Chapter 183. Common Issues Specific to Common Cancers

1. Small cell carcinomas arise at what anatomical sites?

2. How do squamous cell carcinomas behave differently from small cell carcinomas?

3. How does the behavior and treatment of hormone-sensitive adenocarcinomas differ from hormone-independent adenocarcinomas?

In the preantibiotic era of the late nineteenth century, William Osler instructed clinicians to “Know syphilis in all its manifestations and relations and all other things clinical will be added unto you.” In the current era, with Treponema pallidum infection no longer a lifelong and endemic condition, Osler would have little objection to the application of his advice to the dozens of diseases we refer to as cancer. In this chapter, some of the more common clinical presentations and manifestations of solid cancers will be reviewed. This will include, with a deferential nod to Carl Jung, four solid cancer “archetypes,” each with a distinctive character and management approaches. Molecular phenotypes may replace these histological identities in the future. To the degree that pattern recognition can expedite diagnosis and treatment, these descriptions may be of value in providing a sense of the “personality” of common cancers and their presentations and complications. That said, an open mind and high index of suspicion should always be maintained as cancer can be a fascinatingly unpredictable disease.

Solid cancers display impressive heterogeneity, even within the same anatomical tumor sites, but a few general comments can be made. First, solid cancers that are not cured typically recur within months to a few years after completing initial therapy and have an inexorably progressive course to death over a period of months to years. Exceptions occur in clear cell renal cell carcinoma, breast adenocarcinoma, and melanoma patients who may experience recurrences decades after initial diagnosis and treatment. Interestingly, melanoma and renal cell tumors have also been observed to undergo spontaneous remission. Second, solid cancers that have metastasized to distant organs are generally not curable. There are three potential exceptions to this: (1) metastatic germ cell tumors, which typically arise in the testicle in young men (but also rarely in the ovary, pineal gland, mediastinum, or of uncertain primary origin) and are usually cured with systemic chemotherapy; (2) a portion of solid cancer patients with micrometastases treated with anticancer drug therapy added to local therapy can be cured, and this is the basis for adjuvant chemotherapy in breast, colorectal, and lung cancer; and (3) uncommonly, patients with oligometastatic disease treated surgically may be cured, for example, metastatectomy of a solitary lung or liver metastasis in a patient with a soft tissue sarcoma or colorectal cancer. If the clinical situation is at all ...