DISTURBANCES IN CELLULAR FUNCTIONING

PART 1. DEFINITION OF TERMS

Anaplasia – a change in the structure and orientation of cells, characterized by a loss of differentiation and reversion to a more primitive form. Anaplasia is characteristic of malignancy.

Biologic Response Modifier (BRM) Therapy – use of agents or treatment methods that can alter the immunologic relationship between the tumor and the host to provide a therapeutic benefit.

Biopsy – a diagnostic procedure to remove a small sample of tissue to be examined microscopically to detect malignant cells.

Brachytherapy – delivery of radiation through internal implants.

Carcinogenesis – process of transforming normal cells into malignant cells.

Chemotherapy – use of drugs to kill tumor cells by interfering with cellular functions and reproduction.

Cytokines – substances produced by cells of the immune system to enhance production and functioning of components of the immune system.

Dysplasia – any abnormal development of tissues or organs.

Extravasation – leakage of medication from the veins into the subcutaneous tissues.

Hyperplasia – an increase in the number of cells of a body part that result from an increased rate of cellular division.

Metaplasia – the reversible conversion of normal tissue cells into another, less differentiated cell type in response to chronic stress or injury.

Metastasis – spread of cancer cells from the primary tumor to distant sites.

Myelosuppression – suppression of the blood cell – producing functions of the bone marrow.

Nadir – lowest point of WBC depression after therapy that has toxic effects on the bone marrow

Neoplasia – the new and abnormal development of cells that may be benign or malignant.

Neutropenia – abnormally low absolute neutrophil count.

Oncology – field of study of cancer.

Palliation – relief of symptoms associated with cancer.

Thrombocytopenia – decrease in the number of circulating platelets; associated with the potential for bleeding.

Vesicant – substance that can cause tissue necrosis and damage, particularly when extravasated.

Xerostomia – dry oral cavity resulting from decreased function of salivary glands.

PART 2. EPIDEMIOLOGY

most cancers occur in people older than 65 years of age.

Higher in men and higher in industrialized sectors and nations.

The leading causes of cancer deaths in the United States are lung, prostate, and colorectal for men and lung, breast, and colorectal for women.

PART 3. PATHOPHYSIOLOGY OF THE MALIGNANT

PROCESS

Predisposing/etiologic factors 

Genetic mutation of cellular DNA 

Transformation of normal cell to abnormal cell  

Abnormal cells form a clone and proliferate abnormally(Pressure, obstruction, pain, effusion, ulceration and necrosis,

vascular thrombus, embolus, thrombophlebitis) 

Further proliferation and invasion of surrounding tissues 

Gain access to lymph and blood vessels 

Metastasis 

PROLIFERATIVE PATTERNSDuring the lifespan, various body tissues normally experience periods of rapid or proliferative growth that must be distinguished from malignant growth activity.

Cancerous cells are described as malignant neoplasms. They demonstrate uncontrolled cell growth that follows no physiologic demand.

CHARACTERISTICS OF MALIGNANT CELLS

The cell membranes are altered in cancer cells.

Cell membrane of malignant cells contains proteins called tumor-specific antigen. These proteins distinguish the malignant cell from a benign cell of the same tissue type.

Malignant cellular membranes also contain less fibronectin - a cellular cement.

Nuclei of cancer cells are large and irregularly shaped (pleomorphism).

Nucleoli, structures within the nucleus that house RNA, are larger and more numerous in malignant cells, perhaps because of increased RNA synthesis.

Mitosis (cell division) occurs more frequently in malignant cells than in normal cells. As the cells grow and divide, more glucose and oxygen are needed.

INVASION AND METASTASISby circulatory patterns and by specific affinity for certain malignant cells to bind to molecules in specific body tissue.

Invasion, which refers to the growth of primary tumor into the surrounding host tissues, occurs in several ways. Mechanical pressure exerted by rapidly proliferating neoplasms may force fingerlike projections of tumor cells into surrounding tissue and interstitial spaces.

Malignant cells are less adherent and may break off from the primary tumor and invade adjacent structures.

Malignant cells are thought to possess or produce specific destructive enzymes (proteinases), such as collagenases (specific to collagen), plasminogen activators (specific to plasma), and lysosomal hydrolyses

METASTATIC MECHANISMSLymph and blood are key mechanisms by which cancer cells spread.

The most common mechanism of metastasis is lymphatic spread, which is transport of tumor cells through the lymphatic circulation.

Tumor emboli enter the lymph channels by way of the interstitial fluid that communicates with lymphatic fluid.

Malignant cells also may penetrate lymphatic vessels by invasion.

Malignant cells either lodge in the lymph nodes or pass between lymphatic and venous circulation.

Tumors arising in areas of the body with rapid and extensive lymphatic circulation are at high risk for metastasis through lymphatic channels (breast tumors).

Another metastatic mechanism is hematogenous spread, by which malignant cells are disseminated through the bloodstream.

Hematogenous spread is directly related to the vascularity of the tumor.

Malignant cells also have the ability to induce the growth of new capillaries to meet their needs for nutrients and oxygen (angiogenesis).

CARCINOGENESISA three-step cellular process: initiation, promotion, and progression.

Initiation – carcinogens escape normal enzymatic mechanisms and alter the genetic structure of the cellular DNA. The alterations are reversed by DNA repair mechanisms or apoptosis but others escape these protective mechanisms.

Promotion – repeated exposure to promoting agents (co-carcinogens) causes the expression of abnormal or mutant genetic information.

Progression – the cellular changes formed during initiation and promotion now exhibit increased malignant behavior. These cells now show a propensity.

 

PART 4. CHARACTERISTICS OF BENIGN AND

MALIGNANT NEOPLASMS

PART 5. ETIOLOGY

1. Viruses and bacteria

Viruses are thought to incorporate themselves in the genetic structure of cells, thus altering future generations of that cell population

2. Physical agents

Include exposure to sunlight or radiation, chronic irritation or inflammation, and tobacco use.

3. Genetic and familial factors

May be due to genetics, shared environments, cultural or lifestyle factors, or chance alone.

4. Dietary factors

Dietary substances can be proactive (protective), carcinogenic, co-carcinogenic

Dietary substances associated with an increased cancer risk include fats, alcohol, salt-cured or smoked meats, foods containing nitrates and nitrites, and a high caloric dietary intake

Foods to reduce cancer risk are: high fiber foods, cruciferous vegetables, carotenoids and vitamins C & E

Benzopyrene – charcoal broiled meat or fish or foods fried in repeatedly used cooking oil.

Nitrosamines – powerful carcinogens used as preservatives for tocino, longganisa, bacon and hotdog. Formation may be inhibited by taking antioxidants like Vitamin C

5. Chemical agents

Polycyclic hydrocarbons – found in cigarette smoke, industrial agents and smoked foods

Aflatoxin – found in peanuts and peanut butter

Other chemicals include asbestos, formaldehydes, pesticides

Most hazardous chemicals produce their toxic effects by altering the DNA structure in body sites distant from chemical exposure. Liver, lungs, kidneys are the organs systems most often affected

6. Hormonal agents

Tumor growth may be promoted by disturbances in hormonal balance either by the body’s own (endogenous) hormone production or by administration of exogenous hormones

PART 6. WARNING SIGNS OF CANCER BY THE AMERICAN CANCER SOCIETY (CAUTION

US)

C – Change in bowel or bladder habits

Changes in stream/flow of urine or its color and amountChanges in the caliber and color of stoolsPresence of blood in stoolsDifficulty in urination and defecation

A – A sore that does not heal

Skin irritations are usually self-limiting. If changes in the skin and underlying muscles take time to heal, it is recommended to have it examined.

U – Unusual bleeding or discharge

Unusual discharges in the breast, for non-breastfeeding women

 

T – Thickening or lump in the breast

I – Indigestion and difficulty in swallowing O – Obvious change in wart or mole

N – Nagging cough or hoarseness of voice

U – Unexplained anemia

S – Sudden weight loss

PART 7. EARLY DETECTION

BREAST SELF EXAMINATION

Performed every 7 to 10 days after menses

Postmenopausal clients or clients who have had a hysterectomy should select a specific day of the month and perform BSE monthly on that day

First – while in the shower or bath, when the skin is slippery with soap and water, examine your breasts, use the pads of your second, third, fourth fingers to press every part of the breast firmly.

Second – look at your breasts in a mirror stand with your arms at your side

Third – raise your arms overhead and check for any changes in the shape of your breasts, dimpling of the skin, or any changes in the nipple.

Fourth – place your hand on your hips and press down firmly, tightening the pectoral muscles. Observe for asymmetry or changes, keeping in mind that your breasts probably do not match exactly.

Fifth – while lying down, feel your breasts as described in 1. When examining your right breast, place a folded towel under your right shoulder and put your right hand behind your head.

Mark your calendar that you have completed your breast self examination. Note any changes or unique characteristics you want to check with your health care provider.

TESTICULAR SELF EXAMINATIONThe best time to perform this examination is right after a shower when your scrotal skin is moist and relaxed, making the testicles easy to feel

gently lift each testicle. Each one should feel like an egg, firm but not hard, and smooth with no lumps

using both hands, place your middle fingers on the underside of each testicle and your thumb on top

Gently roll the testicle between the thumb and fingers to feel for any lumps, swelling, or mass

If you notice any changes from one month to the next, notify your physician or nurse practitioner.

PART 8. DIAGNOSTIC TESTS

Biopsy

Is the definitive means of diagnosing cancer and provides histological proof of malignancy.

Involves the surgical incision of a small piece of tissue for microscopic examination.

Fine needle aspirationIs the aspiration of cells and tissue fragments through a needle that has been guided to a suspected malignant tissue.

Is the procedure of choice if high risk of malignancy.

Well tolerated with little trauma.

A local anesthetic may be used.

May be guided by CT scan or ultrasound.

Needle core biopsy

This involves obtaining a core of tissue through a specially designed needle introduced into a suspected malignant tissue.

A local anesthetic is used.

Incisional biopsy

Removal of a small wedge of tissue from a larger tumor mass.

Is the preferred method for diagnosing soft tissue and bony sarcomas and used for large tumors that will need major surgery.

Excisional biopsy

Excision of the entire suspected tumor mass with no attempt to obtain generous margins of adjacent normal tissue.

Procedure of choice for small accessible tumors.

Following excision, a frozen section or a permanent paraffin section is prepared to examine the specimen.

The advantage of the frozen section is the speed with which the section can be prepared and the diagnosis made, because only minutes are required for this test.

Permanent paraffin section takes about 24 hours; however, it provides clearer details that the frozen section.

Procedure is usually performed in an outpatient surgical setting.

Obtain an informed consent.

Complete blood count (CBC)

Computed tomography (CT) scanUse of narrow beam x-ray to scan successive layers of tissue for a cross sectional view

Magnetic resonance imaging (MRI)Use of magnetic fields and radiofrequency signals to create sectioned images of various body structures

Tumor marker identificationAnalysis of substances found in blood or other body fluids that are made by the tumor or by the body in response to the tumor.

FluoroscopyUse of x-rays that identify contrasts in body tissue densities; may involve the use of contrast agents.

UltrasonographyHigh frequency sound waves echoing off body tissues are converted electronically into images; used to assess tissues deep within the body.

EndoscopyDirect visualization of a body cavity or passageway by insertion of an endoscope into a body cavity or opening; allows tissue biopsy, fluid aspiration and excision of small tumors; both diagnostic and therapeutic

Positron emission tomography (PET scan)

Computed cross sectional images of increased concentration of radioisotopes in malignant cells provide information about biologic activity of malignant cells; help distinguish between benign and malignant processes and responses to treatment.

Radioimmunoconjugates

Monoclonal antibodies are labeled with a radioisotope and injected intravenously into the patient; the antibodies that aggregate at the tumor site are visualized with scanners.

PART 9. TUMOR STAGING AND GRADING

Grade 1 – cells differ slightly from normal cells and are well differentiated (mild dysplasia)

Grade 2 – cells are more abnormal and are moderately differentiated (moderate dysplasia)

Grade 3 – cells are very abnormal and are poorly differentiated (severe dysplasia)

Grade 4 – cells are immature and undifferentiated; cell of origin is difficult to determine (anaplasia)

Stage 0 – carcinoma in situ

Stage 1 – tumor limited to the tissue of origin; localized tumor growth

Stage 2 – limited local spread

Stage 3 – extensive local and regional spread

Stage 4 – distant metastasis

TNM CLASSIFICATION

T – the extent of the primary tumor

N – the absence or presence and extent of regional lymph node metastasis

M – the absence or presence of distant metastasis 

Primary tumor (T)

TX – primary tumor cannot be assessed

T0 – no evidence of primary tumor

Tis – carcinoma in situ

T1, T2, T3, T4 – increasing size and/or local extent of the primary tumor

Regional lymph nodes (N)

NX – regional lymph nodes cannot be assessed

N0 – no regional lymph node metastasis

N1, N2, N3 – increasing involvement of regional lymph nodes

Distant metastasis (M)

MX – distant metastasis cannot be assessed

M0 – no distant metastasis

M1 – distant metastasis

PART 10. DIFFERENT TYPES OF CANCER

SKIN CANCERIs a malignant lesion of the skin, which may or may not metastasize

Skin cancer causes include chronic friction and irritation to a skin area and exposure to ultraviolet rays.

Diagnosis is confirmed by a skin biopsy that is positive for cancer cells

Types:

Basal cell – the most common type, basal cell cancer arises from the basal cell contained in the epidermis.

Waxy borderpapule, red, central cratermetastasis is rare

Squamous cell – the second most common type of skin cancer in whites; squamous cell cancer is the tumor of the epidermal epidermal keratinocytes and can infiltrate surrounding structures, metastasize to lymph nodes, and subsequently be fatal.

Oozing, bleeding, crusting lesionPotentially metastaticLarge tumors associated with a higher risk for metastasis

Malignant melanoma – may occur any place on the body, especially where birthmarks or new moles are apparent. Cancer of the melanocytes can metastasize to the brain, bones, lung, liver and skin and is ultimately fatal.

Irregular, circular, bordered lesion with hues of tan, black or blueRapid infiltration into tissue, rapid metastasis, significant rate of morbidity and mortality

Instruct the client regarding preventive measures

Instruct the client to monitor for lesions that do not heal or that change characteristics

Instruct the client to have moles or lesions removed that are subject to chronic irritation

Instruct the client to avoid contact with chemical irritants

Instruct the client to wear layered clothing and use sunscreen lotions with an appropriate skin protection factor when outdoors

Instruct the client to avoid sun exposure between 11 AM and 3 PM

Assist with surgical excision of the lesion as prescribed

BREAST CANCERIs classified as invasive when it penetrates the tissue surrounding the mammary duct and grows in an irregular pattern

Metastasis occurs via lymph node

Diagnosis is made by breast biopsy through a needle aspiration or by surgical removal of the tumor with microscopic examination of malignant cells

AssessmentMass felt during BSEAsymmetry, with the affected breast being higherBloody or clear nipple dischargeSkin dimpling, retraction, or ulcerationSkin edema or peau d’orange skinAxillary lymphadenopathyLymphedema of the affected arm

Non surgical interventions

Chemotherapy

Radiation therapy

Hormonal manipulation via the use of medication in post-menopausal women or other medications such as tamoxifen (Nolvadex) for estrogen receptor-positive tumors.

Surgical interventions1. Lumpectomy tumor is excised and removedlymph node dissection may also be performed

2. simple mastectomybreast tissue and the nipple are removedlymph nodes are left intact

3. modified radical mastectomybreast tissue, nipple, and lymph nodes are removedmuscles are left intact

monitor vital signs

position the client in Semi-Fowler’s position

turn from the back to the unaffected side, with the affected arm elevated above the level of the heart to promote drainage and prevent lymphedema

encourage coughing and deep breathing

if a drain (usually Jackson – Pratt) is in place, maintain suction and record the amount of drainage and drainage characteristics

assess operative site for infection, swelling, or presence of fluid collection under the skin flaps or in the arm

place a sign above the bed stating: No IV’s, No injections, No BP’s, No venipuncture in affected arm; the affected arm is protected and any intervention that could traumatize the affected arm is avoided.

Consult with the physician and physical therapist regarding the appropriate exercise program and assist client with prescribed exercise

Client instruction following mastectomy: Avoid overuse of the arm during the first few months

To prevent lymphedema, keep the affected arm elevated

Encourage the client to perform BSE on the remaining breast

Protect the affected hand and arm

Do not let the affected arm hang dependent

Do not carry pocketbook or anything heavy over the affected arm

Avoid trauma, cuts, or bruises, or burns to the affected side

Avoid wearing constricting clothing or jewelry on the affected side

Wear gloves when gardening

Use thick oven mitts when cooking

Use a thimble when sewing

LUNG CANCERMalignant tumor of the bronchi and peripheral lung tissue, is a leading cause of cancer-related deaths in men and women in the United States

The lungs are a common target for metastasis from other organs

Bronchogenic cancer (tumors originate in the epithelium of the bronchus) spreads through direct extension and lymphatic dissemination

Classified according to histological cell type, there are two main types of lung cancer, small cell lung cancer and non-small cell lung cancer.

Diagnosis is made by a chest x-ray, CT scan, or MRI, which will show a lesion or mass and by bronchoscopy and sputum studies, which will demonstrate a positive cytological study for cancer cells

CAUSES

Cigarette smoking, exposure to “passive” tobacco smoke

Exposure to environmental and occupational pollutants

ASSESSMENT

Cough

Wheezing, dyspnea

Hoarseness

Hemoptysis

Chest pain

Anorexia

Weakness

Diminished or absent breath sounds, respiratory changes

INTERVENTIONS

Monitor vital signs

Monitor for breathing patterns and breath sounds

Place in a fowler’s position to help ease breathing

Administer oxygen as prescribed and humidification to moisten and loosen secretions

Monitor pulse oximetry

provide a high calorie, high protein, high vitamin diet

provide activity as tolerated, rest periods, and active and passive range of motion exercises

monitor for bleeding and infection 

NONSURGICAL INTERVENTIONS

radiation therapy may be prescribed for localized intrathoracic lung cancers and for palliation of hemoptysis, obstructions, dysphagia, superior vena cava syndrome, and pain

chemotherapy may be prescribed for treatment of nonresectable tumors or as adjuvant therapy

SURGICAL INTERVENTIONSlaser therapy: to relieve endobronchial obstruction

thoracentesis and pleurodesis: to remove pleural fluid and relive hypoxia

thoracotomy with pneumonectomy: surgical removal of one entire lung

thoracotomy with segmental resection: surgical removal of a lobe segment 

PROSTATE CANCERA slow growing malignancy of the prostate gland; most prostate tumors are adenocarcinoma arising from androgen-dependent epithelial cells

The risk increases in men with each decade after the age of 50 years

Can spread by direct invasion of surrounding tissues or by metastasis, through the blood stream and lymphatics, to the bony pelvis and spine

The cause of prostate cancer is unclear, but advancing age, heavy metal exposure, smoking, and history of sexually transmitted disease are contributing factors

ASSESSMENT

Asymptomatic in early stages

Hard, pea-sized nodule or irregularities palpated on rectal examination

Gross, painless hematuria