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Local invasion assessment begins with the initial complete clinical examination during which the para-clinical examinations necessary to correctly assess local cancer extension and propose a correctly applicable therapy are determined.

If, in theory, all cancers can give birth to any kind of metastases, in reality the elective occurrence of metastases according to the primitive tumour allows the definition of a standard chart for the majority of cancer localisations.

Local extension

The goal of the study of local extension is to identify tumour localisation and dimension and its relation with neighbouring structures. Its evaluation is based on tumour size and using various methods depending on tumour localisation.

Evaluating a superficial tumour

In most cases, the clinical examination can offer substantial data.

For instance, considering breast carcinoma:

• measurement of the diameters of the mammary nodule,
  
• identification of its localisation in relation to the nipple,
  
• verification of its relationship with skin: adhesion, skin invasion ('peau d'orange' phenomenon or orange peel phenomenon),
  
• verification of its mobility with regards to the pectoral muscle and the chest wall,
  
• mammography (and potentially RMI) allows a more objective, accurate evaluation and other specific radiological criteria typical of a cancer: structure irregularity, stellar aspect, micro-calcifications.

The same clinical evaluation can be carried out for other tumours such as thyroid, testis, soft tissue tumours: with a well practised clinical examination, a good classification can be established.

Local evaluation by clinical examination

Combining a quality clinical examination with a few paraclinical tests allows an accurate evaluation of local invasion.

For instance, for cancer of the cervix uteri,

• speculum examination allows a good measurement of the lesion and a definition of vaginal invasion,
  
• pelvic examination (vaginal but especially rectal examination) permits an appreciation of the infiltration of the vaginal wall and of parameters,
  
• the intravenous pyelography detects any ureteral compression (or a non functioning kidney) by a parametrial invasion,
  
• cystoscopy is mandatory to exclude a vesical invasion (and in the case of doubt, a rectoscopy for studying a rectal invasion).

However, to obtain an accurate classification of a cervix uteri tumour, according to FIGO criteria, a gynaecological examination under general anaesthesia should be performed in order to avoid any painful patient reaction and to offer the physician sufficient time to confirm the invasion diagnosis.

Similar situations may be observed for tongue cancer, head and neck cancers, prostate carcinoma and rectal carcinoma. Generally, the clinical examination enables a quality evaluation and classification. However, very often, a calmer and uninterrupted examination can be performed under general anaesthesia (notably to obtain further biopsies).

Profound cancer evaluation

For those cancers, many other complex examinations should be performed:

For colon carcinoma, coloscopy is the most important examination for diagnosis and evaluation of superficial invasion. However, most often, the depth invasion will be evaluated after colectomy on the surgical specimen.

For lung cancer, bronchoscopy allows a good definition of the superficial tumour extension, while a thoracic scanner is mandatory for exploring infiltration and tumour size; a mediastinoscopy may be mandatory. In spite of all these examinations, surprising surgical discoveries are quite frequent.

For ovarian carcinoma, only a well conducted exploratory laparotomy with precise specific surgical exereses will allow an accurate classification.