Oncology

Prepared by: IRENE M. ROCO, PhD 1st Sem SY 2012- 2013

TERMINOLOGIES
Neoplasia

- the development of an abnormal type of growth that is unresponsive to normal growth control mechanism. Neoplasm - a group or clump of neoplastic cells, synonymous with tumor.

 Metastasis

- the ability of the cancer cells to disseminate and establish growth in another area of the body at a distance from its origin. Invasion occurs when cancer cells infiltrate adjacent tissue surrounding the neoplasm

Terminologies..
Aberrant

cellular growth - an alteration in normal cellular growth, which usually means that the normal cell escape the hosts controls the growth and differentiation. Hyperplasia refers to an increase in the number of normal cell

Terminologies.. conversion from a normal pattern of differentiation of one type of cell into another type not normal for that tissue Dysplasia refers to alteration in the shape, size, appearance and distribution of cells
Metaplasia

Anaplasia

- refers to disorganized, irregular cells that have no structure and have loss differentiation, the result is almost always malignant

Cancer warning signals

C - change in bowel or bladder habits A - a sore that does not heal U - unusual bleeding or discharge T- thickening or lump in breast or elsewhere I - indigestion or difficulty in swallowing O - obvious change in wart or mole N - nagging cough or hoarseness U - unexplained anemia S- sudden weight loss

Almost

all names for neoplasms end in the suffixoma, meaning tumor

EPIDEMIOLOGY

1. Viruses and Bacteria infects the cell, causing genetic damage to the cells deoxyribonucleic acid (DNA) thus leading to the development of cancer.

2. Physical Agents
a. Exposure to sunlight or radiation

More than 80% is from natural sources ionizing radiation from cosmic rays and radioactive minerals, such as radon gas, radium, and uranium.

 About

15% is from diagnostic or therapeutic procedures radiographs, radiation therapy, and radioisotopes used in diagnostic imaging. 5% of all secondary cancers are clearly linked to radiation therapy for a previous cancer

b. chronic irritation or inflammation c. tobacco use. Tobacco has been linked not only with lung cancer but also with oropharyngeal, bladder, pancreatic, cervical, and kidney cancers.

3. Chemical Agents

About 75% of all cancers are thought to be related to the environment.

altering DNA structure in body sites distant from chemical exposure. The liver, lungs, and kidneys are the organ systems most often affected,.

 exposure

to chemicals in the workplace aromatic amines and aniline dyes pesticides and formaldehydes; arsenic soot, and tars; asbestos; benzene; betel nut and lime; cadmium; chromium compounds;

4. Genetic and Familial Factors

Approximately 5% to 10% of cancers of adulthood and childhood display a familial predisposition - premenoupausal breast cancer two or more first-degree relatives share the same cancer type

extra

chromosomes, too few chromosomes, or translocated chromosomes.

Specific cancers with underlying genetic abnormalities

chronic

myelogenous leukemia Meningiomas acute leukemias Retinoblastomas Wilms tumor skin cancers, including malignant melanoma

5. Dietary Factors

fats, alcohol, salt-cured or smoke meats, foods containing nitrates, high caloric dietary intake.

6. Hormonal Agents

Oral contraceptives prolonged estrogen replacement therapy endogenous hormonal levels for growth.

Food substances that appear to reduce cancer risk

1. high-fiber foods 2. cruciferous vegetables (cabbage, broccoli, cauliflowers, Brussels, sprouts)

3. carotenoids
Carrots tomatoes Spinach Apricots Peaches dark-green and deep-yellow vegetables possibly vitamins E and C, zinc and selenium.

THE CELL CYCLE

(gap ) the interval separating the cell division (M) - mitosis (S) synthesis
G

STEPS:

Go Phase (resting phase)

the

interval in which the cell is at rest from cell division the beginning of the G1 phase. Some cells do not replicate, or they replicate so infrequently that they are said to always be in G0 or resting state.

G1 Phase

interval

in which ribonucleic acid (RNA) and protein are synthesized.

S Phase
synthesis

of both DNA and proteins of new chromosomes 6-8 hr interval of time although it varies in certain cell populations and under different conditions

G2 Phase

biochemical

processes, including the synthesis of some RNA, occur in preparation for mitosis last only a few hours.

M Phase
actual

division of the cell (mitosis) occurs producing two daughter cells usually ranges from less than an hour to a few hours.

COMPARISON OF THE CHARACTERISTICS OF NORMAL AND CANCER CELLS

normal 1. MITOTIC CELL DIVISION division leads to 2 daughter cancer cells

multiple daughter cells

2. APPEARANCE normal
homogenous in size, shape and growth regular pattern of expansion have characteristic pattern of organization

Cancer
heterogenous

in size and shape larger and grows faster irregular pattern of organization

3. GROWTH PATTERN
normal cancer do not invade adjacent tissueadjacent invade tissues proliferate in response to specific stimuli Proliferates, grows in ideal condition grows in adverse condition such as lack of nutrients

normal cannot

Cancer
invade,

invade, erode or spread cannot grow in the presence of necrosis or inflammation

erode and spread it can invade in the presence of necrosis and inflammation

continuation Cancer cells

cell

birth exceed than cell death loss of cell control - it can migrate thru lymphatics and blood and grow in other sites

4. FUNCTION

Cancer have specific designated purpose no useful contributes to the well being of the host purpose, cells have specific function cells function abnormally, parasitic

normal

CARCINOGENESIS

The

process through which normal cells are transformed into malignant or cancer cells

4 stages of Carcinogenesis
1.

Initiation occurs when a carcinogen damages DNA. cause changes in the structure and function of the cell at the genetic or molecular level. maybe reversible or may lead to genetic mutations if not repaired mutations may not lead immediately to cancer.

2. Promotion
occurs

with additional assaults to the cells

3. malignant conversion.
genetic

damage

4. progression cells are increasingly malignant in appearance and behavior develop into an invasive cancer with metastasis to distant body parts

CLASSIFICATION OF NEOPLASM

1. Benign - comes from the latin benigumus ( kind)

2. Malignant
a. carcinoma tumor that arises from epithelial cell the name of the cancer identifies the location (basal cell carcinoma) b. sarcoma tumor arising from supportive tissue the name of the cancer identifies the specific tissue affected (osteosarcoma

CHARACTERISTICS 1. SPREAD OF GROWTH

malignant grow rapidly, grows slowly usually continue to grow throughout life grow unless surgically removed relentlessly throughout life may have periods of remissions rarely regresses spontaneously benign-

2. MODE OF GROWTH
benign- malignant grows by enlarging and expanding, Grows by remains localized, never infiltrates infiltrating surrounding tissues surrounding tissues
may

remain localize but usually infiltrates other tissues

Malignant cancer
survive

the turbulence of arterial circulation, insufficient oxygenation or destruction by the bodys immune system

3. CAPSULE
benignmalignant almost always within capsule which never contained prevents growth by infiltration within the Can be removed surgically capsule, surgical removal is difficult because of infiltration

4. CELL CHARACTERISTICS benignmalignantcell is differentiated, poorly mature cells differentiated, anaplastic cells absent anaplastic (young, embryonic type) cells function poorly compared to normal cells too abnormal to

perform physiologic function

5. RECURRENCE
malignantbenign common following extremely unusual when surgery surgically removed because

tumor cells spread into surrounding tissues

6. METASTASIS

benign- Malignant very never occur

common

6. EFFECT OF NEOPLASM

benign
not harmful to host unless located in area where it can compress or obstruct vital organs does not produce cachexia ( weight loss, debilitation, anemia, weakness, and wasting )

malignant
always Harmful to host cause death unless treated Cause disfigurement, disrupted organ function, nutritional imbalances produce cachexia, ulcerations, sepsis, hemorrhage

7. PROGNOSIS benignmalignant very good if poor, if poorly tumor is generally removed surgically differentiated

and evidence of metastasis exists

Most common Benign Neoplasm

1. Fibromas (fibrosarcoma malignant) may grow anywhere in the body, but they frequently make their home in the uterus. are easily removed surgically.

2. Lipomas (liposarcoma malignant)

very common benign neoplasm, arises in adipose tissue. rarely cause manifestations, but they are poorly encapsulated and may exert pressure on surrounding tissues as they expand.

3. Leiomyomas

A benign neoplasm of smooth muscle origin is the most common benign tumor in women. May develop anywhere in the body, but most often they grow in the uterus. Rarely these neoplasm become malignant.

Growth of the Primary Malignant Tumor

Environmental factors(chemical,radiation,virus) Genetic

Changes in genome of somatic cells Activation of oncogene and inactivation of cancer suppressing gene Expression of altered products neoplasm malignant

2. Malignant Neoplasms
1. Carcinoma in situ

neoplasm of epithelial tissue that remains confined to the site of origin. typically affects the cervix localized and can be removed surgically but can become invasive, eroding into surrounding tissues.

3. Malignant fibrosarcoma

Bulky, well differentiated tumor masses similar to benign fibromas, tend to grow in the same sites and may originate as benign fibromas, later becoming malignant. usually responsive to surgery. rarely metastasize.

4. Bronchogenic carcinomas

account for 90% of all cases of lung cancer develops in the trachea and lower bronchi. readily gives rise to metastasis; if this occurs, surgery is contraindicated. TX: Surgical excision of the tumor

Tissue of Origin

suffix meaning tumor Adenomyoma - is benign neoplasm that contains both glandular and muscle (Greek genitive myos) cells.
oma

Benign

tumors of epithelial origin are classified according to either their microscopic appearance (e.g.,adenoma) or their macroscopic appearance (e.g., poly, from the Greek polys for many plus pous for foot).

continuation
carcinoma

- a malignant neoplasm that arises from epithelial tissue (adenocarcinoma ) sarcoma -a malignant neoplasm that arises from mesenchymal origins (blood vessels, lymphatic tissue, nerve tissue)

 Hematopoeitic-erythrocytes

(erythroleukemia) lymphatic tissue (hodgkins disease) plasma cells (multiple myeloma)

TUMOR STAGING AND GRADING

Staging
Determines

the size of the tumor and the existence of metastasis. The TNM system is frequently used.

T - refers to the extent of the primary tumor (size),

no involvement Tis indicates tumor in situ T1 ,T2, T3, T4 progressive degrees of tumor size and involvement
T0

N refers to lymph node involvement

no abnormal lymph nodes detected N1a, N2a indicate regional nodes involvement N1b, N2b, N3b regional nodes involvement with metastasis
N0

M refers to the metastasis

no evidence of distance metastasis M1, M2, M3 indicates ascending degrees of distant metastasis and includes distant lymph nodes
M0

Staging Determines the size of the tumor and the existence of metastasis
Stage

0 : Carcinoma in situ Stage I : Tumor limited to the tissue of origin; localized tumor growth. Stage II : Limited local spread. Stage III : Extensive local and regional spread. Stage IV : Metastasis

Grading
Refers

to the classification of the tumor

cells. define the type of tissue from which the tumor originated the degree to which the tumor cells retain the functional and histologic characteristic of the tissue of origin.

 Grade

I : Cells differ slightly from normal cells and are well differentiated ( mild dysplasia ). Grade II : Cells are more abnormal and are moderately differentiated ( moderate dysplasia )

 Grade

III : Cells are very abnormal and are poorly differentiated ( severe dysplasia ). Grade IV : Cells are immature ( anaplasia ) and undifferentiated; cell of origin is difficult to determine

Diagnosis of Cancer
cytology (examination of cells from tissue scrapings, body fluids, secretions, or washings),

biopsy surgical excision.

METASTATIC MECHANISM
Lymph

and blood - key mechanisms by which cancer cells spread. (Breast tumor) Angiogenesis - a mechanism by which the tumor cells ensure a blood supply

A - Lymphatic spread
Tumor

emboli enter the lymphatic channels by way of the interstitial fluid. Malignant cells also may penetrate lymphatic vessels by invasion.

 After

entering the lymphatic circulation, malignant cells either lodge in the lymph nodes or pass between lymphatic and venous circulation. Breast tumors frequently metastasize in this manner through axillary, clavicular and thorax lymph channel.

B - Hematogenous Spread
Malignant cells are disseminated through the blood stream. Hematogenous spread is directly related to the vascularity of the tumor. Few malignant cells can survive the turbulence of arterial circulation, insufficient oxygenation or destruction by the bodys immune system.

Angiogenesis
Malignant

cells have the ability to induce the growth of new capillaries from the host tissue to meet their needs for nutrients and oxygen. It is through this vascular network that the tumor or emboli can enter the systemic circulation and travel to distant sites.

Tumor markers
Protein

substance found in the blood or body fluids, released either by the tumor itself or by the body as a defense in response to the tumor.
(e.g. AFP alpha feto protein ).

Management of Cancer
I.

SURGERY A. Diagnostic surgery

excision

biopsy incisional biopsy needle biopsy

continuation
B. Surgery (Primary Treatment) - to remove the entire tumor as much as possible ( debulking ) and any involved surrounding tissue, including regional lymph nodes. C. Prophylactic Surgery- involves removing non vital tissues or organs that are likely to develop cancer.

D. Palliative Surgery

when cure is not possible the goals of treatment

to make the patient as comfortable as possible to promote a satisfying and productive life for as long as possible.

E. Reconstructive Surgery may

follow curative or radical surgery Goals of treatment:

attempt to improve function obtain a more desirable cosmetic effect.

II. Radiation Therapy

Types: 1. External Beam Radiation Therapy- is the delivery of radiation from a source placed at some distance from the target site. - skin sparing effect - given 15-30 min/day, 5 days/week, for 2-7 weeks - the client does not pose risk for radiation exposure to other people

continuation

Side Effects: 1. tissue damage to the target area ( erythema, sloughing, hemorrhage ) 2. ulceration of oral mucous membrane 3. GI nausea, vomiting, diarrhea 4. fatigue, alopecia, radiation pneumonia 5. immunosuppression

Client education:
1. wash marked area of the skin with plain water 2. pat skin dry, no soap, deodorants, lotion or powder on site during the duration of treatment 3. avoid rubbing, scratching the treatment site

4. do not apply extreme heat or cold 5. loose fitting clothing over the treatment area 6. protect skin from exposure to sun for at least one year after the treatment is completed 5. proper rest and nutrition

Nursing Care:

1. monitor for side effects of radiation 2. monitor for significant decrease in WBC and platelet counts

2. Internal radiation therapy

Involves

placement of specially prepared radioisotopes directly into or near the tumor itself ( brachytherapy ) or into the systemic circulation.

Types:

1. sealed source radio therapy(implant) 2. unsealed source radio therapy ( oral, injection)

Radiation safety standard

Distance- 2 meters ( of exposure )

4 meters ( 1/16 of exposure ) Time- minimize exposure to 30 mins/8hr shift Shielding- device is needed to protect exposure Side effects: fatigue, anorexia, immunosuppression

continuation

Client education: 1. avoid contact with others until treatment is completed 2. maintain balance diet, small frequent meals 3. fluid intake 2-3L/day 4. if implant is temporary, maintain bedrest to prevent dislodge 5. excreted body fluids may be radioactive,

continuation

Nursing management: 1. protect from exposure to radiation: time, distance, and shielding 2. place patient in private room 3. instruct visitors to maintain at least 6 ft from the client and limits visits to 10-30mins 4. ensure proper disposal of body fluids, container should be marked appropriately

continuation
5. in the event of dislodge implant, use long forceps and place implant into a lead container and never touch the implant 6. no pregnant women to come in contact with radiation sources

3. Chemotherapy
Involves the administration of cytotoxic drugs and chemicals to promote tumor cells death. IV ROUTE is most preferred It can also be given through oral, intrathecal, topical, intra arterial, and intracavity.

Goals of therapy: - cure, control, palliation of manifestation

Chemotherapy
a

systematic intervention Indications: - disease is widespread - the risk of undetectable disease is high - the tumor cannot be resected and is resistant to radiation therapy

Chemotherapy
Adjuvant chemotherapy- the client who is at risk for recurrence but shows no evidence of current disease may be a candidate for adjuvant chemotherapy. Neoadjuvant- refers to preoperative use of chemotherapy to reduce the bulk and lower the stage of a tumor, making it amenable to surgery or possibly even a cure with subsequent local therapy.

Chemotherapeutic agents
Alkylating agents- ( cytoxan, busulfan ) non phase specific and act by interfering with the DNA replication Anti metabolites- ( 5 flouroucil, methotrexate ) interfers with metabolite nucliec acids necessary for RNA and DNA synthesis Cytotoxic antibiotics- disrupt or inhibit synthesis of DNA Plant alkaloids- vinka alkaloids phase specific, inhibiting cell division

Side effects
Bone

marrow suppression 1. decrease WBC count ( immunosuppression ) - avoid crowds, people with infection - personal hygiene, avoid undercooked and raw fruits and vegetables - no pets, no visitors with infection

continuation
2. decreased platelet count ( thrombocytopenia ) - monitor stool and urine for bleeding - assess skin for ecchymoses, petechiae and trauma - for shaving use electric razor only - avoid contact sport or activities that may cause trauma - avoid dental work or other invasive

continuation
3. GI effects- anorexia, nausea, vomiting, diarrhea 4. Stomatitis- inflammation of the mouth - use of soft toothbrush, mouth swabs during acute episodes - avoid mouthwash containing alcohol - use chlorhexidine mouthwash to decrease risk to hemorrhage and protect gum from trauma

continuation
5. xerostomia- apply lubricating agent to protect mucous membrane, use hard candy or mints to help with dryness 6. alopecia - encourage to choose wig before hair loss occurs in order to match texture and hair color - care of hair and scalp( no blow dryer ) - allow client to express feelings

continuation
6. fatigue - assure client that it is normal response to therapy and it does not indicate progression of disease - allow rest period in between

Expected outcome of clients with cellular disorders

5

year survival rate for cancer is 59% Cancer of breast, colon, rectum, cervix, prostate, oral cavity, and skin- 5 year survival rate is 80% Approximately 552,000 cancer related deaths occurred in 2000