Clinical case: fatigue as the initial symptom of a breast tumor
The discussion begins with a typical outpatient scenario: a young female patient around 30 years old consults a primary care physician with complaints of severe fatigue in the absence of other obvious symptoms. The diagnostic algorithm starts with a basic workup: complete blood count, which reveals elevated white blood cells, an elevated ESR, and a hemoglobin level of 105 g/L, corresponding to mild anemia.
Upon further history-taking, the patient reports discomfort in the neck area, which necessitates palpation of the lymph nodes. Enlarged, firm, painless cervical and axillary lymph nodes that are fixed to surrounding tissues are found, with changes being more pronounced on the right side. Such a presentation of lymphadenopathy combined with anemia and leukocytosis provides grounds for a targeted examination of the breasts.
Instrumental diagnostics: ultrasound, mammography, and radiological scales
In young women, breast ultrasound is preferred over mammography because the glandular component of the tissue predominates over adipose tissue, which reduces the informativeness of mammography. Breast MRI is used infrequently, mainly in ambiguous cases.
To assess the grade of malignancy of formations, radiological scales adapted for different organs are used:
- BI-RADS — for the breast;
- PI-RADS — for the prostate gland;
- TI-RADS (Bethesda) — for the thyroid gland.
Grading ranges from 1 (benign lesion) to 5 (high probability of malignancy). Category 3 is considered borderline and is an indication for biopsy, especially with an additional increase in specific markers: PSA in case of PI-RADS 3 in the prostate gland, or elevated thyroid hormone levels in the presence of thyroid nodules.
Tumor markers and evaluation of treatment efficacy
For the breast, a specific tumor marker is CA 15-3; however, its elevation does not always correlate with the presence of a tumor, and in confirmed breast cancer, the marker level may remain normal. Similar limitations are characteristic of CA 19-9 (colorectal tumors) and CA 72-4 (gastric tumors).
Tumor markers are determined before starting chemotherapy: if the baseline level is normal, the patient is considered marker-negative, and further marker monitoring is uninformative. When the baseline level is elevated, marker dynamics can be used as an additional criterion for treatment efficacy, except in prostate cancer, where PSA specifically remains the key indicator.
The main method for monitoring disease dynamics is instrumental imaging (CT, MRI), which is standardly performed every three months, corresponding to the completion of several cycles of chemotherapy. To objectively assess the response to treatment, the RECIST scale is used, tracking target lesions: an increase in the sum of the longest diameters of the lesions by 20% or more is considered progression.
Tumor differentiation grade and surgical management tactics
Tumor malignancy is determined by the degree of cell differentiation: well-differentiated cells retain similarities to normal tissue and correspond to a low grade of malignancy, whereas poorly differentiated and undifferentiated cells correspond to a high degree of aggressiveness.
Assessing the state of regional lymph nodes is crucial for choosing tactics: reactive lymph node enlargement (e.g., following a past infection) requires a different strategy than metastatic involvement. In localized disease within an organ, surgical treatment is preferred, whereas if the tumor has spread throughout the body, systemic therapy is administered first to reduce the tumor burden.
Radical surgical treatment implies complete removal of the organ with the tumor, such as mastectomy in breast cancer. Organ-sparing resection is possible only in early, non-invasive disease (carcinoma in situ). After surgery, pathologists evaluate the surgical margin: the presence of tumor cells at the margin requires re-operation, radiation, or chemotherapy, although for the prostate gland, a positive surgical margin is not always critical and requires only active surveillance.
Diagnosis of bowel tumors and the significance of morphological verification
When a tumor of the colon or rectum is suspected (anemia, positive fecal occult blood test), colonoscopy remains the gold standard for morphological verification. However, prior to an invasive procedure, it is advisable to perform a CT colonography or a pelvic MRI for initial visualization to avoid an unjustified invasive procedure, for example, in Crohn's disease.
Surgical treatment for rectal cancer often requires the creation of a colostomy, which significantly impacts the patient's quality of life, unlike colon resection with restoration of bowel continuity. In older patients when surgery is not feasible, chemotherapy should be considered after histological confirmation of the diagnosis.
There are anatomical sites where morphological verification before surgery is impossible or impractical: kidney tumors (renal cell carcinoma), brain tumors, and bladder tumors. In bladder cancer, transurethral resection (TUR) simultaneously serves as both a diagnostic method and a radical treatment for small lesions.
Tumors of unknown primary origin and specific features of chemotherapy
When multiple metastases are identified without an identifiable primary site, chemotherapy cannot be prescribed without histological verification, as the treatment regimen directly depends on the type of tumor cells. A biopsy is performed from the most accessible lesion. Squamous cell carcinoma of unknown primary origin is treatable regardless of location using radiation therapy and platinum-based agents, whereas adenocarcinomas require a differentiated approach depending on the organ of origin.
The use of platinum-based drugs is limited by renal function: when creatinine clearance is below 35–40 mL/min, these drugs are not administered due to the risk of severe toxicity, as they are excreted by the kidneys. In metastatic bladder cancer, renal failure frequently develops due to urinary tract obstruction by the tumor and hydronephrosis, which requires prior decompression (nephrostomy) before initiating systemic therapy. A temporary delay in chemotherapy when blood counts or liver enzymes (ALT/AST) worsen is standard and safe practice.
Key points
- Fatigue and mild anemia accompanied by leukocytosis require an expanded search for the cause, including examination of the lymph nodes and breasts.
- In young women, breast ultrasound is more informative than mammography due to the predominance of the glandular component.
- Radiological scales (BI-RADS, PI-RADS, TI-RADS) of category 3 and higher are an indication for biopsy.
- Tumor markers (CA 15-3, CA 19-9, CA 72-4) do not always correlate with the presence of a tumor and are used for treatment monitoring rather than primary diagnosis.
- The dynamics of the tumor process are assessed using the RECIST scale based on CT/MRI scans performed every three months.
- Radical surgical treatment involves the removal of the organ with the tumor and evaluation of the surgical margin for the presence of tumor cells.
- Kidney, brain, and bladder tumors are verified exclusively through surgical means.
- Platinum-based drugs are contraindicated at low creatinine clearance; temporary discontinuation of chemotherapy when blood test results worsen is safe for the patient.