors, but it is not as effective in detecting small tumors or those far up in your colon.

If a tumor is identified in the colon or rectum, you will probably undergo CT scan of your abdomen and a chest x-ray to make sure the disease has not spread.

As with all cancers, early diagnosis is key to successful treatment and cure. Treating precancerous changes that affect only the surface of a small part of the cervix is much more likely to be successful than treating invasive cancer that affects a large portion of the cervix and has spread to other tissues.

The most important progress that has been made in early detection of cervical cancer is widespread use of the Papanicolaou test (Pap smear).

• The Pap smear is done as part of a regular pelvic examination.
• Named after the pathologist who developed the test, the Pap smear is a quick, painless, and relatively inexpensive way of screening women for precancerous or cancerous changes in their cervix.
• Cells from the surface of the cervix are collected on a slide and examined. Any abnormality found on a Pap smear mandates further evaluation.

Diagnosis of cervical cancer requires that a sample of cervical tissue (called a biopsy) be taken and analyzed under a microscope.

• This tissue sample can be obtained in a number of ways.
• A cervical biopsy is usually done by a specialist in diseases of women’s reproductive and sexual organs (a gynecologist).
• The biopsy is examined by a physician who specializes in diagnosing diseases by looking at cells and tissues under a microscope (a pathologist).

Colposcopy is a procedure similar to a pelvic examination.

• The examination uses a type of microscope called a colposcope to inspect the cervix. The entire area of the cervix is stained with a harmless dye to make abnormal cells easier to see.
• The colposcope magnifies the cervix by 8-10 times, allowing easier identification of any abnormal-appearing tissue that may need biopsy.
• This procedure can usually be done in your gynecologist’s office.
• These abnormalities may be an early step in the slow series of changes that can lead to cancer.

Sometimes a larger biopsy is needed to fully check for invasive cervical cancer.

• The loop electrosurgical excision procedure (LEEP) technique uses an electrified loop of wire to take a sample of tissue from the cervix.
• This procedure can often be performed in your gynecologist’s office.

A cone biopsy is performed in the operating room while you are under anesthesia.

• A small cone-shaped sample of your cervix is removed for examination.
• Like LEEP, cone biopsy procedures result in tissue samples in which the types of cells and how much they have spread to underlying areas can be more fully determined.

Precancerous changesOver the years, different terms have been used to refer to abnormal changes in the cells on the surface of the cervix. These changes are now most often called squamous intraepithelial lesion (SIL). “Lesion” refers to an area of abnormal tissue; intraepithelial means that the abnormal cells are present only in the surface layer of cells. Changes in these cells can be divided into 2 categories.

• Low-grade SIL: Early, subtle changes in the size and shape of cells that form the surface of the cervix are considered low grade.
  • These lesions may go away on their own, but over time, they may become more abnormal, eventually becoming a high-grade lesion.
  • SIL is also called mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1).
  • These early changes in the cervix most often occur in women aged 25-35 years but can appear in women of any age.
• High-grade SIL: A large number of precancerous cells, which look very different from normal cells, constitute a high-grade lesion.
  • Like low-grade SIL, these precancerous changes involve only cells on the surface of the cervix.
  • These lesions are also called moderate or severe dysplasia, CIN 2 or 3, or carcinoma in situ.
  • They develop most often in women aged 30-40 years but can occur at any age.

Precancerous cells, even high-grade lesions, usually do not become cancerous and invade deeper layers of the cervix for many months, perhaps years. Some laboratories may still use an older system for describing abnormalities. This system classifies changes into 1 of 5 groups, 1 being the most mild changes and 5 being the most severe. Ask you health care provider if you do not understand the way the result of your Pap smear is reported.Invasive cancer

If abnormal cells spread deeper into the cervix or to other tissues or organs, the disease is then called cervical cancer, or invasive cervical cancer. Cervical cancer occurs most often in women aged 40 years or older. If the biopsy results show invasive cancer, a series of tests will be performed, all designed to see whether the cancer has spread and, if so, how far.

• A chest x-ray looks for spread to the lungs.
• Blood tests can indicate whether the liver is involved. A CT scan may be necessary if results are not definitive.
• Special x-rays or a CT scan can be used to look at the bladder.
• The vagina and rectum are also examined, sometimes under anesthesia.

These tests are used to “stage” the cancer.

• By finding out how far it has spread, your health care providers can make a reasonable guess about your prognosis and the kind of treatment you will need.
• Cervical cancer is staged from stage 0 (least severe) to stage IV (metastatic disease, the most severe).
• Staging is based on size and depth of the cancerous lesion, as well as degree of spread.

Diagnosis of breast cancer usually is comprised of several steps, including examination of the breast, mammography, possibly ultrasonography or MRI, and, finally, biopsy. Biopsy is the only definitive way to diagnose breast cancer.

Examination of the Breast

• A complete breast examination includes visual inspection and careful palpation (feeling) of the breasts, the armpits, and the areas around your collarbone.
• During that exam, your health-care provider may palpate a lump or just feel a thickening.

Mammography

• Mammograms are x-rays of the breast that may help define the nature of a lump. Mammograms are also recommended for screening to find early cancer.
• Usually, it is possible to tell from the mammogram whether a lump in the breast is breast cancer, but no test is 100% reliable. Mammograms are thought to miss as many as 10-15% of breast cancers.
• A false-positive mammogram is one that suggests malignancy (cancer) when no malignancy is found on biopsy.
• A false-negative mammogram is one that appears normal when in fact cancer is present.
• A mammogram alone is often not enough to evaluate a lump. Your health-care provider will probably request additional tests.
• All breast lumps need to be clearly defined as benign or should be biopsied.

Ultrasound

• Ultrasound of the breast is often done to evaluate a breast lump.
• Ultrasound waves create a “picture” of the inside of the breast.
• It can demonstrate whether a mass is filled with fluid (cystic) or solid. Cancers are usually solid, while many cysts are benign.
• Ultrasound might also be used to guide a biopsy or the removal of fluid.

MRI

• MRI may provide additional information and may clarify findings which have been seen on mammography or ultrasound.
• MRI is not routine for screening for cancer but may be recommended in special situations.

Biopsy

• The only way to diagnose breast cancer with certainty is to biopsy the tissue in question. Biopsy means to take a very small piece of tissue from the body for examination and testing by a pathologist to determine if cancer is present. A number of biopsy techniques are available.
• Fine-needle aspiration consists of placing a needle into the breast and sucking out some cells to be examined by a pathologist. This technique is used most commonly when a fluid-filled mass is identified and cancer is not likely.
• Core-needle biopsy is performed with a special needle that takes a small piece of tissue for examination. Usually the needle is directed into the suspicious area with ultrasound or mammogram guidance. This technique is being used more and more because it is less invasive than surgical biopsy. It obtains only a sample of tissue rather than removing an entire lump. Occasionally, if the mass is easily felt, cells may be removed with a needle without additional guidance.
• Surgical biopsy is done by making an incision in the breast and removing the piece of tissue. Certain techniques allow removal of the entire lump.
• Regardless of how the biopsy is taken, the tissue will be reviewed by a pathologist. These are physicians who are specially trained in diagnosing diseases by looking at cells and tissues under a microscope.
• If a cancer is diagnosed on biopsy, the tissue will be tested for hormone receptors. Receptors are sites on the surface of tumor cells that bind to estrogen or progesterone. In general, the more receptors, the more sensitive the tumor will be to hormone therapy. There are also other tests (for example, measurement of HER-2/neu receptors) that may be performed to help characterize a tumor and determine the type of treatment that will be most effective for a given tumor.

What are the symptoms of Thyroid Cancer?

Early thyroid cancer often does not cause symptoms. But as the cancer grows, symptoms may include:

• A lump, or nodule, in the front of the neck near the Adam’s apple;
• Hoarseness or difficulty speaking in a normal voice;
• Swollen lymph nodes, especially in the neck;
• Difficulty swallowing or breathing;
• Pain in the throat or neck.

These symptoms are not sure signs of thyroid cancer. An infection, a benign goiter, or another problem also could cause these symptoms. Anyone with these symptoms should see a doctor as soon as possible. Only a doctor can diagnose and treat the problem.

How is Thyroid Cancer diagnosed?

Although it’s possible that you may see or feel a lump (nodule) in your thyroid yourself — usually just to the lower right or left of your Adam’s apple — it’s more likely that your doctor will discover a lump during a routine medical exam. You’re usually asked to swallow while your doctor examines your thyroid because the thyroid moves up and down during swallowing, making nodules easier to feel.

Sometimes a thyroid nodule is detected as an incidental finding when you have an imaging test to evaluate another condition in your head or neck. Nodules detected this way are usually too small to be found during a physical exam. To aid in diagnosis, you may have one or more of the following tests:

• Ultrasound scan. This imaging technique uses high-frequency sound waves to outline the neck anatomy and detect abnormal growths. While very good at identifying whether a growth or nodule is present, ultrasound scans can’t tell for sure whether it’s malignant or benign. Ultrasound is safe, with virtually no complications associated with its use.
• Fine-needle aspiration (FNA) biopsy. This test is generally considered the most sensitive for distinguishing between benign and malignant thyroid nodules. During the procedure, your doctor places a thin needle through your skin and into a nodule and removes a sample of cells. Several passes are usually needed to obtain tissue from different parts of the nodule. If you have more than one nodule, your doctor is likely to take samples from as many as possible. Often, your doctor will use ultrasound to help guide the placement of the needle. The samples are then sent to a laboratory and analyzed under a microscope. Only a small percentage of biopsied nodules are malignant. This diagnosis is based on the characteristics of individual cells and patterns in clusters of cells that are different from normal thyroid tissue. In some cases, a pathologist can determine specific types of cancer from an FNA biopsy sample.
• Blood tests. If your doctor suspects medullary cancer, you may have tests that check for high levels of calcitonin in your blood. Other tests can provide information about the function of your thyroid gland. For example, you may have a test that measures thyroid-stimulating hormone (TSH), a hormone made by the pituitary gland that regulates thyroid hormones.

Staging tests - If you receive a diagnosis of thyroid cancer, you’re likely to have tests to help determine whether the cancer has spread (metastasized) — a process known as staging. The stage of cancer helps your doctor determine the best course of treatment and the outlook for your recovery. The staging tests you have may vary, depending on the type of thyroid cancer.

Tests such as ultrasonography, computerized tomography (CT) and magnetic resonance imaging (MRI) may help your doctor to see whether the cancer has spread to the lymph nodes or other areas of your neck. Sometimes you may have an octreotide scan — a test that uses a radioactively tagged hormone to check for the spread of medullary cancer.

Screening tests - If you have medullary cancer, consider having DNA testing, which checks a blood sample for the known genetic defects that cause familial and MEN-associated medullary thyroid cancer. A genetic counselor can help determine what a positive or negative test result may mean for your family.

If you have medullary thyroid cancer but don’t test positive for the RET gene, it’s still important that your close family members have their calcitonin levels tested. This is generally done using a calcium infusion test. Although the calcitonin level of healthy people rises slightly after an injection of calcium, it’s much higher in people with medullary thyroid cancer.

The calcium infusion test usually takes between 15 and 20 minutes and is done on an outpatient basis. You’ll have a small amount of blood drawn before the injection of calcium and again at two, five, 10 and 15 minutes after the injection.

What are the symptoms of Testicular Cancer?

Most testicular cancers are discovered by the man himself when he notices a painless swelling (58%), lump (27%), or pain (33%) in a testicle.

• The lump may be small (the size of a pea) or large (the size of marble or even larger)
• Less common symptoms include a lasting ache or sensation of heaviness in the testicle.
• Significant shrinking of a testicle or a hardness of the testicle are other less common symptoms.
• Occasionally, a dull ache in the pelvis or groin is the only symptom.
• Rarely, the first symptom may be breast tenderness (3%), a result of hormonal changes brought on by the cancer.

Changes in the testicle can be detected early by practicing monthly testicular self-examination. Self-exam is easy to do. Testicular self-examination is key to recognizing testicular cancer early. Males older than 18 years should be encouraged to perform monthly inspections of each testicle. For more information on how to do a testicular self-exam, see Prevention. Notify your health care provider about any suspicious finding or concern.

How is Testicular Cancer diagnosed?

To help find the cause of symptoms, the doctor evaluates a man’s general health. The doctor also performs a physical exam and may order laboratory and diagnostic tests. These tests include:

• Blood tests that measure the levels of tumor markers. Tumor markers are substances often found in higher-than-normal amounts when cancer is present. Tumor markers such as alpha-fetoprotein (AFP), Beta-human chorionic gonadotropin (ßHCG), and lactate dehydrogenase (LDH) may suggest the presence of a testicular tumor, even if it is too small to be detected by physical exams or imaging tests.
• Ultrasound, a test in which high-frequency sound waves are bounced off internal organs and tissues. Their echoes produce a picture called a sonogram. Ultrasound of the scrotum can show the presence and size of a mass in the testicle. It is also helpful in ruling out other conditions, such as swelling due to infection or a collection of fluid unrelated to cancer.
• Biopsy (microscopic examination of testicular tissue by a pathologist) to determine whether cancer is present. In nearly all cases of suspected cancer, the entire affected testicle is removed through an incision in the groin. This procedure is called radical inguinal orchiectomy. In rare cases (for example, when a man has only one testicle), the surgeon performs an inguinal biopsy, removing a sample of tissue from the testicle through an incision in the groin and proceeding with orchiectomy only if the pathologist finds cancer cells. (The surgeon does not cut through the scrotum to remove tissue. If the problem is cancer, this procedure could cause the disease to spread.)

If testicular cancer is found, more tests are needed to find out if the cancer has spread from the testicle to other parts of the body. Determining the stage (extent) of the disease helps the doctor to plan appropriate treatment.

What are the symptoms of Stomach Cancer?

Early symptoms of stomach cancer tend to be vague and nonspecific. Seek medical attention if you have any of the following symptoms:

• Mild upper abdominal discomfort associated with nausea and loss of appetite
• Difficulty swallowing because of a tumor involving the upper part of your stomach, near the esophagus
• Feeling of fullness after taking only a small amount of food

The following symptoms may indicate advanced disease:

• Fatigue
• Weight loss
• Iron deficiency anemia
• Overt blood loss - Vomiting blood or a material that looks like coffee grounds or passing black stools
• Severe nausea and vomiting - A late symptom caused by blockage of the stomach drainage by the enlarging cancer

How is Stomach Cancer diagnosed?

If you have a symptom that suggests stomach cancer, your doctor must find out whether it is really due to cancer or to some other cause. Your doctor may refer you to a gastroenterologist, a doctor whose specialty is diagnosing and treating digestive problems. The doctor asks about your personal and family health history. You may have blood or other lab tests. You also may have:

• Physical exam: The doctor checks your abdomen for fluid, swelling, or other changes. The doctor also feels for swollen lymph nodes. Your skin and eyes are checked to see if they seem yellow.
• Upper GI series: The doctor orders x-rays of your esophagus and stomach. The x-rays are taken after you drink a barium solution. The solution makes your stomach show up more clearly on the x-rays.
• Endoscopy: The doctor uses a thin, lighted tube (endoscope) to look into your stomach. The doctor first numbs your throat with an anesthetic spray. You also may receive medicine to help you relax. The tube is passed through your mouth and esophagus to the stomach.
• Biopsy: The doctor uses an endoscope to remove tissue from the stomach. A pathologist checks the tissue under a microscope for cancer cells. A biopsy is the only sure way to know if cancer cells are present.

You may want to ask your doctor these questions about having a biopsy:

• How will the biopsy be done?
• Will I have to go to the hospital?
• Will I have to do anything to prepare for it?
• How long will it take? Will I be awake? Will it hurt?
• Are there any risks? What are the chances of infection or bleeding after the procedure?
• How long will it take me to recover? When can I resume my normal diet?
• How soon will I know the results? Who will explain them to me?
• If I do have cancer, who will talk to me about next steps? When?

What are the symptoms of Skin Cancer?

A basal cell carcinoma (BCC) usually looks like a raised, smooth, pearly bump on the sun-exposed skin of the head, neck, or shoulders.

• Small blood vessels may be visible within the tumor.
• A central depression with crusting and bleeding (ulceration) frequently develops.
• A BCC is often mistaken for a sore that does not heal.

A squamous cell carcinoma (SCC) is commonly a well-defined, red, scaling, thickened patch on sun-exposed skin.

• Like BCCs, SCCs may ulcerate and bleed.
• Left untreated, SCC may develop into a large mass.

The majority of malignant melanomas are brown to black pigmented lesions.

• Warning signs include change in size, shape, color, or elevation of a mole.
• The appearance of a new mole during adulthood, or new pain, itching, ulceration, or bleeding of an existing mole should all be checked by a health-care provider.

The following easy-to-remember guideline, “ABCD,” is useful for identifying malignant melanoma:

• Asymmetry—One side of the lesion does not look like the other.
• Border irregularity—Margins may be notched or irregular.
• Color—Melanomas are often a mixture of black, tan, brown, blue, red, or white.
• Diameter—Cancerous lesions are usually larger than 6 mm across (about the size of a pencil eraser), but any change in size may be significant.

How is Skin Cancer diagnosed?

Doctors often can recognize skin cancer just by looking at it.

• Encourage your doctor to look for growths by doing a complete examination of the entire skin surface during a physical examination at least once a year; more often if you already have a past history of skin cancer.
• Many people detect skin cancer themselves while doing a regular skin self-examination. A biopsy, however, is the only certain way of identifying skin cancer, and determining the specific type of cancer. In a biopsy, the doctor removes cells or tissues for examination under a microscope. The examination usually is done by a dermatopathologist, a doctor who studies diseased tissue under a microscope.

Two types of biopsy are done for most skin cancers:

• An excisional biopsy excises, or cuts away, the entire visible growth. For small nonmelanoma skin cancer, an excisional biopsy may also be the only treatment necessary, whereas other cancers like malignant melanoma generally require additional removal of a wider margin of normal tissue around the site.
• An incisional biopsy, or core biopsy, removes only a sample of the growth. Further treatment is necessary if the microscopic examination reveals cancer cells. This is the most common type of biopsy.

What are the symptoms of Prostate Cancer?

Most men with prostate cancer have no symptoms. This is particularly true of early prostate cancer.

• Most prostate cancers are discovered incidentally when a digital rectal exam is performed.
• A digital rectal exam is part of a thorough regular health examination. Digital refers to finger.
• During the digital rectal exam, the examiner inserts a gloved and lubricated finger in the rectum to feel the prostate for abnormalities.

Symptoms usually appear when the tumor causes some degree of urinary blockage at the bladder neck or the urethra.

• The usual symptoms include difficulty in starting and stopping the urinary stream, increase in frequency of urination, and pain while urinating.
• The urinary stream may be diminished (urinary retention), or it may simply dribble out.
• Even after urination, there is a sense of bladder fullness because the bladder has not been fully emptied.

Less common symptoms are

• These 3 symptoms are uncommon in early stages of the disease. They usually occur when the cancer is advanced.
• As the cancer advances to cause a greater blockage, bladder function may deteriorate further.
• Men with such advanced cancers sometimes experience recurring urinary tract infections.

Despite these symptoms, many men do not seek medical care until the cancer has spread. Symptoms of metastatic disease include fatigue, malaise, and weight loss. Spread to the bones causes deep bone pain, especially in the hips and back, and bone fractures from weakening of the bone.

How is Prostate Cancer diagnosed?

Prostate cancer is diagnosed from the results of a biopsy of the prostate gland. If the digital rectal exam of the prostate or the PSA blood test is abnormal, a prostate cancer is suspected. A biopsy of the prostate is usually then recommended. The biopsy is done from the rectum (trans-rectally) and is guided by ultrasound images of the area. A small piece of prostate tissue is withdrawn through a cutting needle. The TRUS-guided Tru-Cut biopsy is currently the standard method to diagnose prostate cancer. Classically a 6-core set is taken by sampling the base, apex and mid gland on each side of the gland. More cores may be sampled to increase the yield, especially in larger glands. A pathologist then examines the tissue under a microscope for signs of cancer in the cells of the tissue.

When prostate cancer is diagnosed on the biopsy tissue, the pathologist will then grade each of two pieces of the tissue from 1 to 5 on the Gleason scale. The scale is based on certain microscopic characteristics of the cancerous cells and reflects the aggressiveness of the tumor. The two scores are then added together. Sums of 2 to 4 are considered low, indicating a slowly growing tumor. Sums of 5 and 6 are intermediate, representing an intermediate degree of aggressiveness. Sums of 7 to 10 are considered high, signaling a rapidly growing tumor with the worst prognosis (outcome).

Gleason scores can be helpful in guiding treatment that is based, at least in part, on the aggressiveness of the tumor. The principal application of the Gleason score, however, is in predicting the risk for death from a prostate cancer. The tumor grade strongly affects the prognosis. Higher tumor grades are more frequently associated with lymph node and distant spread (metastases). Thus, recent studies have shown that men with Gleason scores of 2 to 4 face a minimal risk (4 to 7%) of death from prostate cancer over the ensuing 15 years, while men with scores of 8 to 10 face a high risk (60 to 87%) of death from prostate cancer over the 15 year period.