NCMB312 LECTURE: Final Week

15
Cancer Overview and CNS, Breast & Lungs
Bachelor of Science in Nursing 3YA
Professor: Dr. Potenciana A. Maroma
CANCER OVERVIEW AND Pathophysiology of the malignant process
CANCER OF THE CNS, BREAST AND LUNGS - Cancer is a disease process that begins when an
- Cancer is not a single disease with a single cause; rather, abnormal cell is transformed by the genetic mutation of
it is a group of distinct diseases with different causes, the cellular DNA.
manifestations, treatments, and prognoses. - This abnormal cell forms a clone and begins to proliferate
- Cancer nursing practice covers all age groups and nursing abnormally, ignoring growth-regulating signals in the
specialties and is carried out in a variety of health care environment surrounding the cell.
settings, including the home, community, acute care - The cells acquire invasive characteristics, and changes
institutions, outpatient centers, rehabilitation, and long- occur in surrounding tissues.
term care facilities. - The cells infiltrate these tissues and gain access to lymph
- The scope, responsibilities, and goals of cancer nursing, and blood vessels, which carry the cells to other areas of
also called oncology nursing, are as diverse and complex the body.
as those of any nursing specialty. Because many people Proliferative Patterns
associate cancer with pain and death, nurses need to - During the lifespan, various body tissues normally
identify their own reactions to cancer and set realistic undergo periods of rapid or proliferative growth that must
goals to meet the challenges inherent in caring for be distinguished from malignant growth activity.
patients with cancer. - Several patterns of cell growth exist: hyperplasia,
- In addition, cancer nurses must be prepared to support metaplasia, dysplasia, anaplasia, and neoplasia.
patients and families through a wide range of physical, - Cancerous cells are described as malignant neoplasms.
emotional, social, cultural, and spiritual crises. They demonstrate uncontrolled cell growth that follows no
physiologic demand (neoplasia).
Epidemiology of cancer - Benign (noncancerous) and malignant growths are
- Although cancer affects people of all ages, most cancers classified and named by tissue of origin (eg, benign
occur in people older than 65 years of age. tumors of the meninges are called meningioma and
- Overall, the incidence of cancer is higher in men than in malignant tumors of the meninges are called meningeal
women and higher in industrialized sectors and nations. sarcoma).
- Benign and malignant cells differ in many cellular growth
Normal cells vs cancer cells characteristics, including the method and rate of growth,
- The body is made up of approximately 37.2 trillion human ability to metastasize or spread, general effects,
cells – so you can truly appreciate how many that is, here destruction of tissue, and ability to cause death.
is the number written out in full, 37,200,000,000,000 – Characteristic Benign Malignant
that’s a lot of cells. Cell Well-differentiated Cells undifferentiated
- In contrast to normal cells, cancer cells don't stop Characteristics cells that resemble and often bear little
growing and dividing, this uncontrolled cell growth results normal cells of the resemblance to the
in the formation of a tumor. Cancer cells have more tissue from which normal cells of the
genetic changes compared to normal cells, however not the tumor tissue from which
all changes cause cancer, they may be a result of it. originated they arose
Mode of Tumor grows by Grows at the
growth expansion and periphery and sends
does not infiltrate out processes that
the surrounding infiltrate and destroy
tissues; usually the surrounding
encapsulated tissues
Rate of growth Rate of growth is Rate of growth is
usually slow variable and depends
on level of
differentiation; the
more anaplastic the
tumor, the faster its
growth
Metastasis Does not spread by Gains access to the
metastasis blood and lymphatic
channels and
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metastasizes to other altitude, and latitude, all play a role in the amount of
areas of the body exposure to ultraviolet light.
- Exposure to ionizing radiation can occur with repeated
General effects usually a localized Often causes diagnostic x-ray procedures or with radiation therapy used
phenomenon that generalized affects, to treat disease. Fortunately, improved x-ray equipment
does not cause such as anemia, minimizes the risk of extensive radiation exposure.
generalized effects weakness, and - Radiation therapy used in disease treatment and exposure
unless its location weight loss to radioactive materials at nuclear weapon manufacturing
interferes with vital sites or nuclear power plants are associated with a higher
functions incidence of leukemias, multiple myeloma, and cancers
Tissue Does not usually Often causes of the lung, bone, breast, thyroid, and other tissues.
destruction cause tissue extensive tissue Chemical Agents
damage unless its damage as the tumor - About 75% of all cancers are thought to be related to the
location interferes outgrows its blood environment. Most hazardous chemicals produce their
with blood flow supply or encroaches toxic effects by altering DNA structure in body sites
on blood flow to the distant from chemical exposure.
area; may also - The liver, lungs, and kidneys are the organ systems most
produce substances often affected, presumably because of their roles in
that cause cell detoxifying chemicals.
damage - Tobacco smoke, thought to be the single most lethal
Ability to cause Does not usually Usually causes death chemical carcinogen, accounts for at least 30% of cancer
death cause death unless unless growth can be deaths. Smoking is strongly associated with cancers of
its location controlled the lung, head and neck, esophagus, stomach, pancreas,
interferes with vital cervix, kidney, and bladder and with acute myeloblastic
functions leukemia.
Genetics and Familial Factors
Etiology - Almost every cancer type has been shown to run in
- Categories of agents or factors implicated in families. This may be due to genetics, shared
carcinogenesis include viruses and bacteria, physical environments, cultural or lifestyle factors, or chance
agents, chemical agents, genetic or familial factors, alone. Genetic factors play a role in cancer cell
dietary factors, and hormonal agents. development.
Viruses and Bacteria - Abnormal chromosomal patterns and cancer have been
- Viruses are difficult to evaluate as a cause of human associated with extra chromosomes, too few
cancers because they are difficult to isolate. However, chromosomes, or translocated chromosomes.
infectious causes are considered or suspected when - Specific cancers with underlying genetic abnormalities
specific cancers appear in clusters. include Burkitt lymphoma, chronic myelogenous leukemia,
- Viruses are thought to incorporate themselves in the meningiomas, acute leukemias, retinoblastomas, Wilms
genetic structure of cells, thus altering future generations tumor, and skin cancers, including malignant melanoma.
of that cell population, perhaps leading to cancer. Dietary Factors
- For example, the Epstein-Barr virus is highly suspect as a - Dietary factors are also linked to environmental cancers.
cause in Burkitt lymphoma, nasopharyngeal cancers, and - Dietary substances can be proactive (protective),
some types of non- Hodgkin and Hodgkin lymphoma. carcinogenic, or cocarcinogenic.
- Bacteria have been evaluated as a cause of cancer over - The risk of cancer increases with long-term ingestion of
the years but with little evidence to support the link of carcinogens or cocarcinogens or chronic absence of
bacteria to cancer. protective substances in the diet.
- Chronic inflammatory reactions to bacteria and the - Dietary substances that appear to increase the risk of
production of carcinogenic metabolites are possible cancer include fats, alcohol, salt-cured or smoked meats,
mechanisms under investigation. nitrate-containing and nitrite-containing foods, and red
Physical Agents and processed meats.
- Physical factors associated with carcinogenesis include - Alcohol increases the risk of cancers of the mouth,
exposure to sunlight or radiation, chronic irritation or pharynx, larynx, esophagus, liver, colorectum, and breast.
inflammation, and tobacco use. Alcohol intake should be limited to no more than two
- Excessive exposure to the ultraviolet rays of the sun, drinks per day for men and one drink per day for women.
especially in fair-skinned, blue- or green-eyed people, - Greater consumption of vegetables and fruits is
increases the risk of skin cancers. associated with a decreased risk of lung, esophageal,
- Factors such as clothing styles (sleeveless shirts or stomach, and colorectal cancers (Kushi, Byers, Doyle, et
shorts); use of sunscreens; occupation; recreational al., 2006).
habits; and environmental variables, including humidity, - A high caloric dietary intake is also associated with an
increased cancer risk.
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- Obesity is clearly associated with endometrial cancer, Secondary Prevention

postmenopausal breast cancers, and colon, esophagus, - Secondary prevention programs promote screening and
and kidney cancers. early detection activities such as breast and testicular
Hormonal Agents self-examination and Papanicolaou (Pap) tests.
- Tumor growth may be promoted by disturbances in - Many organizations conduct cancer screening events that
hormonal balance, either by the body’s own (endogenous) focus on cancers with the highest incidence rates or those
hormone production or by administration of exogenous that have improved survival rates if diagnosed early, such
hormones. as breast or prostate cancer.
- Cancers of the breast, prostate, and uterus are thought to - These events offer education and examinations such as
depend on endogenous hormonal levels for growth. mammograms, digital rectal examinations, and PSA blood
- Diethylstilbestrol (DES) has long been recognized as a tests for minimal or no cost.
cause of vaginal carcinomas. - These programs often target people who lack access to
- Oral contraceptives and prolonged estrogen therapy are health care insurance or who cannot afford to participate
associated with an increased incidence of hepatocellular, on their own.
endometrial, and breast cancers, but they decrease the
risk of ovarian cancer. Diagnosis of Cancer
- The combination of estrogen and progesterone appears - A cancer diagnosis is based on assessment of physiologic
safer than estrogen alone in decreasing the risk of and functional changes and results of the diagnostic
endometrial cancers; however, studies support evaluation.
discontinuing hormonal therapy containing both estrogen - Patients with suspected cancer undergo extensive testing
and progestin because of the in- creased risk of breast to
cancer, coronary heart disease, stroke, and blood clots 1) Determine the presence and extent of tumor
(Chlebowski, Anderson, Pettinger, et al., 2008). 2) identify possible spread (metastasis) of disease or
invasion of other body tissues,
Detection and Prevention of Cancer 3) evaluate the function of involved and uninvolved body
- Nurses and physicians have traditionally been involved systems and organs, and
with tertiary prevention, the care, and rehabilitation of 4) obtain tissue and cells for analysis, including
patients after cancer diagnosis and treatment. However, evaluation of tumor stage and grade.
the American Cancer Society, the National Cancer - The diagnostic evaluation includes a review of systems,
Institute, clinicians, and researchers also place emphasis physical examination, imaging studies, laboratory tests of
on primary and secondary prevention of cancer. Nurses blood, urine and other body fluids, and surgical and
must be aware of factors such as race, cultural influences, pathology reports.
access to care, patient–physician and patient–nurse - Knowledge of suspicious symptoms and of the behavior of
relationships, level of education, income, and age that particular types of cancer assists in determining relevant
influence the knowledge, attitudes, and beliefs individuals diagnostic tests.
have about cancer. These factors also may affect the Tumor Staging and Grading
health-promoting behaviors that people practice. - A complete diagnostic evaluation includes identifying the
Primary Prevention stage and grade of the tumor.
- Primary prevention is concerned with reducing the risks of - This is accomplished prior to treatment to provide
disease through health promotion strategies. baseline data for evaluating outcomes of therapy and to
- It is estimated that almost one third of all cancers maintain a systematic and consistent approach to
worldwide could be prevented through primary prevention ongoing diagnosis and treatment.
efforts (Williams-Brown & Singh, 2005). - Treatment options and prognosis are based on staging
- By acquiring the knowledge and skills necessary to and grading.
educate the community about cancer risk, nurses in all - Staging determines the size of the tumor and the
settings play a key role in cancer prevention. One way to existence of local invasion and distant metastasis. Several
reduce the risk of cancer is to help patients avoid known systems exist for classifying the anatomic extent of
carcinogens. disease.
- Another strategy involves encouraging patients to make - The tumor, nodes, and metastasis (TNM) system is
dietary and lifestyle changes (smoking cessation, frequently used (American Joint Committee on Cancer,
decreased caloric in- take, increased physical activity) 2006).
that studies show influence the risk for cancer. - A variety of other staging systems are also used to
- Nurses use their teaching and counseling skills to provide describe the extent of cancers, such as central nervous
patient education and support public education system (CNS) cancers, hematologic cancers, and
campaigns through organizations, such as the ACS, that malignant melanoma, which are not well described by the
guide patients and families in taking steps to reduce TNM system.
cancer risks through health promotion behaviors - Grading refers to the classification of the tumor cells.
Grading systems seek to define the type of tissue from
which the tumor originated and the degree to which the
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tumor cells retain the functional and histologic Radiation Therapy

characteristics of the tissue of origin (differentiation). - More than half of patients with cancer receive a form of
- Samples of cells used to establish the grade of a tumor radiation therapy at some point during treatment.
may be obtained from tissue scrapings, body fluids, - Radiation may be used to cure cancer, as in thyroid
secretions, or washings, biopsy, or surgical excision. carcinomas, localized cancers of the head and neck, and
- This information helps the health care team predict the cancers of the uterine cervix.
behavior and prognosis of various tumors. The tumor is - Radiation therapy may also be used to control malignant
assigned a numeric value ranging from I to IV. disease when a tumor cannot be removed surgically or
- Grade I tumors, also known as well-differentiated tumors, when local nodal metastasis is present, or it can be used
closely resemble the tissue of origin in structure and neoadjuvant (prior to local definitive treatment) with or
function. without chemotherapy to reduce the size of a tumor to
- Tumors that do not clearly resemble the tissue of origin in enable surgical resection.
structure or function are described as poorly - Radiation therapy may be used prophylactically to prevent
differentiated or undifferentiated and are assigned grade the spread of a primary cancer to a distant area (e.g.,
IV. These tumors tend to be more aggressive and less irradiating the brain to prevent leukemic infiltration or
responsive to treatment than well-differentiated tumors. metastatic lung cancer).
- Palliative radiation therapy is used to relieve the
Management of Cancer symptoms of metastatic disease, especially when the
- Treatment options offered to cancer patients should be cancer has spread to the brain, bone, or soft tissue, or to
based on treatment goals for each specific type of cancer. treat oncologic emergencies, such as superior vena cava
- The range of possible treatment goals may include syndrome, bronchial airway obstruction, or spinal cord
complete eradication of malignant disease (cure), compression.
prolonged survival and containment of cancer cell growth Chemotherapy
(control), or relief of symptoms associated with the - In chemotherapy, antineoplastic agents are used in an
disease (palliation). attempt to destroy tumor cells by interfering with cellular
- Multiple modalities are commonly used in cancer functions, including replication.
treatment. A variety of approaches, including surgery, - Chemotherapy is used primarily to treat systemic disease
radiation therapy, chemotherapy, and targeted therapies, rather than localized lesions that are amenable to surgery
may be used at various times throughout treatment. or radiation.
- Understanding the principles of each and how they - Chemotherapy may be combined with surgery, radiation
interrelate is important in understanding the rationale and therapy, or both to reduce tumor size preoperatively
goals of treatment. (neoadjuvant), to destroy any remaining tumor cells
Surgery postoperatively (adjuvant), or to treat some forms of
- Surgical removal of the entire cancer remains the ideal leukemia or lymphoma (primary).
and most frequently used treatment method. However, - The goals of chemotherapy (cure, control, palliation) must
the specific surgical approach may vary for several be realistic because they will determine the medications
reasons. that are used and the aggressiveness of the treatment
- Diagnostic surgery is the definitive method of identifying plan.
the cellular characteristics that influence all treatment - Nursing Management in Chemotherapy
decisions. • Nurses play an important role in assessing and
- Surgery may be the primary method of treatment, or it may managing many of the problems experienced by
be prophylactic, palliative, or reconstructive. Surgery as patients undergoing chemotherapy.
Primary Treatment • Chemotherapeutic agents affect both nor- mal and
- When surgery is the primary approach in treating cancer, malignant cells, meaning that these problems are
the goal is to remove the entire tumor or as much as is often widespread, affecting many body systems.
feasible (a procedure sometimes called debulking) and - Assessing Fluid and Electrolyte Status
any involved surrounding tissue, including regional lymph • Anorexia, nausea, vomiting, altered taste, mucositis,
nodes. and diarrhea put patients at risk for nutritional and
- Two common surgical approaches used for treating fluid and electrolyte disturbances.
primary tumors are: • Therefore, it is important for the nurse to assess the
• Local excision, often performed on an outpatient patient’s nutritional and fluid and electrolyte status
basis, is warranted when the mass is small. This frequently and to use creative ways to encourage an
surgical method can result in disfigurement and adequate fluid and dietary intake.
altered functioning, necessitating rehabilitation or - Modifying Risks for Infection and Bleeding
reconstructive procedures. • Suppression of the bone marrow and immune system
• Wide excisions are considered if the tumor can be is expected and frequently serves as a guide in
removed completely, and the chances of cure or determining appropriate chemotherapy dosage but
control are good.

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increases the risk of anemia, infection, and bleeding 2) Neuromas (acoustic neuroma, schwannoma)
disorders. 3) Pituitary adenomas
• Nursing assessment and care address factors that • Developmental Tumors
would further increase the patient’s risk. 1) Angiomas
- Administering Chemotherapy 2) Dermoid, epidermoid, teroma,
• The local effects of the chemotherapeutic agent are craniopharyngioma
also of concern. • Metastatic Lesions Gliomas
• The patient is observed closely during its - Glial tumors, the most common type of
administration because of the risk and consequences intracerebral brain neoplasm, are divided into
of extravasation, particularly of vesicant agent. many categories (Wen & Kesari, 2008).
• Local difficulties or problems with administration of - Astrocytomas are the most common type of
chemotherapeutic agents are brought to the attention glioma and are graded from I to IV, indicating the
of the physician promptly so that corrective measures degree of malignancy (Arzbaecher, 2007). The
can be taken immediately to minimize local tissue grade is based on cellular density, cell mitosis,
damage. and appearance.
- Usually, these tumors spread by infiltrating into
ONCOLOGIC DISORDERS OF THE BRAIN AND SPINAL the surrounding neural connective tissue and
CORD therefore cannot be totally removed without
- Oncologic disorders of the brain and spinal cord include causing considerable damage to vital structures.
several types of neoplasms, each with its own biology, Primary Brain Cancer
prognosis, and treatment options. Because of the unique • Astrocytoma
anatomy and physiology of the central nervous system • Ependymoma
(CNS), this collection of neoplasms is challenging to • Medulloblastoma
diagnose and treat. • Brainstem glioma
Primary Brain Tumors • Acoustic neuroma
- A brain tumor is a localized intracranial lesion that • Choroid plexus papilloma
occupies space within the skull. A tumor usually grows as a • Meningioma
spherical mass, but it also can grow diffusely and infiltrate • Glioblastoma multiforme
tissue. Metastatic brain cancer
- The effects of neoplasms are caused by the compression • Melanoma
and infiltration of tissue.
• Breast Cancer
- A variety of physiologic changes result, causing any or all of
• Renal Cell Carcinoma
the following pathophysiologic events:
• Lung Cancer
• Increased intracranial pressure (ICP) and cerebral
• Colorectal Cancer
edema
• Seizure activity and focal neurologic signs
• Hydrocephalus
• Altered pituitary function
- Types of Primary Brain Tumors
• Brain tumors may be classified into several groups:
those arising from the coverings of the brain (e.g.,
dural meningioma), those developing in or on the
cranial nerves (e.g., acoustic neuroma), those
originating within brain tissue (eg, glioma), and
metastatic lesions originating elsewhere in the body.
Tumors of the pituitary and pineal glands and of
cerebral blood vessels are also types of brain tumors.
- Classification of Brain Tumors in Adults
• Intracerebral Tumors – Gliomas, infiltrate any portion
of the brain; most common type of brain tumor
1) Astrocytomas (grades I and II)
2) Glioblastoma multiforme (astrocytoma grades III
and IV)
3) Oligodendrocytoma (low and high grades)
4) Ependymoma (grades I to IV)
5) Medulloblastoma
• Tumors Arising from Supporting Structures
1) Meningiomas

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Meningiomas
- Meningiomas, which represent 15% of all primary brain
tumors, are common benign encapsulated tumors of
arachnoid cells on the meninges (Pollock, 2006).
- They are slow growing and occur most often in middle-
aged adults (more often in women).
- Preferred treatment for symptomatic lesions is surgery
with complete removal or partial dissection.

Acoustic Neuromas
- An acoustic neuroma is a tumor of the eighth cranial nerve,
the cranial nerve most responsible for hearing and
balance.
- It usually arises just within the internal auditory meatus,
where it frequently expands before filling the
cerebellopontine recess.
- An acoustic neuroma may grow slowly and attain
considerable size before it is correctly diagnosed. The
patient usually experiences loss of hearing, tinnitus, and
episodes of vertigo and staggering gait.
- As the tumor becomes larger, painful sensations of the
face may occur on the same side, as a result of the
tumor’s compression of the fifth cranial nerve. Some
acoustic neuromas may be suitable for stereotactic
radiotherapy rather than open craniotomy.

Pituitary Adenomas
- Pituitary tumors represent about 10% to 15% of all brain
tumors and cause symptoms as a result of pressure on
adjacent structures or hormonal changes such as
hyperfunction or hypofunction of the pituitary (Pollock,
2006).

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Angiomas enhanced by a contrast agent, can give specific

- Brain angiomas (masses composed largely of abnormal information concerning the number, size, and density of
blood vessels) are found either in or on the surface of the the lesions and the extent of secondary cerebral edema.
brain. - CT scans can provide information about the ventricular
- They occur in the cerebellum in 83% of cases. Some system.
persist throughout life without causing symptoms; others - A magnetic resonance imaging (MRI) scan is the most
cause symptoms of a brain tumor. Occasionally, the helpful diagnostic tool for detecting brain tumors,
diagnosis is suggested by the presence of another particularly smaller lesions, and tumors in the brain stem
angioma somewhere in the head or by a bruit (an and pituitary regions, where bone is thick. In a few
abnormal sound) that is audible over the skull. Because instances, the appearance of a brain tumor on an MRI
the walls of the blood vessels in angiomas are thin, these scan is so characteristic that a biopsy is unnecessary,
patients are at risk for hemorrhagic stroke. especially when the tumor is located in a part of the brain
- In fact, cerebral hemorrhage in people younger than 40 that is difficult to biopsy (Rowland, 2005).
years of age should suggest the possibility of an angioma. - Positron emission tomography (PET) is used to
Clinical Manifestations supplement MRI scanning in centers where it is available.
- Brain tumors can produce both focal or generalized On PET scans, low-grade tumors are associated with
neuro- logic signs and symptoms. Generalized symptoms hypometabolism and high-grade tumors show
reflect in- creased ICP, and the most common focal or hypermetabolism. This information can be useful in
specific signs and symptoms result from tumors that making treatment decisions (ABTA, 2007).
interfere with functions in specific brain regions. - Computer-assisted stereotactic (three- dimensional)
Increased Intracranial Pressure biopsy is used to diagnose deep-seated brain tumors and
- Symptoms of increased ICP result from a gradual to provide a basis for treatment and prognosis.
compression of the brain by the enlarging tumor. The - Cerebral angiography provides visualization of cerebral
effect is a disruption of the equilibrium that exists blood vessels and can localize most cerebral tumors. An
between the brain, the CSF, and the cerebral blood. electroencephalogram (EEG) can detect an abnormal
- As the tumor grows, compensatory adjustments may brain wave in regions occupied by tumor; it is used to
occur through compression of intracranial veins, evaluate temporal lobe seizures and to assist in ruling out
reduction of CSF volume (by increased absorption or other disorders.
decreased production), a modest decrease in cerebral - Cytologic studies of the CSF may be per- formed to detect
blood flow, or reduction of intracellular and extracellular malignant cells, because CNS tumors can shed cells into
brain tissue mass. the CSF.
- When these compensatory mechanisms fail, the patient Medical Management
develops signs and symptoms of increased ICP, most - A variety of medical treatment modalities, including
often including headache, nausea with or without vomiting, chemotherapy and external-beam radiation therapy, are
and papilledema (edema of the optic disk) (Rowland, used alone or in combination with surgical resection (Wen
2005). & Kesari, 2008).
- Personality changes and a variety of focal deficits, - Radiation therapy, the cornerstone of treatment for many
including motor, sensory, and cranial nerve dysfunction, brain tumors, decreases the incidence of recurrence of
are common. incompletely resected tumors.
Localized Symptoms - Brachytherapy (the surgical implantation of radiation
- Common focal or localized symptoms are hemiparesis, sources to deliver high doses at a short distance) has had
seizures, and mental status changes (Rowland, 2005). promising results for primary malignancies. It is usually
- When specific regions of the brain are affected, additional used as an adjunct to conventional radiation therapy or as
local signs and symptoms occur, such as sensory and a rescue measure for recurrent disease.
motor abnormalities, visual alterations, alterations in - Intravenous (IV) autologous bone marrow transplantation
cognition, and language disturbances (e.g., aphasia). is used in some patients who will receive chemotherapy or
- The progression of the signs and symptoms is important, radiation therapy, because it can “rescue” the patient
because it indicates tumor growth and expansion. from the bone marrow toxicity associated with high doses
- For example, a rapidly developing hemiparesis is more of chemotherapy and radiation.
typical of a highly malignant glioma than of a low-grade - A fraction of the patient’s bone marrow is aspirated,
tumor. usually from the iliac crest, and stored. The patient
Assessment and Diagnostic Findings receives large doses of chemotherapy or radiation therapy
- The history of the illness and the manner and time frame to destroy large numbers of malignant cells. The marrow
in which the symptoms evolved are key components in the is then reinfused by IV after treatment is completed.
diagnosis of brain tumors.
- A neurologic examination indicates the areas of the CNS
that are involved.
- To assist in the precise localization of the lesion, a battery
of tests is per- formed. Computed tomography (CT) scans,
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- Stereotactic procedures may be performed using a linear

accelerator or gamma knife to perform radiosurgery.
These procedures allow treatment of deep, inaccessible
tumors, often in a single session.
- Gamma Knife is the leading stereotactic radiosurgery
(SRS) platform, offering unparalleled accuracy in both the
localization and radiation dose delivered to targeted brain
tissue.
- Precise localization of the tumor is accomplished by the
stereotactic approach and by minute measurements and
precise positioning of the patient. Multiple narrow beams
then deliver a very high dose of radiation.
- An advantage of this method is that no surgical incision is
needed; a disadvantage is the lag time between treatment
Surgical Management and the desired result (Pollock, 2006; Swinson & Friedman,
- The objective of surgical management is to remove or 2008).
destroy the entire tumor without increasing the neurologic
deficit (paralysis, blindness) or to relieve symptoms by
partial removal (decompression).
- A variety of treatment modalities may be used; the
specific approach depends on the type of tumor, its
location, and its accessibility. In many patients,
combinations of these modalities are used.
- Most pituitary adenomas are treated by transsphenoidal
microsurgical removal, and the remainder of tumors that
cannot be removed completely are treated by radiation.
- An untreated brain tumor ultimately leads to death, either
from increasing ICP or from the damage the tumor causes
to brain tissue.
- Conventional surgical approaches require a craniotomy
(incision into the skull). This approach is used in patients
with meningiomas, acoustic neuromas, cystic
astrocytomas of the cerebellum, colloid cysts of the third
ventricle, congenital tumors such as dermoid cyst, and
some of the granulomas. With improved imaging
techniques and the availability of the operating
microscope and microsurgical instrumentation, even
large tumors can be removed through a relatively small
craniotomy.
- For patients with malignant glioma, complete removal of
the tumor and cure are not possible, but the rationale for
resection includes relief of ICP, removal of any necrotic
tissue, and reduction in the bulk of the tumor, which Nursing Management
theoretically leaves behind fewer cells to become - Preoperative Nursing Care:
resistant to radiation or chemotherapy. • Instruct patient and family about the necessity and
- Stereotactic approaches involve the use of a three-
importance of diagnostic tests to determine the exact
dimensional frame that allows very precise localization of
location of the tumor.
the tumor; a stereotactic frame and multiple imaging
studies (x-rays, CT scans) are used to localize the tumor • Monitor and record vital signs and neurological status
and verify its position. accurately q2-4h, or as ordered.
- New brain-mapping technology helps determine how • Institute measures to prevent inadvertent increases in
close diseased areas of the brain are to structures intracranial pressure.
essential for normal brain function. Lasers or radiation • Institute seizure precautions at patient's bedside.
can be delivered with stereotactic approaches. • Supportive nursing care is given depending upon the
Radioisotopes such as iodine 131 can also be implanted patient's symptoms and ability to perform activities of
directly into the tumor to deliver high doses of radiation to daily living.
the tumor (brachytherapy) while minimizing effects on • Administer all doses of steroids and antiepileptic
surrounding brain tissue.
agents on time.

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- Post-Operative Nursing: Prevention

• Meticulous nursing management and care aimed at - Lifestyle Choices
prevention of postoperative complications are • Diet
imperative for the patient's survival. • Avoid smoking
• Accurately monitor and record all vital signs and • Avoid drinking alcohol
neurological signs. • Proper exercise
• Administer artificial tears (eye drops) as ordered, to • Sweating is powerful way to cleanse your body from
prevent corneal ulceration in the comatose patient. accumulated toxins
• Avoid exposure to chemicals
• Maintain skin integrity.
• Avoid or minimize exposure to radiation
• Bone flap may not have been replaced over surgical
- Stress Management and your Immune System
site; turning patient to the affected side, if the flap has
• Laughter Therapy
been removed, can cause irreversible damage in the
• Change your mood
first 72 hours.
• Boost up your immune system by taking vitamins and
• Maintain head of bed at 30ºelevation. eating nutritious foods
• Perform passive range of motion exercises to all • Avoid junk foods!
extremities every 2-4 hours.
• Maintain body temperature. Spinal Cord Tumors
• Institute seizure precautions at patient's bedside. - Tumors within the spine are classified according to their
• Maintain accurate record of intake and output. anatomic relation to the spinal cord.
• Prevent pulmonary complications associated with - They include intramedullary lesions (within the spinal
bedrest. cord), extramedullary-intradural lesions (within or under
the spinal dura), and extramedullary-extradural lesions
• Continuously talk to the patient while providing care,
(outside the dural membrane).
reorienting him to person, place, and time.
- Tumors that occur within the spinal cord or exert pressure
- The patient with a brain tumor may be at increased risk for
on it cause symptoms ranging from localized or shooting
aspiration as a result of cranial nerve dysfunction.
pains and weakness and loss of reflexes above the tumor
- Preoperatively, the gag reflex and ability to swallow are
level to progressive loss of motor function and paralysis.
evaluated. In patients with diminished gag response, care
- Usually, sharp pain occurs in the area innervated by the
includes teaching the patient to direct food and fluids
spinal roots that arise from the cord in the region of the
toward the unaffected side, having the patient sit upright
tumor. In addition, increasing sensory deficits develop
to eat, offering a semisoft diet, and having suction readily
below the level of the lesion.
available.
Assessment and Diagnostic Findings
- The nurse performs neurologic checks, monitors vital - Neurologic examination and diagnostic studies are used
signs, maintains a neurologic flow chart, spaces nursing to make the diagnosis.
interventions to prevent rapid increase in ICP, and
- Neurologic examination includes assessment of pain, loss
reorients the patient when necessary to person, time, and
of reflexes, loss of sensation or motor function, and the
place.
presence of weakness and paralysis.
- Patients with changes in cognition caused by their lesion - Additional assessment findings usually include pain
require frequent reorientation and the use of orienting duration for longer than 1 month and an elevated
devices (e.g., personal possessions, photographs, lists, a erythrocyte sedimentation rate.
clock), supervision of and assistance with self-care, and
- Helpful diagnostic studies include x-rays, radionuclide
ongoing monitoring and intervention for prevention of
bone scans, CT scans, MRI scans, and biopsy.
injury.
- The MRI scan is the most commonly used and the most
- Patients with seizures are carefully monitored and sensitive diagnostic tool, and it is particularly helpful in
protected from injury. detecting epidural spinal cord compression and
- Motor function is checked at intervals, because specific metastases (Rowland, 2005).
motor deficits may occur, depending on the tumor’s
Medical Management
location.
- Treatment of specific intraspinal tumors depends on the
- Sensory disturbances are assessed. Speech is evaluated. type and location of the tumor and the presenting
- Eye movement and pupillary size and reaction may be symptoms and physical status of the patient.
affected by cranial nerve involvement. - Surgical intervention is the primary treatment for most
- The psychosocial effects on family caregivers of a family
spinal cord tumors.
member who has a primary malignant brain tumor may be
- Other treatment modalities include partial removal of the
significant.
tumor, decompression of the spinal cord, chemotherapy,
- The patient’s functional abilities should be reassessed and radiation therapy, particularly for intramedullary
postoperatively, because changes can occur. tumors and metastatic lesions (Rowland, 2005).

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- Epidural spinal cord compression occurs in 5% to 7% of - There is no one specific cause of breast cancer; rather, a
patients who die of cancer and is considered a neurologic com- bination of genetic, hormonal, and possibly
emergency. environmental events may contribute to its development.
- For the patient with epidural spinal cord compression - If lymph nodes are unaffected, the prognosis is better. The
resulting from metastatic cancer (most commonly from key to improved cure rates is early diagnosis, before
breast, prostate, or lung), high-dose dexamethasone metastasis.
(Decadron) combined with radiation therapy is effective in Risk Factors
relieving pain (Held-Warmkessel, 2005). • Gender (female) and increasing age.
- Palliative care may be an option for the medical • Previous breast cancer: The risk of developing cancer in
management of some patients. the same or opposite breast is significantly increased.
Surgical Management • Family history: Having first-degree relative with breast
- Tumor removal is desirable but not always possible. The cancer (mother, sister, daughter) increases the risk
goal is to remove as much tumor as possible while sparing twofold; having two first-degree relatives increases the
uninvolved portions of the spinal cord. risk fivefold.
- Microsurgical techniques have improved the prognosis for • Genetic mutations (BRCA1 or BRCA2) account for majority
patients with intramedullary tumors. of inherited breast cancers.
- Prognosis is related to the degree of neurologic • Hormonal factors: early menarche (before 12 years of age),
impairment at the time of surgery, the speed with which nulliparity, first birth after 30 years of age, late menopause
symptoms occurred, and the origin of the tumor. (after 55 years of age), and hormone therapy (formerly
- Patients with extensive neurologic deficits before surgery referred to as hormone replacement therapy).
usually do not make significant functional recovery even • Other factors may include exposure to ionizing radiation
after successful tumor removal. during adolescence and early adulthood obesity, alcohol
intake (beer, wine, or liquor), high-fat diet (controversial,
CANCER OF THE BREAST more research needed).
- Breast Cancer occurs when a mutation takes place in the • Factors that cannot be prevented:
cells that line the lobules that manufacture milk or more - Gender
commonly in the ducts that carry it to the nipple. - Aging
- The area around the center of the breast is where most - Genetic Risk Factors (inherited)
cancers occur. - Family History
- It is fairly rare for cancers to form in the fat or non- - Personal History
glandular tissues of the breast. - Race
- The area around the center of the breast is where most - Menstrual Cycle
cancers occur. It is fairly rare for cancers to form in the fat - Estrogen
or non-glandular tissues of the breast. • Lifestyle Risks
- Cancer of the breast is a pathologic entity that starts with - Oral Contraceptive Use
a genetic alteration in a single cell and may take several - Not Having Children
years to become palpable. - Hormone Replacement Therapy
- The most common histologic type of breast cancer is - Not Breast Feeding
infiltrating ductal carcinoma (80% of cases), whereby - Alcohol Use
tumors arise from the duct system and invade the sur- - Obesity
rounding tissues. Infiltrating lobular carcinoma accounts - High Fat Diets
for 10% to 15% of cases. - Physical Inactivity
- These tumors arise from the lobular epithelium and - Smoking
typically occur as an area of ill-defined thick- ening in the • Environmental factors
breast. - Exposure to Estrogen
- Infiltrating ductal and lobular carcinomas usually spread - Radiation
to bone, lung, liver, adrenals, pleura, skin, or brain. - Electromagnetic Fields
Several less common invasive cancers, such as medullary - Xenoestrogens
carcinoma (5% of cases), mucinous carcinoma (3% of - Exposure to Chemicals
cases), and tubular ductal carcinoma (2% of cases) have • Exogenous estrogen
very favorable prognoses. Inflammatory carcinoma and - Hormonal replacement therapy (HRT) – 30%
- Paget’s disease are less common forms of breast cancer. increased risk with long term use
Ductal carci- noma in situ is a noninvasive form of cancer - Oral Contraceptives (OC) – risk slight, risk returns to
(also called intraductal carcinoma), but if left untreated, normal once the use of OC’s has been discontinued
there is an increased likelihood that it will progress to • Other risk factors
invasive cancer. - Radiation exposure
- Breast disease – Atypical Hyperplasia, Intraductal
carcinoma in situ, Intralobular carcinoma in situ

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- Obesity Benign conditions of the breast

- Diet – Fat, Alcohol Fibrocystic Change
• Genetics - occurs as ducts dilate and cysts form
- BRCA-1 - most commonly in women aged 30-50 years
- BRCA-2 - estrogen appears to be a factor because cysts usually
- P53, Rb-1 disappear after menopause
- Her-2/neu, c-erB2, c-myc - usually larger premenstrually and smaller postmenstrually
because of the retention of fluid in the days preceding the
menstrual period
- occur singly or in multiple lumps
- usually tender, round shaped; soft or firm, mobile
- medical management: Danazol ( antiestrogenic property);
used only in severe cases due to its side effects like
flushing, vaginitis and virilization
- Nursing intervention: wear supportive bra day and night
for a week; decrease salt and caffeine intake; ibuprofen

Fibroadenoma
- round, movable benign tumor of the breast
- affects women in their late teens to late 30’s
- no premenstrual changes
- firm, mobile and not fixed to breast tissue or chest wall

Cystosarcoma Phyllodes
- fibroepithelial lesion that tends to grow rapidly
- rarely malignant and is surgically excised
- if it is malignant, mastectomy may follow

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Malignant conditions of the breast Sign and symptoms

Signs are those that are felt by patient (subjective).
• A lump in a breast
• A pain in the armpits or breast that does not seem to be
related to the woman's menstrual period
• Pitting or redness of the skin of the breast; like the skin of
an orange
• A rash around (or on) one of the nipples
• A swelling (lump) in one of the armpits
• An area of thickened tissue in a breast
• One of the nipples has a discharge; sometimes it may
contain blood
• The nipple changes in appearance; it may become sunken
or inverted
• The size or the shape of the breast changes
Carcinoma In Situ (Non-Invasive)
• The nipple-skin or breast-skin may have started to peel,
- proliferation of malignant cells within the ducts and
scale or flake
lobules without invasion to the surrounding tissue
- considered stage 0 breast cancer
- two types: ductal and lobular carcinoma in situ
- Ductal carcinoma in situ (dcis)
- more common; has the capacity to progress to
invasive cancer
- most traditional treatment is total or simple
mastectomy
- Tamoxifen for women after tx with surgery and
radiation
- Lobular carcinoma in situ- proliferation of malignant
cells within the breast lobules; rarely associated with
invasive cancer but maybe a marker of increased risk for
the development of invasive cancer
- Management:
• long term surveillance
• bilateral prophylactic mastectomy to decrease risk
• chemoprevention- Tamoxifen given for 5 years Diagnostic procedures
Invasive Carcinoma • Breast Exam (Initial assessment)
1) Infiltrating Ductal Carcinoma • Mammography 2D + 3D
- most common type of breast cancer and accounts for • X-ray
75% of all breast cancers • Breast Ultrasound (solid mass vs fluid-filled)
- noted for its hardness on palpation • Biopsy (Confirmatory procedure)
- usually metastasize to axillary nodes • Breast MRI (determine extent of cancer)
- poorer prognosis than others
2) Infiltrating Lobular Carcinoma
- 5% - 10% of breast cancers
- occur as an area of ill-defined thickening
- several areas of thickening may occur on one or both
breasts
- metastasize to meninges
- Both infiltrating ductal and infiltrating lobular
carcinomas usually spread to the bone, lung, liver or
brain
3) Inflammatory Carcinoma
- rare type of breast cancer
- localized tumor is tender and painful and the skin over
it is red and dusky
- breast is abnormally firm and enlarged
- often, edema and nipple retraction occur
- Management: chemotherapy, radiation, surgery

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• Advanced signs may include skin dimpling, nipple

retraction, or skin ulceration.
Assessment and Diagnostic Methods
• Biopsy (eg, percutaneous, surgical) and histologic
examination of cancer cells.
• Tumor staging and analysis of additional prognostic
factors are used to determine the prognosis and optimal
treatment regimen.
• Chest x-rays, CT, MRI, PET scan, bone scans, and blood
work (complete blood cell count, comprehensive
metabolic panel, tumor markers
Tumor Markers
- are used to aid in the diagnosis of cancer, to detect
recurrence or identify regression of a known malignancy:
CA 15-3 and CA 27-29
- Specific treatment for breast cancer, these markers are
found in the blood of affected patients and are most
useful in evaluating the effectiveness of treatment for
individuals with advanced disease.
- Both tests are commonly used to monitor the recurrence
in women who have been treated for breast cancer.
- The CA 27-29 test may be more sensitive than CA 15-3.

Staging of Breast Cancer

• Stage II and III tumors represent a wide spectrum of breast
cancers and are subdivided into stage IIA, IIB, IIIA, IIIB,
and IIIC.
• Factors determining stages include number and
characteristics of axillary lymph nodes, status of other
regional lymph nodes, and involvement of the skin or
Protective Factors underlying muscle. See “Staging” under “Cancer.”
- Protective factors may include regular vigorous exercise
(decreased body fat), pregnancy before age 30 years, and
breastfeeding.

Prevention Strategies
- Patients at high risk for breast cancer may consult with
specialists regarding possible or appropriate prevention
strategies such as the following:
• Long-term surveillance consisting of twice-yearly
clinical breast examinations starting at age 25 years,
yearly mammography, and possibly MRI (in BRCA1
and BRCA2 carriers)
• Chemoprevention to prevent disease before it starts,
using tamoxifen (Nolvadex) and possibly raloxifene
(Evista)
• Prophylactic mastectomy (“risk-reducing”
mastectomy) for patients with strong family history of
breast cancer, a diagnosis of lobular carcinoma in situ
(LCIS) or atypical hyperplasia, a BRCA gene mutation, Management (the team)
an extreme fear of cancer (“cancer phobia”), or • Oncologist
previous cancer in one breast • Specialist cancer surgeon
• Specialist nurse
Clinical Manifestations
• Pathologist
• Generally, lesions are nontender, fixed, and hard with
• Radiologist
irregular borders; most occur in the upper outer quadrant.
• Radiographer
• Some women have no symptoms and no palpable lump
• Reconstructive surgeon
but have an abnormal mammogram.
• Occupational therapist
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• Psychologist - Nurse’s focus:

• Dietitian • Post-Operative Care
• Physical therapist • Wound Care
• Management and the nurse’s role • Rehabilitation plan to achieve optimum level of
- Surgery functioning
- Radiotherapy • Psychological care for clients towards changes in
- Chemotherapy body image
- Hormone Therapy
- Biological Treatment

Medical Management
- Various management options are available. The patient
and physician may decide on surgery, radiation therapy,
chemotherapy, or hormonal therapy or a combination of
therapies.
• Modified radical mastectomy involves removal of the
entire breast tissue, including the nipple–areola
complex and a portion of the axillary lymph nodes. Radiotherapy
• Total mastectomy involves removal of the breast and - Brachytherapy
nipple– areola complex but does not include axillary - Linear accelerator
lymph node dissection (ALND). - Nurse’s focus:
• Breast-conserving surgery: lumpectomy, wide • Skin Care
excision, partial or segmental mastectomy, • Prevent fatigue
quadrantectomy followed by lymph node removal for
invasive breast cancer.
• Sentinel lymph node biopsy: considered a standard of
care for the treatment of early-stage breast cancer.
• External-beam radiation therapy: typically whole
breast radiation, but partial breast radiation (radiation
to the lumpectomy site alone) is now being evaluated
at some institutions in carefully selected patients.
•Chemotherapy to eradicate micrometastatic spread
of the disease: cyclophosphamide (Cytoxan),
methotrexate, fluorouracil, anthracycline-based
Chemotherapy
regimens (eg, doxorubicin [Adriamycin], epirubicin
- Nurse’s focus:
[Ellence]), taxanes (paclitaxel [Taxol], docetaxel
[Taxotere]). • Alleviate most common side effects: nausea/
vomiting, diarrhea/ constipation
• Hormonal therapy based on the index of estrogen and
progesterone receptors: Tamoxifen (Soltamox) is the • Prevent extravasation/ phlebitis
primary hormonal agent used to suppress hormonal- • Encourage adherence to treatment plan and schedule
dependent tumors; others are inhibitors anastrazole Hormone Therapy
(Arimidex), letro- zole (Femara), and exemestane - Endocrine receptor – Some breast cancers are stimulated
(Aromasin). by the hormone estrogen. This means that estrogen in the
• Targeted therapy: trastuzumab (Herceptin), body ‘helps’ the cancer to grow. This type of breast cancer
bevacizumab (Avastin). is called estrogen receptor positive (ER+).
- Hormone therapy, also called endocrine therapy, is a
• Breast reconstruction.
treatment that blocks the effect of estrogen on breast
Surgery
cancer cells. Different hormone therapy drugs do this in
• Lumpectomy
different ways.
• Mastectomy
- Nurse’s focus: Client’s adherence to treatment schedule
• Reconstructive Surgery and duration
Biological therapy
- Also known as Targeted Therapy or Immunotherapy
- It uses the body's immune system or hormonal system to
fight breast cancer cells. That does less harm to healthy
cells, so the side effects aren't usually as bad as from
better known treatments like chemotherapy.
- Nurse’s focus:

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• Allergic reaction masses and often metastasizes and includes

• Prevent extravasation/ phlebitis bronchoalveolar carcinoma.
• Adherence to treatment schedule a) Adenocarcinoma- develops peripherally as
peripheral masses or nodules and usually
metastasizes. It is the most common lung cancer
in both sexes
b) Bronchoalveolar carcinoma- located in the
terminal bronchi and alveoli, and for the most
part is slower growing in comparison to the other
bronchogenic carcinomas
c) Large Cell Carcinoma (undifferentiated
carcinoma)- a faster growing tumor that usually
arises peripherally
- Most small cell cancers arise in the major bronchi and
spread by infiltration along the bronchial wall.

Staging
Prevention of breast cancer - the stage of the tumor involves the size of the tumor, its
• Lifestyle Modification location, lymph nodes involvment, and whether the
- Alcohol consumption cancer has spread to other organs
- Physical Exercise - staging helps clinicians better determine prognosis and
- Diet treatment direction
- Postmenopausal Hormone therapy - SCLC typically diagnosed as limited stage (one area of
- Bodyweight chest and usually treatable by radiation, etc.) or extensive
• Breast Cancer Screening stage (spread to other parts of the body, metastasized,
• Breastfeeding etc.)
- NSCLC typically staged as I to IV- Stage I earliest stage,
CANCER OF THE LUNG (BRONCHOGENIC CARCINOMA) highest cure rate ;
- Lung Cancer is the leading cause of death due to cancer - Stage IV-metastatic spread and usually fatal.
among men and
- women in the U.S. Risk factors
- In about 70 % of patients with lung cancer, the disease - include tobacco smoke, second-hand (passive) smoke,
quite frequently has already spread to regional lymph environmental and occupational exposures, gender,
nodes and other areas by the time it is diagnosed genetics, and dietary deficits.
therefore, the long-term survival rate is poor, with the 5 - Other factors that have been associated with lung cancer
year survival rate being a mere 13% include genetic pre- disposition and underlying respiratory
- the most common cause of cancer of the lungs is usually diseases, such as chronic obstructive pulmonary disease
inhaled carcinogens, most often cigarette smoke (90%) (COPD) and tuberculosis (TB).
- Carcinoma usually arises in areas of previous scarring Smoking
(such as TB, fibrosis, etc.) in the lungs - Number one risk factor for lung cancer!
- Lung cancers arise from a single transformed epithelial - In the U.S. cigarette smoking is linked to 80-90% of all
cell in the tracheobronchial airways. lung cancers.
- A carcinogen (cigarette smoke, radon gas, other - People who smoke cigarettes are 15 to 30 times more
occupational and environmental agents) damages the cell, likely to get lung cancer or die from lung cancer than those
causing abnormal growth and development into a who do not smoke.
malignant tumor. - Smoke from other people’s cigarettes, pipes, or cigars
- Most lung cancers are classified into one of two major (secondhand smoke) also causes lung cancer. About
categories: 7,300 people who have never smoked die from lung
• small cell lung cancer (15% to 20% of tumors) cancer each year due to secondhand smoke.
generally includes small cell carcinoma and Radon
combined small cell carcinoma - Radon is a naturally occurring gas that comes from rocks
• non–small cell lung cancer (NSCLC; approximately and dirt and can get trapped in houses and buildings.
80% of tumors). NSCLC cell types include squamous Radon breaks down into radon progeny which can attach
cell carcinoma (20% to 30%), which is usually more to dust and other particles and are then inhaled.
centrally located; large cell carcinoma (15%), which is - Levels are usually highest in basements or crawl spaces,
fast growing and tends to arise peripherally; and which is closest to soil and rocks. Therefore, people who
adenocarcinoma (40%), which presents as peripheral spend a lot of time in these rooms are at a greater risk.
- According to the Environmental Protection Agency (EPA),
radon causes about 20,000 cases of lung cancer each
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year, making it the second leading cause of lung cancer.. Sign and symptoms
Nearly 1 out of 15 homes in the U.S. is thought to have • Cough- The MOST prominent symptom- monitor if the
high radon levels. patient develops any kind of change in character of
Personal family history of lung cancer chronic cough.
- If you are a lung cancer survivor, there is a risk that you • The cough is usually a dry, persistent hacking cough that
may develop another lung cancer, especially if you smoke! may become productive with sputum production if and
- Your risk of lung cancer may be higher if your parents, when infection develops
brothers or sisters, or children have had lung cancer. This • Dyspnea or difficulty breathing (especially early on in the
could be true because they also smoke, or they live or course of the disease)
work in the same place where they are exposed to radon • Blood-tinged sputum (hemoptysis)
and other substances that can cause lung cancer. • Pain –pleuritic or shoulder pain (may occur late in the
Radiation therapy to the chest course of the disease as well if spread to the bone)
- Cancer survivors who have had radiation to the chest are • Fever- due to constant infections in the lung parenchyma
at a higher risk for developing lung cancer. • Nonspecific S/S- Weight loss and generalized weakness
- Examples include people treated for Hodgkin lymphoma
• If tumor metastasizes, S/S include more pronounced
or women who get radiation after a mastectomy for breast
chest pain and tightness, difficulty swallowing, edema of
cancer.
head and neck, & possible pleural/pericardial effusion.
Prevention – work safety
Assessment and Diagnostic Methods
- Many work environments can harbor potentially harmful
• Chest x-ray, CT scans, bone scans, abdominal scans, PET
substances known as carcinogens. These are substances
scans, liver ultrasound, and MRI.
which can cause or increase the risk of acquiring cancer.
• Sputum examinations, fiberoptic bronchoscopy,
It is important for all workers to follow workplace health
transthoracic fine-needle aspiration, endoscopy with
and safety guidelines in order to avoid potential exposure
esophageal ultrasound, mediastinoscopy or
to carcinogens.
mediastinotomy, and biopsy.
- According to the American Cancer Society, these
• Pulmonary function tests, ABG analysis scans, and
chemicals can include:
exercise testing.
• Tetrachlorethylene - a common dry cleaning fluid
• Staging of the tumor refers to the size of the tumor, its
• Asbestos - a naturally occurring group of minerals
location, whether lymph nodes are involved, and whether
• Benzene - a colorless and flammable liquid which
the cancer has spread.
gives off a sweet scent
Diagnostics
• Arsenic - a naturally occurring poisonous substance
• Chest x-Ray- to assess density of the lung, and to search
• Formaldehyde - an odorless chemical used in building for a single lung nodule (or coin lesion), alveolar collapse,
materials
or infection
• CT scan of Chest- to look for smaller nodules that may be
Clinical Manifestations
difficult to see on the x-ray, or to determine lymph node
• Lung cancer often develops insidiously and is pathology
asymptomatic until late in its course.
• Fiberoptic Bronchoscopy –gives an in-detail study of the
• Signs and symptoms depend on location, tumor size, tracheobronchial tree and allows for tissue biopsies to be
degree of obstruction, and existence of metastases to
collected
regional or distant sites.
• Fine-needle Aspiration- done transthoracically and under
• Most common symptom is cough or change in a chronic CT guidance to collect tissue for examination if it cannot
cough.
be collected via bronchoscopy
• Dyspnea may occur early in the disease.
• PET scans, CT scans, bone scans, abdominal scans, and
• Hemoptysis or blood-tinged sputum may be expectorated. ultrasounds of various organs and other areas throughout
• Chest pain or shoulder pain may indicate chest wall or the body may be performed to evaluate for metastasis
pleural involvement. Pain is a late symptom and may be
related to bone metastasis.
• Recurring fever may be an early symptom.
• Chest pain, tightness, hoarseness, dysphagia, head and
neck edema, and symptoms of pleural or pericardial
infusion exist if the tumor spreads to adjacent structures
and lymph nodes.
• Common sites of metastases are lymph nodes, bone,
brain, contralateral lung, adrenal glands, and liver.
• Weakness, anorexia, and weight loss may appear.

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Medical Management Chemotherapy

• The objective of management is to provide a cure if - Chemotherapy treatment plan for lung cancer often
possible. Treatment depends on cell type, stage of the consists of a combination of drugs. Among the drugs most
disease, and physiologic status. commonly used are cisplatin (Platinol)
• Treatment may involve surgery (preferred), radiation • carboplatin (Paraplatin) plus docetaxel (Taxotere)
therapy, or chemotherapy—or a combination of these. • gemcitabine (Gemzar)
Newer and more specific therapies to modulate the • paclitaxel (Taxol and others)
immune system (gene therapy, therapy with defined tumor • vinorelbine (Navelbine and others),
antigens) are under study and show promise. • pemetrexed (Alimta).
Surgery - Chemotherapy after surgery, known as “adjuvant
- Most stage I and stage II non-small cell lung cancers are chemotherapy,” may help prevent the cancer from
treated with surgery to remove the tumor returning.
- Video-assisted thoracoscopic surgery (VATS) is a - Chemotherapy before surgery is known as Neoadjuvant
minimally invasive surgical technique used to diagnose chemotherapy. Used to shrink tumor enough to make it
and treat problems in your chest easier to remove with surgery or increase effectiveness of
- Resection of tumor, lobe: here are some types. radiation.
1) Wedge resection to remove a small section of lung Targeted therapy
that contains the tumor along with a margin of healthy - Targeted treatments are more specific to cancer cells.
tissue They also attach or block targets on CA Cell surface.
2) Segmental resection (segmentectomy) to remove a - Certain cancers have specific biomarkers, used to
larger portion of lung, but not an entire lobe determine eligibility and efficacy.
3) Lobectomy to remove the entire lobe of one lung - These Biomarkers may receive treatment with a targeted
4) Pneumonectomy to remove an entire lung drug alone or in combination with chemotherapy.
Radiation - These treatments for lung cancer include:
• Teletherapy – High-powered energy beams from sources • Erlotinib (Gilotrif).
such as X-rays and protons • Gefitinib (Iressa)
• External beam radiation therapy (EBRT): Delivers high • Bevacizumab (Avastin).
doses of radiation to lung cancer cells from outside the Immunotherapy
body, using a variety of machine-based technologies. • The use of one’s own immune system as treatment
• Stereotactic radiosurgery (track tumor in real time as you against cancer.
breath to avoid healthy tissue) • Monoclonal antibodies are lab-generated molecules that
• High dose rate (HDR) brachytherapy (Internal Radiation): target specific tumor antigens
Delivers high doses of radiation from implants placed • Checkpoint inhibitors target molecules that serve as
close to, or inside, the tumor(s) in the body. checks and balances in the regulation of immune
• Brachytherapy: (instill catheter in bronchial tube ) allow responses.
for faster and precise. bleed and SOB relieved when high • Therapeutic vaccines target shared or tumor-specific
dose radiation delivered to tumor. antigens.
• Adoptive T-cell transfer (removed from the patient,
genetically modified or treated with chemicals to enhance
their activity)

End of life care

Managing fatigue
- The fatigue a cancer patient feels is an abnormal and
enduring feeling of extreme exhaustion that does not
improve with rest.
- For management of fatigue, it is important to improve the
causes which exacerbate it, such as pain, constipation, or
medication. Careful balancing of rest and activity is
Pharmacological therapy imperative.
• Expectorants and antimicrobial agents to relieve dyspnea Pain management
and infection. - Pain generates feelings of irritability, sleeplessness,
• Analgesics given ATC and PRN for breakthrough, expect decrease in appetite and concentration, etc. It is helpful
acute and chronic pain. to understand that pain does not have to be a part of dying.
• Meds to manage side effects of chemo and radiation (dry - Signs of pain can include noisy and labored breathing,
mouth) sounds of pain, such as groaning or moaning, facial
expressions, and body language and movements.

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- Pain can be controlled and managed. Medications for pain • Assist patient and family with informed decision-
range anywhere from Tylenol to opioids such as Morphine. making regarding treatment options.
- Other ways to control pain include nerve blocks, radiation - Risk for infection
treatment, surgery, massage, application of heat or cold, • Teach patient to avoid those with known or recent
meditation, and entertainment like music or movies. infections
Change in appetite • Avoid shaving with a straight edge razor
- In the last months of life body processes start to slow • Avoid heating pads, ice, adhesive tape, and hot
down and the body begins to limit the nutrients necessary showers/baths.
to function. • Avoid rectal or vaginal procedures.
- Appetite loss can be caused by changes in taste and smell, • Discuss dental procedures with PCP
dry mouth, changes in stomach and bowel, shortness of • Avoid IM injections
breath, nausea, vomiting, diarrhea, and constipation.
• Avoid insertion of urinary catheters( but if they are
- Side effects of medication, spiritual distress, and stress
necessary, use aseptic technique)
are also possible causes. Some of these can be managed
- Impaired Tissue Integrity: ALOPECIA
with nutritional support, such as eating strategies and
• Advise that hair loss may occur on body parts other
supplements, as well as medications that decrease
than the head
nausea, stimulate the appetite, or stimulate peristalsis.
• Explain that hair growth usually begins again once
Breathing difficulty management
therapy is completed
- Shortness of breath and labored breathing are common in
• Guide the patient in purchasing a hair piece or wig
advanced cancer.
before hair loss
- Management can include sitting up or propping oneself on
• Lubricate scalp with Vitamin A & D ointment to
pillows, wearing a nasal cannula to deliver supplemental
decrease itching
oxygen or increase airflow, opioid pain and anxiolytic • Have patient wear hat or sunscreen while exposed to
medications, as well as breathing and relaxation the sun
techniques. - Impaired gas exchange
• Maintain the patient in elevated positions in order to
Nursing Management enhance lung expansion
- Managing Symptoms • Assess respiratory rate, rhythm, and depth.
• Instruct patient and family about the side effects of • Assist with deep breathing exercises and pursed-lip
specific treatments and strategies to manage them. breathing as appropriate.
- Relieving Breathing Problems • Administer supplemental oxygen as indicated
• Maintain airway patency; remove secretions through • Monitor ABGs, Pulse oximetry, Hbg & Hct levels.
deep breathing exercises, chest physiotherapy, • Encourage fluid intake (2500 ml/day)
directed cough, suctioning, and in some instances
• Maintain patency of chest drainage system for
bronchoscopy. lobectomy, segmental or wedge resection patient.
• Administer bronchodilator medications; • Avoid positioning patient with a pneumonectomy on
supplemental oxygen will probably be necessary. the operative side; instead, favor the “good lung down”
• Encourage patient to assume positions that promote position.
lung expansion and to perform breathing exercises. - Imbalanced Nutrition: Less than Body Requirements
• Teach energy conservation and airway clearance • Prevent unpleasant sights, odors and sounds during
techniques. mealtime.
• Refer for pulmonary rehabilitation as indicated. • Ensure adequate fluid hydration, before, during, and
Reducing Fatigue after drug administration
• Assess level of fatigue; identify potentially treatable • Adjust diet before and after drug administration
causes. according to patient preference and tolerance.
• Educate patient in energy conservation techniques • Encourage frequent oral hygiene.
and guided exercise as appropriate.
• Encourage the patient to use guided imagery and
• Refer to physical or occupational therapist as relaxation techniques during mealtime.
indicated. - Chronic pain
- Providing Psychological Support
• Offer nonpharmacologic strategies to relieve pain and
• Help patient and family deal with poor prognosis and discomfort.
progression of the disease (when indicated). • Encourage analgesics to be administered AOC rather
• Suggest methods to maintain the patient’s quality of than PRN.
life during the course of this disease.
• Provide education about the use of analgesics (ie;
• Support patient and family in end-of-life decisions adverse effects, potential complications, how to
and treatment options. administer)

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 312 LECTURE: WK15 – CANCER OVERVIEW AND CANCER OF THE CNS AND BREAST

Terminologies • Neurodegenerative: a disease, process, or condition that

• Alopecia: hair loss leads to deterioration of normal cells or function of the
• Anaplasia: cells that lack normal cellular characteristics nervous system papilledema: edema of the optic nerve
and differ in shape and organization with respect to their • Spondylosis: ankylosis or stiffening of the cervical or
cells of origin; usually, anaplastic cells are malignant lumbar vertebrae
• Apoptosis: programmed cell death • Lobular carcinoma in situ (LCIS): atypical change and
• Benign: not cancerous; benign tumors may grow but are proliferation of the lobular cells of the breast; previously
unable to spread to other areas considered a premalignant condition but now considered
• Biologic response modifier (BRM) therapy: use of a marker of increased risk for invasive breast cancer
agents or treatment methods that can alter the • Lymphedema: chronic swelling of an extremity due to
immunologic relationship between the tumor and the host interrupted lymphatic circulation, typically from an axillary
to provide a therapeutic benefit lymph node dissection
• Biopsy: a diagnostic procedure to remove a small sample • Mammoplasty: surgery to reconstruct or change the size
of tissue to be examined microscopically to detect or shape of the breast; can be performed for reduction or
malignant cells augmentation
• Brachytherapy: delivery of radiation therapy through • Mastalgia: breast pain, usually related to hormonal
internal implants fluctuations or irritation of a nerve
• Cancer: a disease process whereby cells proliferate • Modified Radical Mastectomy: removal of the breast
abnormally, ignoring growth-regulating signals in the tissue, nipple–areola complex, and a portion of the axillary
environment surrounding the cells lymph nodes
• Carcinogenesis: process of transforming normal cells • Paget’s Disease: form of breast cancer that begins in the
into malignant cells ductal system and involves the nipple, areola, and
• Chemotherapy: use of medications to kill tumor cells by surrounding skin
interfering with cellular functions and reproduction • Prophylactic Mastectomy: removal of the breast to
• Dysplasia: bizarre cell growth resulting in cells that differ reduce the risk of breast cancer in women considered to
in size, shape, or arrangement from other cells of the be at high risk
same type of tissue • Sentinel Lymph Node: first lymph node(s) in the
• Extravasation: leakage of medication from the veins into lymphatic basin that receives drainage from the primary
the subcutaneous tissues tumor in the breast; identified by a radioisotope and/or
• Grading: identification of the type of tissue from which the blue dye
tumor originated and the degree to which the tumor cells • Stereotactic Core Biopsy: computer-guided method of
retain the functional and structural characteristics of the core needle biopsy that is useful when masses in the
tissue of origin breast cannot be felt but can be visualized using
• Hyperplasia: increase in the number of cells of a tissue; mammography
most often associated with periods of rapid body growth • Tissue Expander followed by Permanent Implant:
• Malignant: having cells or processes that are series of breast-reconstructive surgeries after a
characteristic of cancer metaplasia: conversion of one mastectomy; involves stretching the skin and muscle
type of mature cell into another type of cell before inserting the permanent implant
• Metastasis: spread of cancer cells from the primary • Total Mastectomy: removal of the breast tissue and
tumor to distant sites nipple–areola complex
• Nadir: lowest point of white blood cell depression after • Transverse Rectus Abdominis Myocutaneous (TRAM)
therapy that has toxic effects on the bone marrow Flap: method of breast reconstruction in which a flap of
• Neoplasia: uncontrolled cell growth that follows no skin, fat, and muscle from the lower abdomen, with its
physiologic demand attached blood supply, is rotated to the mastectomy site
• Neutropenia: abnormally low absolute neutrophil count • Ultrasonography: imaging method using high-frequency
• Radiation therapy: use of ionizing radiation to interrupt sound waves to diagnose whether masses are solid or
the growth of malignant cells fluid filled
• Staging: process of determining the extent of disease, • Open Lung Biopsy: biopsy of lung tissue performed
including tumor size and spread or metastasis to distant through a limited thoracotomy incision
sites • Fine-needle Aspiration: insertion of a needle through the
• Tumor-specific antigen (TSA): protein on the membrane chest wall to obtain cells of a mass or tumor; usually
of cancer cells that distinguishes the malignant cell from a performed under fluoroscopy or chest computed
benign cell of the same tissue type tomography guidance
• Vesicant: substance that can cause tissue necrosis and
damage, particularly when extravasated

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 NCMB312 LECTURE: Final Week

16
Genitourinary, Gynecologic & Liver Cancers
Bachelor of Science in Nursing 3YA
Professor: Dr. Potenciana A. Maroma
GENITOURINARY & GYNECOLOGIC CANCERS services of the rural medical clinics and government
- Cancer is the THIRD LEADING CAUSE OF DEATH among hospitals nationwide.
Filipinos. The most common cancers 2) National Integrated Cancer Control Act
are breast, lung, colorectal, liver, and prostate. - Establishes a PHILIPPINE CANCER CENTER and
- Among Filipino women, there are high rates of cervical REGIONAL CANCER CENTERS that aims to improve
cancer, however, breast cancer is still more common. cancer care across the country and provide cancer
- Top 10 leading causes of death in the Philippines 2019: assistance fund
1) Heart diseases 3) Philippine Local Cancer Support Resources
2) Vascular diseases - People with cancer in the Philippines can get financial
3) Malignant Neoplasm assistance from several government offices and
4) Pneumonia agencies which include:
5) Accidents • Philippine Charity Sweepstakes Office (PCSO)
6) Tuberculosis, all forms • Department of Social Welfare and Development
7) Diabetes mellitus (DSWD)
8) Chronic lower respiratory diseases • Philippine Amusement and Gaming Corporation
9) Nephritis, nephrotic syndrome and nephrosis (PAGCOR)
10) Certain conditions originating in the perinatal period • Several non-government organizations (NGO)
Cancer • Philippine Cancer Society Inc. (PCSI)
- Cancer is when “some of the body’s cells begin to divide • Andres Soriano Foundation (ASF)
without stopping and spreading into surrounding Philippine Cancer Society, inc. (PCSI)
tissues. Cancer can start almost anywhere in the human - It is a private, non-stock, non-profit corporation
body, which is made up of trillions of cells. established December 22, 1956.
- Normally, human cells grow and divide to form new cells - It aims to help improve cancer survival, decrease the
as the body needs them. When cells grow old or become incidence of cancer, and improve the quality of life for
damaged, they die, and new cells take their place. cancer patients and their caretakers through information,
- When cancer develops, this orderly process breaks down. education, advocacy and focused services
As cells become more and more abnormal, old or - Address: 310 San Rafael, San Miguel, Manila, 1005 Metro
damaged, cells survive when they should die, and new Manila
cells form when they are not needed. Andres Soriano Foundation, INC. (ASFI)
- These extra cells can divide without stopping and may - It is a non-stock, non-profit foundation established in
form growths called “TUMORS.” 1968.
Cancer VS Tumor - It aims to implement different programs in health,
- CANCER is a disease in which cells, almost anywhere in education, environment, livelihood, and disaster relief.
our body, begin to divide uncontrollably - Address: A. Soriano aviation Hangar, Andrews ave. Pasay,
- TUMOR is when these uncontrolled growth occurs in solid 1300 Metro Manila
tissues such as an organ, muscles or bone Repair and Maintenance of Cancer Institute
• Cancerous/Malignant - ASF was the principal proponent of the full renovation and
• Benign transformation of the 50 year old X-ray and radiology
building of the PHILIPPINE GENERAL HOSPITAL.
Fear - Now, known as the CANCER INSTITUTE, it become a one
- Numerous MEDICAL ADVANCES are continuously being stop center for cancer treatment and management, where
made globally, but still many people think cancer is a thousands of patients from all over the country are treated
DEATH SENTENCE. Other Services
- The physical, psychological, and emotional burden, and • GOVERNMENT HOSPITALS – Provide free or partial free
the financial strain that comes with it, can cause FEAR, consultation and treatment services
ANXIETY, HOPELESSNESS and DEPRESSION. • Other designated CANCER CENTERS under the DOH

Philippine government program to improve access to Genitourinary and Gynecologic Cancers

cancer care. • GENITOURINARY CANCERS develop in the MALE
1) National Health Insurance Program (NHIP) reproductive system
- All Filipino citizens automatically enrolls into the
• GYNECOLOGIC CANCERS develop in the FEMALE
program and avail the Phil Health benefits and
reproductive System

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 312 LECTURE: WK16 – GENITOURINARY, GYNECOLOGIC & LIVER CANCERS

Kidney cancer Diagnosing kidney cancer

- Also called RENAL CANCER 1) Urine Tests – Check presence of blood in the urine or
- Almost all kidney cancers first appear in the lining of the other signs of kidney problems.
tubules in the kidney. 2) Blood Tests – Show how well the kidneys are working. Ex:
- This type of kidney cancer is called RENAL CELL Albumin-creatinine ratio (ACR) or Glomerular filtration
CARCINOMA. rate (GFR)
- In adults, RENAL CELL CARCINOMA, is the most common 3) Intravenous Pyelogram (IVP) – Involves x-raying the
type of kidney cancer. However, other less common types kidneys after injecting a dye that travels to the urinary
of kidney cancer can occur. tract, highlighting any presence of tumors in the kidney.
- In young children, the kidney cancer more likely to 4) Ultrasound – Uses sound waves to create a picture of the
develop is WILM’S TUMOR. kidneys. It can help tell if a tumor is solid or fluid filled.
Symptoms of kidney cancer 5) CT Scan – Uses x-rays and a computer to create a series
• Kidney cancer usually doesn't have signs or symptoms in of detailed pictures of the kidneys. This may also require
its early stages. an injection of dye.
• Blood in the urine, which may appear pink, red or cola 6) Magnetic Resonance Imaging (MRI) – Uses strong
colored magnets and radio waves to create detailed images of soft
• A lump in the side or abdomen tissues in the kidney. A contrast agent may be injected to
• Pain at the back or side that doesn't go away create a better picture of the kidney structures.
• Loss of appetite 7) Renal Arteriogram – Use to evaluate the blood supply to
• Unexplained weight loss the tumor. It is not given often but may help in diagnosing
• Extreme fatigue or tiredness small tumors.
Staging cancers – TNM descriptions
• Fever that lasts for weeks and isn't caused by a cold or
other infection • T - Tumor
- The letter "T" plus a number (0 to 4) describes the size
• Swelling in the ankles or legs
and location of the tumor, including how much the
• Kidney cancer that spreads to other parts of the
tumor has grown into nearby tissues.
body may cause other symptoms, such as: Shortness of
- For some types of cancer, lowercase letters, such as
breath, Coughing up blood & Bone pain
“a,” “b,” or "m" (multiple), are added to the “T”
Risk factors of kidney cancer
category to provide more detailed descriptions. Ex:
• Older age
T1a
• Being male.
• N – Node
• Smoking.
- The letter "N" plus a number (0 to 3) stands for lymph
- Smokers have a greater risk of kidney cancer than
nodes.
nonsmokers do.
- Regional lymph nodes - if near the cancer where it
- Smoking cigars may also increase the risk. The risk
started.
decreases after quitting smoking.
- Distant lymph nodes – if lymph nodes is in other parts
• Being obese of the body
• Having high blood pressure • M – Metastasis
• Using certain pain medications for a long time - The letter "M" indicates whether the cancer has
• Treatment for kidney failure spread to other parts of the body,
• Risk factors of kidney cancer Staging kidney cancer
• Having certain GENETIC CONDITIONS
• Having a FAMILY HISTORY of kidney cancer
• Being exposed to carcinogenic chemicals
• Having LYMPHOMA
Preventing kidney cancer
• QUIT SMOKING
• Avoid being exposed to HARMFUL CHEMICALS.
• Maintain a healthy body weight.
- Proper food intake
- Reduce the number of calories consume each day
- Be physically active most days of the week.
- Seek professional help
• Control high blood pressure
- Change lifestyle.
- Exercise
- Weight loss
- Diet change. Medication compliance

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 312 LECTURE: WK16 – GENITOURINARY, GYNECOLOGIC & LIVER CANCERS

- This therapy causes less harm to normal cells and may

have fewer side effects than other types of cancer
treatment.
• Anti-angiogenic agents.
• Multikinase inhibitor
• Tyrosine kinase inhibitors.
• M-TOR inhibitors.
Other treatment options to destroy the tumor:
1) Cryotherapy – Uses extreme cold to kill the tumor.
2) Radiofrequency ablation – Uses high-energy radio waves
to "cook" the tumor.
3) Arterial embolization – Uses small particles injected into
an artery or vein through a catheter that leads to the
kidney to block the blood flow to the tumor. This may be
done to shrink the tumor before surgery.

Bladder cancer
Treating kidney cancer
- Cancer found in the urinary bladder
Surgery
- It is more common in people older than 50- year old, and
• Radical nephrectomy – Surgical removal of the kidney, affects men more often than women (4:1).
adrenal gland, surrounding tissue and nearby lymph - According to the WHO data published in 2018 bladder
nodes. It is the most common surgery for kidney cancer cancer deaths in Philippines reached 469 or 0.08% of total
and can now be done through a small incision with a deaths. Philippines ranks #174 in the world in the number
laparoscope. of bladder cancer deaths.
• Simple nephrectomy – Surgical removal of the kidney - Bladder cancer most often begins in the UROTHELIAL
only. CELLS that line the inside of the bladder.
• Partial nephrectomy – Surgical removal of the cancer in - Urothelial cells are also found in the kidneys and ureters
the kidney along with some tissue around it. This - Urothelial cancer can also happen in the kidneys and
procedure is used for patients with smaller tumors (less ureters, but it's much more common in the bladder
than 4 cm) or in those patients in which a radical - Cancers arising from the prostate, colon, and rectum in
nephrectomy might affect the other kidney. MEN and from the lower gynecologic tract in WOMEN may
Radiation Therapy metastasize to the bladder
- Uses high-energy x-rays or other types of radiation to kill Clinical Manifestations
cancer cells or stop their growth. • Hematuria which makes urine to appear bright red or cola
• External Beam Radiation Therapy – Comes from a colored
machine that aims radiation at the cancer. • Frequent urination and urgency
• Internal radiation therapy – Source of radiation is put • Painful urination
inside the body in the form of solid or liquid. • Back pain
Brachytherapy – when solid source is used • Any alteration in voiding or change in the urine is indicative.
Biologic Therapy (Immunotherapy) Risk factors of bladder cancer
- Uses the immune system to fight cancer by boosting,
directing, or restoring the body's natural defenses
- Substances for biologic therapy are made by the body or
in a laboratory.
- Takes some of the patient’s own immune cells, genetically
engineers them in a laboratory to fight prostate cancer
and then injects the cells back into the patient’s body
through the vein.
- Examples of biologic therapy for metastatic kidney cancer
• Interferon alpha
• Interleukin-2.
Targeted Therapy Diagnosing bladder cancer
- Uses drugs or other substances to target specific • Bimanual Examination or Pelvic Examination Under
molecules involved in the growth and spread of cancer Anesthesia – Internal exam in the rectum and/or vagina
cells. are perform to feel for the presence of tumors in the
- Blocking these molecules may kill cancer cells or may bladder.
keep cancer cells from growing or spreading. • Urine Analysis

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 312 LECTURE: WK16 – GENITOURINARY, GYNECOLOGIC & LIVER CANCERS

• Cystoscopy – Uses a cystoscope to look inside b) Flat carcinoma in situ (CIS) – Tumor is only in the
the urethra and bladder to determine the cause of bladder inner layer of bladder cells
problems. c) Invasive papillary or flat cancer. Tumor grows into
- Blood in the urine deeper layers of the bladder
- Painful urination Types of Bladder Cancer
- Frequent urination Urothelial Carcinoma
- Urinary retention - Previously called Transitional Cell Carcinoma (TCC).
- Recurrent bladder infections - It is by far the most common type of bladder cancer. If a
- Pelvic pain bladder cancer is diagnosed it is almost certain to be a
• Biopsy urothelial carcinoma.
- Involves taking a small sample of tissue from the - The urothelial cells also line the inside of the kidney,
bladder to be examined under a microscope ureters and the urethra, so cancers can also be formed in
- Biopsy of the tumor and adjacent mucosa are those areas.
definitive diagnosis for cancer, however, cystoscopy Squamous Cell Carcinoma
is the mainstay of diagnosis - It is associated with chronic irritation of the bladder such
• Urography – imaging of the kidneys, ureters and bladder. as infection or long-term use of a urinary catheter.
- Excretory Urography (Intravenous Pyelogram (IVP)) – - It is rare but common in parts of the world where a certain
Urography that uses imaging and contrast material to parasitic infection (schistosomiasis) is a common cause
evaluate or detect blood in urine, kidney or bladder of bladder infections.
stones, and cancer in the urinary tract.
Adenocarcinoma
- CT and MR urography – Proven effective in detecting
urinary tract cancer and other bladder problems. - A rare cancer that begins in cells that make up mucus-
secreting glands in the bladder.
• Ultrasonography – An ultrasound scan using high-
Treating bladder carcinoma
frequency sound waves to capture live images from the
bladder for medical analysis • Grade of tumor
• Urine cytology: • Stage of tumor growth
- A microscope is used to look for cancer cells in the • Multicentricity of the tumor.
urine. However, it's not reliable enough to make a • Age and physical, mental, and emotional status of patient
good screening test. In general, the main treatment options for bladder cancer are:
- A research study findings said that a combination of • Surgery
cystoscopy and urine cytology can improve bladder • Radiation therapy
tumor detection rates and lower the number of • Immunotherapy (local and systemic)
unnecessary biopsies. • Chemotherapy
How far they have spread into the wall of the bladder: • Targeted therapy
1) Non-Invasive Cancers grow only in the inner layer of the Stages of Bladder Cancer and Treatments
cells (transitional epithelium) and not into the deeper • Stage 0a
layers. - It is a noninvasive papillary carcinoma that grow only
2) Invasive Cancers grow into deeper layers of the bladder on a small section of bladder tissue.
wall and more likely to spread thus harder to treat. 1) Low grade non-invasive – This cancer may recur
3) Superficial or Non-Muscle Invasive include both non- 2) High-grade non-invasive – This cancer is more
invasive and invasive cancers that have not grown into the likely to recur and grow
main muscle layer of the bladder. Treatment STAGE 0a – low grade non-invasive
4) Metastatic Cancer is cancer that spreads from its site of • TURBT (Transurethral Resection of Bladder Tumor).
origin to another part of the body. - A surgical operation to remove early cancer in the
How they grow bladder with the use of a resestoscope.
1) Papillary carcinoma • Intravesical Chemotherapy or Local Immunotherapy
- grows in slender, finger-like projections from the inner - It is often done within 24 hours after the TURBT
surface of the bladder toward the hollow center. procedure.
- It is called non-invasive papillary cancer or papillary - The goal is to kill any cancer cells that may be left in
urothelial neoplasm of low-malignant potential the bladder and reduce the risk of future tumors in
(PUNLMP). developing.
- This type of cancer is slow growing or does not grow
• Intravesical Therapy Procedure
into the deeper bladder layers, thus it has a very good
- A liquid drug is put into the bladder through a soft
prognosis.
catheter via the urethra.
2) Flat Carcinoma
- The drug stays in the bladder for up to 2 hours.
- It does not grow toward the hollow part of the bladder. - This way, the drug can affect the cells lining the inside
a) Non-invasive flat carcinoma
of the bladder without having major effects on other
parts of the body.

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 312 LECTURE: WK16 – GENITOURINARY, GYNECOLOGIC & LIVER CANCERS

Stage 0is – CARCINOMA IN SITU Stage ii – Muscle Invasive cancer

- The cancer cells are only found on or near the surface of - The tumor has spread to the muscle of the bladder wall.
the bladder. - T2a - the tumor has spread to the inner half of the muscle
- It also called non-muscle-invasive bladder cancer, of the bladder wall, which may be called the superficial
superficial bladder cancer, or non-invasive flat carcinoma. muscle.
- This type of bladder cancer often comes back after - T2b: - the tumor has spread to the deep muscle of the
treatment, usually as another non-invasive cancer in the bladder (the outer half of the muscle).
bladder. Stage III – Fatty Tissue Invasive cancer
Stage I – NON-MUSCLE INVASIVE cancer - The tumor has grown into the fatty tissue that surrounds
- The tumor has spread to the connective tissue (lamina the bladder).
propria) that separates the lining of the bladder from the - T3a: the tumor has grown into the fatty tissue (perivesical
muscles. tissue), as seen through a microscope.
Treatment: STAGE 0a-high grade non-invasive - T3b: the tumor has grown into the fatty tissue
STAGE 0is and STAGE I macroscopically.
1) TURBT – Transurethral Resection of Bladder Tumor Treatments FOR STAGE II and STAGE III
2) Radical cystectomy 1) Neoadjuvant Chemotherapy – A systemic chemotherapy
- A surgical removal of the whole bladder to prevent the given before surgery to shrink the tumor in the bladder or
tumor to recur destroy microscopic cancer cells that have spread beyond
- In MEN, it includes removal of the prostate and the bladder.
seminal vesicles. 2) Radical Cystectomy
- In WOMEN, it includes removal of the uterus, ovaries 3) Trimodal Therapy (TMT) (Bladder Preservation
and part of the vagina. Approach) – An approach using chemotherapy with
- Procedures after cystectomy: radiation therapy using Cisplatin alone or a combination
• Ileal conduit – An option for urinary diversion after with Mitomycin-C and Fluorouracil (5-FU).
cystectomy using a short segment of the small 4) TURBT – Used to determine the extent of the cancer,
intestine and places it at an opening on the rather than as a treatment.
surface of the abdomen to create a mouth, or Stage IV – metastatic bladder cancer
stoma. - The tumor has spread to other parts of the body.
• Continent urinary diversion – An internal pouch is - T4a: the tumor has spread to the MAN’s prostate or
made to hold the urine allowing the patient to seminal vesicle, or the WOMAN’s uterus or vagina
control (be continent) when urine comes out. - T4b: the tumor has spread to the pelvic wall or the
• Orthotopic neobladder – A new reservoir is abdominal wall.
constructed using various segments of intestine, - Treatment:
ileum and colon to allow the patient to urinate • Clinical Trials are often the best treatment option for
voluntarily and maintain continence . most patients.
3) Local Intravesical Immunotherapy - Goals for treatment:
- using Bacillus Calmette-Guerin (BCG) to reduce the • To slow the spread of cancer.
risk of recurrence and the development of muscle- • To shrink the tumor.
invasive disease. • To help relieve symptoms through palliative care.
- The first round of BCG treatment is given every week • To extend life for as long as possible and make them
for 6 weeks. feel better
- Then, cystoscopy and sometimes a bladder biopsy is
perform to see if all of the cancer has been eliminated. Ureteral cancer
- If the cancer is gone, the patient usually - Cancer found in the ureters
have maintenance therapy with BCG, - Begins in the cells that line the inside of the ureters
• once every 3 months for the first 6 months - It affects both MEN and WOMEN but it is uncommon
• once every 6 months - It occurs most often in older adults and in people who
• once every 1 to 3 years. have previously been treated for bladder cancer.
• Followed with long-term surveillance. Signs and symptoms of ureteral cancer
4) Pembrolizumab (Keytruda) • Blood in urine
- A humanized antibody used in cancer immunotherapy. • Back pain
- Used when the patient is unresponsive to BCG • Pain when urinating
treatment (“BCG-unresponsive”) or when radical • Losing weight without trying
cystectomy cannot be performed because of other • Fatigue
medical reasons or the patient chooses not to have Risk factors for ureteral cancers
surgery.
• Increasing age (70s-80s)
• Smoking

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 312 LECTURE: WK16 – GENITOURINARY, GYNECOLOGIC & LIVER CANCERS

• Previous bladder or kidney cancer 2) Squamous cell carcinoma – In WOMEN, it develops in

Diagnostic Tests and procedures the urethral cells near the bladder. In MEN, it affects the
• Imaging tests. urethral lining in the penis.
- To help assess the extent of the ureteral cancer. 3) Transitional cell carcinoma – In WOMEN, it develops in
- Intravenous pyelogram (IVP) the area near the urethral opening. In MEN, it passes
- CT urography through the prostate gland
- Detect blood in urine, kidney or bladder stones, and Risk factors for urethral cancer
cancer in the urinary tract. • Over age 60
- Magnetic resonance urogram – Produce detailed • Had previous bladder cancer
pictures of the kidneys, ureters and bladder • Had frequent urinary tract infections
• Urine tests • Had sexually transmitted diseases
- Determine abnormalities in the urine. • Had been exposed to human papillomavirus (HPV)
- Urinalysis - HPV vaccine – Recommended for girls and boys at
- Urine cytology ages 11 or 12. Although it can be given as early as age
• Ureteroscopy 9
- An invasive procedure that uses a URETEROSCOPE to - Gardasil 9 HPV vaccine – Recommended for males
look inside the ureters and kidneys. and females ages 9 to 45.
Stages of ureteral cancer Stages OF Urethral Cancer
• Stage 0, 0a and 0is – The tumor is only in the lining of the • Stage 0a and 0is: Abnormal cells are inside the lining of
ureter. the urethra
• Stage 1 – The tumor has grown through the lining into the • Stage 1: Cancer has spread to the connective tissues
connective tissue layer of the ureter. underneath the lining of the urethra.
• Stage 2 – The tumor has grown through the connective • Stage 2: Cancer spread in the muscle around the urethra.
tissue and into the muscle layer of the ureter. For MEN, the penile tissue that surrounds the urethra may
• Stage 3 – The tumor has grown through the muscle layer be involved
and into the kidney or fat that surrounds the ureter. • Stage 3: Cancer has spread beyond the urethra. In
• Stage 4 – The cancer cells has spread to other organs WOMEN, it spread in the vagina, vaginal lips or nearby
Treating ureteral cancer muscle. In MEN, it spread in the penis or nearby muscle.
1) Surgery • Stage 4: Cancer has spread to other organs of the body
- Ureterectomy – surgical removal of a portion or all (nearby/distant lymph nodes in the pelvis and groin; lungs;
parts of ureter liver; and bone.
- nephroureterectomy – surgical removal of ureter Diagnosing Urethral Cancer
and/or a portion of the bladder. • Medical Exam
2) Chemotherapy to kill cancer cells. - Taking medical history
- Chemotherapy before surgery is to shrink the tumor - Physical exam
and make it easier to remove during surgery. - In WOMEN, a pelvic exam will be performed to
- Chemotherapy after surgery is to kill any cancer cells determine the size and shape of the uterus and
that remain in the area. ovaries.
- MEN and WOMEN may undergo a digital rectal exam
Urethral Cancer to test for lumps or skin thickening that could indicate
- Cancer that occurs in the urethra. potentially cancerous cells.
- urethra is a tube that connects the bladder to the urinary • Laboratory Testing
meatus, allowing urine to exit the body. - Tissue, blood and urine tests will be done to inspect
- In WOMEN, the urethra is about 1.5 inches long and abnormal cells that may indicate presence of cancer.
emerges above the vaginal opening. • Imaging TESTS
- In MEN, the urethra is about 8 inches long, travels through - MRI
the penis and prostate - Intravenous urography (IVU)
Symptoms Associated with Urethral Cancer - Computed Tomography (CT) Scanning.
• Abdominal pain - Urethrography – To determine the extent of cancer
• Increase urinary frequency or urgency cells in the urethra
• Difficulty urinating • Cystoscopy – Uses cystoscope to look inside the urethra
• Pain during urination and the bladder
• Blood in urine Treating Urethral Cancer
• Blood in semen • Surgery
Types of Urethral Cancer a) Electro-resection with fulguration
1) Adenocarcinoma – occurs in the glands around the - Uses a tool that transmits electric current to burn
urethra away cancerous cells without surgical incision.

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- Use for superficial cancers that have not yet Orchiopexy. The testicle is moved to the scrotum through
spread to surrounding tissues. a surgery
b) Laser surgery • Abnormal development of the testicle (Klinefelter
- Uses a laser beam to remove or destroy Syndrome) – The syndrome may adversely affect
cancerous tissue. testicular growth, resulting in smaller than normal
- Most often used on superficial tumors that have testicles that lead to lower production of testosterone or
not spread significantly. little or no sperm production
c) Radical penectomy Preventing testicular cancer
- Surgical removal of the entire penis • There's no way to prevent testicular cancer.
- Performed when the cancer has spread beyond • Some doctors recommend regular testicle self-
the urethra and deep into a man's erectile tissues. examinations to identify testicular cancer at its earliest
- Reconstructive procedures are possible and a stage.
new opening for the urethra can be created to Stages of testicular cancer
allow proper urine flow. • Stage I – Cancer is found only in the testicle.
d) Partial penectomy • Stage II – Cancer has spread to nearby lymph nodes in the
- Surgical removal of the head of the penis. abdomen or pelvis.
Performed when the cancer affects only a portion • Stage III – Cancer has spread to other organs of the body
of the male urethra and enough tissue can be (nearby/distant lymph nodes, lungs, brain, liver, or others)
spared so that a man can still urinate while parts
standing. Diagnosing testicular cancer
e) Cystoprostatectomy 1) Ultrasound – Use to determine the nature of any
- A combination of cystectomy and prostatectomy testicular lumps, if it is solid or fluid-filled.
to remove the urethral cancers that extend to the 2) Blood tests – Use to determine the levels of tumor
bladder and prostate gland. markers in the blood.
f) Cystourethrectomy 3) Computerized tomography (CT) scan/ Magnetic
- A combination of cystectomy and urethrectomy resonance imaging (MRI) – Use to determine the extent
for invasive cancers that affect the urethra and metastasis.
the bladder Treating testicular cancer
g) Anterior exenteration • Surgery
- A surgery that removes the organs from the a) Radical inguinal orchiectomy
urinary and gynecologic systems. - Surgical removal of the testicle
• Radiation Therapy - Primary treatment for nearly all stages and types
• Chemotherapy of testicular cancers
- The testicle can be replaced by a prosthetic,
Testicular Cancer saline-filled testicle
- Cancer that occur in the testicles (testes). b) Retroperitoneal lymph node dissection
- Rare but is the most common cancer in American males - Surgical removal of the nearby lymph nodes.
between the ages of 15 and 35. • Radiation Therapy
- It usually affects only one testicle • Chemotherapy
- It is highly treatable, even when cancer has spread beyond
the testicle. Prostate cancer
Signs and Symptoms - Cancers that develop from the prostate gland cells
• Lump or enlargement in either testicle - It is the most common types of cancer in the urinary tract
• Feeling of heaviness in the scrotum among men.
• Sudden collection of fluid in the scrotum - Almost all prostate cancers are adenocarcinoma.
• Pain or discomfort in a testicle or the scrotum - According to the WHO data published in 2018 prostate
• Dull ache in the abdomen or groin cancer deaths in Philippines reached 3,319 or 0.54% of
• Enlargement or tenderness of the breasts total deaths. Philippines ranks #104 in the world in the
• Back pain total number of deaths of prostate cancer.
Risk factors Symptoms of Prostate cancer
• Family History • Prostate cancer is often called the “SILENT KILLER”
• Age – It affects teens and younger men between ages 15 because it doesn’t always have symptoms.
and 35. However, it can occur at any age. • Painful or burning sensation during urination or
• Race – It is more common in white men than in black men. ejaculation.
• Undescended testicle (cryptorchidism) – The testes is • Frequent urination, particularly at night.
formed in the abdominal area during fetal development • Difficulty stopping or starting urination.
and normally descend into the scrotum before birth. • Sudden erectile dysfunction.
• Blood in urine or semen
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Risk factors - Luteinizing Hormone-Releasing Hormone (LHRH)

• Family History agonists and antagonists
• Age - most common after age 50 - Gonadotropin-Releasing Hormone (GNRH) agonists
• Race – Common in black men than in white men. and antagonists
Preventing prostate cancer - ORCHIECTOMY – Removing the testicles reduces
1) Maintain a healthy weight. testosterone levels in the body quickly and
2) Exercise most days of the week. significantly.
3) Choose a healthy diet full of fruits and vegetables. • Chemotherapy
4) Choose healthy foods over supplements. - Uses drugs to kill rapidly growing cells
5) See a doctor if risk of prostate cancer is increased. • Immunotherapy
Diagnosing prostate cancer - Monoclonal antibodies – antibodies can be produced
2) Transrectal ultrasound – use to create a picture of the that target and destroy cancer cells
prostate gland to determine abnormalities. - Cancer vaccines – vaccines given to prevent cancer
3) Prostate-specific antigen (PSA) test. (HPV & HBV)
- PSA is a substance that's naturally produced by the o Sipuleucel-t (Provenge) – cancer vaccine
prostate gland. - Non-specific Immunotherapies
- Small amount of PSA – normal o Cytokines – stimulate the immune system
- High than usual amount – may indicate prostate o Pembrolizumab (Keytruda) - Immunomodulators
infection, inflammation, enlargement, or CANCER.
4) Digital rectal exam (DRE) Penile Cancer
5) Transrectal biopsy of the prostate - Cancer of the penis
6) Imaging Tests - Rare form of cancer, which targets the skin around the
- Use to create a more detailed picture of the prostate penis before getting its way further inside.
gland. - Affects men over the age of 60, but there are cases where
- Magnetic resonance imaging (MRI) younger adults have also been diagnosed.
- Ultrasound Symptoms of Penile Cancer
- Computerized tomography (CT) scan • Changes in the skin of the penis are the most common
Staging Prostate Cancer symptom of penile cancer. They can show up on the
7) Stage I: foreskin of uncircumcised men, on the penis tip (the
- Cancer is usually slow growing. glans), or on the shaft.
- Involves one-half or less of 1 side of the prostate. • Changes in skin color and thickness
- Cancer cells are well differentiated and PSA levels are • Rash or small crusty bumps that looks like an unhealed
low. scab.
- The tumor cannot be felt during the DRE or seen • Growths that looks bluish-brown
during imaging • Lump on the penis or under the skin of the groin
• Stage II: • Bad-smelling discharge underneath the foreskin
- The tumor is confined to the prostate. • Sore on the penis which may bleed
- It can be felt during DRE because of the increased • Swelling at the end of the penis
in size. Types of Penile Cancer
• Stage III: 1) Squamous cell or epidermoid carcinoma.
- The tumor has grown outside the prostate. It may have - This makes up 95% of penile cancer cases. It usually
spread to the seminal vesicles. starts on or under the foreskin but can also appear on
• Stage IV: other parts of the penis.
- The tumor has spread to other organ of the body 2) Sarcoma.
(rectum, bladder, urethral sphincter and/or pelvic - This cancer form in tissues like blood vessels, muscle,
wall). and fat.
Treating prostate cancer 3) Melanoma.
• Surgery - This is cancers start in the cells that gives color to the
- Radiation therapy skin.
- radical prostatectomy 4) Basal cell carcinoma.
- external beam radiation - This cancer start deep in the skin. They grow slowly
- Brachytherapy and aren’t likely to spread to other areas of the body.
• Hormone therapy Penile Cancer Risk Factors
- Use to stop the body from producing the male • Are over age 60
hormone testosterone. • Is moking
- Prostate cancer cells rely on testosterone to help • Aren’t circumcised
them grow. Cutting off the supply of testosterone may • Have HPV infections
cause cancer cells to die or to grow more slowly. • Poor hygiene
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• Have a weakened immune system because of HIV/AIDS • RADIATION and/or CHEMOTHERAPY to get rid of the
• Had psoriasis treatment with the drug Psoralen and cancer cells from the body
Ultraviolet (UV) light
• Have PHIMOSIS, which makes the foreskin of the penis Gynecologic cancers
tight and cannot be stretched to be pulled back over the - Cancers found in the female reproductive system: Uterus,
glans Vagina, Ovaries/ Vulva, Fallopian tube, Cervix
Penile Cancer Prevention
There’s no one way to prevent penile cancer, but some Uterine cancer
things can lower the risk: - Also called Endometrial Cancer.
• Have a circumcision. When you don’t have a foreskin, it’s - Begins in the lining (endometrium) of the uterus
easier to keep the area clean. - Endometrial cancer – Most common type of uterine
• Promote hygiene. If you have a foreskin, make sure to cancer, accounting for more than 90 percent of cases.
carefully clean underneath. - Uterine sarcoma – Rarer type of uterine cancer, and forms
• Avoid using cigarette and tobacco. in the muscles or other tissues of the uterus.
• Use safe sex practices to avoid HPV and HIV infections Symptoms of Uterine Cancer
Stages of Penile Cancer • Heavy periods
• Stage 0 – carcinoma in situ – cancer cells are only on the • Pain and/or a mass in the pelvic area
surface of the skin. • Abnormal vaginal bleeding
• Stage I – Cancer cells have grown into the tissue just • Change in bowel movement
below the surface of the skin but not into blood vessels or • Difficult or painful urination
lymph nodes. • Pain during intercourse
• Stage II – Cancer cells have spread to the deeper tissues • Unusual vaginal discharge
of the penis, but not to lymph nodes or distant organs • Unintentional weight loss
• Stage III – Cancer cells have grown into the urethra and/or Factors that increase the risk of uterine cancer
the deeper tissues of the penis. It may have spread to one 1) Changes in the balance of female hormones in the body.
or more lymph nodes but not to distant organs. 2) More years of menstruation. “The more periods of
• Stage IV – Cancer cells have spread to nearby structures, menstruation the more exposure of the endometrium to
to the lymph nodes deep in the groin, and to other parts of estrogen”.
the body 3) Never having been pregnant.
Penile Cancer Diagnosis 4) Older age. Occurs most often after menopause.
• History taking 5) Obesity
• Physical exam 6) Hormone therapy for breast cancer. Tamoxifen - hormone
• Biopsy therapy drug for breast cancer
• Imaging tests 7) Inherited colon cancer syndrome. Lynch syndrome
(hereditary nonpolyposis colorectal cancer (HNPCC)
• Ultrasounds,
Stages of uterine cancer
• CT scan
• Stage I – Cancerous cells are found only in the uterus.
• Magnetic resonance imaging (MRI)
Standard approaches for treating penile cancer • Stage II – Cancer has spread into connective tissue of the
cervix but has not spread outside the uterus.
• Surgery, Radiation, and Chemotherapy are the STANDARD
APPROACHES for treating penile cancer. • Stage III – Cancer has spread beyond the uterus and
cervix but has not spread beyond the pelvis.
• The main goal of all penile cancer treatments is to
eliminate disease while maintaining as much as possible • Stage IV – Cancer has spread beyond the pelvis.
Diagnostic Tests
the appearance and function of the penis.
Penile Cancer Treatment • Physical examination
• Topical cream for penile cancer at early stages • Pelvic examination – Assess the uterus, vagina, ovaries,
- 5-fluorouracil (5-FU) cream given twice a day. and rectum to check for any unusual findings.
• Surgery • Pap Smear Test – Check presence of cervical cancer.
• Circumcision – Surgical removal of the foreskin of the • Endometrial biopsy – Provide a definite diagnosis of
penis to patient if cancer is only found in the foreskin. uterine cancer.
• Cryotherapy – Uses an extremely cold liquid or a device to • Transvaginal ultrasound – Uses sound waves to create a
freeze and destroy cancerous tissue picture of the uterus.
• Laser therapy – Uses to cut and destroy areas that contain • Hysteroscopy – A visualization of the lining of the uterus
the cancer cells with the use of HYSTEROSCOPE (thin, lighted flexible
tube) through the cervix into the vagina and uterus.
• Penectomy – surgical removal of some or all parts of the
penis • Dilation and curettage (D&C) – A surgical procedure
involving dilatation of the cervix and curettage of the
• Mohs surgery – is the surgical removal of the affected skin
uterus to remove a cyst/tumor and is performed after a
one layer at a time until they reach healthy tissue
miscarriage.
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• Computed tomography (CT) scan. Ovarian cancer

• Magnetic resonance imaging (MRI) – Provide a pictures - A type of cancer that begins in the ovaries.
of the inside of the uterus using x-rays taken from different - Ovaries are two female reproductive glands that produce
angles to measure the tumor’s size. Sometimes, a ova, or eggs and produces the estrogen and progesterone.
contrast medium is given before the scan to provide better - Ovarian cancers are usually asymptomatic at the outset
detail on the image. and many case are detected late.
Standard treatment for uterine cancer - Considered a “Silent Killer”
1) Surgery Symptoms of Ovarian cancer
• Total hysterectomy – Surgical removal the uterus, • Abdominal bloating
including the cervix • Stomach upset
• Vaginal hysterectomy – Surgical removal of the uterus • Indigestion
and cervix through the vagina • Constipation
• Total abdominal hysterectomy – Surgical removal of • Abdominal pain
the uterus and cervix through a large incision in the • Pelvic pain
abdomen • Feeling full quickly
• Laparoscopic hysterectomy – Surgical removal of the • Urinary symptoms, such as urgency or frequency
uterus and cervix through a small incision in the • Fatigue
abdomen using a laparoscope • Back pain
• Bilateral salpingooophorectomy – Surgical removal of • Pain with intercourse
the ovaries and fallopian tubes. • Menstrual irregularities
• Radical hysterectomy – Surgical removal of the uterus, • Swelling in the pelvis or abdomen
cervix, and part of the vagina. May include the ovaries, • Vaginal discharge, which may be clear, white, or tinged
fallopian tubes, or nearby lymph nodes with blood
• Lymph node dissection (lymphadenectomy) – Surgical Epidemiology
procedure in which the lymph nodes are removed • Below 20 yo – 1%
from the pelvic area and a sample of tissue is checked • 20 – 34 yo – 4 %
under a microscope for signs of cancer.
• 35 – 44 yo – 7%
2) Radiation therapy
• 45 – 54 yo – 16 %
- It uses high-energy x-rays or other types of radiation to
• 55 – 64 yo – 24%
kill cancer cells or to keep them from growing.
• 65 – 74 yo – 21%
- External radiation therapy - uses a machine outside
the body to send radiation toward the cancer. • 75 – 84 yo – 17%
- Internal radiation therapy - uses a radioactive Risk factors
substance sealed in needles, seeds, wires, or • Age
catheters that are placed directly into or near the - Ovarian cancer increases with age however women of
cancer site. all ages have a risk of developing ovarian cancer
3) Chemotherapy - Women between age 55 - 65 are more likely to
- Uses drugs to stop the growth of cancer cells, either develop ovarian cancer.
by killing the cells or by stopping the cells from • Weight.
dividing. - Recent studies show that women who were obese in
- Systemic chemotherapy – When chemotherapy is early adulthood, but not those who gain weight later in
taken by mouth or injected into a vein or muscle, the life, may have an increased risk of developing ovarian
drugs enter the bloodstream and can reach cancer cancer.
cells throughout the body. • Family history.
- Regional chemotherapy – When chemotherapy is • Reproductive history
placed directly into the uterus - Started their menstrual periods much earlier than the
4) Hormone therapy average age of about 12
- Uses drugs to remove hormones or blocks their action - Have never given birth to a child (nulliparous)
and stops cancer cells from growing. - Have unexplained infertility
5) Targeted therapy - Have not taken birth control pills
- Uses drugs or other substances to identify and attack - Entered menopause much later than the average age
specific cancer cells without harming normal cells. of 51.
• Monoclonal antibodies, • Endometriosis.
• M-TOR inhibitors, - When the inside lining of a woman’s uterus grows
• Signal transduction inhibitors outside of the uterine cavity
• Hormone replacement therapy.
- Women who have this therapy after menopause may
have a higher risk of ovarian/fallopian tube cancer.

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Preventing ovarian cancer • Cytoreductive/ debulking surgery – Surgical removal

• Taking birth control pills – Women who took oral tissue from nearby organs, such as the spleen, liver, and
contraceptives for 3 or more years are 30% to 50% less part of the small bowel or colon used to cancers that
likely to develop ovarian/fallopian tube cancer. metastasized
Intrauterine devices (IUD) have also been linked to a
decreased risk in ovarian cancer. Cervical cancer
• Breastfeeding – The longer a woman breastfeeds, the - Cancer that occur in the cervix.
lower her risk of developing ovarian/fallopian tube cancer. - Cervix – a part of the uterus located at the end of the
• Pregnancy – The more full-term pregnancies a woman vagina that serves as the opening into the uterus
has had, the lower her risk of ovarian/fallopian tube - Most common gynecologic malignancy
cancer. - In the Philippines, cervical cancer is the 2nd leading
• Surgical procedures – Women who have had a cancer site among women. An estimated 7,277 new cases
hysterectomy, tubal ligation or bilateral salpingo- and 3,807 deaths and is expected to increase every year.
oophorectomy may have a lower risk of developing - The most common type of cervical cancer is SQUAMOUS
ovarian/fallopian tube cancer. CELL CARCINOMA (80%)
Diagnosing Ovarian Cancer - Various strains of the human papillomavirus (HPV), play a
• There are often delay in diagnosing ovarian cancer role in causing most cervical cancer.
because there is no early detection test AND symptoms Clinical Manifestations
are often confused with symptoms of other less severe • Early-stage of cervical cancer generally produces no signs
illnesses, particularly gastrointestinal complaints. or symptoms.
• Ovarian cancer has the lowest survival rate of all female • Signs and symptoms of more-advanced cervical cancer
cancers. include:
• Most women are diagnosed when the cancer has already - Vaginal bleeding after intercourse, between periods or
spread, making it more difficult to treat. after menopause
Stages of Ovarian Cancer - Watery, bloody vaginal discharge that may be heavy
• Stage I: The cancer is only in the ovaries or fallopian tubes. and have a foul odor
• Stage II: The cancer involves 1 or both of the ovaries or - Pelvic pain or pain during intercourse
fallopian tubes and has spread inside the pelvis
• Stage III: The cancer spread to the abdominal cavity and
lymph nodes
• Stage IV: The cancer has spread to organs outside of the
abdominal area.

Reducing the risk of cervical cancer

• Undergo screening tests
• Receive HPV vaccine
Treating Ovarian Cancer • Avoid multiple sex partners and early sexual activity
- Often times, doctors will choose 2 or 3 treatment options • Avoid smoking
depending upon the type, stage and grade of the ovarian Diagnosing cervical cancer
or fallopian tube cancer • Pap smear test
- Radiation therapy, hormone therapy, surgery, • HPV testing – Collecting cells from the cervix to check for
chemotherapy, targeted therapy abnormalities or presence of cancer.
Surgery • Cervical biopsy
• Salpingo-oophorectomy – Surgical removal of the ovaries - Punch biopsy - uses a circular blade, like a paper hole
and fallopian tubes. puncher, to remove a tissue sample.
• Hysterectomy – Surgical removal of the uterus - Cone biopsy - uses a laser or scalpel to remove a
• Lymphadenectomy/lymph node dissection - surgical large cone-shaped piece of tissue from the cervix.
removal of the lymph nodes in the pelvis and paraortic - Endocervical curettage (ECC) - uses a narrow
areas. instrument (curette) to scrape the lining of the endo-
• Omentectomy – surgical removal of the thin tissue that cervical canal
covers the stomach and intestines.
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• Punch biopsy • Stage III – The cancer has spread to the lower part of the
vagina or the walls of the pelvis. The cancer may blocked
the ureters
• Stage IV – The cancer has grown into the bladder or
rectum or to far away organs like the lungs, liver or bones.
Treating cervical cancer
• Surgery for cervical pre-cancers
• Cryosurgery – Destroys the abnormal cells by freezing
them with a very cold metal probe placed directly on the
cervix.
• Laser ablation – Directs a focused laser beam through
the vagina to burn off abnormal cells.
• Cone biopsy Surgery for invasive cervical cancer
• Hysterectomy
- partial hysterectomy – Surgical removal of the uterus,
leaving the cervix
- total hysterectomy – Surgical removal of the uterus
and the cervix.
- Radical Hysterectomy – Surgical removal of the uterus,
cervix, and the upper part of the vagina about 1 inch
(2-3cm) next to the cervix.
• Abdominal hysterectomy – Surgical removal of the
uterus through abdominal incision
• Vaginal hysterectomy – Surgical removal of the uterus
• Endocervical curettage through the vagina.
• Laparoscopic hysterectomy - Surgical removal of the
uterus using laparoscope to visualize inside the abdomen
and pelvis. (laparoscopy).
• Robotic-assisted surgery - Uses special tools attached
to robotic arms that are controlled by the doctor to help
perform precise surgery.
• Trachelectomy - Surgical removal of the cervix and the
upper part of the vagina but not the body of the uterus.

Vaginal cancer
- Occurs in the cells that line the surface of the vagina (birth
canal).
- Rare type of cancer
• Loop electrosurgical excision procedure (LEEP) - Vaginal cancer accounts only for about 1 % of cases
- Uses a wire loop heated by electric current to remove (National Cancer Institute)
cells and tissue in the cervix or vagina Symptoms of vaginal cancer
- It is used as part of the diagnosis and treatment for • In some cases, vaginal cancer has no symptoms:
abnormal or cancerous conditions of the cervix. • Vaginal bleeding (after menopause, during or after sex,
• Colposcopy - used to closely examine the cervix, and between menstruation)
vagina and vulva for signs of disease with the use of • Watery vaginal discharge
colposcope. • Painful or frequent urination
- Colposcopy is recommended if the result of the pap • Pelvic pain, especially during sex
test is abnormal. • Unusual itchiness of the vagina
- Tissue sample maybe collected for biopsy if there is • Fistulas, in later-stage of cancer
abnormalities of cells during the colposcopy Types of vaginal cancer
procedure 1) Squamous cell carcinoma – Starts in the vaginal lining
Stages of cervical cancer and develops slowly. Accounts approximately 75% of
• Stage I – The cancer cells have grown from the surface of vaginal cancers, according to the University of Texas.
the cervix into deeper tissues of the cervix. 2) Sarcoma – Starts in the vaginal walls and accounts only
• Stage II – The cancer has grown beyond the cervix and 4% of vaginal cancers.
uterus but has not spread into the tissues next to the 3) Adenocarcinoma – Starts in the vaginal gland cells. It’s
cervix most common in women over 50. It’s the second-most
common type of vaginal cancer.
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4) Melanoma – Starts in the cells that give skin color. • Hysterectomy – Sometimes to remove a vaginal cancer,
Risk factors the uterus and cervix must be removed, as well as all or
• Having had a previous hysterectomy, whether it was for a part of the vagina.
benign or malignant mass Treating vaginal Cancer
• Smoking, which doubles the risk of vaginal cancer • Radiation Therapy
• Being older than 60 • Chemotherapy
• Having HIV/AIDS or other sexual transmitted diseases
• Being exposed early to HPV through sexual activity Vulvar cancer
• Being exposed to Diethylstilbestrol (DES) – use to prevent - Cancer of the vulva, or a female external genitals.
miscarriage, premature labor, and related complications - Commonly forms as a lump or sore on the vulva that often
of pregnancy causes itchiness.
Preventing vaginal cancer - Occur at any age, but most commonly diagnosed in older
• Get HPV vaccine adults.
• Use condoms Symptoms of vulvar cancer
• Avoid multiple sex partner • Itching, bleeding or burning sensation on the vulva that is
• Avoid early sexual activity not relieved.
• Quit smoking • Occurrence of skin changes such as rashes or warts on
• Drink only in moderation the vulva.
• Get regular pelvic exams and pap smears • Pelvic pain, particularly during sex or urination.
Diagnostic tests • Changes in skin color of the vulva (abnormally red or
• Medical history – To find out more about the patient’s white).
symptoms and possible risk factors. • Lumps, ulcers or sores that occur on the vulva which do
• Pelvic exam – To look for possible causes of the not subside
symptoms Types of Vulvar Cancer
• Pap smear – To check for any abnormal cells in the • Squamous cell carcinoma
vaginal area. - Starts in the skin cells of the vulva.
- Most common type.
• Colposcopy – To examine the vaginal walls and cervix for
- Maybe linked to human papillomavirus (HPV),
abnormal cells and its origin.
especially in younger women
• Biopsy – To have a definite diagnosis
• Adenocarcinoma
• Imaging (MRI, CT Scan, or PET Scan) – To determine the
- BARTHOLIN GLAND CANCER if it starts in the cells of
extent cancer has spread to other parts of the body.
the Bartholin’s glands just inside the opening of the
Stages of vaginal cancer
vagina .
• Vaginal intraepithelial neoplasia (VAIN) – A pre-cancer
- PAGET’S DISEASE if it forms in the sweat glands or top
stage where there are abnormal cells in the vaginal lining
layer of vulvar skin
but not growing or spreading. VAIN isn’t cancer.
• Melanoma
• Stage 1 – Cancer is only in the vaginal wall.
- Starts in the cells that give skin color of the vulva.
• Stage 2 – Cancer has spread to the tissue next to the
• Sarcoma
vagina but hasn’t yet spread to the pelvic wall.
- Starts in bone, muscle, or connective tissue cells. it
• Stage 3 – Cancer has spread further into the pelvis and can happen at any age, including in childhood.
pelvic wall. It might’ve also spread to nearby lymph nodes.
• Basal cell carcinoma
• Stage 4 – Cancer has spread further throughout the body
- Rarely occur in vulva but most common in skin
to organs, such as the lungs, liver, or more distant lymph
cancer. It usually appears on skin that’s exposed to
nodes
the sun
Treating vaginal cancer
Risk Factors of Vulvar Cancer
• Surgery
• Age – More than half of cases are in women over age 70.
• Vaginectomy
• HPV infections
- Partial Vaginectomy – Surgical removal of part of the
• Smoking
vagina.
• Immune system deficiency
- Total Vaginectomy – surgical removal of the entire
vagina • A precancerous condition
- Radical Vaginectomy – Surgical removal of the vagina • Poor hygiene
along with the supporting tissues around it. • Obesity
• Local Excision (Wide Excision) – Cancer and an edge of • Hypertension
normal, healthy skin (usually at least ½ inch) around it and • Diabetes
a thin layer of fat below it are excised (cut out) • Lichen Sclerosus – A condition that makes vulvar skin thin
and itchy

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Preventing Vulvar Cancer Nursing Process

• Avoid HPV infection. Assessment
• Limit number of sex partners. • Collect patient’s pertinent data
• Practice safe sex • Physical and emotional status
• Use condoms • Obtain past and present health history.
• Get HPV vaccine • Obtain health practices and life style
• Don’t smoke. • Identify psychosocial supports and responses.
• Get regular checkups • Knowledge of the disease and its treatment (patient &
Diagnosing Vulvar Cancer family)
• Medical history – To determine the overall health, • Awareness of the results and general implications of all
including habits and illnesses of the patient. relevant laboratory, pathology, and imaging studies
• Pelvic exam – To check any signs of cancer in the uterus, • Be aware of the side effects of cancer and cancer
ovaries, bladder, vagina, and rectum. treatments
• Colposcopy (Vulvoscopy) – Use of colposcope to Side effects of treatment
determine any problem areas in the vagina, vulva, and • Anemia
cervix. • Appetite loss
• Biopsy – To have a definite diagnosis • Bleeding and bruising (thrombocytopenia)
• Imaging tests - (MRI, CT scan, or PET scan) to provide a • Constipation
detailed pictures if the cancer has spread to other parts of • Delirium
the body. • Depression
Stages of vulvar cancer • Diarrhea
• Stage I – The tumor is small and hasn’t spread past the • Edema (swelling)
vulva and perineum. • Fatigue
• Stage II – The cancer has moved into nearby tissues but • Fertility issues in boys and men
not the lymph nodes. • Fertility issues in girls and women
• Stage III – It spread to nearby tissues and to the lymph • Hair loss (alopecia)
nodes in the groin. • Infection and neutropenia
• Stage IV – It spread to the upper part of the vagina, • Lymphedema
urethra, or anus, or a part of the body that’s farther away. • Memory or concentration problems
Treating Vulvar Cancer
• Mouth and throat problems
• Surgery
• Nausea and vomiting
a) Laser Surgery – Uses laser to remove affected tissue
• Nerve problems (peripheral neuropathy)
such as the lymph nodes, parts of the vulva, or other
• Immunotherapy and organ-related inflammation
organs. It is not used for invasive tumors.
• Pain
b) Excision – Wide local excision - small portion of the
cancerous tissue. RADICAL LOCAL EXCISION - • Sexual health issues in men
removing a major portion of benign tissues and • Sexual health issues in women
possibly lymph nodes • Sleep problems and insomnia
c) Ultrasonic surgical aspiration – Tumor is broken into • Urinary and bladder problems
small pieces using fine vibrations • NOTE: Side effects vary from person to person, even
d) Vulvectomy – surgical removal of the vulva. among people receiving the same type of cancer
- Skinning vulvectomy - Surgical removal of the top treatment.
layer of skin off from the vulva. Nursing Diagnoses
- Simple vulvectomy - Surgical removal of the entire • Anxiety related to the diagnosis of cancer, fear of pain,
vulva and tissue just under the skin. perceived loss of masculinity/ femininity, or childbearing
- Partial or modified radical vulvectomy - Surgical potential, etc.
removal of most of the vulva and possibly nearby • Disturbed body image related to altered fertility, fears
lymph nodes. about sexuality, and relationships with partner and family
- Radical vulvectomy - Surgical removal of the • Pain related to surgery and other adjuvant therapy
entire vulva and nearby lymph nodes. • Deficient knowledge of perioperative aspects of surgery
- Pelvic exenteration - Surgical removal of the vulva and self-care
and lymph nodes and nearby organs: lower colon, Planning and Goals
rectum, bladder, uterus, cervix, or vagina. • Relief of anxiety,
• Radiation Therapy • Acceptance of loss of body parts
• Chemotherapy • Absence of pain or discomfort
• Increased knowledge of self-care requirements
• Absence of complications.

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• Relieving Anxiety • Avoid lifting, straining, sexual intercourse, or driving until

- Determine how this experience affects the patient advised by physician.
- Allow the patient to verbalize feelings • Report abnormal discharges, foul odor, excessive
- Identify strengths and reinforce coping. bleeding, leg redness or pain, or elevated temperature to
- Explain all pre- and postoperative and recovery period health care professional promptly.
preparations and procedures. Psychological interventions
• Improving Body Image • Basic principles in providing psychosocial support to
- Assess how patient feels about undergoing cancer cancer patients is caring for patients’ basic needs
treatments related to the nature of diagnosis, • Adequate communication
significant others, religious beliefs, and prognosis. • Informational needs
- Acknowledge patient’s concerns about ability to have • Basic emotional support
children, loss of femininity, and impact on sexual • Screening of needs
relations. • Symptom management.
- Educate patient about sexual relations: sexual • Nonpharmacologic include:
satisfaction, sexual feeling, or comfort related to
• Cognitive behavioral therapy,
condition.
• Supportive psychotherapy,
- Explain that depression and heightened emotional
• Family therapy.
sensitivity are expected because of upset hormonal
balances. • These interventions are proven to be connected to
increased well-being, improved adjustment in coping, and
- Exhibit interest, concern, and willingness to listen to
reduction in distress
fears.
Cognitive Behavioral Therapy (CBT)
• Relieving Pain
- Assess the location, quality, character and intensity of • most widely used form of therapy for cancer patients and
has been proved effective in the treatment of depression,
the patient’s pain and administer medications as
anxiety, pain, fatigue, and insomnia, all of which are
prescribed.
common in cancer patients.
- Encourage patient to resume intake of food and fluids
gradually when peristalsis is auscultated (1 to 2 days). • Some commonly used CBT interventions includes:
Encourage early ambulation. - Relaxation training
- Provide diversional activities - Distraction
- Apply heat to abdomen or insert a rectal tube if - Realistic goal setting.
prescribed for abdominal distention. Evaluation: Expected Patient Outcomes
Monitoring and Managing Complications • Experiences decreased anxiety
• Hemorrhage: count perineal pads used and assess extent • Has improved body image
of saturation; monitor vital signs; check dressings for • Effective coping
drainage; give guidelines for restricting activity to promote • Experiences minimal pain and discomfort
healing and prevent bleeding. • Verbalizes knowledge and understanding of self-care
• Deep vein thrombosis: apply elastic compression • Experiences no complications
stockings; encourage and assist in changing positions
frequently; assist with early ambulation and leg exercises; Cancer of the Colon and Rectum (Colorectal Cancer)
monitor leg pain; instruct patient to avoid prolonged - Colorectal cancer is predominantly (95%)
pressure at the knees (sitting) and immobility. adenocarcinoma, with colon cancer affecting more than
• Bladder dysfunction: monitor urinary output and assess twice as many people as rectal cancer.
for abdominal distention after catheter is removed; initiate - It may start as a benign polyp but may become malignant,
measures to encourage voiding. invade and destroy normal tissues, and extend into
• Infection surrounding structures.
Promoting Home- and Community-Based Care: - Cancer cells may migrate away from the primary tumor
Teaching Patients Self-Care and spread to other parts of the body (most often to the
• Tailor information according to patient’s needs: no liver, peritoneum, and lungs).
menstrual cycles, need for hormones. - Incidence increases with age (the incidence is highest in
• Instruct patient to check surgical incision daily and report people older than 85 years) and is higher in people with a
redness, purulent drainage, or discharge. family history of colon cancer and those with
inflammatory bowel disease (IBD) or polyps. If the disease
• Stress the importance of adequate oral intake and
is detected and treated at an early stage before the
maintaining bowel and urinary tract function.
disease spreads, the 5-year survival rate is 90%; however,
• Instruct patient to resume activities gradually; no sitting
only 39% of colorectal cancers are detected at an early
for long periods; postoperative fatigue should gradually
stage.
decrease.
- Survival rates after late diagnosis are very low.
• Teach that showers are preferable to tub baths to reduce
risk for infection and injury getting in and out of tub.

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Clinical Manifestations • Assess dietary patterns, including fat and fiber intake,
• Changes in bowel habits (most common presenting amounts of alcohol consumed, and history of smoking;
symptom), passage of blood in or on the stools (second describe and document a history of weight loss and
most common symptom). feelings of weakness and fatigue.
• Unexplained anemia, anorexia, weight loss, and fatigue. • Auscultate abdomen for bowel sounds; palpate for areas
• Right-sided lesions are possibly accompanied by dull of tenderness, distention, and solid masses; inspect stool
abdominal pain and melena (black tarry stools). for blood.
• Left-sided lesions are associated with obstruction Nursing Diagnoses
(abdominal pain and cramping, narrowing stools, • Imbalanced nutrition: less than body requirements related
constipation, and distention) and bright red blood in stool. to nausea and anorexia
• Rectal lesions are associated with tenesmus (ineffective • Risk for deficient fluid volume related to vomiting and
painful straining at stool), rectal pain, feeling of dehydration
incomplete evacuation after a bowel movement, • Anxiety related to impending surgery and diagnosis of
alternating constipation and diarrhea, and bloody stool. cancer
Signs of complications: • Risk for ineffective therapeutic regimen management
• Partial or complete bowel obstruction, tumor extension related to deficient knowledge concerning the diagnosis,
and ulceration into the surrounding blood vessels surgical procedure, and self-care after discharge
(perforation, abscess formation, peritonitis, sepsis, or • Impaired skin integrity related to surgical incisions, stoma,
shock). and fecal contamination of peristomal skin
• In many instances, symptoms do not develop until • Disturbed body image related to colostomy
colorectal cancer is at an advanced stage. • Ineffective sexuality patterns related to ostomy and self-
Assessment and Diagnostic Methods concept
• Abdominal and rectal examination; fecal occult blood Planning and Goals
testing; barium enema; proctosigmoidoscopy; and • The major goals may include attainment of optimal level of
colonoscopy, biopsy, or cytology smears. nutrition; maintenance of fluid and electrolyte balance;
• CEA studies should return to normal within 48 hours of reduction of anxiety; learning about the diagnosis, surgical
tumor excision (reliable in predicting prognosis and procedure, and self-care after discharge; maintenance of
recurrence). optimal tis- sue healing; protection of peristomal skin;
Medical Management learning how to irrigate the colostomy (sigmoid
• Treatment of cancer depends on the stage of disease and colostomies) and change the appliance; expressing
related complications. feelings and concerns about the colostomy and the
• Obstruction is treated with IV fluids and nasogastric impact on self; and avoidance of complications.
suction and with blood therapy if bleeding is significant. Nursing Interventions: Teaching Patients Self-Care
• Supportive therapy and adjuvant therapy (eg, • Assess patient’s need and desire for information, and
chemotherapy, radiation therapy, immunotherapy) are provide information to patient and family
included. • Provide patients being discharged with specific
Surgical Management information relevant to their needs.
• Surgery is the primary treatment for most colon and rectal • If patient has an ostomy, include information about
cancers; the type of surgery depends on the location and ostomy care and complications to observe for, including
size of tumor, and it may be curative or palliative. obstruction, infection, stoma stenosis, retraction or
• Cancers limited to one site can be removed through a prolapse, and peristomal skin irritation.
colonoscope. • Provide dietary instructions to help patient identify and
• Laparoscopic colotomy with polypectomy minimizes the eliminate foods that can cause diarrhea or constipation.
extent of surgery needed in some cases. • Provide patient with a list of prescribed medications, with
• Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser is information on action, purpose, and possible side effects.
effective with some lesions. • Demonstrate and review treatments and dressing changes,
• Bowel resection with anastomosis and possible stoma care, and ostomy irrigations, and encourage family
temporary or permanent colostomy or ileostomy (less to participate.
than one third of patients) or coloanal reservoir (colonic J Evaluation: Expected Patient Outcomes
pouch). • Consumes a healthy diet and maintains fluid balance
Assessment • Experiences reduced anxiety
• Obtain a health history about the presence of fatigue, • Learns about diagnosis, surgical procedure, preoperative
abdominal or rectal pain, past and present elimination preparation, and self-care after discharge
patterns, and characteristics of stool. • Maintains clean incision, stoma, and perineal wound
• Obtain a history of IBD or colorectal polyps, a family • Verbalizes feelings and concerns about self
history of colorectal disease, and current medication • Recovers without complications
therapy.

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LIVER CANCER • Cirrhosis, HBV, and HCV have been implicated in its
- Tumors of the liver are either primary or metastasic. etiology.
Primary liver tumors may arise from hepatocytes • Rarer associated causes are hemochromatosis;
connective tissue, blood vessels, or bile ducts. aflatoxins; chemical toxins, such as vinyl chloride and
- These tumors are either benign or malignant. Metastatic Thorotrast; carcinogens in herbal med­icines;
malignant tumors arise from the gastrointestinal tract, the nitrosamines; and ingestion of hormones, as in oral
lungs and the breast. contraceptives.
1) Malignant neoplastic disease of the liver usually • Arises in normal tissue as a discrete tumor or in end-stage
occurring as a metastasis from another cancer; cirrhosis in a multinodular pattern.
symptoms include loss of appetite and weakness and • Liver metastasis reaches the liver by way of the portal
bloating and jaundice and upper abdominal sys­tem or the lymphatic channels or by direct extension
discomfort. from an abdominal tumor.
2) Liver cancer or hepatic cancer (from the Greek hēpar,
meaning liver) is a cancer that originates in the liver. Risk Factors
Incidence • Hepatitis C Virus (HCV): Hepatitis C is the leading cause
- Liver cancer occurrence has been steadily increasing of both HCC and chronic liver disease. It is of special
since the early 1980s in the U.S. Before 2010, importance because unlike hepatitis B virus, there is no
the American Cancer Society estimated that 24,120 new vaccine available for hepatitis C virus.
cases and 18,910 deaths would occur in the U.S. during • Excessive alcohol intake: Alcohol liver disease is the
this year (2010). second most common risk factor for HCC .
- The number of people with liver cancer increased by • Geography: More than 80% of HCC cases appear in
approximately 2% annually. Eastern Asia and Africa America.
• Sex: Males have a higher liver cancer rate than females.
Types of Liver Cancer The difference in the male:female ratio is greatest among
Hepatocellular carcinoma (HCC) Europeans. The difference between the rates is likely
- The most common type of liver cancer is hepatocellular caused by different exposure to risk factors including
carcinoma and it is the result of a tumor formed by the alcohol consumption, cigarettes, and infection with
abnormal growth of the liver-specific cells called hepatitis B virus (HBV) or hepatitis C virus (HCV).
hepatocytes (‘hepat’ and ‘hepato’ are derived from the
• Age: In HCC incidence rate is in people 75 years old and
Greek word for liver).
older. The peak age for African women occurs between 65
- Most patients with this type of cancer are over 50 and it is
and 70 years old and then decreases.
more common in males than in females. Hepatocellular
• Hepatitis B Virus (HBV): In places with high HCC
carcinoma can metastasize, and when it does, it
incidence rates, HBV is usually transmitted from mother
frequently goes to nearby lymph nodes and to the lungs.
to child, whereas in areas with low HCC incidence rates
Cholangiocarcinoma
patients usually get infected with HBV through sexual and
- This kind of carcinoma, also known as bile duct cancer,
parenteral ways .
arises from the connective tissues of the tubes that
• Obesity: increase in cancer mortality in people with great
connect the liver to the gallbladder and the gallbladder to
body mass index in contrast to those who had a normal
the small intestine (hepatic bile ducts) as well as the
body mass index. Liver cancer is frequently found in
ducts, located inside the liver (intrahepatic ducts). Most
patients with metabolic disarrangements.
cholangiocarcinomas are adenocarcinomas (they form in
glandular tissue)but they frequently grow slowly and don’t • Diabetes Mellitus: Many studies around the world have
metastasize for long periods of time. found a significant relationship between diabetes and the
Hepatoblastoma development of HCC.
- Hepatoblastoma characteristically develops in children; it • Tobacco: smoking may be a higher risk factor for women
is most frequently diagnosed in infants between 14 and 24 than men.
months and almost all patients are diagnosed by the age • Exposure to aflatoxins: Aflatoxins are a type of mycotoxin,
of 5. Older children and adults can develop this toxic chemicals made by some types of fungi. Aflatoxin is
carcinoma, but it is very rare. produced by Aspergillus fungi when the fungus grows on
- This malignancy is the result of an improperly stored food products. Aflatoxins are capable of
uncontrolled proliferation of undeveloped liver cells causing DNA mutations, including the tumor.
(hepatocytes).
- Hepatoblastoma is usually found in only one place Symptoms & Detection
(unifocal), it’s uncommon for it to metastasize. • Nonspecific symptoms that can be associated with HCC
may include:
Etiology & Pathophysiology • Yellowish color of the skin (Jaundice)
• Incidence of primary cancer of the liver is increasing in the • Inability to eat (Anorexia)
younger population and in females in US and the world. • Weight loss
• Abdominal pain and/or swelling
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• Hepatomegaly Nursing Management

• Diaphoresis, fatigue , ascites - Nursing diagnosis and intervention for clients with liver
• Fever cancers vary according to the amount of liver dysfunction
• Most common presenting symptom is right upper and the treatment modalities ,plan to assess the client for
quadrant abdominal pain, usually dull or aching, and metabolic malfunctions ,pain ,bleeding
may radiate to the right shoulder. problem ,ascites ,edema ,jaundice and endocrine
• A right upper quadrant mass, weight loss, abdominal complication .
distention with ascites, fatigue, anorexia, malaise, and - Acute and Chronic Pain related to growth of tumor
fever. - Intervention-Administer medication at the prescribed time
• Jaundice is present only in a minority of patients at and dosage ,assist the client and family members to gain
diagnosis in primary cancer of the liver. knowledge about the condition .
• With portal vein obstruction, ascites and esophageal - Imbalanced Nutrition: Less Than Body Requirements
varices occurs related to anorexia
- Intervention- Instruct the client to take low fat and sodium
Diagnostic evaluation: diet ,provide multivitamin supplementation diet, After
surgery give low fat diet and semisolid diet to the patient
• Increased levels of serum bilirubin, alkaline phosphatase
and liver enzymes. (AST & ALT)
Complications:
• AFP(alpha fetoprotein)
• Malnutrition,
• Ultrasonography and CT along with MRI
• Biliary obstruction with jaundice.
• PET scan
• Sepsis,
• CT scans and MRI
• Liver abscesses.
• Percutaneous needle biopsy
• Fulminant liver failure
Medical Management • Metastasis
• Treatment of liver cancer is aimed at relieving • Portal hypertension
manifestation and supporting the client physically and
emotionally .The treatment option for medical Liver Failure
management include chemotherapy, and radiation • Hepatic Encephalopathy- increase ammonia level – 15-45
therapy . u/dl
• Nonsurgical Treatment • Altered level of consciousness
- Neoadjuvant therapies for liver cancer, including • Asterixis or flapping tremors
trans- arterial chemoembolization, combination • Fetor hepaticus
chemotherapy, chemotherapy along with • Ascites, bleeding
radiotherapy, These therapies are used to reduce the • Seizures, coma and death
size of the tumor and make surgical excision possible. Portal Hypertension
• Liver cancer is radiosensitive, but treatment is restricted-, • Clinical Manifestations
by the limited radiation tolerance of the normal liver. • Ascites
• Radiation therapy can help reduce pain and discomfort of • Splenomegaly
large unresectable tumors. • Hemorrhoids
• Chemotherapy is used as an adjuvant therapy after • Esophageal Varices
surgical resection of liver cancer.
• Systemic chemotherapy is the only treatment applicable
when the cancer has spread outside the liver.
Chemotherapy
• Atezolizumab
• Bevacizumab
• Cabozantinib S-Maleate
• Lenvatinib Mesylate
• Gemcitabine
• Oxaliplatin

Surgical Treatment
• Surgical resection
• Cryo­surgery
• Liver transplantation
• Care of the patient after liver surgery is similar to general
abdominal surgery.

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Prognosis
- Because hepatic tumors may be far advanced before
clinical manifestation or laboratory data indicate their
presence ,and severe liver disease liver cancer carries a
poor prognosis .most clients with hepatic carcinoma have
a median survival time of 3 to 6 months.

Terminologies
• Constipation: subjectively described infrequency or
irregularity of defecation, with or without an abnormal
hardening of feces that makes their passage difficult and
sometimes painful, with or without a decrease in fecal
volume
• Fecal incontinence: involuntary passage of feces
• Fissure: normal or abnormal fold, groove, or crack in body
tissue
• Fistula: anatomically abnormal tract that arises between
two internal organs or between an internal organ and the
body surface
• Hemorrhoids: dilated portions of the anal veins; can
occur internal or external to the anal sphincter
• Ileostomy: surgical opening into the ileum by means of a
stoma to allow drainage of bowel contents; one type of
fecal diversion
• Inflammatory bowel disease (IBD): group of chronic
disorders (most common are ulcerative colitis and
Crohn’s disease) that result in inflammation or ulceration
(or both) of the bowel lining; associated with abdominal
pain, diarrhea, fever, and weight loss
• Cystectomy: removal of the urinary bladder
• Cystitis: inflammation of the urinary bladder
• Frequency: voiding more often than every 3 hours
• Ileal conduit: transplantation of the ureters to an isolated
section of the terminal ileum, with one end of the ureters
brought to the abdominal wall
• Interstitial cystitis: inflammation of the bladder wall that
eventually causes disintegration of the lining and loss of
bladder elasticity
• Urinary incontinence: involuntary or uncontrolled loss of
urine from the bladder sufficient to cause a social or
hygienic problem
• Urosepsis: sepsis resulting from infected urine, most
often a UTI
• Endometriosis: endometrial tissue in abnormal locations;
causes pain with menstruation, scarring, and possible
infertility
• Hysterectomy: surgical removal of the uterus
• Laparoscope: surgical device inserted through a
periumbilical incision to facilitate visualization and
surgical procedures
• Salpingo-oophorectomy: removal of the ovary and its
fallopian tube (removal of the fallopian tube alone is a
salpingectomy)

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 NCMB312 LECTURE: Final Week

17
Blood Cancer
Bachelor of Science in Nursing 3YA
Professor: Dr. Potenciana A. Maroma
BLOOD CANCER - The common feature of the leukemias is an unregulated
Hematopoiesis proliferation or accumulation of white blood cells (WBCs)
- Hematopoietic stem cells in the bone marrow.
• Where all circulating blood cells arise from - There is also proliferation in the liver and spleen and
• Also known as Pluripotent Stem Cells invasion of other organs, such as the meninges, lymph
• Can proliferate and differentiate depends on the nodes, gums, and skin. The leukemias are commonly
body’s need classified according to the stem cell line involved, either
- Blast cells lymphoid or myeloid.
• Least differentiated cells - Leukemia is also classified as acute (abrupt onset) or
• Cannot function as mature cells chronic (evolves over months to years). Its cause is
• When matured, released to the peripheral circulation unknown. There is some evidence that genetic influence
and viral pathogenesis may be involved.
- Bone marrow damage from radiation exposure or
chemicals such as benzene and alkylating agents can also
cause leukemia.
- Clinical Manifestations: Cardinal signs and symptoms
include weakness and fatigue, bleeding tendencies,
petechiae and ecchymoses, pain, headache, vomiting,
fever, and infection.
- Assessment and Diagnostic Findings: Blood and bone
marrow studies confirm proliferation of WBCs
(leukocytes) in the bone marrow.
Etiology: The risk factors of leukemia.
- Genetic disorders
• Down syndrome
• Klinefelter syndrome
• Patau syndrome
• Ataxia telangiectasia
Leukemia • Shwachman syndrome
- This is a cancer that starts in the tissue that forms blood. • Kostman syndrome
- Most blood cells develop from cells in the bone marrow • Neurofibromatosis
called stem cells. In a person with leukemia, the bone • Fanconi anemia
marrow makes abnormal white blood cells. • Li-Fraumeni syndrome
- The abnormal cells are leukemia cells. Unlike normal - Radiation exposure
blood cells, leukemia cells don't die when they should. • Nontherapeutic, therapeutic radiation
- They may crowd out normal white blood cells, red blood - Physical and chemical exposures
cells, and platelets. This makes it hard for normal blood
• Benzene, Drugs such as pipobroman
cells to do their work.
• Pesticides, Cigarette smoking
- The four main types of leukemia are:
• Embalming fluids
• Acute lymphoblastic leukemia (ALL)
• Herbicides
• Acute myelogenous leukemia (AML)
- Chemotherapy
• Chronic lymphocytic leukemia (CLL)
• Alkylating agents
• Chronic myelogenous leukemia (CML)
• Topoisomerase-II inhibitors
• Anthracyclines
• Taxanes
Epidemiology (June 3, 2019)
- According to the Department of Health (DOH), leukemia is
among the top 5 killer-cancers in the country. To raise the
profile of this “silent killer,” the department has
designated September as “Leukemia Awareness Month,”
coinciding with the “Blood Cancer Awareness Month”

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which is also celebrated internationally, September of - The following conditions can develop in Leukemia
each year. patients
- The Philippine Cancer Society, for their “2015 Philippine - Anemia (a deficiency of red blood cells and hemoglobin)
Cancer Facts & Estimates” report, has said that around • shortness of breath
4.5 individuals per 100,000 Filipinos will develop the • Paleness
disease. The same report estimated that around 4,270 • Palpitations (rapid heartbeat)
new cases were diagnosed for the year, plus 3,386 • Weakness, tiredness
leukemia-caused deaths in 2015. • Dizziness
- Of the different types of leukemias, lymphoid leukemia is • Headaches
highest in Filipino children and those over 70 years of age. - Thrombocytopenia (a low blood platelet count)
The survival rate of Metro Manila children with acute • Easy bleeding
lymphoid leukemia is only 34%. This figure is lower than
• Widespread bruising, purple patches under the skin
those of developed countries like the US (86%). The 5-year
• Frequent nosebleeds
survival rate of adults with leukemia in Metro Manila is
• Bleeding gums
only 5.2%. Again, this is lower than those from developed
countries like the US (48.4%). • Red spots on the skin
- Enlarged liver or spleen (leukemia cells build up in the
Pathophysiology
liver or spleen)
1) A clone of invasive cells may arise at any stage of cell
maturation and specialization in the lymphoid, myeloid, or • Can be felt by swelling or discomfort in the abdomen.
pluripotential stage. • Loss 0f appetite
2) The cause of this clonal development is quite unknown in • Losing weight without trying
most cases, however; it appears to involve the • The lower ribs usually cover these organs, but when
rearrangement of sequence of bases on DNA molecules. they are enlarged, the doctor can feel them
3) External and internal factors such as ionizing radiation - Leukopenia (A low white blood cell count)
and chemicals, as well as chromosomal abnormalities aid • Weak immunity system:
these changes. • Therefore, a patient will have more frequent or severe
4) The DNA changes will lead to a uncontrollable mitosis of infections.
cells which will give rise to cells that could potentially be - Rare symptoms
cancerous- some of which are leukemic blasts (abnormal • Chloroma (granulocytic sarcoma) – a tumour-like
white blood cells) collection of leukemia cells under the skin or in other
5) These leukemic blasts infiltrate into the bone marrow and parts of the body can occur
secrete factors which inhibit normal hematopoiesis • Leukemia Cutis: These are skin lesions that occur in
(formation of cellular components of the blood) 25% of Chronic Lymphocytic Leukemia patients
6) They eventually infiltrate into other organs as well- such as - Other symptoms
the spleen, or the liver- and therefore disrupting their • Leukemia can also cause vomiting, confusion, loss of
regular processes. muscle control and seizures.
7) The blood becomes unable to carry out its functions and • Swollen Lymph nodes
the individual affected will experience increased fatigue, • Fever or Chills
infections and will bruise and bleed more easily than they • Night Sweating
usually would’ve. • Joint and bone pain

Leukemia Diagnostic tests

• Physical exam. The doctor will look for physical signs of
leukemia, such as pale skin from anemia and swelling of
your lymph nodes, liver and spleen.
• Blood tests. By looking at a blood sample, the doctor can
Signs and Symptoms determine if there are abnormal levels of white blood
- The symptoms of Acute Leukemia develop very quickly cells or platelets, which may suggest leukemia.
(within a few days or weeks ) whereas, Chronic Leukemia • Bone marrow test. The doctor may recommend a
can go unnoticed for years and is usually found in a procedure to remove a sample of bone marrow from
routine blood test. hipbone. The sample is sent to a laboratory to look for
leukemia cells.
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Types of Leukemia - Plant Alkaloids- Vincristine- Oncovin

- Leukemia is classified according to the rate of progression Nursing process: the patient with leukemia
and the type of white blood cell involved. Assessment
- Leukemia, according to the rate of progression, has • Identify range of signs and symptoms reported by patient
two types: in nursing history and physical examination.
• Acute leukemia — a rapidly developing condition. The • Assess results of blood studies, and report alterations of
cells divide rapidly so the disease escalates very WBCs, absolute neutrophil count (ANC), hematocrit,
quickly. For acute leukemia, aggressive treatment is platelet, creatinine and electrolyte levels, hepatic function
required. tests, and culture results.
• Chronic leukemia — characterized by mature blood Nursing Diagnoses
cells that divide and replicate more slowly. These
- Risk for infection and bleeding
cells could initially function like a normal WBC. As a
- Risk for impaired skin integrity related to toxic effects of
result, chronic leukemia could remain undiagnosed
chemotherapy, alteration in nutrition, and impaired
for years.
mobility
- Leukemia, according to the type of white blood cell
- Impaired gas exchange
involved, also has two types:
- Impaired mucous membranes from changes in epithelial
• Lymphocytic leukemia — affects the lymphoid cells.
lining of the gastrointestinal (GI) tract from chemotherapy
The symptoms include swollen lymph nodes in the
or antimicrobial medications
neck, armpits and groin.
- Imbalanced nutrition: less than body requirements related
• Myelogenous leukemia — affects myeloid cells, which to hypermetabolic state, anorexia, mucositis, pain, and
are immature white blood cells. nausea
The 4 Main Types of Leukemia - Acute pain and discomfort related to mucositis,
1) Acute lymphocytic leukemia (ALL) – This is the most leukocytic infiltration of systemic tissues, fever, and
common type of leukemia affecting young children. ALL infection
still does affect adults. But when this happens, the - Hyperthermia related to tumor lysis and infection
affected adults usually have a worse prognosis than - Fatigue and activity intolerance related to anemia,
children suffering from the same condition. infection, and deconditioning
2) Acute myelogenous leukemia (AML) – This is the most - Impaired physical mobility due to anemia, malaise,
common type of acute leukemia in adults. It is a rapidly- discomfort, and protective isolation
developing condition. AML can quickly spread to different - Risk for excess fluid volume related to renal dysfunction,
parts of the body like spleen, liver and brain. hypoproteinemia, need for multiple intravenous (IV)
3) Chronic lymphocytic leukemia (CLL)– Many people with medications and blood products
the condition will not have any symptoms for years. This - Diarrhea due to altered GI flora, mucosal denudation,
being the case, chronic leukemias tend to be harder to prolonged use of broad-spectrum antibiotics
manage than acute ones. - Risk for deficient fluid volume related to potential for
4) Chronic myelogenous leukemia (CML) – CML affects diarrhea, bleeding, infection, and increased metabolic
mostly adults. It is a slow-moving subtype. But that said, rate
CML can alter its progression and suddenly become an - Self-care deficits related to fatigue, malaise, and
acute, rapidly-progressing condition. protective isolation
Leukemia treatment - Anxiety due to knowledge deficit and uncertain future
• Induction Therapy: Killing of leukemia cells in the blood - Disturbed body image related to change in appearance,
and bone marrow. Treatments include chemotherapy. function, and roles
Induction usually lasts for 4-6 weeks. - Grieving related to anticipatory loss and altered role
• Consolidation Therapy: Killing off the remaining leukemia functioning
cells or the aberrant cells. If these cells are not killed, they - Risk for spiritual distress
could re-grow and could cause a relapse. Treatment - Deficient knowledge of disease process, treatment,
include chemotherapy and may include stem cell complication management, and self-care measures
transplant (replacement of damaged bone marrow cells
Collaborative Problems/Potential Complications
with healthy ones).
- Infection
• Maintenance Therapy: Preventing any remaining
- Bleeding/disseminated intravascular coagulation (DIC)
leukemia cells from growing or from coming back by using
- Renal dysfunction
low doses of chemotherapy and intravenous treatment
- Tumor lysis syndrome
(the infusion of liquid substances directly into a vein).
- Nutritional depletion
• Chemotherapy
- Mucositis
- Alkylating Agents- Busulfan- Myleran
- Depression and anxiety
- Anthracyclines- Doxorubicin- Adriamycin
- Antimetabolites- Fludarabine- Fludara
- Corticosteroids- Prednisone

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Planning and Goals - Maintain nutrition with palatable, small, frequent

• The major goals of the patient may include absence of feedings of soft nonirritating foods; provide nutritional
complications and pain, attainment and maintenance of supplements, as prescribed.
adequate nutrition, activity tolerance, ability to provide - Record daily boy weight, as well as intake and output,
self- care and to cope with the diagnosis and prognosis, to monitor fluid status.
positive body image, and an understanding of the disease - Perform calorie counts and other more formal
process and its treatment. nutritional assessments.
- Provide parenteral nutrition, if required.
Nursing Interventions
• Easing Pain and Discomfort
• Preventing or Managing Bleeding
- Administer acetaminophen rather than aspirin for
- Assess for thrombocytopenia, granulocytopenia, and
analgesia.
anemia.
- Sponge patient with cool water for fever; avoid cold
- Report any increase in petechiae, melena, hematuria,
water or ice packs; frequently change bedclothes;
or nosebleeds.
provide gentle back and shoulder massage.
- Avoid trauma and injections; use small-gauge needles
- Provide oral hygiene (for stomatitis), and assist the
when analgesics are administered parenterally, and
patient with use of patient-controlled analgesia (PCA)
apply pressure after injections to avoid bleeding.
for pain.
- Use acetaminophen instead of aspirin for analgesia.
- Use creative strategies to permit uninterrupted sleep
- Give prescribed hormone therapy to prevent menses.
(a few hours). Assist the patient when awake to
- Manage hemorrhage with bed rest and transfuse red
balance rest and activity to prevent deconditioning.
blood cells and platelets as ordered.
- Listen actively to patients enduring pain.
• Preventing Infection
• Decreasing Fatigue and Deconditioning
- Infection is a major cause of death in leukemia
- Assist in choosing activity priorities; help patient
patients.
balance activity and rest; suggest a stationary bicycle
- Assess temperature elevation, flushed appearance,
and sitting up in chair.
chills, tachycardia, and appearance of white patches
- Assist patient in using a high-efficiency particulate air
in the mouth.
(HEPA) filter mask to ambulate outside room.
- Observe for redness, swelling, heat, or pain in eyes,
- Arrange for physical therapy when indicated.
ears, throat, skin, joints, abdomen, and rectal and
• Maintaining Fluid and Electrolyte Balance
perineal areas.
- Measure intake and output accurately; weigh the
- Assess for cough and changes in character or color of
patient daily.
sputum.
- Assess for signs of fluid overload or dehydration.
- Give frequent oral hygiene.
- Monitor laboratory tests (electrolytes, blood urea
- Wear sterile gloves to start infusions.
nitrogen [BUN], creatinine, and hematocrit), and
- Provide daily IV site care; observe for signs of infection.
replace blood, fluids, and electrolyte components as
- Ensure normal elimination; avoid rectal thermometers,
ordered and indicated.
enemas, and rectal trauma; avoid vaginal tampons.
• Improving Self-Care
- Avoid catheterization unless essential. Practice
- Encourage the patient to do as much as possible.
scrupulous asepsis if catheterization is necessary.
- Listen empathetically to the patient.
• Managing Mucositis
- Assist patient to resume more self-care during
- Assess the oral mucosa thoroughly; identify and
recovery from treatment.
describe lesions; note color and moisture (remove
• Managing Anxiety and Grief
dentures first).
- Provide emotional support, and discuss the impact of
- Assist patient with oral hygiene with soft-bristled
uncertain future.
toothbrush.
- Assess how much information patient wants to have
- Avoid drying agents, such as lemon–glycerin swabs
regarding the illness, its treatment, and potential
and commercial mouthwashes (use saline or saline
complications; reassess at intervals.
and baking soda).
- Assist patient to identify the source of grief, and
- Emphasize the importance of oral rinse medications
encourage patient to allow time to adjust to the major
to prevent yeast infections.
life changes rendered by the illness.
- Instruct patient to cleanse the perirectal area after
- Arrange to have communication with nurses across
each bowel movement; monitor frequency of stools,
care settings to reassure patient that he or she has
and stop stool softener with loose stool.
not been abandoned.
• Improving Nutritional Intake
• Encouraging Spiritual Well-Being
- Give frequent oral hygiene (before and after meals) to
- Assess the patient’s spiritual and religious practices,
promote appetite; with oral anesthetics, caution
and offer relevant services.
patient to prevent self-injury and to chew carefully.

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- Assist the patient to maintain realistic hope over the average. The longest recorded survival of a patient
course of the illness (initially for a cure, in later stages affected by chronic myeloid leukemia has been 117
for a quiet, dignified death). months. Several drugs, still in clinical trials may change
Promoting Home- and Community-Based Care the picture in the coming years and increase the survival
• Teaching Patients Self-Care rate.
- Ensure that patients and their families have a clear - Chronic myeloid leukemia (CML) arises from a mutation in
understanding of disease and complications (risk for the myeloid stem cells. A wide spectrum of cell types
infection and bleeding). exists within the blood, from blast forms through mature
- Teach family members about home care while patient neutrophils. A cytogenetic abnormality termed the
is still in the hospital, particularly vascular access Philadelphia chromosome is found in 90% to 95% of
device management if applicable. patients. CML is uncommon before 20 years of age, but
• Continuing Care the incidence increases with age (mean age is 67 years).
- Maintain communication between the patient and CML has three stages: chronic, transformation, and
nurses across care settings. accelerated or blast crisis. Mar- row expands into cavities
- Provide specific instructions regarding when and how of the long bones, and cells are formed in the liver and
to seek care from the physician. spleen, with resultant painful enlargement problems.
Infection and bleeding are rare until the dis- ease
• Terminal Care
- Respect the patient’s choices about treatment, transforms to the acute phase.
including measures to prolong life and other end-of- Clinical Manifestations
life measures. Advance directives, including living • Many patients are asymptomatic, and leukocytosis is
wills, provide patients with some measure of control detected by a CBC count performed for some other
during terminal illness. reason.
- Support families and coordinate home care services • Leukocyte count commonly exceeds 100,000/mm .
to alleviate anxiety about managing the patient’s care • Patients with extremely high leukocyte counts may be
in the home. some- what short of breath or slightly confused because
- Provide respite for the caregivers and patient with of leukostasis.
hospice volunteers. • Splenomegaly with tenderness and hepatomegaly are
- Give the patient and caregivers assistance to cope common.
with changes in their roles and responsibilities (ie, • Some patients have insidious symptoms, such as malaise,
anticipatory grieving). anorexia, and weight loss.
- Provide information on hospital-based hospice • In the transforming phase, bone pain, fever, weight loss,
programs for patients to receive palliative care in the anemia, and thrombocytopenia are noted.
hospital when care at home is no longer possible. Medical Management: Pharmacologic Therapy
Evaluation: Expected Patient Outcomes • Oral formulation of a tyrosine kinase inhibitor, imatinib
• Shows no evidence of infection mesylate (Gleevec).
• Experiences no bleeding • In those instances where imatinib (at conventional doses)
• Exhibits intact oral mucous membranes does not elicit a molecular remission, or when that
remission is not maintained, other treatment options may
• Attains optimal level of nutrition
be considered: The dosage of imatinib can be increased
• Reports satisfaction with pain and discomfort levels
(with increased toxicity), another inhibitor of BCR-ABL can
• Experiences less fatigue and increases activity
be used (eg, dasatinib [Sprycel]), or allogeneic transplant
• Maintains fluid and electrolyte balance can be used.
• Participates in self-care • Bone marrow transplant and peripheral blood stem cell
• Copes with anxiety and grief transplantation are additional treatment strategies.
• Experiences absence of complications • In the acute form of CML (blast crisis), treatment may
resemble induction therapy for acute leukemia, using the
Chronic Myeloid Leukemia same medications as for AML or ALL.
- This type affects the lymphoid cells created in the bone • Oral chemotherapeutic agents, typically hydroxyurea or
marrow. It is classified as chronic leukemia, because the busulfan (Myleran); leukapheresis (leukocyte count
affected cells carry out some of their normal functions greater than 300,000/mm3); anthracycline
initially, making it difficult to detect. chemotherapeutic agent (eg, daunomycin [Cerubidine])
- The progression of this disease is slow and symptoms for purely palliative approach (rare).
show up only in the later stages.
- The prognosis depends on the stage in which the disease Acute Myeloid Leukemia
has advanced. People in the early stages may have a life - The more severe form of the disease is acute myeloid
expectancy of 98 months, those in intermediate stages leukemia, which is characterized by faster progression of
may be expected to live for 65 months, while last stage the disease. This is the most commonly type among
patients may be expected to live for 42 months on an

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adults. If detected early, statistics show that 20% to 40% • Neutropenia

of patients survive for at least 60 months. • Thrombocytopenia
- Chemotherapy is the recommended treatment method. • Bone pain is less seen but more of pain in
Older people in the sixty plus age group, affected by it, • the soft tissues
have a very low life expectancy. • Gingival bleeding 4 weeks prior to onset of other signs &
- Genetic changes in the bone marrow stem cells symptoms
- The cancer grows from cells that would normally turn into • Most signs and symptoms evolve from insufficient
white blood cells production of normal blood cells: Fever and infection
- Age : 40 – 60 y/o (Common in adult) result from neutropenia, weakness and fatigue from
- Men than women anemia, and bleeding tendencies from thrombocytopenia.
- Acute myeloid leukemia (AML) results from a defect in the Major hemorrhage occurs with a platelet count of less
hematopoietic stem cell that differentiates into all than 10,000/mm . The most common sites of bleeding are
myeloid cells: monocytes, granulocytes (eg, neutrophils, GI, pulmonary, and intracranial.
basophils, eosinophils), erythrocytes, and platelets. AML • Proliferation of leukemic cells within organs leads to a
can be further classified into seven different subgroups variety of additional symptoms: pain from an enlarged
based on cytogenetics, histology, and morphology liver or spleen, hyperplasia of the gums, and bone pain
(appearance) of the blasts. All age groups are affected; from expansion of marrow.
incidence rises with age and peaks at 67 years of age. It is
• AML has its onset without warning; symptoms develop
the most common nonlymphocytic leukemia. Death
over weeks or over months.
usually occurs secondary to infection or hemorrhage.
• Peripheral blood shows decreased erythrocyte and
- Assessment and Diagnostic Methods
platelet counts.
• Bone marrow specimen (excess of immature blast
• The leukocyte count is low, normal, or high; the
cells)
percentage of normal cells is usually vastly decreased.
• Complete blood cell (CBC) count (decreased platelet Diagnosis
count and erythrocyte count)
• Peripheral Blood Smears
- Medical Management – The objective is to achieve
• Bone Marrow Aspiration
complete remission, typically with chemotherapy
• Immunophenotyping
(induction therapy), which in some instances results in
remissions lasting a year or longer. • Cytogenic analysis
- Chemotherapy Treatment
• Cytarabine (Cytosar, Ara-C) and daunorubicin • Induction chemo
(Cerubidine) - 7+3 regimen
o Cytarabine for 7 days plus Daunorubicin for 3
• Mitoxantrone (Novantrone) or idarubicin (Idamycin)
days
• • Sometimes etoposide (VP-16, VePesid) is added
o Idarubicin
• • Consolidation therapy (postremission therapy with
- Bone marrow is examined after 14 days of treatment
chemotherapy agents)
- Must be hypocellular aplastic marrow
- Supportive Care
• Cytarabine for CNS disease
• Administration of blood products
• Post remission
• Prompt treatment of infections
- High dose cytarabine (HIDAC)
• Granulocyte colony-stimulating factor (G-CSF
[filgrastim]) or granulocyte-macrophage colony-
Chronic Lymphocytic Leukemia (CLL)
stimulating factor (GM- CSF [sargramostim]) to
- This type almost never occurs among children and has a
decrease neutropenia
very high incidence rate among people aged more than 60.
• Antimicrobial therapy and transfusions as needed - Men are more likely to be affected by it, than women.
• Occasionally, hydroxyurea (Hydrea) may be used - Progression of this disease is slow.
briefly to control the increase of blast cells - If the disease has affected the B-cells, then life
- Bone Marrow Transplantation – Bone marrow expectancy can be anywhere between 10 to 20 years, if
transplantation is used when a tissue match can be treatment begins early. However, those with T cell chronic
obtained. The transplantation procedure follows lymphocytic leukemia have a very low life expectancy.
destruction of the leukemic marrow by chemotherapy. - A slow increase in white blood cells called B lymphocytes
Risk factors - Accumulation of incompetent lymphocytes
• Genetic disorder – Down syndrome (trisomy 21) - Majority are B cells
• Smoking - Eventually causes the bone marrow to fail
• Post-chemotherapy - Chronic lymphocytic leukemia (CLL) is a common cancer
• Chemical exposure (Pesticides, Benzenes) of older adulthood; the average age at diagnosis is 72
• Radiation years. It is derived from a malignant clone of B-
Clinical features lymphocytes. It was initially hypothesized that these cells
• Anemia can escape apoptosis (programmed cell death); however,
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this hypothesis is now being questioned. Most of the • The chemotherapy agents fludarabine (Fludara) and
leukemia cells in CLL are fully mature, so it tends to be a cyclophosphamide (Cytoxan) are often given in
mild disorder compared with the acute form. The disease combination with the monoclonal antibody rituximab
is classified into three or four stages (two classification (Rituxan).
systems are in use). In the early stage, an elevated • The monoclonal antibody alemtuzumab (Campath) is
lymphocyte count is seen; it can exceed 100,000/mm. The often used in combination with other chemotherapeutic
disease is usually diagnosed during physical examination agents when the disease is refractory to fludarabine, the
or treatment for another disease. patient has very poor prognostic markers, or it is
Risk Factors necessary to eradicate residual disease after initial
• Genetic predisposition treatment
• 25% asymptomatic • Prophylactic use of antiviral agents and antibiotics (eg,
• Enlarged abdominal lymph nodes trimethoprim/sulfamethoxazole [Bactrim, Septra]) for
• Infection (death) patients receiving alemtuzumab (at significant risk for
Clinical features infection).
• Asymptomatic (early stages) • IV immunoglobulin may prevent recurrent bacterial
• Abnormal bruising (occurs late in the disease) infections in selected patients.
• Enlarged lymph nodes, liver, or spleen
• Excessive sweating, night sweats Acute Lymphocytic Leukemia
• Fatigue - The most common form of cancer in children is acute
• Fever lymphocytic leukemia. One-fourth of all cancers in
• Recurrent infections children belong to this type.
- It has a high incidence rate among adults, older than 45
• Many cases are asymptomatic.
years of age. Chemotherapy is the established treatment
• Lymphocytosis is always present.
method for this disease.
• Erythrocyte and platelet counts may be normal or
- Before chemotherapy and other cancer cure methods
decreased.
were invented, a patient with acute lymphocytic leukemia
• Lymphadenopathy (enlargement of lymph nodes), which
could survive for 4 months at the most.
is sometimes severe and painful, and splenomegaly may
- However, thanks to modern treatment methods, about
be noted.
80% of the affected children are completely cured. Adults
• CLL patients can develop “B symptoms”: fevers, sweats have been seen to have a 40% chance of complete cure.
(especially night), and unintentional weight loss. - The prognosis for this type will vary, depending on the
Infections are common. stage of disease progression, but children in the age group
• Anergy (decreased or absent reaction to skin sensitivity of 3 to 7 seem to have the highest chance of complete
tests) reveals the defect in cellular immunity. recovery.
• In the later stages, anemia and thrombocytopenia may - The prognosis made previously is based on statistical data
develop. collected all over the world.
Treatment - The factor that can lengthen life expectancy or increase
• Chemo the likelihood of the disease going into remission is early
- Fludarabine detection and treatment.
o Nucleoside Analogues - The survival rate and chances of complete recovery can
- Chlorambucil, cyclophosphamide (Cytoxan) only be determined by an oncologist after he has studied
o Single agent chemo the biopsy and blood test reports.
- Rituximab (Rituxan) - It is vital that early symptoms of the disease are
o Combination with the others recognized and prompt action is taken immediately, to
• RT increase the chances of recovery.
- For painfully enlarged lymph nodes - Body produces a large number of immature white blood
• Stem cell transplantation cells
- Autologous - Most common cancer in children
- Allogenic • 1st peak - 2 to 4 y/o
Medical Management • 2nd peak – 50 y/o
A major paradigm shift has occurred in CLL therapy. For years, Clinical Manifestations
there appeared to be no survival advantage in treat- ing CLL in • Immature lymphocytes proliferate in marrow and impede
its early stages. However, with the advent of more sensitive development of normal myeloid cells.
means of assessing therapeutic response, it has been • Normal hematopoiesis is inhibited, resulting in reduced
demonstrated that achieving a complete remission and numbers of leukocytes, erythrocytes, and platelets.
eradicating even minimal residual disease results in improved • Leukocyte counts are low or high but always include
survival. immature cells.

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• Manifestations of leukemic cell infiltration into other • Corticosteroids and vinca alkaloids are an integral part of
organs are more common with ALL than with other forms the initial induction therapy. Typically, an anthracycline is
of leukemia and include pain from an enlarged liver or included, sometimes with asparaginase (Elspar).
spleen and bone pain. • Once a patient is in remission, intensification therapy
• The central nervous system is frequently a site for (consolidation) ensues. In the adult with ALL, allogeneic
leukemic cells; thus, patients may exhibit headache and trans- plant may be used for intensification therapy. For
vomiting because of meningeal involvement. Other those for whom transplant is not an option (or is reserved
extranodal sites include the testes and breasts. for relapse), a prolonged maintenance phase ensues,
Risk Factors when L lower doses of medications are given for up to 3
• Age (bimodal = 2-4y/o & 50y/o & years.
• above)
• Radiation Chronic Myelogenous Leukemia
• Post-chemotherapy - Uncommon in people under 20 years of age; incidence
• Chemical exposure (benzene) rises with age
• Virus (HIV, EBV) - Usually associated with an abnormal chromosome called
• Genetics the Philadelphia chromosome (hallmark)
Clinical Features Clinical Features
• Anemia • Chronic phase
- Last for months or years, blood and bone marrow
• Neutropenia
contains 10 percent blast cells
• Thrombocytopenia
- May have few or no symptoms during this time
• Bone Pain- in children
- Usual symptoms are fatigue, night sweats, pallor,
• CNS involvement- rare – CN 3, 4, 6, and 7 dyspnea, splenomegaly
• Hepatomegaly & lymphadenopathy - Most people are diagnosed during this stage, when
• Splenomegaly they are having blood tests done for other reasons.
Diagnostic Tests • Accelerated phase
1) Peripheral Blood Smear - Leukemia cells grow more quickly, about 10-19
- WBC- >100,000/mm3 percent are blast cells
- Neutrophil – low, despite increased WBC - Usually clients who are treated but disease still
- Platelet - <50,000/mm3 progresses
2) Bone marrow aspiration - Common symptoms include fever (without
- Lymphoblasts comprise at least 20% infection), bone pain, and a swollen spleen.
- Smears to assess cell morphology
• Blast phase
3) Lumbar puncture
- Aggressive
- Leukemic cells in the CSF
- Terminal phase
Treatment
- Resembles ALL or AML
1) Induction Chemo
Diagnosis
- Vincristine, corticosteroid and anthracycline
• Bone marrow biopsy
2) CNS treatment
• Blood and bone marrow testing for the presence of
- Cranial irradiation
the Philadelphia chromosome
- Intrathecal chemo with methotrexate or cytarabine
- Cytogenetic analysis
3) Stem cell transplant
a) FISH (Flourescence in situ hybridization)-
- Offered only to high risk ALL
presence of gene sequence known as BCR-ABL 1
4) Post remission Therapy
confirms the diagnosis
- Consolidation/ Intensification
b) PCR- polymerase chain reaction- sensitive blood
• Chemo
test which also measures leukemic cancer cells
• Stem cell transplant - Offered only to high risk Treatment
ALL
• Busulfan, Hydroxyurea
- Maintenance Therapy
• Imatinib (Gleevec)
• Lower-dose treatment for 2-3 years
- First treatment for nearly everyone with CML
• 6-MP Mercaptopurine- given daily
- Taken by mouth
• Methotrexate (oral) – weekly - Eliminates production of malignant clone
• Vincristine and Prednisone – monthly • Allogenic stem cell transplant
Medical Management - Only known cure for CML
• Because ALL frequently invades the central nervous - Allogenic Bone marrow transplant
system, preventive cranial irradiation or intrathecal
chemotherapy (eg, methotrexate) or both is also a key part
of the treatment plan.

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Radiation Priority Nursing Diagnoses

- Radiation therapy uses high-energy beams directed at • Risk for infection
specific parts of the body in order to destroy leukemia • Risk for bleeding
cells or stop them from dividing. It’s like getting an X-ray, • Imbalanced nutrition, less than body requirements
only the radiation used is much stronger. • Fatigue
- The patient lies on a table, and a machine moves around • Activity intolerance
to administer the beam to specific targets of the body. The • Pain
patient does not see or feel the radiation. The session • Anticipatory breathing
itself is painless and lasts only a few minutes.
- If necessary, radiation and chemotherapy are often used Planning and Implementation
to prepare the patient for the next treatment option: bone
• Assist in bone marrow biopsy. Apply pressure on the site
marrow transplant.
for 5 minutes or until bleeding stops.
• Frequently assess for bleeding up to 4 hours after the
Stem Cell or Bone Marrow Transplant
procedure.
- The bone marrow is a spongy tissue found that produces
• Place on reverse isolation.
the white blood cells, red blood cells and blood platelets.
A bone marrow transplant is not a surgery like a heart • Plan activities to prevent fatigue. Provide measures for
uninterrupted rest and sleep.
transplant. It is the act of replacing, via infusion, a faulty
bone marrow with one that’s able to produce healthy • Assist in maintaining good personal hygiene, oral hygiene
blood cells. with saline solution, lubricate the lips with water soluble
- This is achieved by using “stem cells” either from the lubricants every 2 hours.
patient himself or from a suitable donor. Stem cells are
undifferentiated cells that have the ability to develop and Hodgkin’s Lymphoma
mature into any type of cell. - A type of lymphoma (cancer of lymph tissue found in the
- Prior to infusing the stem cells, chemotherapy or radiation lymph nodes, spleen, liver, and bone marrow)
is used to destroy the old and unhealthy leukemia cells - Involved cells are Reed-Sternberg cells
and bone marrow. The process takes about 5-7 days. After • Binucleated or multinucleated cells
this is done, stem cells are introduced and infused • Large malformed cells with 2 nuclei
through a tube connected to a major vein in the chest. The • Distinguishes Hodgkins and Non-hodgkins
stem cells enter the bloodstream and find their way to the - What is the difference between Non-Hodgkin’s
marrow and jump start the production of healthy blood lymphoma and Hodgkin’s lymphoma?
cells. • Medical professionals are able to distinguish non-
Hodgkin’s from Hodgkin’s lymphoma (formerly
referred to as Hodgkin’s disease) by examining the
white blood cells affected by the disease. If the doctor
does not detect what is known as a Reed-Sternberg
cell, the lymphoma is classified as non-Hodgkin’s. If
there are Reed-Sternberg cells present, it is classified
as Hodgkin’s lymphoma. Reed-Sternberg cells are
giant cells found in lymph fluid. They are relatively
easy to identify under the microscope due to the fact
that they are so large and often contain more than one
nucleus.
Risk Factors
• Age : 1st peak – 20s to 30s; 2nd peak – 50s and up
• Family History
• Male
• Epstein Barr Virus
Prevention, Screening & Detection
• Check up for persistent:
• Fatigue
• Weight loss
• Night sweats
• Fever
Clinical Features
• Lymphadenopathy – painless – Neck, above the clavicle,
elbow, under the arms or near the groin
• Fever

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• Persistent fatigue Treatment

• Night sweats • Stage I or II
• Weight loss - RT, Chemo or both
• Pruritus - Pt are treated according to stage and prognosis
Diagnosis and staging - Chemo regimen: MOPP- usually for older than 75 y/o –
• History and Physical exam Mechlorethamine, vincristine/ Oncovin, procarbazine.
• Chest X-ray prednisone
• CT scan – Chest, abdomen, pelvis - ABVD- Primary choice – Doxorubicin, bleomycin,
• Lymphangiogram vinblastine, dacarbazine
- Dose-escalated BEACOPP – Bleomycin, etoposide,
• PET scan
doxorubicin/ Adriamycin, cyclophosphamide,
• Gallium-67 scan – Widely used in nuclear medicine as a
vincristine, procarbazine, prednisone)
tumor-imaging agent by gamma-emission scintigraphy
• Stage III or IV
• Lab – CBC, LDH & Liver and Renal function test
- Presence of B symptoms or bulky disease
• Bone marrow biopsy- lymphoma cells
- ABVD
• Percutaneous needle biopsy
o Improved compliance due to IV administration
• Staging laparotomy – Rarely done today because NHL is o Less cumulative myelotoxicity
considered systemic o Lower risk of secondary malignancy
• Immunophenotyping – Process used to identify cells, o Lower rate of infertility
based on the types of antigens or markers on the surface • Relapsed or Recurrent
of the cell - BEAM- the most common high dose regimen
- B-Carmustine, etoposide, cytarabine, melphalan
- Bone marrow or peripheral blood stem cells are
removed before therapy

Prognosis
- Treated stage I or II- 20 year survival is 70% to 80%
- Stage III or IV treated with ABVD – Achieve remission after
chemo with a rate of 89%
- Most common complications - Malignancy and ischemic
heart disease
- Common secondary malignancies: Lung CA, AML, NHL,
thyroid CA, breast CA

Non- Hodgkins Lymphoma

- Malignancies that arise from proliferation of B or T
Lymphocytes
- Morphologically and clinically different from HD
- Diagnosed at more advanced stage
Risk Factors
• Immunodeficiency
- AIDS, Immunosuppression
- Ataxia-telangiectasia – Recessive, complex,
multisystem disorder characterized by progressive
neurologic impairment, variable immunodeficiency
• Wiscott-Aldrich syndrome
- A condition with variable expression, but commonly
includes immunoglobulin M (IgM) deficiency
• Autoimmune disorders
- RA, SLE, Hashimoto’s disease
• Infectious Agents
- EBV, Herpes, H. Pylori, Hep C
Metastasis
• Environmental factors
- Spreads from 1 lymph node to another
- Carcinogen exposures
- Retroperitoneal node
Classification
- Liver
• Indolent (Low grade)
- Lungs
- Slow growing
- Spleen
- Occurs in patient with a median age of 50-60 y/o
- Bone Marrow
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- Follicular lymphoma Multiple Myeloma

- Cutaneous T-cell lymphoma - Cancer that forms in a type of WBC called plasma cell
- Lymphoplasmacytic lymphoma which helps fight infection by making antibodies that
- Marginal zone B-cell lymphoma recognizes and attacks foreign antigens.
- MALT lymphoma - Cancerous plasma cells accumulate in bone marrow and
- Small-cell lymphocytic lymphoma crowd out normal healthy cells.
• Aggressive (High grade) - No cure, but can live in 10-20 years
- fast growing
- Diffuse large B-cell lymphoma
- Anaplastic large-cell lymphoma
- Burkitt lymphoma
- Lymphoblastic lymphoma
- Mantle cell lymphoma
- Peripheral T-cell lymphoma
Clinical Features
• Generalized lymphadenopathy
• Bone marrow involvement
• Coughing or shortness of breath – may occur if the cancer
affects the thymus gland or lymph nodes in the chest Risk Factors
• Abdominal pain or swelling • Chromosomal abnormalities
Diagnosis • 70 y/o and above
• Labs • Male
• CXR, CT of thorax, abdomen, pelvis and head • Black-American Race
• PET scan • Family history
• Gallium 67 scan • Occupational exposure to ionizing radiation
• MRI • Pesticides, oil-related, farming chemicals, Wood, leather
• Bone scans Clinical Features
Metastasis • Bone pain – common in humerus, scapula, spine;
• Follicular- bone marrow osteoporosis
• Diffuse- CNS, bone and GI tract • Hypercalcemia – loss of appetite, constipation; feeling
Treatment sleepy or confused
• Indolent/ low grade NHL • Kidney problems
- RT- field or total nodal radiation • Anemia (weakness, pale skin, SOB, dizziness)
- Chemo- no improved survival shown • Infections
o CVP- cyclophosphamide, vincristine, prednisone • Low platelet count = bleeding, bruising
o CHOP- cyclophosphamide, doxorubicin, Signs and Symptoms
vincristine, prednisone • Frequent infections
o Interferon • Weakness due to anemia
o Nucleosides Analogues – fludarabine and • Bone pain (often in back, ribs, and hips)
cladribine • Kidney problems
• Aggressive Lymphoma • Excessive thirst
- Chemotherapy • Nausea and vomiting
- CHOP • Shortness of breath
- RT
• Frequent urination
• Highly aggressive lymphoma Diagnosis
- CNS prophylaxis (methotrexate)
• Serum and urine electrophoretic and immunologic studies
- Hyper CVAD – Cyclophosphamide, mesna, vincristine,
- Elevations in immunoglobulin = tall, narrow based
doxyrubicin, decadron
monoclonal spike (M-spike) – all the exact same-
Nursing Management
hallmark
• Lymphadenopathy - 24-hr urine – reveals Bence Jones Protein
- Can cause pain and dysfunction due to compression
• Laboratory studies- increase creatinine, low albumin, high
- Can obstruct venous blood flow
calcium , anemia
- Assess the function of the surrounding organs and
• Bone marrow biopsy
tissues and the presence of lymphedema
• MRI, X-rays
- Encourage mobility of the affected lymph
• Myelosuppression
• CNS involvement – Can cause Altered mental status,
seizures
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 312 LECTURE: WK17 – BLOOD CANCER

- VBCMP –vincristine + melphalan + carmustine +

cyclophosphamide + prednisone
- VBAP – vincristine + melphalan + carmustine +
doxorubicin + prednisone + doxorubicin + prednisone
- VAD – vincristine
• Radiation – for chemo-resistant
- Relieves bone pain
- Treat spinal cord compression
- Improves quality of life but does not enhanced
survival

Disease Related Complications Terminologies

1) Hypercalcemia • Leukemia: uncontrolled proliferation of WBCs, often
- hydration using isotonic saline immature
- Diuretics • Leukopenia: less-than-normal amount of WBCs in
- Corticosteroids circulation
- biphosphonates (prevent the loss of bone mass) • Lymphocyte: form of WBC involved in immune functions
- Side effects: thirst, bone pain, polyuria • Lymphoid: pertaining to lymphocytes lysis: destruction of
- Increased fluids and fiber cells
- Stool softener • Macrophage: reticuloendothelial cells capable of
- Privacy for bowel elimination phagocytosis
2) Hyper viscosity • Microcytosis: smaller-than-normal RBCs
- oronasal bleeding, blurred vision, CHF • Monocyte: large WBC that becomes a macrophage when
- Analgesics it leaves the circulation and moves into body tissues
- Assess for numbness, tingling, loss of balance • Myeloid: pertaining to nonlymphoid blood cells that
- Progressive dysuria, constipation differentiate into RBCs, platelets, macrophages, mast
- Plasmapheresis, Corticosteroids, Radiation cells, and various WBCs
3) Anemia
• Myelopoiesis: formation and maturation of cells derived
- fatigue, dyspnea, headache
from myeloid stem cell
- Hgb <10g/dl
• Neutropenia: lower-than-normal number of neutrophils
- Packed RBC transfusion
• Neutrophil: fully mature WBC capable of phagocytosis;
- Colony-stimulating factors (epoetin alfa)
primary defense against bacterial infection
- Teach about side effects of transfusion
• Normochromic: normal RBC color, indicating normal
- Report promptly for adverse reactions
amount of hemoglobin
4) Bone Disease
- Fixations (intermedullary rods, vertebroplasty) • Normocytic: normal size of RBC
- IV bisphosphonates, Zoledronic acid, Pamidronate • Nucleated RBC: immature form of RBC; portion of
- Active lifestyle, Exercise nucleus remains within the RBC
- Prompt and timely meds (e.g. round-the-clock
analgesics
- Report unrelieved pain
5) Renal Failure
a) Hyperuricemia – Allopurinol
b) Azotemia – Hemodialysis, plasmapheresis
- Explain hemodialysis and plasmapheresis
- Each session 60-90 mins
- Obtain daily/weekly weight
- Monitor I&O
- Increase fluids while taking allopurinol
6) Infections
- Gram (+) i.e. S. pneumoniae, S. Aureus, H. influenzae
- Prompt administration of antibiotics and round-the-
clock analgesics
- Hydration and nutrition
Treatment
• Chemotherapy – Combination chemotherapy
- MP – melphalan + prednisone

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