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U - Unexplained anemia
exam •
The Cell
• Cell cycle (Go, G1, S, G2,
mitosis)
• Normal Cell Characteristics
- Appearance
- Growth pattern
- Differentiated functions
- Non-migratory
Characteristics of Early
Embryonic Cells
• Rapid & continuous cell division
• Large nucleus
• Perform no differentiated functions
• Adhere loosely together
• Able to migrate
• Not contact inhibited
•
*Embroyonic Cell Testing
Commitment Phase of Early
Embryonic Cells
• Turn off proto-oncogenes
• Expression of specfic genes
•
Biology of Abnormal Cells
carried through the body until they reach a juncture through which
they cannot pass. At this point, they lodge and new tumors form.
Metastasis, the spreading of cancer from its original location to other
parts of the body, is the disease’s most destructive characteristic.
Routes of Metastasis
• Local Seeding
• Bloodborne
• Lymphatic
Secondary Tumors
Breast: Bone & lung
Prostate: Bone (spine & legs); Pelvic nodes
Phases of Cancer
• Pre-diagnosis
• Initial Diagnosis
• Treatment Phase
• Readmission Phase
• Reoccurrence
• Terminal
• Survival
Assessment
• History – depends on phase of cancer
- Focus on system of body
- Height, weight, vital signs
- Focus on effects of treatment
- Review medications
- Determine knowledge level
• Subjective Data
• Objective Data
Collaborative Assessment
• Laboratory blood tests
– CBC
– Platelet count
– WBC with differential
– Blood chemistry (ca ++; alkaline
phosphatase
– Coagulation studies (PT,Ptt)
– Tumor markers (specific for types of
cancer)
Collaborative Assessment
• Cytology Studies
• Biopsy
• Body Imaging – MRI, CT Scan
• Radiological Studies
• Ultrasound
• Endoscopies
• Immune Studies – antigen skin testing
•
Nursing Diagnoses
• Physiological
- Imbalanced nutrition
- Fatigue
- Altered comfort
- Altered oral mucosa
- Impaired skin integrity
- Disturbed sensory perceptions
Nursing Diagnoses
• Psycho-social
- Altered coping, individual/family
- Knowledge deficit
- Decisional conflict
- Grieving
- Powerlessness
- Hopelessness
- Altered body image
Surgical Interventions
• Purposes
- Diagnosis
- Cure
- Control
- Palliation
- Reconstruction
Surgical Interventions
• Biopsies – Needle, incisional,
excisional,staging
• Local Incision
• Wide Local Incision
• Wide Excision
• Extended Radical Excision
Radiation Therapy
• Treatment of disease with ionizing radiation - damage to
DNA leads to cell death
• Underlying Principles:
- Dose Determination
- Fractionalization
• Purposes
- Cure
- Control
- Palliation
• Radiation Treatment
• In this procedure the radioisotope cobalt 60 is used as the source of
gamma radiation. A high dose of gamma radiation is guided by
laser targeting to a localized area of treatment.
Radiation Therapy
• Tele “distant” therapy – beam radiation (Cobolt 60)
• Patient Preparation
•
Brachytherapy
• Use of high energy radioactive materials within
body tissues
• Rationale: A very limited dose, directly absorbed
into malignant tissue for specific period of time
• Types
- Sealed isotopes (Molds, Plaques, Needles)
- Unsealed (orally or IV for dx. or Rx. Of
hyperthyroidism i.e.. iodine 131)
Brachytherapy – Safety Principles
- Mucositis/stomatitis
• Fatigue
• Alopecia
• Infection
Side Effects of Chemotherapy
• Bone Marrow Suppression
- Anemia
- Neutropenia
- Granulocytopenia
- Leukopenia
- Thrombocytopenia
NIC – Nutrition/Nausea & Vomiting
Surgical biopsy
lobular, etc
grade of the tumor
potential
c-erb
How is breast cancer treated?
Side effects
uterus
blood clots
Can breast cancer be prevented?
Source: American Cancer Society
Statistics
• 10,520 new cases in the U.S. this year
• 3,900 will die
• 50% are diagnosed between ages 35 and 55.
• 20% at the age of 65 or over.
• Rarely occurs in women younger than 20
• Noninvasive is four times more common
• 74% decrease in deaths between 1955 and
1992 in the U.S.
• Death rate continuous to decline by 2% a year
Source: American Cancer Society
Lifetime Probability of Developing Cancer, by
Site, Women, US, 1998-2000
Site Risk
All sites 1 in 3
Breast 1 in 7
Lung & bronchus 1 in 17
Colon & rectum 1 in 18
Uterine corpus 1 in 38
Non-Hodgkin lymphoma 1 in 57
Ovary 1 in 59
Pancreas 1 in 83
Melanoma 1 in 82
Urinary bladder 1 in 91
Uterine cervix 1 in 128
Source:DevCan: Probability of Developing or Dying of Cancer Software, Version 5.1 Statistical Research and
Applications Branch, NCI, 2003. http://srab.cancer.gov/devcan
Signs and Symptoms
• Vaginal bleeding
•
• Menstrual bleeding is longer and heavier than usual
Smoking
HIV infection
Chlamydia infection
Diet
Oral contraceptives
Multiple pregnancies
Diethylstilbestrol (DES)
Family history
Diagnosis
Cervical Cytology (Pap Test)
Source: American Cancer Society
Diagnosis
Additional testing
Colposcopy
Cervix is viewed through a colposcope and the
surface of the cervix can be seen close and
clear.
Cervical Biopsies
Colposcopic biopsy – removal of small section
of the abnormal area of the surface.
Endocervical curettage – removing some tissue
lining from the endocervical canal.
Cone biopsy – cone-shaped piece of tissue is
removed from the cervix
Staging
FIGO System (International Federation Of Gynecology and Obstetrics)
Has five stages – 0 to 4
Stage 0 Carcinoma in situ
Stage 1 Invaded cervix, but has not spread.
Stage 2 Has spread to nearby areas, not leaving pelvic area.
Stage 3 Cancer has spread to the lower part of the vagina.
Stage 4Cancer has spread to nearby organs; metastasis.
Chemotherapy
What’s new in cervical cancer
research and treatment?
• HPV test
• HPV vaccine
•
• Radical trachelectomy procedure
Fibromuscular
zone
Urethra
Ductus
deferens Capsule
Peripheral zone
nld.by/e/current/stat13.htm#15
Lobes of the Prostate
Anterior lobe
Median lobe
Lateral lobe
Posterior lobe
• Peripheral
• Central
• Transitional
Male
Age
Race
Age influenced
40 - 49 / 2.5
50 - 59 / 3.5
60 - 69 / 4.5
70 - 79 / 6.5
Elevated indicates possible CA dx
PSA that
circulates in
blood w/o
carrier protein
The lower the %
• Hypoechoi
c shows
abnorma
l area
needing
biopsy
Transrectal
sonogram of the
prostate. Looking up
from the feet of a
patient toward his
head.
Other Workup
• Bone scan
• CT abdomen/pelvis
• PET scan
• Chest x-ray
Histology
99% Adenocarcinoma
1% Other
visualsonline.cancer.gov
www.prostate-cancer.org
Grade Priority (FORDS)
1. Gleason’s grade
2. Terminology
2, 3, 4 1, 2 I Well 1
differentiated
5, 6 3 II Moderately 2
differentiated
7, 8, 9, 10 4, 5 III Poorly 3
differentiated
Partin nonogram
Doctors need PSA, Gleason score, and
clinical staging items (PE)
Can determine probability of:
Organ-confined disease
Extraprostatic extension
Seminal vesical invasion
Lymph node involvement
urology.jhu.edu/prostate/partintables.php
TABLE I. Clinical Stage T1c (nonpalpable, PSA elevated)
PSA Pathologic Stage Gleason Score
Range
(ng/ 2-4 5-6 3+4=7 4+3=7 8-10
mL)
4.1–6.0 Organ confined 90 (78–98) 80 (78–83) 63 (58–68) 52 (43–60) 46 (36–56)
Clinically Inapparent
00 in situ §Not palpable
10 – T1 NOS §Not visible on
≤ 5%
13 – T1a ≤ 5%
imaging
§Not visible on sono
14 – T1b > 5%
§Incidental finding
15 – T1c because
§Latent
of needle biopsy §Occult
> 5%
www.upmccancercenters.com
CS Extension - Clinical
Clinically Apparent
20 – T2 NOS 1 §Palpable
lobe §Nodule
21 – T2a ≤ ½ §Induration
24 – Stage B
§Streaky
densities
NOS
30 – Localized
CS Extension - Clinical
• 41 - T3 NOS thru
capsule NOS T3a
• 42 – T3a unilateral
• 43 – T3a bilateral T3a
• 45 – T3b seminal
vesicle
• 49 – T3 NOS T3b
Periprostatic
extension NOS
www.upmccancercenters.com
CS Extension - Clinical
• 50 – T4 extension to/
fixation to adjacent
• 52 – T4 muscles,
ureter
• 60 – T4 pelvic wall or
bone, “frozen”
pelvis
• 70 – T4 further
contiguous
extension
•
www.upmccancercenters.com
• 95 No evidence
CS Evaluation Fields (CS/TS)
• Prostate is
inaccessible organ
(pg 14)
• 00 None
• 10 Regional LNs
• 80 LNs NOS
• 99 Unknown
•
• CS Reg Nodes Eval,
# Pos, # Eval
Use Standard Table www.upmccancercenters.com
CS Mets at Dx
• Prostate is inaccessible
organ
• 00 None
• 11 Common iliac LN
• 12 Other distant LN
• 30 Bone mets (not direct*)
• 35 – 30 + 11 or 12
• 40 Other distant mets
• 45 Mets NOS
• 50 40 - + 11 or 12
• 55 40 - + 30 or 35
• 99 Unknown
Site Specific Factors
SSF 1 PSA Value SSF 2 PSA
000 Test not done 000 Test not done
999 Unknown
1 No involvement
2 Into/arising in
3 Arising in
4 Extension into
5 Apex extension
unk
1st number =
www.upmccancercenters.com clinical
SSF4 Apex
• 1 No involve – statement of normal apex
or neg on path
• 2 Into/arising NOS – can’t be determined
where cancer started (avoid this code)
• 3 Arising in – If apex is ONLY site of
cancer
• 4 Extension to – cancer present in other
parts + apex
• 5 Unknown – no description; no
prostatectomy
SSF 5 & 6
SSF 5 Gleason’s pattern SSF 6 Gleason’s
Observation
Beam RT
Hormone
Experimental
Seed RT
Surgery
Watchful Waiting
• aka Active Surveillance
• PSA q 6 mos
• Slow growing cancer
• Delay for other diseases to improve
• Comorbidities prevent other tx
•
Surgery
TURP
CRYOSURGERY
kidney.niddk.nih.gov www.nemc.org
Prostatectomy
Perineal,
Retropubic,
Suprapubic –
depends on patient
anatomy and
surgical history
Nerve-sparing
Robotic
www.prostate-cancer.org
Brachytherapy
www.prostate-cancer.org
Beam Radiation
IMRT
3-D
www.prostate-cancer-radiotherapy.org.uk
Hormone Therapy
LHRH analogs
Lupron, Zoladex
Androgen blockades
Casodex, Eulexin,
Nilandrone
Estrogen therapy
(DES)
NOT orchiectomy
www.upmccancercenters.com
Other
Chemotherapy
Procedures Stage IV
Endocrine surgery or
Hormone refractory
radiation
Bilateral
Could have
subcapsular orchi
Could have testicular
prosthesis
Experimental
Hyperthermia
Laser ablation
Alternative medicine
Pomegranate juice
Ginseng
Fasting
Mini-trampoline
Vitamin D
Vaccines
www.cdc.gov/cancer/prostate/screening
Treatment for Recurrence/Mets
Hormones
Orchiectomy
Radiation to mets
Radioisotopes
strontium-89 (Metastron)
samarium-153 (Quadramet)
Chemotherapy
Follow-Up (NCCN Guidelines)
OBSERVATIO
CURATIVE STAGE IV
N §PSA q 6 mos x 5 §PSA q 3-6 mos
yr §H&P w/sx
§ < 10 years?
§DRE q year x 5 discussion
§ H&P q 6 yr
mos
§ 10 years?
§ PSA &
DRE q
6 mos
§ Repeat
bx at 1
year
LUNG CANCER
Lung Cancer: Defined
• Uncontrolled growth of malignant cells in
one or both lungs and tracheo-bronchial
tree
• A result of repeated carcinogenic irritation
causing increased rates of cell
replication
• Proliferation of abnormal cells leads to
hyperplasia, dysplasia or carcinoma in
situ
Picture of the Lungs
Lung Cancer in the US
• According to 2004 statistics,
there were 1,800,000
173,770 new cases and 1,600,000
1,400,000
160,440 deaths yearly 1,200,000
1,000,000
800,000
• More deaths from lung 600,000
Asbestos
Radon
Passive smoke
Smoking Facts
Tobacco use is the
leading cause of lung
cancer
87% of lung cancers are
related to smoking
Risk related to:
Diagnosis
History and Physical exam
Diagnostic tests
Chest x-ray
Biopsy (bronchoscopy, needle biopsy,
surgery)
Staging tests
CT chest/abdomen
Bone scan
Bone marrow aspiration
PET scan
Symptoms
cough
dyspnea
hemoptysis
recurrent infections
chest pain
Syndromes/Symptoms secondary
to regional metastases:
Esophageal compression dysphagia
Laryngeal nerve paralysis hoarseness
Symptomatic nerve paralysis Horner’s
syndrome
Cervical/thoracic nerve invasion Pancoast
syndrome
Lymphatic obstruction pleural effusion
Vascular obstruction SVC syndrome
Pericardial/cardiac extension effusion,
tamponade
Two Lung Cancer Cells,
Classified
Non Small Cell Small Cell Lung
Lung Cancer Cancer (SCLC)
(NSCLC)
Oat Cell
Adenocarcinoma
Intermediate
Squamous Cell Carcinoma
Combined
Large Cell Carcinoma
Treatment and Staging
NSCLC
Stage Description Treatment Options
Stage III a Tumor has spread to the lymph nodes Chemotherapy followed by
in the tracheal area, including chest wall radiation or surgery
and diaphragm
• Extensive Stage
Defined as tumor that has spread beyond one
lung, mediastinum, and supraclavicular lymph
nodes. Common distant sites of metastases are
the adrenals, bone, liver, bone marrow, and
brain.
• Cancerous Human
Lung
• This dissection of human
lung tissue shows light-
colored cancerous
tissue in the center of
the photograph. the
tissue surrounding the
cancer is black and
airless, the result of a
tarlike residue left by
cigarette smoke.
Conclusion
• Smoking cessation is essential for
prevention of lung cancer.
• New screening tools under way.
• Clinical trials under way.
• New treatments under way.
• Treatment can palliate symptoms and
improve quality of life.
• Read first bullet again!!
•
Gastric Cancer
Gastric Cancer :Biology
• There are several Hystological
types of Gastric Cancer of
which adenocarcinoma is by far
the most frequent.
•
• Sarcomas and Lymphomas can
also occur.
•
• This presentation refers basically
to adenocarcinoma.
Gastric Cancer Prevention
Biology: Hystopathology
(cont.)
Gastric Cancer Prevention:
Chronic Atrophic Gastritis
•
Gastric Cancer Prevention:
Tobacco
•Blood type A.
•Hereditary non-polyposis
colorectal cancer.
•e-cadherin gene mutations.
•A first degree relative with
Gastric Cancer.
Gastric Cancer Prevention:
Genetic Factors
•
•Presently they are not subject
to preventive measures
except for prophylactic
gastrectomy in e-cadherin
mutations.
Gastric Cancer Prevention:
Secondry Prevention
• Secondary prevention is the
“early” detection of cancer
through screening.
• This is done in populations where
the disease is a major health
problem.
• Examples of this approach can be
found in Japan and Costa Rica.
Gastric Cancer Prevention:
Secondary Prevention
•
•In Japan gas-contrast Stomach
Fluorography is done in the
mass population.
(cont.)
Gastric Cancer Prevention:
Secondary Prevention
•
• Those considered abnormal
(about 13%) will undergo
further studies, including
endoscopy and biopsy.
•
Gastric Cancer Prevention:
Conclusions
• Double-Contrast
Barium X Ray of the
Large Intestine
• used to detect colorectal
cancer. Barium, an X-
ray opaque material or
contrast medium is
used. The American
Cancer Society
recommends people
over age 50 have a
double-contrast barium
enema every 5 to 10
years.
Leukemia
Leukemia