Mammography is a radiographic technique used to detect breast cysts or tumors, especially those not palpable on physical examination.

In xeromammography, a specially charged plate records the radiographic images and transfers them to a special paper. Biopsy of suspicious areas may be required to confirm malignancy. Although 90% to 95% of malignant breast tumors can be detected by mammography, this test produces many false positive results. Mammography may follow such screening procedures as ultrasonography or thermography. Purpose of Mammography To screen for malignant breast tumors. To investigate breast masses, breast pain, or nipple discharge. To differentiate between benign breast disease and malignant tumors. To monitor patients with breast cancer who are treated with breast-conserving surgery and radiation. Mammography Procedure Patient Preparation 1. Instruct the patient to avoid using underarm deodorant or powder the day of the exam. 2. Explain that the test takes about 15 minutes. 3. Explain to the patient that she may be asked to wait while the films are checked. 4. When scheduling the test, inform the staff if patient has breast implants. 5. Make sure the patient has signed an appropriate consent form. 6. Note and report all allergies. Implementation 1. The patient rests one breast on a table above the X-ray cassette. 2. The compressor is placed on the breast. 3. The patient holds her breath until the X-ray is taken and shes told to breathe again. 4. An X-ray of the cranicaudal view is taken. 5. The machine is rotated, and the breast is compressed again. 6. An X-ray of the lateral view is taken. 7. The procedure is repeated for the other breast. 8. The film is developed and checked for quality. Nursing Intervention 1. Answer the patients questions about the test. 2. Encourage the patient to deep breathe to alleviate fear and anxiety. 3. Make the patient feel comfortable after the procedure. 4. Prepare to educate the patient about her diagnosis. 5. Prepare the patient for further testing or surgery, as indicated. Interpretation Normal Results The test reveals normal ducts, glandular tissue, and fat architecture. No abnormal masses or calcifications are present. Abnormal Results Irregular, poorly outlined, opaque areas suggest malignant tumors, especially if solitary and unilateral. Well-outlined, regular, clear spots may be benign, especially if bilateral.

Interfering Factors Powders, deodorants, or salves on the breast and axilla that may cause false positive results. Failure to remove jewelry and clothing (possible false-positive results or poor imaging). Glandualr breasts that are common in patients younger than age 30, active lactation and previous breast surgery (possible poor imaging). Breast implants (possible hindrance in detecting masses). Comlications Vasovagal reaction during compression.

The Papanicolaou test (Pap smear) is a widely known cystologic test for early detection of cervical cancer. The can also be used to detect cancerous cells of the breast, lung, stomach, and renal system. A physician or specifically trained nurse scrapes secretions from the patients cervic and spreads them on a slide, which is sent to the laboratory for cystologic analysis. An alternative method is to use the ThinPrep preservative solution rather than a slide. The ThinPrep was introduced in 1996 and allows testing for malignancy cells from the cervix and shows the cell maturity, metabolic activity, and morphology variations. The American Cancer Society recommends a Pap test every 3 years for women between ages 20 and 40 who aren t in a high-risk category and who have had negative results from three previous Pap tests. Yearly tests (or tests at physician-recommended intervals) are advised for women older than age 40, for those in a high risk category, and for those who had a positive test previously. If a Pap test is positive or suggest malignancy, cervical biopsy can confirm the diagnosis. Purpose of Pap Smear To detect malignant cells. To detect inflammatory changes in tissue. To assess response to chemotherapy and radiation therapy. To detect viral, fungal, and occasionally, parasitic invasions. Pap Smear Procedure Patient Preparation 1. Instruct the patient to avoid intercourse for 24 hours, douching for 48 hours, and vaginal creams or medication for 1 week. 2. Just before the test, instruct the patient to empty her bladder. 3. During the procedure, she might experience a slight discomfort but no pain from the speculum; however, she may feel some pain when the cervix is scraped. 4. Explain the procedure takes only 5 to 10 minutes to perform. 5. Instruct the patient to disrobe from the waist down and to drape herself. 6. Ask her to lie on the examining table and to place her heels in the stirrups. 7. Tell her to slide her buttocks to the edge of the table. Implementation 1. The patient is assisted into the lithotomy position with her feet in the stirrups. 2. An unlubricated speculum is inserted into the vagina. 3. The cervix is located.

4. 5. 6. 7. 8.

Secretions from the cervix and material from the endocervical canal are collected with an endocervical brush and wooden spatula. Specimens are spread on slides and immediately immersed in fixative or sprayed with a fixative. Specimens are appropriately labeled with date of last menses, collection site, and method. If vaginal or vulval lesions are present, scrapings taken directly from the lesion are preferred. The slides are preserved immediately.

Nursing Interventions 1. Help the patient up and ask her to dress when the examination is completed. 2. Supply the patient with a sanitary napkin if cervical bleeding occurs. 3. Tell the patient when to return for her next Pap test. Interpretation Normal Results No malignant cells or abnormalities are present. Abnormal Results Cells with relatively large nuclei, only small amounts of cytoplasm, abnormal nuclear chromatin patterns, and marked variation in size, shape, and staining properties, with prominent nucleoli, suggest malignancy. Atypical but nonmalignant cells suggest a benign abnormality. Atypical cells may suggest dysplasia. Interfering Factors Douching within 24 hours of testing. Excessive use of lubricating jelly on the slide. Collection of specimen during menstruation Delay in fixing the specimens Consistency of specimen too thin or too thick. Precautions Preserve the slides immediately after the specimen is collected. Preserve the ThinPrep solution by immediately placing the lid back on the container, as exposure to air or light can cause distortion of cells. Complications Bleeding

Bone marrow, the soft tissue contained in the medullary canals of long bone and the interstices of cancellous bone, may be removed by aspiration or needle biopsy under local anesthesia. In aspiration biopsy, a fluid specimen in which pustulae of marrow is suspended is removed. In needle biopsy, a core of marrows cells, not fluid its removed. These methods are commonly used concurrently to obtain the best possible marrow specimens. Red marrow, which constitutes about 50% of an adults marrow, actively produces stem cells that ultimately evolve into red blood cells, white blood cells and platelets. Yellow marrow contains fat cells and connective tissue and is inactive, but it can become active in response to the bodys needs. Bleeding and infection may result from bone marrow biopsy at any site, but the most serious complications occur at the sternum. Such complications are rare but include puncture of the heartand major vessels, causing severe hemorrhage, and puncture of the mediastinum, causing mediastinitis of pneumomediastinum. Purpose of Bone Marrow Aspiration and Biopsy To diagnose thrombocytopenia, leukemia, granulomas, anemias, and primary and metastatic tumors. To determine the causes of infection. To help stage disease such as with Hodgins disease. To evaluate chemotherapy. To monitor myelosuppression. Bone Marrow Aspiration and Biopsy Procedure Patient Preparation 1. Explain the procedure to the patient. A mild sedative will be given 1 hour before the test, if ordered. 2. Tell the patient the test usually takes only 5 to 10 minutes and that more than one bone marrow specimen may be required. 3. Let him know a blood sample will be collected before the biopsy for laboratory testing. 4. Make sure the patient has signed a consent form. 5. Check the patient for hypersensitivity to the local anesthetic. 6. After confirming with the doctor, tell the patient which bone- sternum, anterior or posterior iliac crest, vertebral spinous process, ribs, or tibia will be used as the biopsy site. Implementation Aspiration Biopsy 1. The doctor prepares the biopsy site and injects a local anesthetic. He then inserts the needle through the skin, the subcutaneous tissue, and the cortex of the bone. 2. The doctor removes the stylet from the needle and attaches a 10 to 20 ml syringe. He aspirates 0.2 to 0.5 ml of marrow and withdraws the needle. 3. Pressure is applied to the site for 5 minutes while the marrow slides are being prepared. If the patient has thrombocytopenia, pressure is applied for 10 to 15 minutes. 4. The biopsy site is cleaned again, and a sterile adhesive bandage is applied. 5. If the doctor doesnt obtain an adequate marrow specimen on the first attempt, he may reposition the needle or remove and reinsert it in another site within the anesthetized area. If the second attempt fails, a needle biopsy may be necessary. Needle Biopsy 1. After preparing the biopsy site and draping the area, the examiner marks the skin at the site with an indelible pencil or marking pen. 2. A local anesthetic is then injected intradermally, subcutaneously, and at the bones surface. 3. The biopsy needle is inserted into the periosteum, and the needle guard is set as indicated. The needle is advanced with a steady boring motion until the outer needle passes through the bones cortex.

4.

5. 6.

The inner needle with trephine tip is inserted into the outer needle. By alternately rotating the inner needle clockwise and counterclockwise, the examiner directs the needle into the marrow cavity and then removes a tissue plug. The needle assembly is withdrawn, and the marrow is expelled into a labeled bottle containing Zenkers acetic acid solution. After the biopsy site is cleaned, a sterile adhesive bandage or a pressure dressing is applied.

Nursing Interventions 1. While the marrow slides are being prepared, apply pressure to the biopsy site until bleeding stops. 2. Clean the biopsy site and apply a sterile dressing. 3. Monitor the patients vital signs and the biopsy site for signs and symptoms of infection. Interpretation Normal Results 1. Yellow marrow contains fat cells and connective tissue. 2. Red marrow contains hematopoietic cells, fat cells, and connective tissue. 3. The iron satin, which measures hemosiderin (storage iron), has a +2 level. 4. The sudan black B satin, which shows granulocytes is negative. 5. The periodic acid-Schiff (PAS) stain, which detects glycogen reactions, is negative. Abnormal Results 1. Decreased hemosiderin levels in an iron stain may indicate a true iron deficiency. 2. Increased hemosiderin levels may suggest other types of anemias or blood disorders. 3. A positive stain can differentiate acute myelogenous leukemia from acute lymphoblastic leukemia (negative stain). 4. A positive stain may also suggest granulation in myeloblasts. 5. A positive PAS stain may suggest acute or chronic lymphocyte leukemia, amyloidosis, thalasemia, lymphoma, infectious mononucleosis, iron-deficiency anemia, or sideroblastic anemia. Complications 1. Hemorrhage and infection 2. Puncture of the mediastinum (sternum) Precautions Know that bone marrow biopsy is contraindicated in the patient with a severe bleeding disorder. Send the tissue specimen or slide to the laboratory immediately. Interfering Factors Failure to obtain a representative specimen. Failure to use a fixative for histologic analysis.

Breast biopsy is necessary to confirm or rule out cancer. Needle biopsy or fine-needle biopsy can provide a core of tissue or a fluid aspirate, but needle biopsy should be restricted to fluid-filled cysts and advanced malignant lesions. Both methods have limited diagnostic value because of the small and perhaps unrepresentative specimens they provide. Open biopsy provides a complete tissue specimen, which can be sectioned to allow more accurate evaluation. A breast biopsy can usually be done on an outpatient basis under local anesthesia; however, an excisional open biopsy may require general anesthesia. In sufficient tissue is obtained and the mass is found to be a malignant tumor, specimens are sent for estrogen and progesterone receptor assays to assist in determining future therapy and the prognosis. Purpose Breast Biopsy To differentiate between benign and malignant breast tumors. Breast Biopsy Procedure Patient Preparation 1. Make sure the patient has signed a consent form. 2. Note and report all allergies. 3. If the patient is to receive a local anesthesia, tell her she need not restrict food or fluids. 4. If the patient is to have a general anesthesia, tell her she is to have nothing by mouth after midnight or before the procedure. 5. Obtain and report abnormal results of prebiopsy studies, such as blood tests, urine tests, and radiographs of the chest. 6. Explain that the test takes 15 to 30 minutes. Implementation Needle Biopsy 1. Instruct your patient to undress to the waist. 2. After guiding her to a sitting or recumbent position with her hands at her sides, tell her to remain still. 3. The doctor then prepares the biopsy site, administers a local anesthetic, and introduces the syringe (luer-lock syringe for aspiration, Vim-Silverman needle for tissue specimen) into the lesion. 4. Fluid aspirated from the breast is expelled into a properly labeled, heparinized tube; the tissue specimen is placed in a labeled specimen bottle containing normal saline solution or formalin. 5. Send both specimens to the laboratory immediately. (With fine needle aspiration, a slide is made and viewed immediately under a microscope). 6. Because breast fluid aspiration isnt diagnostically accurate, some doctors aspirate fluid only from cysts. If such fluid is clear yellow and the mass disappears, the aspiration is both diagnostic and therapeutic, and the aspirate is discarded. If aspiration yields no fluid or if the lesion recurs two or three times, an open biopsy is then considered appropriate. 7. After the procedure, pressure is exerted on the biopsy site and, after bleeding has stopped, an adhesive bandage is applied.

Open Biopsy

1. 2. 3. 4. 5.

The site is prepared and draped, and the patient is given a local or general anesthetic. An incision is made in the breast to expose the mass. A portion of tissue or the entire mass is extracted. Benign-appearing masses smaller than (2cm) in diameter are usually excised. The specimens are placed in properly labeled specimen bottles containing 10% formalin solution. The malignant-appearing tissue is sent for frozen suction and receptor assays.

Nursing Interventions 1. If the patient has received a general or local anesthetic, monitor the patients vital signs regularly. If she has received a general anesthetic, check her vital signs every 15 minutes for 1 hour, every 30 minutes for 2 hours, every hour for the next 4 hours, and then every 4 hours. 2. Administer analgesics for pain, as ordered, and provide ice bags for comfort. 3. Instruct the patient to wear a support bra at all times until healing is complete. 4. Observe for and report bleeding, tenderness, and redness at the biopsy site. 5. Provide emotional support to the patient awaiting diagnosis. Interpretation Normal Results 1. Breast tissue consists of cellular and noncellular connective tissue, fat lobules, and various lactiferous ducts. 2. Breast tissue is pink, more fatty than fibrous, and shows no abnormal development of cells or tissue elements. Abnormal Results 1. Benign tumors may suggest fibrocystic disease, adenofibroma, intraductal papilloma, mammary fat necrosis, or plasma cell mastitis. 2. Malignant tumors may suggest adenocarcinoma, cystosarcoma, intraductal and infiltrating carcinoma, inflammatory carcinoma, medullary or circumscribed carcinoma, colloid carcinoma, lobular carcinoma, sarcoma, or Pagets disease. Precaution Breast biopsy is contraindicated in the patient with a condition that precludes surgery. Interfering Factors Failure to obtain an adequate tissue specimen or to place the specimen in the proper solution container interfering with test results.

A noninvasive technique, skeletal magnetic resonance imaging (MRI)produces clear and sensitive images of bone and soft tissue. The scan provides superior contrast of body tissues and allows imaging of multiple planes, including direct sagittal and coronal views in regions that cant be easily visualized with X -rays or computed tomography scans. MRIeliminates any risks associated with exposure to X-ray beams and causes no known harm to cells. There are two types of MRI. Closed MRI uses scanning equipment that resembles a tunnel like chamber. While open MRI uses more sophisticated equipment. During open MRI, the patient can comfortably see the surroundings from all views while the scan is in progress. This is ideal for patients who are claustrophobic or anxious, children, elderly, and the very obese. Purpose To evaluate bony and soft-tissue tumors. To identify changes in bone marrow composition. To identify spinal disorders. Patient Preparation 1. Make sure the scanner can accommodate the patients weight and abdominal girth. 2. Explain to the patient that skeletal MRI assesses bone and soft tissue. Tell him who will perform the test and where it will take place. 3. Explain that the test takes 30 to 90 minutes. 4. Explain to the patient that although MRI is painless and involves no exposure to radiation from the scanner, a contrast medium may be used, depending on the type of tissue being studied. 5. If the patient is claustrophobic or if extensive time is required for scanning, explain to him that a mild sedative may be administered to reduce anxiety. Open scanners have been developed for use on the patient with extreme claustrophobia or morbid obesity, but tests using such machine take longer. 6. An anesthesiologist may need to be present to monitor a heavily sedated patient. 7. Tell the patient that he must lie flat, and describe the test procedure. 8. Explain to the patient that hell hear the scanner clicking, whirring, and thumping as it moves inside its housing. 9. Reassure the patient that hell be able to communicate with the technician at all times. 10. Instruct the patient to remove all metallic objects, including jewelry, hairpins, or watches. 11. Stop I.V. infusion pumps, feeding tubes with metal tips, pulmonary artery catheters, and similar devices before the test. 12. Ask whether the patient has any surgically implanted joints, pins, clips, valves, pumps, or pacemakers containing metal that could be attracted to strong MRI magnet. If he does, he wont be able to have the test. 13. Note and report all allergies. 14. Make sure that the patient or a responsible family member has signed an informed consent form, if required. MRI Procedure 1. At the scanner room door, check the patient one last time for metal objects. 2. The patient is placed on a narrow, padded, nonmetallic table that moves into the scanner tunnel. Fans continuously circulate air in the tunnel, and a call bell or intercom is used to maintain verbal contact. 3. Remind the patient to remain still throughout the procedure. 4. While the patient lies within the strong magnetic field, the area to be studied in stimulated withradio-frequency waves. 5. If the test is prolonged with the patient lying flat, monitor him for orthostatic hypotension. 6. Provide comfort measures and pain medication as needed and ordered because of prolonged positioning in the scanner. 7. After the test, tell the patient that he may resume his usual activity. 8. Provide emotional support to the patient with claustrophobia or anxiety over his diagnosis.

Nursing Interventions for MRI 1. Provide patient with comfort measures as needed. 2. Tell the patient to resume his normal diet and activities unless otherwise indicated. 3. Monitor vital signs. 4. Monitor the patient for orthostatic hypotension. MRI Precautions 1. Be aware that MRI cant be performed on a patient with a pacemaker, intracranial aneurysm clip, or other ferrous metal implants. Ventilators, I.V. infusion pumps, oxygen tanks, and other metallic or computer based equipment must be kept out of the MRI area. 2. If the patient is unstable, make sure an I.V. line without metal components is in place and that all equipment is compatible with MRI imaging. If necessary, monitor the patients oxygen saturation, cardiac, rhythm, and respiratory status during the test. An anesthesiologist may be needed to monitor a heavily sedated patient. 3. Make sure that the technician maintains verbal contact with the conscious patient. MRI Interpretation Normal Results MRI should reveal no evidence of pathology in bone, muscles, and joints. Abnormal Findings MRI is excellent for visualizing disease of the spinal canal and cord and for identifying primary and metastatic bone tumors. Its beneficial in anatomic delineation of muscles, ligaments, and bones. The image show superior contrast of body tissues and sharply defines healthy, benign, and malignant tissues. Interfering Objects Metal objects, such as I.V. pumps, ventilators, other metallic equipment, or computer-based equipment, in the MRI area. MRI Complications Orthostatic hypotension Anxiety Claustrophobia

Diagnostic Tests
for

Cancer

Prepared By: Keith Jan Fantinalgo