What is the workup to rule out malignancy?

From the Guidelines

The workup to rule out malignancy should include a complete history and physical examination, laboratory tests such as complete blood count and comprehensive metabolic panel, imaging studies like CT scans or MRI, and endoscopic procedures with biopsy as needed, as recommended by the most recent guidelines 1. The approach to ruling out malignancy involves a systematic evaluation based on the patient's symptoms, risk factors, and physical examination findings. Key components of the workup include:

• Laboratory tests: complete blood count, comprehensive metabolic panel, and tumor markers specific to suspected cancer types
• Imaging studies: CT scans, MRI, or PET scans depending on the suspected location and type of malignancy
• Endoscopic procedures: colonoscopy, bronchoscopy, or upper endoscopy for direct visualization and tissue sampling of suspicious areas
• Biopsy: for definitive diagnosis, obtaining tissue samples through needle aspiration, endoscopic biopsy, or surgical excision for histopathological examination The specific workup should be tailored to the patient's presentation, considering that early symptoms of cancer can be vague or mimic other conditions. A thorough family history is also important due to the role of genetic predisposition in many cancers. The goal is to detect malignancy at the earliest possible stage when treatment options are most effective and outcomes are generally better, as emphasized in recent guidelines 1. In cases where gastric disease is suspected, a CT examination with IV contrast and neutral oral contrast is recommended to assess for nodular wall thickening and other signs concerning for gastric cancer 1. For patients with a suspicious pelvic mass, the primary workup should include an ultrasound and/or abdominal/pelvic CT/MRI scan, along with appropriate laboratory studies, including tumor markers like CA 125 for ovarian cancer 1. Newly diagnosed patients with gastric cancer should undergo a complete history, physical examination, upper GI endoscopy with biopsy, complete blood count, comprehensive chemistry profile, and CT scan of the chest, abdomen, and pelvis, with EUS and PET/CT evaluation recommended if metastatic cancer is not evident 1. Given the variety of potential malignancies and their differing presentations, a flexible and comprehensive approach to the workup is essential, incorporating the latest recommendations from clinical practice guidelines 1.

From the Research

Workup to Rule Out Malignancy

The workup to rule out malignancy involves a systematic approach to diagnose and determine the type of tumor. The following steps are involved:

• Recognize whether the specimen contains a lesion and determine whether the lesion is neoplastic or non-neoplastic 2
• Determine the origin of the neoplasm, whether it is of epithelial or mesenchymal origin 2
• Decide whether the tumor is benign or malignant based on differences in differentiation, growth rate, growth pattern, and metastasis 2
• Classify the type of tumor based on cellular differentiation and gross and microscopic growth pattern 2

Diagnostic Techniques

Various diagnostic techniques can be used to rule out malignancy, including:

• Biopsy or needle aspiration 3
• Endoscopic ultrasonography with fine needle aspiration (EUS/FNA) 3
• Image-guided percutaneous biopsy (IGPB) 3
• Magnetic resonance imaging (MRI) 4
• Tumor markers, such as serum levels of certain proteins or enzymes 5

Clinical Predictors of Cancer

Certain clinical predictors can increase the suspicion of cancer, including:

• Age of 50 years or older 3
• Jaundice 3
• Weight loss 3
• Percentage of monocytes greater than 7 3
• Platelet count greater than 440x10/L 3
• Prior history of malignancy 3
• Abnormally high percentage of monocytes 3
• Thrombocytosis 3

Diagnostic Work-up

The diagnostic work-up for malignancy may involve:

• Initial symptoms, such as defecation abnormality, palpable mass in the breast, cough, or symptoms of prostatism 6
• Diagnostic procedures, such as fecal occult blood tests, rectoscopy, and nonspecific blood laboratory tests 6
• Level of care, including primary health care and specialized care 6
• Doctor's delay, which can affect the outcome of the diagnostic process 6