Cancer Disease

Christine Joy Bandala

Liver Cancer
Occurs majority to male Hepatocellular carcinoma most common cause of primary liver cancer Other cause: Cholangiomas and bile duct carcinomas 80% of people with primary liver cancer has liver cirrhosis Cirrhosis is a risk factor 50-60% is caused by hepatitis Cinfection 20% - is due to Hepatitis B

Liver Cancer
Metastatic liver carcinoma is more common than primary carcinoma Clinical Manifestations
Difficult to diagnose liver cancer in early stage cause it resembles with cirrhosis (Eg, hepatomegaly, spleenomegaly , jaundice weight loss, peripheral edema, ascites and portal hypertension)

Other CM: abd pain in R epigastric or right upper quadrant anorexia, vomiting and inc. abd girth, pulmonary embolism

Liver Cancer
Diagnostic Studies
Liver scan. MRI, hepatic angiography, endoscopic retrograde cholangiopancreatography elevated AFP

Nursing and Collaborative Management 1. Prevention, Identification and treatment of Hep B and C virus, and chronic alcohol ingestion 2. Treatment is dependent with liver cancer size and number of tumors present of spread beyond the liver, age and overall patient health

Liver Cancer
3. surgical excision, or liver transpalant of tumor is localized to one portion of the liver (15%) 4.Other therapies - radiofrequency ablation, cryosurgery, alcohol injection and chemotherapy and or chemoembolization

Liver Cancer
Radiofrequency ablation
A thin needle is inserted in the core of tumor, then electrical energy is used to create heat in a specific location for a limited time Done with tumor less than 5 cm and considered resectable and palliative purpose

Cyroablation
Used when tumor is unresectable but has no signs of metastasis Open surgical approach where cryoprobes are placed. Liquid nitrogen /argon gas is introduced to the liver and freezes the tissue

Liver Cancer
Percutaneous Ethanol Injection (PEI)/ Percutaneous acetic Injection (PAI)
Used for unresectable liver that has not metastasized outside the liver A catheter is inserted into the liver guided via ultrasound, then ethanol or acetic acid is injected for 6-8 treatments over a 3-4 hour period with 2 -3 injections per week SE. transient pain, intraperitoneal hemorrhage bile duct necrosis, hepatic infarction, transient hypotension Chemotherapy 5 flourouracil and leucovorin can be administered systemically or regionally, Sorafinib (Nexavar) : TI

Liver Cancer
Chemoembolization
Minimally invasive, a catheter is placed into the arteries to the tumor

Nursing Management of all procedures 1.making the patient comfortable 2. Address the signs and symptoms manifested 3. Most interventions are the same to clients with liver cirrhosis

Liver Transplant
Practical option for clients with end stage liver cancer Not recommended to patients with wide spread liver disease Candidates must go through rigorous physical exam CI: for pts with sever pulmonary hypertension, morbid obesity, obstructed splanchnic blood flow Donors can be live or cadaver

Liver Transplant
Comp for donor: billiary problems, hepatic artery thrombosis, wound infection, postoperative ileus and pneumothorax Split organ transplant Comp: rejection:
Hyperacute rejection Acute rejection Chronic rejection

Ist 2 months after surgery is the most critical for monitoring

Pancreatic cancer
Adenocarcinomas originating from the epithelium of the ductal system More than half of the tumor originates in the head of pancreas; metastatic if it originates from the tail Poor prognosis patient dies within 3-12 mos of initial diagnosis and 5 year survival rate is less than 5 %

Pancreatic Cancer
Etiology Unknown cause but high risk with DM and with chronic pancreatitis Risk factors: cigarette smoking family history of pancreatic cancer, high fat diet, and exposure to benzidine and coke Smokers and alcohol drinkers are twice likely to develop pancreatic cancer Acute pancreatitis persons have a higher survival rate if one vomits.

Pancreatic Cancer
CM
Left hypochondriac pain that radiates at the back, obstructive jaundice, anorexia rapid and progesive weight loss

Diagnostic Staging
transabdominal ultrasound and CT scan- initial study and provides information on metastasis involvement.
ERCP(endoscopic retrograde cholangiopancreatography) allows visualization of pancreatic duct and biliary study, pancreatic secretions and tissues can be collected for tumor markers (CA 199)

Pancreatic Cancer
Collaborative Care Surgery: most effective care
Classical surgery : radical pancreaticoduodenectomy or whipple procedure

Cholecystojejunostomy Total pancreaticoduodonectomy with spleenecotmy Biliary Stents (Cotton Leung Stents)
Most patient dont opt to surgery

Pancreatic Cancer
Chemotherapy Gencitabine in combinatio with capecitabine or erlotinib Nursing Management 1. Provide symptomatic and supportive nursing care 2. Pain relief 3. adequate nutrition 4. Help patient and family members in the grieving process

Bladder Cancer
The most frequent type of cancer in the urinary tract is transitional cell carcinoma Common between 60-70 yrs. Old PF: cigarette smoking, exposure to dyes used to rubber and cable industries and chronic abuse of phenacetin-containing analgesics. Women who is treated with cervical cancer and patients receiving cyclophosphomide also have increased risk with unknown cause

Bladder Cancer
CM: painless hematuria(initial), bladder irritability with dysuria, frequency and urgency Dx. Urine specimen specimen for cytology can be obtained to determine presence of neoplastic or atypical cells. Cystoscopy- the most reliable test for detecting bladder tumor.

Clinical Staging is determined by depth of invasion of the bladder and surrounding tissue

Bladder Cancer
Jewett Strong Marshall Classification Superficial (CIS- carcinoma in situ, O, A) Invasiveness (B1, B2, C) Metastasis (D1 to D4)

Low grade tumors (Superficial) are more responsive to transvesical chemotherapy and transurethral resection of bladder tumor (TURBT)-chemotherapy is given directly to bladder (2L and then removed); given through the catheter

Bladder Cancer
Collaborative Care 1. Surgical Treatment
transurethral resection with fulguration, laser photocoagulation, open loop resection with fulguration, cystectomy (segmental, partial, radical)

2. Radiation therapy 3. Intravesical immunotherapy

Bacille Calmette Guerin (BCG)(promotes antibodies to kill tumor cells. A interferon

4. Intravesical Chemotherapy
Thiotepa, valrubin

5. Systemic Chemotherapy(through central axis device) with chemotherapy every 15 min. change in position)

Bladder Cancer
Transurethral resection with fulguration (electrocautery)
Treatment of superficial lesions with low recurrence rate To control bleeding in patients with poor operative risk or who has advance tumor

Laser photocoagulation
Treat of superficial bladder cancer Adv. Bloodless destruction of lesions, minimal risk for perforation, lack of need for urinary catheter

Open loop resection

Snaring of polyp type of lesion Used to control bleeding for large superficial tumors and multiple lesions used together with segmental resection Open surgery Segmental resection and partial resection; then find an alternative route for urine

Bladder Cancer
Postoperative Management: 1. Instruct patient to drink large volume of fluid each day for the 1st week following the procedure 2. Teach patient self monitor the urine 3. Instruct patient that pinkish urine is normal within the the 1st several days but should not be bright red or with clots(severe upper bleeding) 4. 7-10 days following the procedure, patient may observe urine, dark red or rust colored flecks in the urine(if happens within first day after surgery, emergency; normal if after 7-10 days because scarring causes dark red. 5. 15-20 min sitz bath, 2-3 times a day 6. Follow up cystoscopy schedule which is every 3-6 months for 3years and yearly thereafter
Bladder Cancer has good prognosis. If metastasize, then spine first.

Bladder Cancer
Radiation therapy when cancer is inoperable or when surgery is refused Combined with systemic chemotherapy (cisplatin, vinblastin, doxorubucin, and methotrexate)

Intravesical Therapy
Protocol varies but cycle is for 6-12 weeks(regional uses arteries) Patient position maybe changed every 15 min(to spread chemotherapy thoroughly)

BCG Thiotepa (alkylating agent) reduce WBC and platelets within the bladder

Breast cancer
Common malignancy to women, 2nd cause of death Etiology and risk factors Heredity, hormonal regulation, dietary fat intake, weight gain in adolescence, obesity and alcohol intake Combined hormone therapy (estrogen and progesterone) Pathophysiology
May arise from epithelial lining of the ducts (ductal carcinoma) or epithelium lobules (lobular carcinoma)

Breast Cancer Types

Types of Breast Cancer 1. Non invasive Breast Cancer
Ductal carcinoma in Situ (infiltrating ductal cell carcinoma) tamoxifen, lumpectomy and radiation therapy Lobular carcinoma in Situ

2. Pagets disease
Persistent nipple and areola lesions with or without palpable mass, nipple changes are diagnosed as infection or dermatitis w/ch cause delays of treatment

3. Inflammatory breast Cancer

Most malignant form of all breast cancers, breast looks red, feels warm and has thickened appearance resembling an orange peel (peau de orange)

Breast Cancer

Breast Cancer

Breast cancer
Clinical Manifestations Detected as a lump or mammographic abnormality in the breast Irregular shaped poorly delineated non mobile non tender

Complication: Recurrence either local, regional or distant, Metastsis primarily occurs via lymphnode

Slide master
Diagnostic study Axillary lymph node involvement Mammography, ultrasound , biopsy, MRI Collaborative care: 1. Surgery a. Breast conserving (lumpectomy) with sentinel lymph node involvement
B, Biopsy/dissection

and or lymph node dissection C. Modified radical mastectomy, D. Radical mastectomy e. Oopherectomy d. adrenalectomy

Breast Cancer
Collaborative Therapy 2. Radiation Therapy 3. Chemotherapy 4. Hormonal therapy 5. Biologic and target therapy

Breast Cancer
Post OP Care

1. Check for bleeding(hemovac or JP drain) 2. dec incisional pain (splinting area during coughing, DBE, managed cough) 3. Prevent lymphedema 4. maintain abduction of affected arm 5. NO BP taking on affected arm 6. Post mastectomy exercises

Breast cancer
Post mastectomy exercises 1. Ball squezzing (8-10 hrs post op) 2. hand wall climbing (7-10 day post op) 3. back scratch: non operative scapula (7-10 day post op)

Follow up care 1. CBE every 6 months for 2 years then annually 2. manage postmastectomy pain syndrome (EMLA: eutectic mixture of local anesthetics) 3. avoid gardening 4. wear gloves when performing household chores.

Breast Cancer
Radiation Therapy Performed after locally excision of the breast mass or surgery High dose brachytherapy Alternative to traditional radiation treatment Traditional 5-6 weeks Alternative- balloon catheter 1-5 days

Breast Cancer
Chemotherapy 1. CMF (cyclophosphamide, methotrexate, 5fluorouracil) 2. AC (adriamycin, cyclophosphamide) w/ or w/o paclitaxel, or docetaxel 3. CEF or CAF (cyclophosphamide, epirubicin or adriamycin, 5 FU) 4. vinorelbine new drug for metastatic cancer Hormone Therapy Removes or blocks source of estrogen promoting tumor regression

Breast Cancer
Mechanism of action Blocks estrogen receptors Examples Tamoxifen Toremifine (metastatic breast cancer in postmenopausal women) Fulvestrant (Faslodex), IM Anastrozole Letrozole Exemestane aminogluthetemide

Destroys estrogen receptor Prevents production of estrogen by inhibiting aromatase