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3. CELLULAR ABERRATIONThe Biology Cancer Part 2
DIAGNOSIS Imaging studies Excision or Fine Needle Aspiration Biopsy with microscopic histologic examination Pap smear Blood tests – for example PSA for prostate carcinoma, CEA or AFP for HCC or testicular, CEA for colorectal carcinoma, CA-125 for ovarian carcinoma, ALP for HCC or bone Cytologic examination of blood cells – for leukemia
DIAGNOSTIC AIDS USED TO DETECT CANCER Nuclear medicine imaging – bone, liver, kidney, spleen, brain, thyroid cancers PET – lung, colon, liver, pancreatic, head and neck cancers; Hodgkin and Non-Hodgkin lymphoma and melanoma PET fusion – see PET Radioimmunoconjugates – colorectal, breast, ovarian, head and neck cancers; lymphoma and melanoma
Site Gender Age Evaluation FrequencyBreast F 20-39 Clinical breast Every 3 years examination (CBE) Self breast Every month examination (SBE) >40 CBE Every year SBE Every month Mammogram Every yearColon and F/M >50 Fecal occult Every 5 yearsrectum blood and flexible Every 10 years sigmoidoscopy or colonoscopy or double- Every 5 years contrast barium enema
Site Gender Age Evaluation FrequencyProstate M >50 (or 40-45 if PSA and DRE Every year at high risk)Cervix F >21 or within 3 Pap smear Every year if years after regular Pap; starting to have every 2 years if intercourse liquid Pap testCancer-related M/F >20-39 Pelvic Every yearcheck ups examination Examination for Every 3 years cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity and skin as well as counseling about health practices and risk factors 40+ Same as 20-39 Every year
MANAGEMENT OF CANCER Surgery surgical removal of the entire cancer remains the ideal and most frequently used treatment methoda. Diagnostic surgery – biopsyb. As primary treatmentc. Prophylactic treatmentd. Palliative treatmente. Reconstructive surgery
MANAGEMENT OF CANCER Nursing management in cancer surgerya. The nurse completes a thorough preoperative assessment for factors that may affect the patient undergoing the surgical procedureb. The patient and family require time and assistance to deal with the possible changes and the outcomes resulting from the surgeryc. The nurse provides education and emotional support by assessing the needs of the patient and family and by discussing their fear and coping mechanisms with them
MANAGEMENT OF CANCER Nursing management in cancer surgeryd. After surgery, the nurse assesses the patient’s responses to the surgery and monitors the patient for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunctione. The nurse also provides for the patient’s comfort. Postoperative teaching addresses wound care, activity, nutrition, and medication informationf. Plans for discharge, follow-up and home care, and treatment are initiated as early as possible to ensure continuity of care from hospital to home or from a cancer referral center to the patient’s local hospital and health care provider.
MANAGEMENT OF CANCER Radiation therapya. External radiationb. Internal radiation or brachytherapyc. Radiation dosage – dependent on the sensitivity of the target tissue to radiation and on the tumor sized. Toxicity – localized to the region being irradiated
MANAGEMENT OF CANCER Nursing Management in Radiation therapya. The nurse can explain the procedure for delivering radiation and describe the equipment, the duration of the procedure (often minutes only), the possible need for immobilizing the patient during the procedureb. The nurse informs the family about restrictions placed on visitors and health personnel and other radiation precautions, for radioactive implants
MANAGEMENT OF CANCER Chemotherapya. Antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions, including replicationb. Used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiationc. May be combined with surgery, radiation therapy, or both, to reduce tumor size preoperatively, to destroy any remaining tumor cells postoperatively, or to treat some forms of leukemiad. Goals: cure, control and palliation
MANAGEMENT OF CANCER Classification of Chemotherapeutic Agentsf. Mitotic spindle poisons – plant alkaloids (vinblastine, vincristine), taxanes (paclitaxel, docetaxel)g. Hormonal agents – androgens and antiandrogens, estrogens and antiestrogens, progestins and antiprogestins, aromatase inhibitors, LH-releasing hormone analogues, steroidsh. Miscellaneous agents - asparaginase, procarbazine
MANAGEMENT OF CANCER Nursing management in chemotherapya. Assess fluid and electrolyte imbalanceb. Modify risks for infection and bleedingc. Administering chemotherapyd. Protecting caregivers
MANAGEMENT OF CANCER Bone Marrow Transplantationa. Allogenic (from a donor other than the patient); either a related donor or a matched unrelated donorb. Autologous (from patient)c. Syngeneic (from an identical twin)
MANAGEMENT OF CANCER Nursing Management in Bone Marrow Transplantationa. Implementing pretransplantation careb. Providing care during treatmentc. Providing posttransplantation care
MANAGEMENT OF CANCER Hyperthermia Targeted therapiesa. BRMb. Gene therapyc. Growth factors Photodynamic therapy Cancer rehabilitation
SQUAMOUS CELL CARCINOMA SCC The second most common tumor arising on sun- exposed sites in older people, exceeded only by basal cell carcinoma Except for lesions on the lower legs, these tumors have a higher incidence in men than in women The most important cause of cutaneous SCC is DNA damage induced by exposure to UV light Is invasive, can recur and metastasize
SQUAMOUS CELL CARCINOMA Other Risk Factors1. Age older than 50 years2. Light skin; blonde or light brown hair; green, blue, or gray eyes3. Skin that sunburns easily (Fitzpatrick skin types I and II)4. Geography (closer to the equator) (http://emedicine.medscape.com/article/1101535-overview)
SQUAMOUS CELL CARCINOMA Immunosuppression may contribute to carcinogenesis by reducing host surveillance and increasing the susceptibility of keratinocytes to infection and transformation by oncogenic viruses, particularly HPV subtypes 5 and 8 Other risk fatcors include industrial carcinogens (tars and oils), chronic ulcers and draining osteomyelitis, old burn scars, ingestion of arsenicals, ionizing radiation, and (in the oral cavity) tobacco and betel nut chewing
SQUAMOUS CELL CARCINOMA History A new and enlarging lesion that concerns the patient Most lesions are slow growing, while others rapidly enlarges Symptoms such as bleeding, weeping, pain, or tenderness may be noted, especially with larger tumors Numbness, tingling, or muscle weakness may reflect underlying perineural involvement, and this history finding is important to elicit because it adversely impacts prognosis. May be asymptomatic (http://emedicine.medscape.com/article/1101535- overview)
SQUAMOUS CELL CARCINOMA Imaging studies like CT scan are done for patients with neurologic symptoms and with (+) lymphadenopathy FNAB or excision biopsy of palpable lymph nodes Small biopsies of the lesion suspected to be SCC (http://emedicine.medscape.com/article/1101535- overview)
SQUAMOUS CELL CARCINOMA Surgical treatment options:1. Cryotherapy – for in-situ lesions; makes use of liquid nitrogen2. Electrodesiccation and curettage – for low-risk carcinomas of the trunk and extremities3. Excision with conventional margins (http://emedicine.medscape.com/article/1101535- overview)
BASAL CELL CARCINOMA BCC The most common invasive cancer in humans Slow-growing tumors that rarely metastasize Have a tendency to occur in sun-exposed areas and in lightly pigmented people Incidence rises sharply with immunosuppression and in people with inherited defects in DNA repair
BASAL CELL CARCINOMA Tumors present clinically as pearly papules often containing prominent dilated subepidermal blood vessels Advanced lesion may ulcerate, and extensive local invasion of bone and facial sinuses may occur after many years of neglect (rodent ulcers)
BASAL CELL CARCINOMA Treatment1. Electrodessication and curettage involves destroying the tumor with an electrocautery device then scraping the area with a curette2. Surgical excision of the lesion including a margin of normal skin. This method is preferred for larger lesions (>2cm) on the cheek, forehead, trunk, and legs3. Radiation therapy - may also be used where tumors are difficult to excise or where it is important to preserve surrounding tissue such as the lip. Its use is declining.4. Cryotherapy - involves destroying the tissue by freezing it with liquid nitrogen. This may be effective for small, well-defined superficial tumors
BASAL CELL CARCINOMA Prevention1. Avoid UVB radiation from sun exposure especially midday sun2. Use protective clothing3. Use sunscreen with an SPF of at least 15. This is especially important for children.4. Have suspicious lesions checked out - If you have a question, get it checked out. Treating premalignant lesions prevents their transformation to potentially metastatic cancers.
MELANOMA A relatively common neoplasm that remains deadly if not caught at its earliest stages Can occur in the oral and anogenital mucosal surfaces, esophagus, meninges, and the eye Melanomas evolve over time from localized skin lesions to aggressive tumors that metastatize and are resistant to therapy Early recognition and complete excision are critical
MELANOMA Usually asymptomatic Itching or pain may be an early manifestation Majority of lesions are greater than 10 mm in diameter at diagnosis Most consistent clinical signs (in pigmented lesions):1. Changes in color2. Changes in size3. Changes in shape
MELANOMA Unlike benign tumors, these tumors show variations in color (shades of black, brown, red, dark blue, and gray) There may be areas of hypopigmentation Borders are irregular and often notched, not smooth, round, and uniform Important warning signs (ABCs):1. Asymmetry2. Irregular borders3. Variegated color
MELANOMA Other features:1. Diameter greater than 6 mm2. Any change in appearance3. New onset of itching4. Or new onset of pain
MELANOMA Prognostic factors:1. Tumor depth - <1.7mm (favorable)2. Number of mitoses – no or few mitoses (favorable)3. Evidence of tumor regression – absence (favorable)4. The presence and number of tumor infiltrating lymphocytes – brisk (favorable)5. Gender – female (favorable)6. Location – location on an extremity (favorable)
MELANOMA The two most important predisposing factors are inherited genes and sun exposure Treatment is by stage
Stage 0 melanoma. Abnormal melanocytes are in the epidermis (outerlayer of the skin).
Stage I melanoma. In stage IA, the tumor is not more than 1 millimeter thick, with noulceration (break in the skin). In stage IB, the tumor is either not more than 1millimeter thick, with ulceration, OR more than 1 but not more than 2 millimeters thick,with no ulceration. Skin thickness is different on different parts of the body.
Stage II melanoma. In stage IIA, the tumor is either more than 1 but not more than 2millimeters thick, with ulceration (break in the skin), OR it is more than 2 but not more than 4millimeters thick, with no ulceration. In stage IIB, the tumor is either more than 2 but not morethan 4 millimeters thick, with ulceration, OR it is more than 4 millimeters thick, with noulceration. In stage IIC, the tumor is more than 4 millimeters thick, with ulceration. Skinthickness is different on different parts of the body.
Stage III melanoma. Thetumor may be anythickness with or withoutulceration. It has spreadeither (a) into a nearbylymph vessel and mayhave spread to nearbylymph nodes; OR (b) to 1or more lymph nodes,which may be matted (notmoveable). Skin thicknessis different on differentparts of the body.
Stage IV melanoma. The tumor has spreadto other parts of the body.
MELANOMA Stage 0 (Melanoma in Situ) - Treatment of stage 0 is usually surgery to remove the area of abnormal cells and a small amount of normal tissue around it. Stage I Melanoma1. Surgery to remove the tumor and some of the normal tissue around it.2. A clinical trial of surgery to remove the tumor and some of the normal tissue around it, with or without lymph node mapping and lymphadenectomy.3. A clinical trial of new techniques to detect cancer cells in the lymph nodes.4. A clinical trial of lymphadenectomy with or without adjuvant therapy.
MELANOMA Stage II Melanoma1. Surgery to remove the tumor and some of the normal tissue around it, followed by removal of nearby lymph nodes.2. Lymph node mapping and sentinel lymph node biopsy, followed by surgery to remove the tumor and some of the normal tissue around it. If cancer is found in the sentinel lymph node, a second surgery may be done to remove more nearby lymph nodes.3. Surgery followed by high- dose biologic therapy.4. A clinical trial of adjuvant chemotherapy and/or biologic therapy.5. A clinical trial of new techniques to detect cancer cells in the lymph nodes.
MELANOMA Stage III Melanoma1. Surgery to remove the tumor and some of the normal tissue around it.2. Surgery to remove the tumor with skin grafting to cover the wound caused by surgery.3. Surgery followed by biologic therapy.4. A clinical trial of surgery followed by chemotherapy and/or biologic therapy.5. A clinical trial of biologic therapy.6. A clinical trial comparing surgery alone to surgery with biologic therapy.7. A clinical trial of chemoimmunotherapy or biologic therapy.8. A clinical trial of hyperthermic isolated limb perfusion using chemotherapy and biologic therapy.9. A clinical trial of biologic therapy and radiation therapy.
MELANOMA Stage IV Melanoma1. Surgery or radiation therapy as palliative therapy to relieve symptoms and improve quality of life.2. Chemotherapy and/or biologic therapy.3. A clinical trial of new chemotherapy, biologic therapy, and/or targeted therapy with monoclonal antibodies, or vaccine therapy.4. A clinical trial of radiation therapy as palliative therapy to relieve symptoms and improve quality of life.5. A clinical trial of surgery to remove all known cancer.