3. cellular aberration

3. CELLULAR ABERRATION The 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

Urine with cancer cells (urine cytology

DIAGNOSTIC AIDS USED TO DETECT CANCER

Tumor markers – breast, colon, lung, ovarian, testicular, prostate cancers

MRI – neurologic, pelvic, abdominal, thoracic cancers

Fluoroscopy – neurologic, pelvic, skeletal, abdominal, thoracic cancers

UTZ – abdominal and pelvic cancers Endoscopy – bronchial, GIT cancers

MRI

Fluoroscopy

UTZ

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

Nuclear Imaging

Nuclear Imaging

PET scan

Nomenclature

Tissue of origin

Benign Malignant

Ectoderm/endoderm

Epithelium Papilloma Carcinoma

Gland Adenoma Adenocarcinoma

Liver cells Adenoma HCC

Neuroglia Glioma Glioma

Melanocytes Malignant melanoma

Basal cells Basal cell carcinoma

Germ cells Mature teratoma Seminoma

Mesoderm Connective tissue

Adipose tissue Lipoma Liposarcoma

Fibrous Fibroma Fibrosarcoma

Bone Osteoma Osteosarcoma

Cartilage Chondroma Chondrosarcoma

Nomenclature

Tissue of origin Benign Malignant

Mesoderm Muscle

Smooth muscle Leiomyoma Leiomyosarcoma

Striated muscle Rhabdomyoma Rhabdomyosarcoma

Neural tissue

Nerve cells Ganglioneuroma Neuroblastoma

Endothelial tissue

Blood vessels Hemagioma AngiosarcomaKaposi sarcoma

Meninges Meningioma Malignant meningioma

Hematopioetic tissue

Granulocytes Leukemia

Plasma cells Multiple myelomaplasmacytoma

Lymphocytes Lymphoma

Site Gender Age Evaluation Frequency

Breast

Colon and rectum

F

F/M

20-39

>40

>50

Clinical breast examination (CBE)Self breast examination (SBE)CBESBEMammogram

Fecal occult blood and flexible sigmoidoscopy or colonoscopy or double-contrast barium enema

Every 3 years

Every month

Every yearEvery monthEvery year

Every 5 years

Every 10 years

Every 5 years

Site Gender Age Evaluation Frequency

Prostate

Cervix

Cancer-related check ups

M

F

M/F

>50 (or 40-45 if at high risk)

>21 or within 3 years after starting to have intercourse

>20-39

40+

PSA and DRE

Pap smear

Pelvic examinationExamination for cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity and skin as well as counseling about health practices and risk factorsSame as 20-39

Every year

Every year if regular Pap; every 2 years if liquid Pap test

Every year

Every 3 years

Every year

MANAGEMENT OF CANCER

Surgery surgical removal of the entire cancer remains the ideal and most frequently used treatment method

a. Diagnostic surgery – biopsyb. As primary treatmentc. Prophylactic treatmentd. Palliative treatmente. Reconstructive surgery


Nursing management in cancer surgerya. The nurse completes a thorough preoperative

assessment for factors that may affect the patient undergoing the surgical procedure

b. The patient and family require time and assistance to deal with the possible changes and the outcomes resulting from the surgery

c. 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 dysfunction

e. The nurse also provides for the patient’s comfort. Postoperative teaching addresses wound care, activity, nutrition, and medication information

f. 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.


Radiation therapya. External radiationb. Internal radiation or brachytherapyc. Radiation dosage – dependent on the

sensitivity of the target tissue to radiation and on the tumor size

d. Toxicity – localized to the region being irradiated


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 procedure

b. The nurse informs the family about restrictions placed on visitors and health personnel and other radiation precautions, for radioactive implants


Chemotherapy a. Antineoplastic agents are used in an attempt

to destroy tumor cells by interfering with cellular functions, including replication

b. Used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiation

c. 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 leukemia

d. Goals: cure, control and palliation


Classification of Chemotherapeutic Agentsa. Alkylating agents – busulfan, carboplatin,

cisplatin, cyclophosphamideb. Nitrosureas – carmusine, streptozocinc. Topoisomerase I inhibitors – irinotecan,

topotecand. Antimetabolites – cytarabine, 5-FU,

hydroxyurea, methotrexatee. Antitumor antibiotics – bleomycin,

daunorubicin, doxorubicin, mitomycin


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, steroids

h. Miscellaneous agents - asparaginase, procarbazine


Nursing management in chemotherapya. Assess fluid and electrolyte imbalanceb. Modify risks for infection and bleedingc. Administering chemotherapyd. Protecting caregivers


Bone Marrow Transplantationa. Allogenic (from a donor other than the

patient); either a related donor or a matched unrelated donor

b. Autologous (from patient)c. Syngeneic (from an identical twin)


Nursing Management in Bone Marrow Transplantation

a. Implementing pretransplantation careb. Providing care during treatmentc. Providing posttransplantation care


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


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)


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)


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)


Nonsurgical treatment options:1. topical chemotherapy - 5-FU2. topical immune response modifiers –

sirolimus, prednisone, cyclosporine, azathioprine, and mycophenolate

3. photodynamic therapy (PDT)4. Radiotherapy5. Systemic chemotherapy – 5-FU and

cetuximab (EGFR antagonist)(http://emedicine.medscape.com/article/

1101535-overview)

http://emedicine.medscape.com/article/1121517-overview


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 extremities

3. Excision with conventional margins(http://emedicine.medscape.com/article/

1101535-overview)

Electrodesiccation

Excision biopsy

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


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 curette

2. 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 legs

3. 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


Prevention 1. Avoid UVB radiation from sun exposure

especially midday sun 2. Use protective clothing 3. 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.

http://dermatology.about.com/library/bldefuvb.htm

http://dermatology.about.com/cs/skincareproducts/l/blsunscreen.htm

http://dermatology.about.com/cs/skincareproducts/a/spf.htm

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 (outer layer of the skin).

Stage I melanoma. In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration (break in the skin). In stage IB, the tumor is either not more than 1 millimeter 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 2 millimeters thick, with ulceration (break in the skin), OR it is more than 2 but not more than 4 millimeters thick, with no ulceration. In stage IIB, the tumor is either more than 2 but not more than 4 millimeters thick, with ulceration, OR it is more than 4 millimeters thick, with no ulceration. In stage IIC, the tumor is more than 4 millimeters thick, with ulceration. Skin thickness is different on different parts of the body.

Stage III melanoma. The tumor may be any thickness with or without ulceration. It has spread either (a) into a nearby lymph vessel and may have spread to nearby lymph nodes; OR (b) to 1 or more lymph nodes, which may be matted (not moveable). Skin thickness is different on different parts of the body.

Stage IV melanoma. The tumor has spread to 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 Melanoma 1. 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.

http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=352156&version=Patient&language=English















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 Melanoma

1. 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.












3. cellular aberration

Education