NCM112 LECTURE

MEDICAL-SURGICAL NURSING

CELLULAR ABERATIONS
TOPIC OUTLINE: CANCER DESCRIPTION

ALCON, MARY GRACE  Cancer is a disease in which some of the body’s cells
AQUINO, JVY MARIE grow uncontrollably and spread to other parts of the
AZUTEN, ZYZA-ZHOLEY body.
BALLESTA, ERIKA  Cancer can start almost anywhere in the human body,
BORJA, RIVERT JAMES which is made up of trillions of cells. Normally, human
CARTUJANO, DAZLYNE cells grow and multiply (through a process called cell
CASTERAL, EILEITHIA CHYAVANNA division) to form new cells as the body needs them.
CORPUZ, MARK ANTHONY When cells grow old or become damaged, they die, and
DERY, JOHN BRYAN new cells take their place.
TACCAD, HANNAH  Sometimes this orderly process breaks down, and
TALOSIG, KEZIAH abnormal or damaged cells grow and multiply when they
SOMERA, KARLA MAE shouldn’t. These cells may form tumors, which are
lumps of tissue. Tumors can be cancerous(malignant) or
I. CANCER DESCRIPTION not cancerous (benign).
a. Common sites of metastasis  Cancerous tumors spread into, or invade, nearby tissues
b. Grading and staging and can travel to distant places in the body to form new
c. General pathophysiology tumors (a process called metastasis). Cancerous tumors
1. Factors that influence cancer development may also be called malignant tumors. Many cancers
2. Prevention form solid tumors, but cancers of the blood, such as
3. Early detection leukemias, generally do not.
4. Warning signs (CAUTION)  Benign tumors do not spread into, or invade, nearby
d. Diagnostic tests tissues. When removed, benign tumors usually don’t
1. Biopsy grow back, whereas cancerous tumors sometimes do.
2. Bone marrow examination Benign tumors can sometimes be quite large, however.
3. Chest radiograph Some can cause serious symptoms or be life
4. CBC threatening, such as benign tumors in the brain.
5. MRI

II. PAIN CONTROL COMMON SITES OF METASTASIS

a. Causes
b. Interventions

III. CHEMOTHERAPY
a. Description and classification
b. General nursing responsibilities

IV. RADIATION THERAPY

a. Description and classification
1. Teletherapy  Cancer can spread to almost any part of the body,
2. Brachytherapy although different types of cancer are more likely to
b. General nursing responsibilities spread to certain areas than others. The most common
sites for cancers to metastasize include the lungs, liver,
V. COMMON CELLULAR ABERRATIONS bones and brain. Other places include the adrenal
a. Breast cancer gland, lymph nodes, skin and other organs. The
b. Lung cancer following list shows the most common sites of
c. Colon cancer metastasis, not including the lymph nodes, for some
d. Liver cancer common cancers:
e. Cervical cancer
f. Ovarian cancer
g. Prostate cancer

VI. HEMATOLOGIC CELLULAR

ABERRATIONS
a. Leukemia
b. Lymphoma

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Tumor grading:
 Sometimes, a metastasis will be found without a known
primary cancer (point of origin). In this situation, your
health care provider will search extensively for the
primary cancer source. If none can be found, it’s called
cancer of unknown primary (CUPS).
GRADING AND STAGING
GRADING
Grading is the histologic assessment of tumor cells
according to their state of differentiation.
 Microscopic examination of tumor cells after surgery
or biopsy
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 Tumor cells are grouped into 4 types based on their
resemblance to/difference from healthy cells (G1,
G2, G3, G4):
o Well-differentiated tumors (low grade, G1)
generally have a better prognosis than
poorly differentiated tumors (high grade,
G4).
o Poorly differentiated tumors are called
anaplastic.
 Tissue markers are helpful if cells of unknown origin
are found:
o Cytokeratin is expressed by carcinomas.
o Vimentin is expressed by sarcomas.
o CD45 is expressed by lymphomas.
Grading is performed for most types of tumors, but there
are specific exceptions.
 Prostate cancer: uses the Gleason score ranging
from 2–10
o Based on the growth pattern and degree of
differentiation of tumor cells
o A higher score is associated with disease
outside the prostate.
o A higher score indicates a greater likelihood
of a worse prognosis.
 Brain tumors: specific WHO classification
o Uses both genotype and phenotype for
some tumors
o Immunohistochemical data for molecular
genetic alterations are used in addition to
histology.
 Breast cancer: uses the Nottingham grading system
o Based on tubule formation of the tumor,
nuclear grade, and mitotic rate
o Each category is scored between 1 and 3,
and a total score is calculated.
o Total score of 3–5 is G1 (low grade; well
differentiated).
o Total score of 6–7 is G2 (intermediate
grade; moderately differentiated).
o Total score of 8–9 is G3 (high grade; poorly
differentiated).
 Gx = grade cannot be assessed (undetermined
grade)
 G1 = well differentiated, close similarity to original
tissue (low grade)
 G2 = somewhat differentiated malignant tissue
(intermediate grade)
 G3 = poorly differentiated malignant tissue (high
grade)
 G4 = undifferentiated malignant tissue: The original
tissue that gave rise to the tumor can be determined
only by immunohistochemical evaluation or not at all
(high grade).
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STAGING o Cervical and ovarian cancer: International
Federation of Gynecology and Obstetrics
Staging for cancer describes the extent of the disease (FIGO) system
and is used to help communicate with other members of o Breast carcinoma staging uses TNM plus
the medical and surgical team for treatment decisions other factors to determine stage:
and prognosis. For example, with colon cancer, after  Grade
surgery and pathologic staging, chemotherapy given to  Receptor status: human epidermal
individuals with stage III disease eradicates growth factor receptor(HER)-
micrometastases, reduces the likelihood of disease 2, estrogen receptor (ER),
recurrence, and increases cure rates. and progesterone receptor (PR)
o Lung cancer:
 Clinical staging (“c” before the stage) happens before  T relates to tumor size but also to
surgery. whether it has invaded nearby
o Physical exam structures.
o Imaging with CT, MRI, or PET scans  N of the TNM stage uses the
 Pathologic staging (“p” before the stage) is done number of involved nodal stations.
after biopsy or surgical removal.  M of the TNM stage is divided
 Stages range from localized to widespread: according to whether metastatic
o Stage 0: carcinoma in situ (marked growth disease is limited to the chest or
of abnormal cells that have not spread to single/multiple extrathoracic sites
neighboring tissue but have the potential to of metastasis.
develop into a tumor) o Melanoma uses the TNM staging system;
o Stage I: localized (beyond the basement however:
membrane)  Concordance with consensus
o Stage II: early localized advanced reference diagnosis and
o Stage III: late locally advanced reproducibility between
o Stage IV: metastasized to different organs pathologists remains low.
 Stage is applied after a tumor is classified using  T of the TNM stage takes into
the TNM system. account tumor thickness
o The American Joint Committee on Cancer in mm and the presence or
(AJCC) updates the staging system absence of ulceration.
periodically; currently, the 8th edition is  M of the TNM stage takes into
being followed (effective 2018). account the lab LDH levels.
o Relies on anatomic, macroscopic groupings o Colon cancer staging:
of disease with similar prognoses  Clinical staging is based on exam,
o T = size and extent of the primary tumor: CT results, and tumor marker
 Tx: Primary tumor cannot be carcinoembryonic
measured. (CEA) antigen levels.
 T0: absence of primary tumor  Pathologic staging is based on
 T1–T4: assignment according to TNM.
the specific type of tumor
considering criteria such as size,
invasive depth, and infiltration of
neighboring tissue and organs
o N = involvement of lymph nodes:
 Nx: Involvement of
neighboring lymph nodes cannot
be assessed.
 N0: no involvement of
neighboring lymph nodes
 N1–N3: number and localization
of lymph nodes with cancer
o M = status of metastases:
 Mx: Distant metastases cannot be
assessed.
 M0: no metastases
 M1: distant metastases observed
 Staging is specific for each cancer; some deviate
from the commonly used TNM system.
o Lymphoma: Ann Arbor staging

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Example of T1–T4 staging for tumor in the colon

T1: Tumor invades the submucosa (through the muscularis
mucosa but not into the muscularis propria).
T2: Tumor invades the muscularis propria.
T3: Tumor invades through the muscularis propria into the
surrounding tissues.
T4: Direct extension through the serosa, invading the visceral
peritoneum or adhering to adjacent organs

GENERAL PATHOPHYSIOLOGY

FACTORS THAT INFLUENCE CANCER DEVELOPMENT

 Carcinogenesis- Carcinogenesis is the

development of cancer by transforming healthy cells
into cancer cells.
o Molecular Process
 Initiation
 Promotion
 Progression
 Proliferative Patterns
o Etiology- Factors implicated or known to
induce carcinogenesis include viruses and
bacteria, physical agents, chemicals,
genetic or familial factors, lifestyle factors,
and hormones. Additional research is
needed for a better understanding of the
relationships among etiologic factors and
cancer.
 Viruses and Bacteria- Examples of
these viruses that are known to
cause cancer include human
papillomavirus (HPV) (cervical
and head and neck cancers),
hepatitis B virus (HBV) (liver
cancer), and Epstein–Barr virus
(EBV) (Burkitt lymphoma and
nasopharyngeal cancer).
Examples of bacteria that are
associated with an increased risk
of cancer include: Helicobacter
pylori (stomach cancer),

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Salmonella enteritidis (colon
cancer), and Chlamydia
trachomatis (ovarian and cervical
cancers)
 Physical Agents- Physical factors
associated with carcinogenesis
include exposure to sunlight,
radiation, chronic irritation or
inflammation, tobacco
carcinogens, industrial chemicals,
and asbestos (ACS, 2019b).
 Chemical Agents (Tobacco,
Cigarette smoking, Environmental
tobacco smoke (ETS), otherwise
known as secondhand smoke.
Other combustible forms of
tobacco, such as cigars, pipes,
roll-your-own products, and water
 pipes (or hookah), are also
associated with increased cancer
risk (ACS, 2019d). Electronic
nicotine delivery systems (ENDS)
including e-cigarettes, e-pens,
epipes, e-hookah and e-cigars
have gained increased popularity
as an alternative to tobacco.
Smokeless tobacco products,
such as chewing tobacco, snuff
and snus, used most often by
young adults aged 18 to 25 years,
are associated with an increased
risk of oral, pancreatic, and
esophageal cancer. The extensive
list of suspected chemical
substances continues to grow and
includes aromatic amines and
aniline dyes; pesticides and
formaldehydes; arsenic, soot, and
tars; asbestos; benzene;
cadmium; chromium compounds;
nickel and zinc ores; wood dust;
beryllium compounds; and
polyvinyl chloride. Betel quid,
which are chewed as stimulants in
some cultures, are also included.
 Genetics and Familial Factors
 Lifestyle Factors (e.g., obesity,
alcohol intake, poor diet, physical
inactivity)
 Hormonal Agents (Prenatal
exposure to diethylstilbestrol,
Hormonal changes related to the
female reproductive cycle,
Estrogen, Combination estrogen
and progesterone therapy)
 Role of the Immune System
o Normal Immune Response
o Immune System Evasion
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PREVENTION
 Eat a healthy diet. Consider the following:
o Eat plenty of fruits and vegetables and other
foods from plant sources — such as whole
grains and beans.
o Drink alcohol only in moderation.
o Limit processed meats.
 Maintain a healthy weight and be physically
active.
 Don’t use tobacco. Smoking has been linked to
many types of cancer, including cancer of the lung,
mouth, throat, pancreas, bladder, cervix, and kidney.
 Protect yourself from the sun. Skin cancer is one
of the most common kinds of cancer and one of the
most preventable. Stay out of the sun between 10am
and 4pm when the sun’s rays are the strongest.
 Get vaccinated. Protecting against certain viral
infections can help protect against cancer.
 Get regular medical care and cancer screening
tests. Doing regular self-exams and having
screening for cancers — such as cancer of the skin,
color, cervix and breast can raise the chances of
finding cancer early.
 Know yourself, your family history, and your
risks.
EARLY DETECTION
 Screening tests are used to find cancer before a person
has any symptoms.
 Regular screenings can help find and treat pre-cancers
and cancers early, before they have a chance to spread.
BREAST CANCER
 Women ages 40-44 should have the choice to start
annual breast cancer screening with mammogram (x-rays
of the breast).
 Women ages 45-older should get mammograms every
year.
 Women should also know how their breasts normally look
and report any breast changes to a health care provider.
COLON AND RECTAL CANCER AND POLYPS
 The American Cancer Society recommends starting
regular screening at age 45.
 This can be done through a stool-based test, or with an
exam that looks at the colon and rectum (a visual exam).
CERVICAL CANCER
 Screening should start at age 25.
 Ages 25-65 should get a primary HPV (human
papilomavirus) test done every 5 years.
 Pap-smear test every 3 years.
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ENDOMETRIAL CANCER
 The American Cancer Society recommends that at the
time of menopause, all women should be told about the
risks and symptoms of endometrial cancer.
 core needle biopsy uses a larger needle to remove a
 Women should report any unexpected vaginal bleeding
or spotting.
LUNG CANCER
 People at increased risk for lung cancer is recommended
to get an annual lung screening test.
 People who currently smoke or have quit in the past 15
years and have at least a 20 pack-year smoking history
are required to have a screening test for LDCT scans.
PROSTATE CANCER
 Starting at age 50, men should talk to a health care
provider about the pros and cons of testing.
 Men who have a family history of prostate CA should start
at age 45.
 Women should also know how their breasts normally look
and report any breast changes to a health care provider.
WARNING SIGNS (CAUTION)
 Change in bowel or bladder habits
 A sore that does not heal
 Unusual bleeding or discharge
 Thickening or lumps
 Indigestion or difficulty in swallowing
 Obvious change in wart or mole
 Nagging or persistent cough or hoarseness
 Unexplained anemia
 Sudden unexplained weight loss
DIAGNOSTIC TESTS
BIOPSY
 In a biopsy, a doctor takes a small amount of tissue from
the area of the body where cancer may be present. The
tissue is sent to a laboratory and examined under a
microscope for cancer cells by a specialist called a
pathologist. Other tests can suggest that cancer is in the
body, but only a biopsy can test to show whether there
are cancer cells.
 The type of biopsy you have depends on where the
possible cancer is located.
TYPES OF BIOPSIES
 Needle biopsies. This general category refers to
different biopsies, each using a special needle to collect
cells to test an area for cancer.
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For instance, in a fine needle aspiration biopsy, the
doctor inserts a very thin, hollow needle through the skin
to collect a sample of cells and sometimes fluid for
examination. This is the most simple type of biopsy. It is
often used when a mass can be felt through the skin. A
larger tissue sample than a fine needle biopsy. A vacuum-
assisted biopsy uses a suction device to collect a tissue
sample through a specially designed needle. Your doctor
can collect multiple or large samples from the same
biopsy site with this method.
 Image-guided biopsy. This type of biopsy uses imaging
equipment to help your doctor take the sample. You might
have this if your doctor cannot feel a tumor, or it may be
deeper inside the body. Sometimes, even if a tumor is
large enough to feel, image-guided biopsy can be used to
help direct the doctor to the right part of the body. This
helps the doctor do the biopsy in the safest way possible.
The imaging equipment may be:
o Ultrasound
o Fluoroscopy
o Computed tomography (CT) scan
o X-ray
o Magnetic resonance imaging (MRI) scan
 Surgical (excisional) biopsy. This type of biopsy is
done using surgery to remove the tissue your doctor
thinks may be cancer. The surgeon makes an incision
(cut) into the skin to remove the suspicious tissue. The
complexity of the surgery depends on the area of the body
involved.
 Shave biopsy/punch biopsy. For a shave biopsy, the
doctor removes some tissue by scraping the surface of
the skin. In a punch biopsy, they use a small circular
instrument to push through the surface of the skin and
take a sample of tissue from below the skin's surface.
These are used most commonly for a skin biopsy.
 Endoscopic biopsy. An endoscope is a thin, lighted,
flexible tube with a camera that allows doctors to view the
inside of the body, including the esophagus, stomach,
bladder, and joints. The endoscope goes in through the
mouth, nose, or a small incision in the skin. The attached
camera helps the doctor see any abnormal areas. Your
doctor can also take tissue samples for a biopsy. Learn
more about the different endoscopic techniques.
 Laparoscopic biopsy. Similar to an endoscopic biopsy,
this type of biopsy is used to examine for certain areas of
the body, including the abdomen or pelvis. When used for
the chest, it is called a thoracoscopy or thoracoscopic
biopsy. In this type of biopsy, the doctor inserts a thin tube
with a video camera called a laparoscope into the
abdomen through small incisions. This allows the doctor
to see abnormal areas and take tissue samples for
examination.
 Bone marrow aspiration and biopsy. Bone marrow is
the soft tissue and liquid inside your bones. The
aspiration takes a small sample of the liquid with a needle,
while the biopsy takes a sample of solid tissue. A bone
marrow aspiration and biopsy is done to check for a
blood disorder or blood cancer, such as leukemia,
lymphoma, or multiple myeloma. Bone marrow aspiration
and biopsy are often taken from the pelvic bone. This is
on the lower back, near the hip.
 Liquid biopsy. Testing a blood sample for cancer is
called a liquid biopsy. You give a small sample of blood,
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and it is sent to the lab for specific tests. It can also show
how cancer is responding to treatment. A liquid
biopsy has less risk than taking a sample of tissue, and
your doctor can do it multiple times. However, this type of
biopsy is still new and it is not done for most types of
cancer. There is a lot of research ongoing to expand
usage of this technique.
GETTING READY FOR BIOPSY
 You might need to remove your clothing and jewelry and
put on a hospital gown after you arrive.
 Ask whether there are restrictions on what you can
eat or drink before the biopsy. If there are
restrictions, ask for how long beforehand.
 Ask if you should take your regular medications that
day. For certain biopsies, your doctor will want to
know if you are taking blood thinners or aspirin. Tell
your doctor about all medications and supplements
you are taking.
 Tell your doctor about any allergies or other medical
conditions you have.
 Be sure you understand where the biopsy will take
place. If it is at a different location than your doctor's
office, be sure to talk with that location about your
health insurance coverage for the test.
 You will be asked to sign a consent form saying you
understand the benefits and risks and agree to have
the biopsy. Ask any questions you may have about
this legal form.
 Being nervous about an upcoming medical test is
common and is sometimes called scanxiety. If you
feel very worried, talk with your health care team
about ways to cope with these feelings.
 Ask what to expect about your recovery after the test.
DURING BIOPSY
 Depending on the part of your body being checked, you
might lie down or sit up. You might need to hold your
breath or stay still. Your health care team will let you know
what to expect.
 Before the procedure, you may receive a type of
anesthesia to block the awareness of pain. The type
depends on biopsy and where it is done. You may have
local anesthesia to numb the area, conscious sedation, or
general anesthesia.
AFTER BIOPSY
 Your recovery period will depend a lot on the type of
biopsy done. You might be able to go back to normal
activities as soon as the test is over. Or you may need to
rest at home for some time or stay in the hospital to begin
your recovery. If your anesthesia includes a sedative, you
need someone to drive you home afterwards.
 Talk with your doctor or nurse about how you should take
care of the biopsy area during your recovery. Contact
your doctor’s office if you experience:
o Redness or swelling in the area where the
biopsy was done
o Severe pain
o Fever
o Bleeding
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BONE MARROW EXAMINATION
 crucial when additional information is needed to
assess how a patient’s blood cells are being formed
 to assess the quantity and quality of each type of
cell produced within the marrow
 results of these tests can be used to document
infection or tumor within the marrow.
 Normal bone marrow: semifluid state and can be
aspirated through a special large needle
o Adults
 LOCATION of bone marrow
aspiration: iliac crest & sternum
 BONE MARROW ASPIRATE: provides a sample of
cells from the more fluid part of the bone marrow
 BONE MARROW BIOPSY: examines the solid part
of the bone marrow
o LOCATION: posterior iliac crest
o shows the architecture of the bone marrow
as well as its degree of cellularity
BEFORE ASPIRATION
 Skin is cleansed using ASEPTIC TECHNIQUE
 Small area is anesthesized with LOCAL
ANESTHETIC AGENT thru the skin and
SUBCUTANEOUS TISSUE TO THE PERIOSTEUM
OF THE BONE
 Note: Not possible to anesthesize the bone itself
 Bone marrow is introduced with stylet in place
 When the needle moves through the outer cortex of
bone and enters the marrow cavity, the stylet is
removed, and a syringe is attached
 A small volume (5 mL) of blood and marrow is then
aspirated.
 Px feel pressure sensation as the needle is
advanced
 Actual aspiration causes sharp but brief pain
o Management: Deep breaths and relaxation
techniques
BONE MARROW BIOPSY
 Uses large special needle
 Skin may be punctured first with a surgical blade to
make a 3-4 mm incision (advanced to the marrow
cavity)
 Patient will feel pressure pressure but not pain
COMPLICATIONS OF BONE MARROW ASPIRATION OR
BIOPSY
 Bleeding — increased if px platelet count is LOW
 Infection
AFTER THE BIOPSY
 After marrow sample is obtained, pressure is
applied to site for several minutes
 Site will be covered with sterile dressing
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 Most patients have no discomfort but site of biopsy
may ache for 1 to 2 days
o Management: warm tub baths and mild
analgesic agent
o Do not use aspirin-containing analgesic
agent — may increase risk of bleeding
o Do not perform rigorous activity or exercise
for 1 to 2 days
CHEST RADIOGRAPH
 obtained to determine the size, contour, and
position of the heart, lungs, bronchi, aorta,
pulmonary arteries, mediastinum, bones of your
chest
 reveals cardiac and pericardial calcifications and
demonstrates physiologic alterations in the
pulmonary circulation.
 often the first imaging test a doctor will order if lung
or heart disease is suspected
 white or gray area: absorbed more radiation (e.g.,
white — bones; gray — lungs)
 black: absorbed less radiation (e.g. gases In lungs)
CHEST X-RAY IN DIAGNOSING LUNG CANCERS
 poor tool in diagnosing lung cancer since tumors
are also seen during advanced stages
 advanced lung cancer(stage 3b or 4) — more
difficult to treat
 Lung Nodule: spot is 3cm or approx 1.5 inches or
less in dm
 Lung mass: spot greater than 3cm
 Lung neoplasm: new growth in the lungs
 Lung lesion: any abnormalities
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 Note: Tumors appear as a white-grey mass on x-
ray
BEFORE CHEST X-RAY
 Wear loose and comfortable clothing that does not
contain metal
 Do not wear jewelry.
 Ask the radiologist for specific instructions regarding
body piercings.
DURING CHEST X-RAY
 change into a medical gown
 remove all metal, such as eyeglasses, jewelry or
hairpins
 You stand with your chest against the metal plate of
the X-ray machine and your hands on your hips.
This position produces an image of the front of your
chest.
 You stand with your side against the metal plate of
the X-ray machine and your arms in the air. This
position creates an image of the side of your chest.
 During the chest X-ray, you need to remain very still
and hold your breath. Any movement, even
breathing in and out, can blur the X-ray image.
CBC
 A complete blood count (CBC) is a common medical test
that your doctor may recommend to monitor your health.
In cancer care, this blood test can be used to help
diagnose a cancer or monitor how cancer or its treatment
is affecting your body. For example, people undergoing
chemotherapy often receive regular CBCs.
 may be used to evaluate for the presence of anemia.
Assessment of tumor markers (blood analysis for antigens
indicative of cancer), such as carcinoembryonic antigen
(CEA), carbohydrate antigen (CA 19-9), and CA 50 are
monitored to determine the effectiveness of treatment(s)
 Help diagnose some blood cancers, such as leukemia and
lymphoma.
 Helps find out if cancer has spread to bone marrow.
HOW IS CBC PERFORMED?
 First, your doctor will order the CBC test be done as
part of your medical care. Then, your blood will be
drawn for a blood sample. Sometimes you will need
to avoid eating or taking certain medications before
getting a CBC to get the most accurate results. Your
health care provider will let you know if this is the case.
 After your blood is drawn, the sample is sent to a
laboratory for analysis. Your health care provider will
let you the results, such as through a phone call or
your online patient portal.
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WHAT DO CBC RESULTS MEAN?
 Low white blood cell count. Some cancer
treatments, mainly chemotherapy, can lower your
white blood cell count.
 Cancers that affect the blood can also lower white
blood cell count. These types of cancers include
leukemia, lymphoma, and multiple myeloma.
 High and low results in the white blood cell
differential. Having results that show higher or lower
than normal numbers of certain white blood cells can
mean different things.
 Higher-than-normal numbers of lymphocytes or
monocytes can indicate the possibility of certain types
of cancer. Some cancers and their treatment may
cause low numbers of neutrophils, a condition
called neutropenia. Neutropenia can increase your
chance of a bacterial infection.
 Low red blood cell count. Some cancer treatments,
such as chemotherapy and radiation therapy, can
lower your red blood cell count. This condition is
known as anemia.
 Low platelet count. Some cancer treatments, such
as chemotherapy or radiation therapy, can lower
platelet count. Cancers that affect the bone marrow
can also lower the platelet count.
MRI
 MRI (also known as magnetic resonance
imaging, magnetic resonance, MR, and nuclear magnetic
resonance [NMR] imaging) helps doctors find cancer in the
body and look for signs that it has spread. MRI also can
help doctors plan cancer treatment, like surgery or
radiation. MRI is painless and you don’t have to do
anything special to get ready for this test.
WHAT DOES MRI SHOW?
 MRI creates cross-section pictures of your insides. But
MRI uses strong magnets to make the images – not
radiation. An MRI scan takes cross-sectional slices (views)
from many angles, as if someone were looking at a slice
of your body from the front, from the side, or from above
your head. MRI creates pictures of soft tissue parts of the
body that are sometimes hard to see using other imaging
tests.
 MRI is very good at finding and pinpointing some cancers.
An MRI with contrast dye is the best way to see brain and
spinal cord tumors. Using MRI, doctors can sometimes tell
if a tumor is or isn’t cancer.
 MRI can also be used to look for signs that cancer may
have metastasized (spread) from where it started to
another part of the body.
 MRI images can also help doctors plan treatment such as
surgery or radiation therapy.
BSN3A | PBL GROUP 1
HOW DOES MRI WORK?
 An MRI scanner is a long cylinder or tube that holds a
large, very strong magnet. You lie on a table that
slides into the tube, and the machine surrounds you
with a powerful magnetic field. The machine uses a
powerful magnetic force and a burst of radiofrequency
waves to pick up signals from the nuclei (centers) of
hydrogen atoms in your body. A computer converts
these signals them into a black and white picture.
 Contrast materials can be put into the body through a
vein to make the images clearer. Once absorbed by
the body, the contrast speeds up the rate at which
tissue responds to the magnetic and radio waves. The
stronger signals give clearer pictures.
PAIN CONTROL
 Not everyone with cancer has cancer pain, but some
do. If you have cancer that's spread or recurred, your
chance of having pain is higher.
 Cancer pain takes many forms. It can be dull, achy,
sharp or burning. It can be constant, intermittent,
mild, moderate or severe. How much pain you feel
depends on a number of factors, including the type
of cancer you have, how advanced it is, where it's
situated and your pain tolerance.
 Most cancer pain is manageable, and controlling
your pain is an essential part of your treatment.
CAUSES CANCER PAIN
 Pain can be caused by the cancer itself. Pain could
happen if the cancer grows into or destroys nearby
tissue. As a tumor grows, it can press on nerves,
bones or organs. The tumor can also release
chemicals that can cause pain.
 Treatment of the cancer can help the pain in these
situations. However, cancer treatments, including
surgery, radiation and chemotherapy, also can cause
pain.
SYMPTOMS
Signs and symptoms caused by cancer will vary depending on
what part of the body is affected.
Some general signs and symptoms associated with, but not
specific to, cancer, include:
 Fatigue
 Lump or area of thickening that can be felt under the
skin
 Weight changes, including unintended loss or gain
 Skin changes, such as yellowing, darkening or
redness of the skin, sores that won't heal, or changes
to existing moles
 Changes in bowel or bladder habits
 Persistent cough or trouble breathing
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 Difficulty swallowing
 Hoarseness
 Persistent indigestion or discomfort after eating
 Persistent, unexplained muscle or joint pain
 Persistent, unexplained fevers or night sweats
 Unexplained bleeding or bruising
CAUSES
 Cancer is caused by changes (mutations) to the DNA
within cells. The DNA inside a cell is packaged into a
large number of individual genes, each of which
contains a set of instructions telling the cell what
functions to perform, as well as how to grow and
divide. Errors in the instructions can cause the cell to
stop its normal function and may allow a cell to
become cancerous.
A gene mutation can instruct a healthy cell to:
 Allow rapid growth. A gene mutation can tell a cell
to grow and divide more rapidly. This creates many
new cells that all have that same mutation.
 Fail to stop uncontrolled cell growth. Normal cells
know when to stop growing so that you have just the
right number of each type of cell. Cancer cells lose
the controls (tumor suppressor genes) that tell them
when to stop growing. A mutation in a tumor
suppressor gene allows cancer cells to continue
growing and accumulating.
 Make mistakes when repairing DNA errors. DNA
repair genes look for errors in a cell's DNA and make
corrections. A mutation in a DNA repair gene may
mean that other errors aren't corrected, leading cells
to become cancerous.
These mutations are the most common ones found in cancer.
But many other gene mutations can contribute to causing
cancer.
CAUSES GENE MUTATION
Gene mutations can occur for several reasons, for instance:
 Gene mutations you're born with. You may be
born with a genetic mutation that you inherited from
your parents. This type of mutation accounts for a
small percentage of cancers.
 Gene mutations that occur after birth. Most gene
mutations occur after you're born and aren't
inherited. A number of forces can cause gene
mutations, such as smoking, radiation, viruses,
cancer-causing chemicals (carcinogens), obesity,
hormones, chronic inflammation and a lack of
exercise.
 Gene mutations occur frequently during normal cell
growth. However, cells contain a mechanism that
recognizes when a mistake occurs and repairs the
mistake. Occasionally, a mistake is missed. This
could cause a cell to become cancerous.
BSN3A | PBL GROUP 1
INTERVENTIONS
 A number of treatments are available for cancer pain.
Your options may depend on what's causing your
cancer pain and the intensity of the pain you're
feeling. You may need a combination of pain
treatments to find the most relief.
Options include:
 Over-the-counter pain relievers. For mild and
moderate levels of pain, pain relievers that don't
require a prescription may help. Examples include
aspirin, acetaminophen (Tylenol, others) and
ibuprofen (Advil, Motrin IB, others).
 Medications derived from opium
(opioids). Opioids are prescription medications
used to treat moderate to severe pain. Examples of
opioids include morphine (Kadian, Ms Contin, others)
and oxycodone (Oxycontin, Roxicodone, others).
Some opioids are short-acting medicines, so pain relief comes
quickly but you may need to take them more often. Other
opioid drugs are long-acting medicines, so pain relief takes
longer but the medicine doesn't need to be taken as often.
Sometimes short-acting and long-acting opioids are used
together.
 Other prescription medicines. Other types of
medicine can help relieve pain, including
antidepressants, anti-seizure drugs and steroids.
 Procedures to block pain signals. A nerve block
procedure can be used to stop pain signals from
being sent to the brain. In this procedure, a numbing
medicine is injected around or into a nerve.
 Integrative therapies. Some people find some pain
relief through acupuncture, massage, physical
therapy, relaxation exercises, meditation and
hypnosis.
Other treatments may be available for your particular
situation. In some places, it may be legal to use medical
marijuana for cancer pain.
All pain medicines have side effects. Work with your
doctor to understand the benefits and risks of each pain
treatment and how to manage the side effects. Together
you can decide which treatments may be best for you.
CHEMOTHERAPY
DESCRIPTION AND CLASSIFICATION
 Chemotherapy is a type of cancer treatment that uses
drugs to destroy cancer cells. The drugs work by stopping
or slowing the growth of cancer cells, which can help to
shrink tumors or prevent them from spreading to other
parts of the body. Chemotherapy can be used alone or in
combination with other treatments such as surgery or
radiation therapy. Chemotherapy drugs work by targeting
rapidly dividing cells, which includes cancer cells.
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However, they can also affect healthy cells in the body
that divide rapidly, such as those in the bone marrow, hair
follicles, and digestive tract.
 One of the most common side effects of chemotherapy is
nausea and vomiting, which can be managed with anti-
nausea medications. Hair loss is another common side
effect, but it is usually temporary and hair will usually grow
back after treatment has ended. Chemotherapy can also
weaken the immune system, making patients more
susceptible to infections. Patients may need to take
precautions to avoid exposure to infectious agents and
may require antibiotics or antifungal medications to
prevent or treat infections.
 Another important consideration in chemotherapy
treatment is the timing and dosage of the drugs.
Chemotherapy is usually administered in cycles, with
each cycle consisting of a period of treatment followed by
a period of rest. The length of each cycle and the number
of cycles will depend on the type and stage of cancer
being treated, as well as the patient's overall health and
tolerance for chemotherapy. In addition to traditional
chemotherapy drugs, there are also targeted therapies
that are designed to target specific molecules or
pathways involved in cancer growth. These therapies can
be more effective and have fewer side effects than
traditional chemotherapy, but they are often more
expensive and may only be effective for certain types of
cancer.
 Chemotherapy drugs can be classified into several
different categories based on their mode of action and the
types of cancer they are used to treat:
o Alkylating agents: These drugs work by attaching
alkyl groups to DNA strands, which makes it difficult
for cancer cells to divide and grow. Examples of
alkylating agents include cyclophosphamide,
cisplatin, and carmustine.
o Antimetabolites: These drugs interfere with the
synthesis of nucleic acids, which are essential for cell
division. Antimetabolites include drugs like
methotrexate, 5-fluorouracil, and gemcitabine.
o Anthracyclines: These drugs work by interfering
with the DNA of cancer cells and preventing them
from dividing and growing. Examples include
doxorubicin and epirubicin.
o Topoisomerase inhibitors: These drugs prevent
DNA from unwinding and replicating, which can
cause cancer cells to die. Topoisomerase inhibitors
include drugs like etoposide, irinotecan, and
topotecan.
o Plant alkaloids: Also called mitotic inhibitors, these
drugs interrupt the M phase of the cell cycle and
inhibit mitosis. They are used to treat breast and lung
cancers and myeloma, lymphoma, and leukemia.
Examples of drugs in this class include taxanes such
as paclitaxel and docetaxel, vinca alkaloids such as
vinblastine, vincristine and vinorelbine.
o Corticosteroids: This drug class includes naturally
occurring hormones such as the steroid hormones as
well as artificially synthesized analogues of these
hormones. They are used to treat lymphoma,
BSN3A | PBL GROUP 1
leukemia and multiple myeloma and examples
include prednisone, methylprednisolone and
dexamethasone.
o Mitotic inhibitors: These drugs prevent the mitotic
spindle from forming during cell division, which can
lead to cell death. Mitotic inhibitors include drugs like
paclitaxel, docetaxel, and vinblastine.
o Hormone therapy: This type of chemotherapy is
used to treat hormone-dependent cancers like breast
and prostate cancer. Hormone therapy drugs block
the production or activity of hormones that promote
cancer growth, such as estrogen or testosterone.
Examples of hormone therapy drugs include
tamoxifen, anastrozole, and leuprolide.
o Immunomodulators: These drugs help stimulate
the immune system to attack cancer cells. Examples
of immunomodulators include interferon, interleukin-
2, and monoclonal antibodies.
GENERAL NURSING RESPONSIBILITIES
Chemotherapy is a common cancer treatment that
involves the use of drugs to destroy cancer cells. As a
nurse, it is important to understand the general nursing
responsibilities related to chemotherapy administration to
ensure patient safety and optimal treatment outcomes.
Here are some of the general nursing responsibilities
related to chemotherapy:
 Preparing the patient for chemotherapy: Before the
patient undergoes chemotherapy, the nurse should
perform a thorough assessment of their physical and
emotional status. The assessment should include a
review of the patient's medical history, current
medications, and any allergies or prior reactions to
chemotherapy drugs. The nurse should also obtain
informed consent from the patient and educate them on
the treatment plan, including the benefits and potential
risks. It is important to provide the patient with clear and
concise information to ensure that they fully understand
the treatment plan and can make informed decisions.
 Monitoring the patient during chemotherapy:
Chemotherapy drugs can have significant effects on the
body, including changes in blood pressure, heart rate,
and oxygen saturation. Therefore, it is essential that the
nurse monitor the patient's vital signs throughout the
chemotherapy administration process. The nurse should
also be alert for any signs of allergic reactions, such as
itching, hives, or difficulty breathing, and respond
promptly if these occur.
 Administering chemotherapy drugs: The nurse should
follow the prescribed chemotherapy protocol, which
includes the correct dosage, timing, and administration
route. Chemotherapy drugs can be administered through
various routes, including intravenous (IV), intramuscular
(IM), and oral. The nurse should be familiar with the
different administration routes and know how to prepare
the chemotherapy drugs properly to ensure their efficacy
and minimize the risk of contamination.
 Managing chemotherapy side effects: Chemotherapy
can cause a range of side effects, including nausea,
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vomiting, fatigue, hair loss, and anemia. The nurse should
educate the patient on the potential side effects of
chemotherapy and provide supportive care to help
alleviate these symptoms. This may include administering
anti-nausea medication, providing hydration therapy, and
managing pain. It is important to monitor the patient's
response to the supportive care and adjust the treatment
plan as needed.
 Monitoring and managing complications:
Chemotherapy can also cause complications such as
infections, bleeding, or changes in blood counts. The
nurse should monitor the patient for any signs of
complications and take appropriate measures to manage
them. For example, if the patient develops an infection,
the nurse should administer antibiotics and monitor the
patient closely for any changes in their condition.
 Documenting chemotherapy administration and
patient response: The nurse should document the
chemotherapy administration details, including the drug
name, dose, route of administration, and patient
response. Documentation is essential for ensuring that
the patient receives the correct chemotherapy dose and
for tracking the patient's response to treatment. The nurse
should also report any adverse effects or complications
to the healthcare team to ensure that appropriate
measures are taken.
 Ensuring safety measures: Chemotherapy drugs are
potent medications that can be hazardous to healthcare
providers if not handled properly. Therefore, the nurse
should follow safety measures, such as wearing personal
protective equipment, handling chemotherapy drugs with
caution, and disposing of waste materials properly. It is
also important to educate the patient and their family
members on safety measures to minimize the risk of
exposure to chemotherapy drugs.
In summary, nursing responsibilities related to
chemotherapy involve preparing the patient for treatment,
administering chemotherapy drugs, monitoring the
patient for complications, managing side effects,
documenting treatment details, and ensuring safety
measures. By providing safe and effective care, nurses
can help improve treatment outcomes and enhance the
patient's quality of life during cancer treatment.
RADIATION THERAPY
DESCRIPTION AND CLASSIFICATION
 Radiation therapy is a cancer treatment that uses
high-energy x-ray or other particles to destroy cancer
cells. A doctor who specializes in giving radiation
therapy to treat cancer is called a radiation
oncologist.
 Radiation therapy can treat many different types of
cancer. It can also be used in combination with other
cancer treatments, such as chemotherapy and/or
surgery.
BSN3A | PBL GROUP 1
WHAT ARE THE GOALS OF RADIATION THERAPY?
The goals of radiation therapy depend on your type of cancer
and if and how far it has spread. Radiation therapy can be
given alone or as a part of a treatment plan that includes
different treatments. Some of the ways radiation therapy is
used include:
 As the primary treatment. Often, the goal of radiation
therapy is to get rid of all the cancer and keep it from
coming back.
 Before other treatments. Radiation therapy can be
given before other treatments, such as surgery, to
shrink a large tumor. This is called "neoadjuvant
radiation therapy."
 After other treatments. Radiation therapy can be
given after other kinds of treatments to destroy any
remaining cancer cells. This is called "adjuvant
radiation therapy."
 To relieve symptoms. Radiation therapy can be used
to relieve the signs and symptoms of cancer. This is
called "palliative radiation therapy."
TELETHERAPY
 Is the most common type of radiation used in the
treatment of cancer. This type of radiation uses an
external machine away from the body to direct
radiation towards the area of the body affected by
cancer
 It is a treatment option for patients with low-risk
prostate cancer; progression-free survival is similar
to that of low-risk patients treated with radical
prostatectomy.
 is prescribed by the radiation oncologist for a total
dose over a certain time frame—for example, 28
treatments over 5½ weeks.
The different types of external-beam radiation therapy
are:
 Three-dimensional conformal radiation therapy
(3D-CRT) – During this type of radiation therapy,
detailed 3-dimensional pictures of the cancer are
created from computed tomography (CT) or
magnetic resonance imaging (MRI) scans.
 Intensity modulated radiation therapy (IMRT) –
this is a more complex form of radiation therapy. With
IMRT, the intensity of the radiation is varied. This is
different than conventional 3D-CRT, which uses the
same intensity with each beam. IMRT targets the
tumor and avoids healthy tissue better than
conventional 3D-CRT.
 Proton beam therapy – this treatment uses protons
rather than x-rays. Proton therapy is a relatively new
treatment that requires special equipment. It is
currently only used to treat certain types of cancer.
Learn more about proton therapy.
 Image-guided radiation therapy (IGRT) – IGRT
uses imaging during radiation treatment. Images are
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CELLULAR ABERATIONS
taken right before and during treatment and
compared to imaging taken before treatment began.
This helps doctors position the radiation as precisely
as possible.
 Stereotactic radiation therapy (SRT) – this
treatment delivers a large, precise dose to a small
tumor area. The patient must remain very still. A
head frame or individual body molds help limit
movement. SRT is often given as a single treatment
or in fewer than 10 treatments. Some people may
need more than one course of SRT.
BRACHYTHERAPY
 Is the placement of radioactive sources within or
immediately next to the cancer site in order to
provide a highly targeted, intense dose of radiation
beyond a dose that is usually provided by EBRT.
 This form of radiation delivery helps to spare
exposure to normal surrounding tissue. The radiation
source can be implanted by means of needles or
rods, seeds, beads, ribbons, or catheters placed into
body cavities (vagina, abdomen, pleura), lumens
within organs, or interstitial tissue compartments
(breast, prostate). Multiple imaging techniques such
as ultrasound, CT, or MRI are used to guide
placement of radiation sources.
 May be delivered as a temporary or a permanent
implant. Temporary applications are delivered as
high-dose radiation (HDR) for short periods of time,
while low-dose radiation (LDR) is delivered over a
more extended period.
o ADVANTAGE OF HDR BRACHYTHERAPY
– Treatment time is shorter.
– There is reduced exposure to personnel.
– The procedure can be performed on an
outpatient basis over several days.
– Can be used for intraluminal, surface, interstitial,
and intracavitary lesions.
TOXICITY
 Unfavorable and unintended sign, symptom, or
condition associated with cancer treatment.
Toxicities associated with radiation therapy are most
often localized in the region being irradiated and may
be increased if concomitant chemotherapy is given.
 Acute or early toxicities most often begin within 2
weeks of the initiation of treatment and occur when
normal cells within the treatment area are damaged
and cellular death exceeds regeneration. Body
tissues most affected are those that normally
proliferate rapidly, such as the skin, the epithelial
lining of the gastrointestinal tract, and the bone
marrow.
 Altered skin integrity is common and can include
alopecia (hair loss) associated with whole brain
BSN3A | PBL GROUP 1
radiation. Other skin reactions, referred to as
radiodermatitis, occur along a continuum ranging
from erythema and dry desquamation (flaking of
skin) to moist or wet desquamation (dermis exposed,
skin oozing serous fluid) to, potentially, ulceration.
 Factors that contribute to the severity of
radiodermatitis include the dose and form of
radiation; use of concurrent chemotherapy,
immunotherapy, or targeted therapy; inclusion of skin
folds in the irradiated area; increased age, poor
nutritional status, chronic sun exposure, current
smoking status, and the presence of medical
comorbidities, such as diabetes or kidney failure.
NURSING MANAGEMENT
— Nurses anticipate, prevent, and work collaboratively
with other providers to manage symptoms
associated with radiation therapy in order to promote
healing, patient comfort, and quality of life.
Symptoms that are not appropriately managed may
lead to poor outcomes as a result of interruptions,
decreased doses, or early cessation of treatment.
— In particular, advanced age, elevated radiation dose,
and BMI have been associated with greater toxicity
and symptoms.
— The nature of the relationship between body mass
index (BMI) and radiation toxicities is less clear. For
example, a decreased BMI was found to be
associated with an increased incidence of toxicities
in women with cervical cancer; whereas, an
increased BMI (obesity) was associated with
increased incidence of late toxicities in men being
treated for prostate cancer. Consequently, the area
of the body being irradiated must be used as the
focus of nursing assessments of radiation toxicities.
— In patients receiving EBRT, the nurse assesses the
patient’s skin, nutritional status, and general feelings
of well-being throughout the course of treatment.
— If systemic symptoms such as fatigue occur the
nurse explains that these symptoms are a result of
the treatment and do not represent deterioration or
progression of the disease. The nurse should
recommend evidence-based interventions for the
management of fatigue, which should include
aerobic exercise, which is most effective when
adherence is high.
PROTECTING CAREGIVERS
— Patients receiving internal radiation emit radiation
while the implant is in place; therefore, contact with
the health care team is guided by principles of time,
distance, and shielding to minimize exposure of
personnel to radiation.
— Specific instructions are provided by the radiation
safety officer from the radiology department and
specify the maximum time that can be spent safely in
the patient’s room, the shielding equipment to be
used, and special precautions and actions to be
taken if the implant is dislodged.
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— Safety precautions used in caring for a patient
receiving brachytherapy include assigning the
patient to a private room, posting appropriate notices
about radiation safety precautions, having staff
members wear dosimeter badges, making sure that
pregnant staff members are not assigned to the
patient’s care, prohibiting visits by children or
pregnant visitors, limiting visits from others to 30
minutes daily, and seeing that visitors maintain a 6-
foot distance from the radiation source.
— Patients with seed implants typically return home;
radiation exposure to others is minimal.
— Information about any precautions, if needed, is
provided to the patient and family members to ensure
safety.
— Depending on the dose and energy emitted by a
systemic radionuclide, patients may or may not
require special precautions or hospitalization. The
nurse should explain the rationale for these
precautions to keep the patient from feeling unduly
isolated.
GENERAL NURSING RESPONSIBILITIES
— Patient education: The oncology nurse coordinator
educates patients about brachytherapy and what to
expect during the treatment process. This may
include information about the procedure, potential
side effects, and self-care instructions.
— Treatment planning: The nurse coordinator works
closely with the radiation oncologist to plan the
brachytherapy treatment, including selecting
appropriate radioactive sources and determining the
length and frequency of treatment.
— Coordination of care: The nurse coordinator
coordinates care for the patient, including scheduling
appointments, patient assessment and arranging for
any necessary tests or procedures as part of the
cancer care. They may also collaborate with other
healthcare providers, such as radiation therapists
and oncology nurses, to ensure a seamless patient
experience.
— Support for patients and families: The nurse
coordinator provides emotional support to patients
and their families throughout the cancer treatments,
helping them to cope with the stress and uncertainty
of a cancer diagnosis.
— Follow-up care: The nurse coordinator helps to
ensure that patients receive appropriate follow-up
care after the brachytherapy treatment is complete,
including monitoring for any potential side effects and
scheduling any necessary imaging or tests.
RADIATION SAFETY
— Nurses monitor the patient's exposure to
radiation during the brachytherapy procedure. This
includes calculating the dose of radiation the patient
will receive and monitoring the equipment to ensure
the correct amount of radiation is delivered to the
tumor site. They also work with radiation physicists
and radiation safety officers to ensure the correct
BSN3A | PBL GROUP 1
procedures are followed and all necessary safety
measures are in place.
— Nurses handle and dispose of radioactive
sources used in brachytherapy, which require
careful handling to prevent radiation exposure. They
must be trained in handling and disposing of
radioactive materials to ensure the safety of the
patient and the healthcare team.
— Nurses implement safety measures to protect the
patient and healthcare team during the
brachytherapy procedure. This includes wearing
protective equipment such as lead aprons and
gloves, as well as implementing procedures to
ensure the safe transport of radioactive sources and
equipment.
COMMON CELLULAR ABERRATIONS
BREAST CANCER
 Breast cancer happens when cells in your breast
grow and divide in an uncontrolled way, creating a
mass of tissue called a tumor.
 Breast cancer is a major health problem in the United
States. Current statistics indicate tha tover a lifetime
(birth to death), a woman’s risk of developing breast
cancer is about 12%, or one in eight.
 Risk of developing breast cancer increases with
increasing age. About two of three invasive breast
cancers are found in women 55 years or older. About
5% to 10% of breast cancer cases are thought to be
hereditary, resulting directly from gene defects (cell
mutations) inherited from a biologic parent.
TYPES OF BREAST CANCER
DUCTAL CARCINOMA IN SITU (DCIS)
 It is characterized by the proliferation of malignant
cells inside the milk ducts without invasion into the
surrounding tissue.
 Unlike invasive breast cancer, DCIS does not
metastasize and a woman generally does not die of
DCIS unless it develops into invasive breast cancer.
 DCIS can develop into invasive breast cancer if left
untreated.
INFILTRATING DUCTAL CARCINOMA
 70% tp 80% of all cases.
 The most common histologic type of breast cancer.
 The tumors arise from the duct system and invade
the surrounding tissues.
 They often form a solid irregular mass in the breast.
 Micropapillary invasive ductal carcinoma is a rare
type of aggressive ductal cancer characterized by a
high rate of axillary node metastasis and skin
involvement.
INFILTRATING LOBULAR CARCINOMA
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CELLULAR ABERATIONS
 10% to 15% of breast cancers. RISK FACTORS
 The tumors arise from the lobular epithelium and
typically occur as an area of ill-defined thickening in  Genetic mutation
the breast.  Increasing age
 They are often multicentric and can be bilateral.  Personal history
 Family history
MEDULLARY CARCINOMA  Early menarche
 Less than 1% of breast cancers and it tends to be  Late menopause
diagnosed more often in women younger than 50  Obesity
years.  High-fat diet
 Alcohol intake
 The tumors grow in a capsule inside a duct. They can
become large and may be mistaken for a PREVENTIVE STRATEGIES
fibroadenoma.
 The prognosis is often favorable.  Long-term Surveillance
 Chemoprevention
MUCINOUS CARCINOMA  Prophylactic Masectomy
 2% of breast cancers and often presents in women
who are postmenopausal and are 75 years and
CLINICAL MANIFESTATIONS
older.
 A mucin producer, the tumor is also slow growing;  Lesions
thus, the prognosis is more favorable than in many  Breast pain
other types.
 Skin dimpling
 Nipple retractions
TUBULAR CARCINOMA
 1% to 5% of breast cancers.  Skin ulceration
 Because axillary metastases are uncommon with this
histology, prognosis is usually excellent. ASSESSMENT AND DIAGNOSTIC FINDINGS

INFLAMMATORY CARCINOMA Staging

 Inflammatory carcinoma is a rare (1% to 5%) and
aggressive type of breast cancer that has unique
symptoms.
 The cancer is characterized by diffuse edema and
erythema of the skin, often referred to as peau
d’orange.
 This is caused by malignant cells blocking the lymph
channels in the skin.
 An associated mass may or may not be present; if
there is a mass, it is often a large area of indiscrete
thickening.
 Inflammatory carcinoma can be confused with an
infection because of its presentation.
 The disease can spread to other parts of the body
rapidly.
 Chemotherapy often plays an initial role in controlling
disease progression, but radiation and surgery may
also follow.
 Involves classifying the cancer by the extent of the
disease in the body.
 It is based on whether the cancer is invasive or
noninvasive, the size of the tumor, how many lymph
nodes are involved, and if it has spread to other parts
of the body.
 The stage of a cancer is one of the most important
factors in determining prognosis and treatment
options.
 Other diagnostic tests may be performed before or
after surgery to help in the staging of the disease.
 The extent of testing often depends on the clinical
presentation of the disease and may include chest
x-rays, computed tomography (CT) scan, MRI
scan, positron emission tomography (PET) scan,
bone scans, and blood work (complete blood
count, comprehensive metabolic panel, and
tumor markers.

Prognosis
PAGET DISEASE
 In general, the smaller the tumor appears, the better
 1% to 4% of diagnosed cases of breast cancer; it is
the prognosis.
more common in men than in women.
 A tumor starts with a genetic alteration in a single cell
 Symptoms typically include a scaly, erythematous,
and takes time to divide and double in size.
pruritic lesion of the nipple.
 A carcinoma may double in size 30 times to become
 Paget disease often represents DCIS of the nipple
1 cm or larger, at which point it becomes clinically
but may have an invasive component.
apparent.
 If no lump can be felt in the breast tissue and the
 Prognosis also depends on the extent of spread of
biopsy shows DCIS without invasion, the prognosis
the breast cancer.
is very favorable.

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CELLULAR ABERATIONS
 The most common route of regional spread is to the
axillary lymph nodes.
 Other sites of lymphatic spread include the internal
mammary and supraclavicular nodes.
LUNG CANCER
 Lung cancer is cancer that forms in tissues of the
lung, usually in the cells that line the air passages.
 It is the leading cause of cancer death in both men
and women.
 It is the leading cancer killer among men and women
in the United States, with about 1 out of 4 cancer
deaths from lung cancer; over 135,000 deaths were
estimated in 2018.

PATHOPHYSIOLOGY

 The most common cause of lung cancer is inhaled

carcinogens, most often cigarette smoke (>85%);
other carcinogens include radon gas and
occupational and environmental agents.
 Lung cancers arise from a single transformed
epithelial cell in the tracheobronchial airways, in
which the carcinogen binds to and damages the
cell’s DNA.
 This damage results in cellular changes, abnormal
SURGICAL MANAGEMENT cell growth, and eventually a malignant cell.
 As the damaged DNA is passed on to daughter cells,
 Modified Radical Mastectomy the DNA undergoes further changes and becomes
 Total Mastectomy unstable.
 Breast Conservation Treatment  With the accumulation of genetic changes, the
 Sentinel Lymph Node Biopsy pulmonary epithelium undergoes malignant
NURSING MANAGEMENT  transformation from normal epithelium eventually to
invasive carcinoma.
 Patients who undergo SLNB in conjunction with  Carcinoma tends to arise at sites of previous scarring
breast conservation treatments are generally in the lung.
discharged the same day.
 Patients who undergo SLNB with total mastectomy RISK FACTORS
usually stay in the hospital overnight, possibly longer
if breast reconstruction is being performed.  Tobacco smoke
 The patient must be informed that although frozen-  Electronic Nicotine Delivery Systems
section analysis is highly accurate, falsenegative  Secondhand Smoke
results can occur.  Environmental and Occupational Exposure
 A negative sentinel lymph node on frozen-section  Genetic Mutations
analysis may show metastatic disease on
subsequent analysis, indicating that ALND is still CLINICAL MANIFESTATIONS
necessary.
 The patient should also be reassured that the  Chronic cough
radioisotope and blue dye are generally safe.  Dyspnea
 The nurse informs patients that they may notice a  Lung parenchyma
blue-green discoloration in the urine or stool for the
 Pleural effusion,
first 24 hours as the blue dye is excreted.
 Pneumonia
 The incidence of lymphedema, decreased arm
mobility, and seroma formation (collection of serous  Hemoptysis
fluid) in the axilla is generally low, but the patient  Chest or shoulder pain
should be prepared for these possibilities.  Fever
 Women who have SLNB alone have neuropathic  Dysphagia
sensations similar to those who undergo ALND,  Head and neck edema
although the prevalence and severity of these  Weakness
sensations and the resulting distress are lower with  Anorexia
SLNB.  Weight loss

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CELLULAR ABERATIONS
blebs or bullae, benign tumors, metastatic malignant
tumors, bronchiectasis, and fungal infections.

ASSESSMENT AND DIAGNOSTIC FINDINGS Pneumonectomy

 Removal of an entire lung.
 CT Scan
 It is performed chiefly for cancer when the lesion
 Chest x-ray cannot be removed by a less extensive procedure.
 Fiberoptic bronchoscopy  It also may be performed for lung abscesses,
 Bone scans bronchiectasis, or extensive unilateral tuberculosis.
 Abdominal scans  The removal of the right lung is riskier than the
 Positron Emission Tomography (PET) scan removal of the left, because the right lung has a
 Liver ultrasound larger vascular bed and its removal imposes a
 Magnetic resonance imaging (MRI) greater physiologic burden.
 Mediastinoscopy  A posterolateral or anterolateral thoracotomy incision
 Endobronchial ultrasound biopsy is made, sometimes with resection of a rib.
 The pulmonary artery and the pulmonary veins are
 Endoscopy with esophageal ultrasound
ligated and severed.
 The main bronchus is divided and the lung removed.
MEDICAL MANAGEMENT
The bronchial stump is stapled, and usually no drains
are used because the accumulation of fluid in the
 Surgery
empty hemithorax prevents mediastinal shift.
 Radiation and Laser therapy
 Chemotherapy
 Immunotherapy
 Gene therapy
 Endoscopic stent placement

SURGICAL MANAGEMENT

Thoracotomy
 Creation of a surgical opening into the thoracic
cavity.
 Surgery is primarily used for patients with NSCLC, NURSING MANAGEMENT
because SCLC grows rapidly and metastasizes early
and extensively.  Patients are typically admitted on the day of surgery.
 Surgical resection is the preferred method of treating  The nurse in the outpatient surgical clinic setting is
patients with localized NSCLCs without evidence of responsible for performing the preoperative
metastatic spread, and with adequate assessment and education and for alleviating the
cardiopulmonary function. anxiety experienced by the patient and family
members by providing them with anticipatory
Lobectomy guidance.
 Removal of a lobe of a lung.  Postoperatively, the patient may be managed by the
 Lobectomy, which is more common than nurse in the ICU.
pneumonectomy, may be carried out for  Successfully managing transitions in care for the
bronchogenic carcinoma, giant emphysematous patient from the ICU to other inpatient acute care
settings (e.g., medical-surgical unit, step-down unit)

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NCM112 LECTURE
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to the outpatient setting is a key nursing
responsibility.
 A reduction in lung capacity requires a period of
physiologic adjustment, and fluids may be given at a
low hourly rate to prevent fluid overload and
pulmonary edema.
 After the patient has recovered from anesthesia and
the vital signs have stabilized, the head of the bed
may be elevated 30 to 45 degrees.
 Careful positioning of the patient is important.
COLON CANCER
 Colorectal cancer is a disease in which cells in the colon
or rectum grow out of control. Sometimes it is called colon
cancer, for short. The colon is the large intestine or large
bowel. The rectum is the passageway that connects the
colon to the anus.
 Sometimes abnormal growths, called polyps, form in the
colon or rectum. Over time, some polyps may turn into
cancer.
DIFFERENT TYPES OF POLYPS
 Adenomatous polyps (adenomas): These polyps
sometimes change into cancer. Because of this,
adenomas are called a pre-cancerous condition. The 3
types of adenomas are tubular, villous, and tubulovillous.
 Hyperplastic polyps and inflammatory polyps: These
polyps are more common, but in general they are not pre-
cancerous. Some people with large (more than 1cm)
hyperplastic polyps might need colorectal cancer
screening with colonoscopy more often.
 Sessile serrated polyps (SSP) and traditional serrated
adenomas (TSA): These polyps are often treated like
adenomas because they have a higher risk of colorectal
cancer.
Other factors that can make a polyp more likely to contain
cancer or increase someone’s risk of developing colorectal
cancer include:
 If a polyp larger than 1 cm is found
 If more than 3 polyps are found
 If dysplasia is seen in the polyp after it's removed.
Dysplasia is another precancerous condition. It means
BSN3A | PBL GROUP 1
there's an area in a polyp or in the lining of the colon or
rectum where the cells look abnormal, but they haven't
become cancer.
SIGNS AND SYMPTOMS
 A persistent change in your bowel habits, including
diarrhea or constipation or a change in the consistency of
your stool
 Rectal bleeding or blood in your stool
 Persistent abdominal discomforts, such as cramps, gas,
or pain
 A feeling that your bowel doesn't empty completely
 Weakness or fatigue
 Unexplained weight loss
CAUSES
 In colon cancer, cells lining your colon and rectum keep
growing and dividing even when they’re supposed to die.
These cancerous cells may come from polyps in your
colon.
 Medical researchers aren’t sure why some people
develop precancerous colon polyps that become colon
cancer. They do know certain risk factors increase
people’s chances of developing precancerous polyps and
colon cancer.
 Inherited conditions, and lifestyle choices
RISK FACTORS
 Smoking: Using tobacco products, including chewing
tobacco and e-cigarettes, increases your risk of
developing colon cancer.
 Excessive alcohol use: In general, men and people
AMAB should limit beverages containing alcohol to two
servings a day. Women and people AFAB should limit
beverages containing alcohol to one serving a day. Even
light alcohol use can increase your risk of developing
cancer.
 Having obesity: Eating high-fat, high-calorie foods may
affect your weight and increase your risk of colon cancer.
 Having a diet that includes lots of red meat and
processed meat: Processed meat includes bacon
sausage and lunchmeat. Healthcare providers
recommend you limit red meat and processed meat to
two servings a week.
 Not exercising: Any kind of physical activity may reduce
your risk of developing colon cancer.
MEDICAL CONDITIONS THAT INCREASE COLON
CANCER RISK
 Inflammatory bowel disease: People who have
conditions like chronic ulcerative colitis and Crohn’s
colitis, which cause inflammation in their colon lining, may
have an increased risk of colon cancer. The risk
increases if you have inflammatory bowel disease that
lasts more than seven years and affects large parts of
your colon.
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 Inherited conditions: Certain conditions like Lynch
syndrome and familial adenomatous polyposis may
increase your risk of developing colon cancer. Colon
cancer may happen if you inherit a gene that causes
cancer.
 A family history of colon and other kinds of cancer: If
a close family member has colon cancer, you may have
an increased risk of developing the condition. Close
family members include your biological parents, siblings,
and children. Your risk may be higher if any biological
family member developed colon cancer before age 45.
 A family history of polyps: If your parent, sibling, or
child has an advanced polyp, you may have an increased
risk of getting colon cancer. An advanced polyp may be a
large polyp. Medical pathologists may characterize a
polyp as being advanced if they see certain changes in
the polyp when they look at it under a microscope that
signs the polyp may contain cancerous cells.
 Many polyps: People with numerous colon polyps —
including adenomas, serrated polyps, or other types of
polyps — often have an increased risk of developing
polyps and colon cancer. People may inherit a tendency
toward having many colon polyps.
DIAGNOSIS AND TESTS
Healthcare providers use several tests to diagnose colon
cancer. Those tests include:
 Complete blood count (CBC).
 Comprehensive metabolic panel (CMP).
 Carcinoembryonic antigen (CEA) assay: Cancer
cells and normal cells release CEA into your
bloodstream. High CEA levels may be a sign of colon
cancer.
 X-rays.
 Computed tomography (CT) scan.
 Magnetic resonance imaging (MRI) scan.
 Positron emission tomography (PET) scan.
 Ultrasound.
 Biopsy.
THE DIFFERENCE BETWEEN A SCREENING TEST AND
TESTS THAT DIAGNOSE COLON CANCER
 Cancer screening test: checks for cancer when you
don’t have any signs or symptoms of cancer. If your
screening test shows abnormalities, a healthcare provider
may recommend additional tests.
COMMON COLON CANCER SCREENING TESTS
 Colonoscopy is the most common screening test for
colon cancer. Other tests include:
 Fecal immunochemical test (FIT): This test detects
hidden blood in your poop. Medical pathologists test
samples of your poop for blood that you may not see just
by looking.
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 Guaiac-based fecal occult blood test (gFOBT): Like
the FIT, this test looks for blood in poop that may not be
visible.
 Fecal DNA test: This test looks for signs of genetic
mutations and blood products in your poop.
 Flexible sigmoidoscopy: Healthcare providers use a
flexible scope called a sigmoidoscope to see inside your
lower colon and rectum.
 Virtual colonoscopy: A virtual colonoscopy is an X-ray
that looks for polyps, tumors and ulcers (sores) in your
colon and rectum.
STAGES OF COLON CANCER
 Stage 0: Healthcare providers may refer to this as
carcinoma in situ. When they do, they’re talking about
abnormal or precancerous cells in your mucosa, the
innermost layer of your colon wall.
 Stage I: Stage I colorectal cancer has grown into the wall
of your intestine but hasn’t spread beyond the muscular
coat or into close lymph nodes.
 Stage II: The cancer has spread farther into the wall of
your intestine but hasn’t spread to nearby lymph nodes.
There are three types of Stage II colon cancer:
o Stage IIA: Cancer has spread through most of your
colon wall but hasn’t grown into the wall’s outer
layer.
o Stage IIB: Cancer has spread into the outer layer of
your colon wall or through the wall.
o Stage IIC: Cancer has spread to a nearby organ.
 Stage III: In this stage, colon cancer has spread to your
lymph nodes. Like Stage II colon cancer, there are three
sub-stages of Stage III colon cancer:
o Stage IIIA: There’s cancer in the first or second
layers of your colon wall and it’s spread to one to
four lymph nodes.
o Stage IIIB: The cancer affects more layers of your
colon wall but only affects one to three lymph
nodes. Cancer that affects fewer colon wall layers
but has spread to four or more lymph nodes is also
a stage IIIB colon cancer.
o Stage IIIC: There’s cancer in the outer layer or the
next outermost layer of your colon and in four or
more lymph nodes. Cancer that’s spread into a
nearby organ and one or more lymph nodes is also
a stage IIIC colon cancer.
 Stage IV: Cancer has spread (metastasized) to other
areas of your body, such as your liver, lungs, or ovaries:
o Stage IVA: In this stage, cancer has spread to one
organ or to lymph nodes that are farther or more
distant from your colon.
o Stage IVB: Cancer has moved to more than one
distant organ and more lymph nodes.
o Stage IVC: Cancer affects distant organs, lymph
nodes and abdominal tissue.
MANAGEMENT AND TREATMENT
 Polypectomy: This surgery removes cancerous polyps.
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CELLULAR ABERATIONS
 Partial colectomy: This is also called colon resection  Angiosarcoma, which starts in the blood vessels. This is
surgery. Surgeons remove the section of your colon that a rare type of liver cancer that is more likely to occur in
contains a tumor and some surrounding healthy tissue. people over 70.
They’ll reconnect healthy colon sections in a procedure  Secondary cancer in the liver is cancer that started in
called anastomosis. another part of the body but has spread to the liver. If you
 Surgical resection with colostomy: Like a colectomy, have secondary cancer in the liver, it may be useful to
surgeons remove the section of your colon that contains read information about primary cancer in conjunction with
a tumor. In this surgery, however, they can’t connect this information or about cancer of unknown primary. A
healthy colon sections. Instead, they do a colostomy. In a secondary cancer is named after the primary site where
colostomy, your bowel is moved to an opening in your it began, for example bowel cancer with liver secondaries.
abdominal wall so your poop is collected in a bag. In this information, we use the term "secondary cancer in
 Radiofrequency ablation: This procedure uses heat to the liver" to refer to any cancer type that has spread to
destroy cancer cells. the liver.
 Chemotherapy: Healthcare providers may use
chemotherapy drugs to shrink tumors and ease colon
cancer symptoms.
 Targeted therapy: This treatment targets the genes,
proteins and tissues that help colon cancer cells grow and
multiply. Healthcare providers often use a type of targeted
therapy called monoclonal antibody therapy. This therapy
uses lab-created antibodies that attach to specific targets
on cancer cells or cells that help cancer cells grow. The
antibodies kill the cancer cells.

PREVENTION

 Avoid tobacco. If you smoke and want help quitting, talk

to a healthcare provider about smoking cessation
programs.
 Use moderation when you drink beverages
containing alcohol.
 Maintain a healthy weight.
 Eat a healthy diet. Add fruit and vegetables to your diet
and cut back on red meat processed foods, and high-fat
and high-calorie foods. Drinking coffee may lower your
risk of developing colon cancer.
 Keep track of your family medical history. Colon
cancer can run in families. Tell your healthcare provider if
your biological parents, siblings or children have colon
cancer or an advanced polyp or if any of your family has
cancer before age 45.
 Follow colon cancer screening guidelines. Ask your
healthcare provider when you should have colon cancer
screening. If you have chronic irritable bowel disease or
a family history of colon cancer, your healthcare provider
may recommend you start screening earlier than age 45.
LIVER CANCER
 Primary liver cancer is a malignant tumor that begins in
the liver.
DIFFERENT TYPES OF LIVER CANCER
 Hepatocellular carcinoma (HCC) or hepatoma, is the
most common type of primary liver cancer and it starts in
the main cell type in the liver, the hepatocytes
 Cholangiocarcinoma, or bile duct cancer, starts in the
cells lining the bile ducts (which connect the liver to the
bowel and gall bladder)
SIGNS AND SYMPTOMS
 Losing weight without trying
 Loss of appetite
 Upper abdominal pain
 Nausea and vomiting
 General weakness and fatigue
 Abdominal swelling
 Yellow discoloration of your skin and the whites of your
eyes (jaundice)
 White, chalky stools
HOW DOES LIVER CANCER AFFECT THE BODY?
 Collects and filters blood flowing from your intestines.
 Processes and stores nutrients that your intestines
absorb.
 Changes some nutrients into energy or substances that
your body needs to build tissue.
 Makes bile, a fluid that helps digest fat.
 Digests and stores other nutrients from food like sugar,
which makes energy.
 Makes substances that help your blood to clot.
RISK FACTORS
 Chronic infection with HBV or HCV. Chronic infection with
the hepatitis B virus (HBV) or hepatitis C virus (HCV)
increases your risk of liver cancer.

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CELLULAR ABERATIONS
 Cirrhosis. This progressive and irreversible condition
causes scar tissue to form in your liver and increases your
chances of developing liver cancer.
 Certain inherited liver diseases. Liver diseases that can
increase the risk of liver cancer include hemochromatosis
and Wilson's disease.
 Diabetes. People with this blood sugar disorder have a
greater risk of liver cancer than those who don't have
diabetes.
 Nonalcoholic fatty liver disease. An accumulation of fat in
the liver increases the risk of liver cancer.
 Exposure to aflatoxins. Aflatoxins are poisons produced
by molds that grow on crops that are stored poorly. Crops,
such as grains and nuts, can become contaminated with
aflatoxins, which can end up in foods made of these
products.
 Excessive alcohol consumption. Consuming more than a
moderate amount of alcohol daily over many years can
lead to irreversible liver damage and increase your risk of
liver cancer.
DIAGNOSIS AND TESTS
 Blood tests: Healthcare providers may do blood tests for
cancer, such as a liver function test, to check on liver
enzymes, proteins and other substances that show
whether your liver is healthy or damaged. They may test
for alfa-fetoprotein (AFP). High AFP levels may indicate
liver cancer.
 Ultrasound (sonography): This test provides pictures of
your soft tissue structures. Healthcare providers use
ultrasound to look for liver tumors.
 Computed tomography (CT) scan: This special type of
X-ray takes detailed images of your liver, providing
information about liver tumor size and location.
 Magnetic resonance imaging (MRI): This test produces
very clear images of your body using a large magnet,
radio waves and a computer.
 Angiogram: This test helps healthcare providers
examine your liver’s blood vessels. During this test, your
healthcare provider injects dye into an artery so they can
track blood vessel activity and look for blockages.
 Biopsy: Healthcare providers remove liver tissue to look
for signs of cancer. Biopsies are the most reliable way to
confirm a liver cancer diagnosis.
 Endoscopic retrograde cholangiopancreatography
(ERCP): ERCP uses an endoscope and a catheter (thin,
flexible tubes) to examine your bile ducts.
 Percutaneous transhepatic cholangiography (PTC):
A PTC creates X-rays of your bile ducts like an ERCP.
Instead of an endoscope and catheter, your healthcare
provider delivers contrast dye by inserting a needle
directly into your bile ducts and liver. A PTC is usually only
for people who can’t have an ERCP.
STAGES OF LIVER CANCER
 Stage I/very early stage/stage 0: You have a single
tumor in your liver that measures less than 2 centimeters
(cm). Blood tests show your bilirubin level is normal.
BSN3A | PBL GROUP 1
 Stage II/early stage/stage A: You have a single tumor
that measures 5 cm or less or you have more than one
tumor that measures less than 3 cm. The tumor may have
spread to your blood vessels.
 Stage III/intermediate stage/stage B: In this stage, you
may have more than one tumor and/or a tumor that
measures more than 5 cm. The tumor may have spread
to your lymph nodes, large blood vessels or another
organ.
 Stage IV/advanced stage/stage C: The cancer has
spread to other places in your body, such as your lungs
or bones, as well as lymph nodes.
MANAGEMENT AND TREATMENT
 Healthcare providers have several common treatments
for HCC and IHC, including surgery to remove part of your
liver, liver transplantation, and liver-directed treatments
like hepatic arterial embolization and ablation. They may
also use several types of chemotherapy,
chemoembolization, radiation therapy, radioembolization,
immunotherapy, and targeted therapy.
SURGICAL MANAGEMENT
 Surgical resection is the treatment of choice when HCC
is confined to one lobe of the liver and the function of the
remaining liver is considered adequate for postoperative
recovery.
 In the case of metastasis, hepatic resection can be
performed if the primary site can be completely excised
and the metastasis is limited. However, metastases to the
liver are rarely limited or solitary. Capitalizing on the
regenerative capacity of the liver cells, some surgeons
have 3786 successfully removed 90% of the liver.
However, the presence of cirrhosis limits the ability of the
liver to regenerate.
 Laparoscopic liver resection for malignant tumors has
also been described. staging of liver tumors aids in
predicting the likelihood of surgical cure
 In preparation for surgery, the patient’s nutritional, fluid,
and general physical status are assessed, and efforts are
undertaken to ensure the best physical condition
possible. Extensive diagnostic studies may be performed.
Specific studies may include liver scan, liver biopsy,
cholangiography, selective hepatic angiography,
percutaneous needle biopsy, peritoneoscopy,
laparoscopy, ultrasound, CT scan, PET scan, MRI, and
blood tests, particularly determinations of serum alkaline
phosphatase, AST, and GGT and its isoenzymes.
 Lobectomy
o Removal of a lobe of the liver is the most
common surgical procedure for excising a
liver tumor. If it is necessary to restrict blood
flow from the hepatic artery and portal vein
for longer than 15 minutes, it is likely that
hypothermia will be used. For a right-liver
lobectomy or an extended right lobectomy
(including the medial left lobe), a
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thoracoabdominal incision is used. An
extensive abdominal incision is made for a
left lobectomy
 Local Ablation
o In patients who are not candidates for
resection or transplantation, ablation of
HCC may be accomplished by chemicals
such as ethanol or by physical means such
as radiofrequency ablation (most frequently
used local ablative therapy) or microwave
coagulation. These techniques may be
performed under ultrasound or CT
guidance laparoscopically or
percutaneously. Radiofrequency ablation is
becoming a standard mode of treatment; a
tumor up to 5 cm in size can be destroyed
in one session. The most common
complications following ablation are local
pain or bleeding. Serious complications are
rare. Immunotherapy with interferon may be
used after surgical resection for HCC to
prevent the recurrence of the lesion in those
patients who have developed the lesion
related to hepatitis B or C.
 Liver Transplantation
o Liver transplantation offers good patient
outcomes. Candidates with liver cancer
meet stringent selection criteria, including
having small, early-stage lesions. The Milan
criteria have been developed to limit
transplantation to patients who are most
likely to have better outcomes.
COMPLICATION
 Bleeding
 Infection
 Rejection
PREVENTION
 Avoid behaviors that lead to cirrhosis.
 Reach or maintain a healthy weight.
 Get a hepatitis B vaccine. This vaccine is safe for nearly
everyone. Ask your doctor about the hepatitis A vaccine.
 Avoid hepatitis C.
 If you have any liver disease, have diabetes, obesity or
are a heavy drinker, ask your healthcare provider about
liver cancer screenings.
CERVICAL CANCER
 Cervical cancer is a type of cancer that occurs in the
cells of the cervix — the lower part of the uterus that
connects to the vagina.
 Various strains of the human papillomavirus (HPV), a
sexually transmitted infection, play a role in causing
most cervical cancer.
 Cervical cancer occurs most commonly in women ages
30 to 45, but it can occur as early as age 18.
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 Cervical cancer begins when healthy cells in the cervix
develop changes (mutations) in their DNA. A cell's DNA
contains the instructions that tell a cell what to do.
 Healthy cells grow and multiply at a set rate, eventually
dying at a set time. The mutations tell the cells to grow
and multiply out of control, and they don't die. The
accumulating abnormal cells form a mass (tumor).
 Cancer cells invade nearby tissues and can break off
from a tumor to spread (metastasize) elsewhere in the
body.
 It isn't clear what causes cervical cancer, but it's certain
that HPV plays a role. HPV is very common, and most
people with the virus never develop cancer. This means
other factors — such as your environment or your
lifestyle choices — also determine whether you'll
develop cervical cancer.
TYPES OF CERVICAL CANCER
 The type of cervical cancer that you have helps
determine your prognosis and treatment. The main
types of cervical cancer are:
o Squamous cell carcinoma : this type of cervical
cancer begins in the thin, flat cells (squamous cells)
lining the outer part of the cervix, which projects
into the vagina. Most cervical cancers are
squamous cell carcinomas.
o Adenocarcinoma - this type of cervical cancer
begins in the column-shaped glandular cells that
line the cervical canal.
 Sometimes, both types of cells are involved in cervical
cancer. Very rarely, cancer occurs in other cells in the
cervix.
STAGES OF CERVICAL CANCER
 Stage I - Cancer is found only in your cervix. It hasn't
spread and is small.
 Stage II - Cancer has spread beyond your cervix and
uterus but hasn't yet spread to your pelvic wall (the
tissues that line the part of the body between your hips)
or your vagina.
 Stage III - Cancer has spread to the lower part of your
vagina and may have spread to your pelvic wall, ureters
(tubes that carry urine) and nearby lymph nodes.
 Stage IV - Cancer has spread to your bladder, rectum or
other parts of the body like your bones or lungs.
RISK FACTORS
 Early childbearing
 Exposure to diethylstilbestrol in utero
 Exposure to human papillomavirus, types 16 and 18
 Family history of cervical cancer
 HIV infection and other causes of immune
deficiency
 Low socioeconomic status (may be related to early
marriage and early
 childbearing)
 Nutritional deficiencies (folate, beta-carotene, and
vitamin C levels are
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CELLULAR ABERATIONS
lower in women with cervical cancer than in women
without it)
 Overweight status
 Prolonged use of oral contraceptives
 Sexual activity:
o Multiple sex partners
o Early age (<20 years) at first coitus
(exposes the vulnerable young cervix to
potential viruses from a partner)
 Sexual contact with men whose partners have had
cervical cancer
 Sex with uncircumcised men
 Smoking and exposure to secondhand smoke
CLINICAL MANIFESTATIONS
 Early-stage cervical cancer generally produces no signs
or symptoms.
 Signs and symptoms of more-advanced cervical cancer
include:
o Vaginal bleeding after intercourse,
between periods or after menopause
o Watery, bloody vaginal discharge that may
be heavy and have a foul odor
o Pelvic pain or pain during intercourse
o Menstrual periods may be heavier and last
longer than normal.
 If cancer has spread to nearby tissues or organs,
symptoms may include:
 Difficult or painful urination, sometimes with blood in
urine.
 Diarrhea, or pain or bleeding from your rectum when
pooping.
 Fatigue, loss of weight and appetite.
 A general feeling of illness.
 Dull backache or swelling in your legs.
 Pelvic/abdominal pain.
ASSESSMENT AND DIAGONOSIS
 Regular gynecological screenings with a Pap test can
detect most cases of cervical cancer.
o A Pap test, or Pap smear- this test detects
abnormal or irregular cells in your cervix. These
cells are examined for signs of precancers or other
irregularities.
 If your Pap comes back as abnormal, further testing is
necessary. This could include an HPV test, which is a
specific test that checks the cells of your cervix for HPV
infection. Certain types of HPV infection are linked to
cervical cancer.
o HPV test - this test detects the high-risk types of
HPV infection that are most likely to cause cervical
cancer.
MEDICAL MANAGEMENT & TREATMENT
 The cervical cancer treatment team includes a
gynecologic oncologist (a doctor who specializes in
cancers of female reproductive organs). Recommended
treatment for cervical cancer is based on many factors
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including the stage of the disease, your age and general
health, and if you want children in the future.
 The treatments for cervical cancer are radiation,
chemotherapy, surgery, targeted therapy and
immunotherapy.
o Radiation - Radiation therapy uses energy beams
to kill cancer cells on your cervix. There are two
types of radiation therapy:
o External beam radiation therapy (EBRT) - Aims
high-powered radiation at cancer from a machine
outside your body.
o Brachytherapy - puts the radiation in or just near
cancer.
o Chemotherapy - Chemotherapy (chemo) uses
drugs that are injected through your veins or taken
by mouth to kill cancer cells. It enters your blood
and is effective for killing cells anywhere in your
body. There are several drugs used for chemo and
they can be combined. Chemo is often given in
cycles. The length of the cycle and the schedule or
frequency of chemotherapy varies depending on the
drug used and where cancer is located.
 Surgery. Different kinds of surgery are used to treat
cervical cancer. Some of the most common kinds of
surgery for cervical cancer include:
o Laser surgery - This surgery uses a laser beam to
burn off cancer cells.
o Cryosurgery - This surgery freezes cancer cells.
o Cone biopsy - A surgery in which a cone-shaped
piece of tissue is removed from your cervix.
o Simple hysterectomy - This surgery involves the
removal of your uterus but not the tissue next to
your uterus. Your vagina and pelvic lymph nodes
aren't removed.
o Radical hysterectomy with pelvic lymph node
dissection - With this surgery, your uterus,
surrounding tissue called the parametrium, your
cervix, a small portion of the upper part of your
vagina and lymph nodes from your pelvis are
removed.
o Trachelectomy - This procedure removes your
cervix and the upper part of your vagina but not
your uterus.
o Pelvic exenteration - This is the same as a radical
hysterectomy but includes your bladder, vagina,
rectum and part of your colon, depending on where
cancer has spread.
OVARIAN CANCER
 Ovarian cancer is a growth of cells that forms in the
ovaries. The cells multiply quickly and can invade
and destroy healthy body tissue.
 The female reproductive system contains two
ovaries, one on each side of the uterus. The ovaries
each about the size of an almond produce eggs
(ova) as well as the hormones estrogen and
progesterone.
 It's not clear what causes ovarian cancer, though
doctors have identified things that can increase the
risk of the disease.
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NCM112 LECTURE
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 Doctors know that ovarian cancer begins when cells
in or near the ovaries develop changes (mutations)
in their DNA.
 A cell's DNA contains the instructions that tell the
cell what to do. The changes tell the cells to grow
and multiply quickly, creating a mass (tumor) of
cancer cells. The cancer cells continue living when
healthy cells would die. They can invade nearby
tissues and break off from an initial tumor to spread
(metastasize) to other parts of the body
TYPES OF OVARIAN CANCER
 The type of cell where the cancer begins determines the
type of ovarian cancer you have and helps your doctor
determine which treatments are best for you. Ovarian
cancer types include:
o Epithelial ovarian cancer - this type is the most
common. It includes several subtypes, including
serous carcinoma and mucinous carcinoma.
o Stromal tumors - these rare tumors are usually
diagnosed at an earlier stage than other ovarian
cancers.
o Germ cell tumors - these rare ovarian cancers
tend to occur at a younger age.
STAGES OF OVARIAN CANCER
 Stage I—Growth limited to the ovaries.
 Stage II—Growth involves one or both ovaries with
pelvic extension.
 Stage III—Growth involves one or both ovaries with
metastases outside the pelvis or positive retroperitoneal
or inguinal nodes.
 Stage IV—Growth involves one or both ovaries with
distant metastases.
CLINICAL MANIFESTATIONS
 When ovarian cancer first develops, it might not cause
any noticeable symptoms. When ovarian cancer
symptoms happen, they're usually attributed to other,
more common conditions.
 Signs and symptoms of ovarian cancer may include:
o Abdominal bloating or swelling
o Quickly feeling full when eating
o Weight loss
o Discomfort in the pelvic area
o Fatigue
o Back pain
o Changes in bowel habits, such as constipation
o A frequent need to urinate
RISK FACTORS
 Factors that can increase your risk of ovarian cancer
include:
o Older age - the risk of ovarian cancer increases as
you age. It's most often diagnosed in older adults.
Inherited gene changes. A small percentage of
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ovarian cancers are caused by genes changes you
inherit from your parents.
o Family history of ovarian cancer - If you have
blood relatives who have been diagnosed with
ovarian cancer, you may have an increased risk of
the disease.
o Being overweight or obese - increases the risk of
ovarian cancer.
o Postmenopausal hormone replacement therapy
- taking hormone replacement therapy to control
menopause signs and symptoms may increase the
risk of ovarian cancer.
o Endometriosis - is an often painful disorder in
which tissue similar to the tissue that lines the
inside of your uterus grows outside your uterus.
o Age when menstruation started and ended -
beginning menstruation at an early age or starting
menopause at a later age, or both, may increase
the risk of ovarian cancer.
o Never having been pregnant - If you've never
been pregnant, you may have an increased risk of
ovarian cancer.
ASSESSMENT AND DIAGNOSIS
 Despite years of research, experts haven’t yet
developed a successful ovarian cancer screening test.
For this reason, the condition is often difficult to
diagnose in the early stages.
 If doctors suspects ovarian cancer, they’ll ask about
symptoms and perform a pelvic exam. During the exam,
they’ll check for any abnormal growths or enlarged
organs.
 They may recommend additional tests, including:
o Imaging tests - Providers may use several imaging
tests, including:
 Pelvic ultrasound.
 MRI (magnetic resonance imaging).
 CT scan (computed tomography).
 PET scan (positron emission tomography).
o Blood tests - Blood tests look for a substance
called CA-125. High levels of CA-125 in your blood
can be a sign of cancer. However, CA-125 levels
can be normal, even when cancer is present, and
higher in many conditions that aren’t cancer.
Because of this, providers use blood tests in
combination with other tests to diagnose ovarian
cancer.
o Surgical evaluation - Providers can diagnose
ovarian cancer during surgery. Typically, if they find
abnormal growths, they’ll remove them during the
same procedure.
o Laparoscopy - During laparoscopic surgery, a
surgeon places a thin camera (laparoscope)
through a small cut (incision) made in your
abdomen. Using the scope as a guide, along with
additional ports to hold instruments, the surgeon
can assess the cancer, perform staging biopsies
and, in some circumstances, remove ovarian
tumors.
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MEDICAL MANAGEMENT AND TREATMENT
 The goal in treating cancer is to remove as much, if not
all, cancer from your body as possible.
 Common ovarian cancer treatments include:
o Surgery - this typically involves the removal of your
reproductive organs and any organ that has cancer
on it. Your surgeon may use laparoscopy (a
minimally invasive surgery) or laparotomy (open
surgery that requires an abdominal incision).
o Chemotherapy - provider may recommend
chemotherapy either before or after surgery.
Chemotherapy are drugs designed to target and kill
cancerous cells. Your provider may give you
chemotherapy intravenously (through a vein) or
orally (in pill form).
o Targeted therapy - this cancer treatment uses
drugs to identify and attack cancer cells. Targeted
therapy changes the way cancer cells grow and
divide.
o Hormone therapy - some ovarian cancers use
hormones to grow. This type of therapy blocks
hormones, slowing or stopping the growth of
cancer.
o Radiation therapy - providers rarely use radiation
therapy for treatment of ovarian cancer.
PROSTATE CANCER
 Prostate cancer is the most common cancer in men
other than nonmelanoma skin cancer. It is the
second most common cause of cancer death in
American men, exceeded only by lung cancer, and is
responsible for 10% of cancer-related deaths in men.
Among men diagnosed with prostate cancer, 98%
survive at least 5 years, 84% survive at least 10
years, and 56% survive 15 years (ACS, 2020).
 Prostate cancer is common in the United States and
northwestern Europe but is rare in Africa, Central
America, South America, China, and other parts of
Asia. African American men have a high risk of
prostate cancer; furthermore, they are more than
twice as likely to die of prostate cancer as men of
other racial or ethnic groups
 Other risk factors for prostate cancer include
increasing age; the incidence of prostate cancer
increases rapidly after the age of 50 years. More than
70% of cases occur in men older than 65 years. A
familial predisposition may occur in men who have a
BSN3A | PBL GROUP 1
father or brother previously diagnosed with prostate
cancer, especially if their relatives were diagnosed at
a young age.
 Genes that may be associated with increased risk of
prostate cancer include hereditary prostate cancer 1
(HPC1) and BRCA1 and BRCA2 mutations (Cheng
et al., 2019). The risk of prostate cancer is also
greater in men whose diet contains excessive
amounts of red meat or dairy products that are high
in fat (ACS, 2020). Endogenous hormones, such as
androgens and estrogens, also may be associated
with the development of prostate cancer.
PATHOPHYSIOLOGY
 In prostate cancer, the cells of these prostate glands
mutate into cancer cells. Mutation is majorly in p53
gene, BCL2 and ERK5 or alteration in Akt kinase
signaling contribute toward the development of
prostate cancer. The prostate glands require
hormones, known as androgens that are involved in
cell survival and apoptosis. Androgens include
testosterone, dehydroepiandrosterone and
dihydrotestosterone.
 Initially, small clumps of cancer cells remain confined
to prostate glands, condition known as carcinoma in
situ or prostatic intraepithelial
neoplasia (PIN). Over time, these cancer cells begin to
multiply and spread to the surrounding prostate tissue
forming a tumor. Eventually, the tumor may grow large
enough to invade nearby organs such as the nearby
lymph nodes or the rectum, or metastasize to bone,
lymphatic system and bladder.
CLINICAL MANIFESTATIONS
 The majority of diagnosed patients are identified by
screening for prostate cancer.
 Usually asymptomatic in early stages
 Manifestations in later stages:
o Bone pain (most common site of
disseminated prostate cancer)
o Weakness from spinal-cord compression
o Weight loss
o Fatigue
o Urinary retention
o Hematuria
o Erectile dysfunction
o Hydronephrosis
ASSESSMENT AND DIAGNOSTIC FINDINGS
 If prostate cancer is detected early, the likelihood of
cure is high (Brant, 2019). It can be diagnosed
through an abnormal finding with the DRE, serum
PSA, and TRUS with biopsy. Detection is more likely
with the use of combined diagnostic procedures.
Routine repeated DRE (preferably by the same
examiner) is important because early cancer may be
detected as a nodule within the gland or as an
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CELLULAR ABERATIONS
extensive hardening in the posterior lobe. The more that can be used to detect either recurrent prostate
advanced lesion is “stony hard” and fixed. DRE also cancer at low PSA levels or metastatic disease
provides useful clinical information about the rectum, (NCCN, 2020b).
anal sphincter, and quality of stool.
 The diagnosis of prostate cancer is confirmed by a MEDICAL MANAGEMENT
histologic examination of tissue removed surgically
Principles of treatment
by TURP, open prostatectomy, or ultrasound-guided
 Prostate cancer is associated with slow growth and
transrectal needle biopsy. Fine-needle aspiration is a
may not be clinically significant during the lifetime of
quick, painless method of obtaining prostate cells for
a patient.
cytologic examination and determining the stage of
disease.  Definitive treatments are associated with substantial
side effects that impact the quality of life.
 Most prostate cancers are detected when a man
seeks medical attention for symptoms of urinary  Multiple factors are considered in treatment:
obstruction or are found by routine DRE and PSA o Age and life expectancy
testing Cancer detected incidentally when TURP is o Overall health and comorbidities
performed for clinically benign disease and lower o Characteristics of the cancer and risk
urinary tract symptoms occurs in about 1 of 10 cases. stratification
o DRE and PSA testing are important o Patient preferences
Management options
screening procedures because abnormal
o DRE and elevated levels of PSA may  Active surveillance:
raise suspicion of prostate cancer. o Deferred treatment with monitoring:
o However, a diagnosis of cancer requires  Serial PSA and DREs over regular
confirmation with a prostate biopsy. intervals
 TRUS helps detect nonpalpable prostate cancers  Repeat biopsies
and assists with staging of localized prostate cancer.  MRI
Needle biopsies of the prostate are commonly o Intention to treat for disease progression or
guided by TRUS. The biopsies are examined by a change in patient preference
pathologist to both determine if cancer is present and o Preferred in patients with very low- or low-
to grade the tumor. The most commonly used tumor risk cancer
grading system is the Gleason score. This  Radiation therapy (RT):
 o External beam RT (EBRT): can cause
erectile dysfunction and radiation proctitis
 system assigns a grade of 1 to 5 for the most
o Brachytherapy:
predominant architectural pattern of the glands of the
 Radioactive seed implants
prostate and a secondary grade of 1 to 5 to the
 Can cause bladder irritation
second most predominant pattern. The Gleason
score is then reported as, for example, 2 + 4; the
combined value can range from 2 to 10. With each
increase in Gleason score, there is an increase in
 Surgery (radical prostatectomy):
tumor aggressiveness. Lower Gleason scores
indicate well-differentiated and less aggressive o Options:
tumor cells; higher Gleason scores indicate  Open surgery
undifferentiated cells and more aggressive cancer.  Laparoscopy with or without
robotic assistance
 A total score of 8 to 10 indicates a high-grade cancer
o Removal of the prostate gland, seminal
(Smith et al., 2019; Zhou, Salles, Samarska, et al.,
vesicles, and pelvic lymph nodes, followed
2019).
by reconstruction (reconnecting the bladder
 Categorization of low-, intermediate-, and high-risk
neck and the urethra)
prostate cancer is determined by the extent of cancer
o Can cause erectile dysfunction and stress
in the prostate gland, whether or not the cancer is
urinary incontinence
localized to the prostate, the aggressiveness of the
cells, and the spread to the lymph nodes and
 Androgen deprivation therapy (ADT):
beyond. Level of risk, in turn, is used to determine
o Luteinizing hormone-releasing hormone
treatment options.
(LHRH) agonists:
 Bone scans, skeletal x-rays, and magnetic
 Leuprolide acetate, goserelin,
resonance imaging (MRI) may be used to identify
triptorelin, and histrelin
metastatic bone disease. Pelvic computed
 Initial release/surge of LH, then ↓
tomography (CT) scans may be performed to
pituitary LH → ↓ testosterone
determine if the cancer has spread to the lymph
o LHRH antagonists:
nodes. The radiolabeled monoclonal antibody
 Degarelix, relugolix
capromab pendetide with indium 111 is an antibody

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↓ Pituitary drive without an initial
  Stage II:
surge in LH → ↓ testosterone o Active surveillance
o Antiandrogens:  If no symptoms
 Androgen receptor antagonists:  In the elderly
flutamide, bicalutamide,  If serious health issues
apalutamide, and enzalutamide o RT with or without ADT
 Androgen synthesis inhibitors: o Surgery with or without EBRT
abiraterone, ketoconazole, and  Stage III:
aminoglutethimide o Recurrence after treatment is more likely.
o Surgical castration with simple orchiectomy o EBRT plus ADT: Brachytherapy may be
(removal of the testicles): ↓ testosterone added.
levels o Surgery followed by RT and/or ADT
o General side effects:  Stage IV:
 Reduced sexual desire o Lymph-node involvement:
 Impotence  RT plus ADT
 Hot flashes  In young individuals with minimal
 Gynecomastia and breast regional lymph-node spread,
tenderness surgery followed by ADT with or
 Depression without RT can be considered.
 Chemotherapy: o Metastatic disease: ADT plus
o Docetaxel chemotherapy
o Cabazitaxel o Other options:
 ADT-resistant cancer:
 Immunotherapy: immunotherapy or PARP
o Sipuleucel-T (Provenge) inhibitors
 Vaccine  Symptomatic bone metastasis
 Made from autologous without visceral disease: radium-
mononuclear cells 223
 Induces immunity against prostate Differential Diagnosis
cancer  BPH: a condition caused by an increase in the
 For metastatic ADT-resistant number of stromal and epithelial cells within the
prostate cancer prostate gland. Patients are usually > 50 years of age
o Pembrolizumab: and present with symptoms of bladder obstruction
 Programmed cell death receptor-1 and/or bladder-storage problems. Benign prostatic
ligand (PD-L1) inhibitor hyperplasia can lead to an increase in PSA levels.
 For patients lacking the mismatch- Diagnosis is based on history and invasive testing
repair (dMMR) mechanism, and (cystoscopy, urodynamics, transrectal ultrasound
for individuals with high levels of imaging). Management is with medications and/or
microsatellite instability (MSI-H) surgery.
 Other therapies:  Prostatitis: a group of inflammatory conditions of the
o Targeted therapy prostate gland. Patients may be asymptomatic or
 Poly-ADP-ribose polymerase present with urinary symptoms, such as perineal
(PARP) inhibitors pain, increased urinary frequency and urgency,
 For patients with germline or urinary obstruction, and fever. The diagnosis is
somatic DNA repair mutation
(BRCA) generally clinical and supported by urinalysis and
o Radium-223 culture data. Management depends on the etiology,
 Emits alpha radiation but can include antibiotics in cases of infection.
 Prevents complications due to Prostate-specific antigen levels may be elevated. To
bone metastasis differentiate prostatitis from prostate cancer, PSA
levels are remeasured after the treatment of
The following management options are based on prognostic prostatitis.
stage, and should be guided by the age, health, and  Erectile dysfunction (ED): the consistent inability to
preferences of the patient: acquire or maintain an erection. Erectile dysfunction
is associated with diabetes mellitus, heart disease,
 Stage I: and certain drugs (e.g., antidepressants).
o Active surveillance (preferred)  Treatments for prostate cancer (RT, prostatectomy)
o RT or surgery: considered in patients with a can also result in ED. Management is with
high probability of progression

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phosphodiesterase-5 inhibitors and vacuum-
assisted erection devices.
 Urinary incontinence (UI): the involuntary leakage of
urine. There are many types of incontinence,
including stress, urge, and mixed type. Radical
prostatectomy can result in stress UI, which presents
as urine leakage with exertion or as gravitational
incontinence. Lifestyle intervention (Kegel
exercises), medical therapy, and surgical procedures
are options in managing post-surgical UI.
HEMATOLOGIC CELLULAR ABERRATIONS
LEUKEMIA
 The term leukocytosis refers to an increase of
leukocytes (WBCs) in the circulation.
 Typically, only one specific cell type is increased.
 the proportions of several types of leukocytes (e.g.,
eosinophils, basophils, monocytes) are small, an
increase in other types can be great enough to elevate
the total leukocyte count, particularly the neutrophils or
lymphocytes.
 leukocytosis can be a normal response to increased need
(e.g., in acute infection), the elevation in leukocytes
should decrease as the physiologic need decreases.
 A prolonged or progressively increasing elevation in
leukocytes is abnormal and should be evaluated. A
significant cause of persistent leukocytosis is a
hematologic malignancy (i.e., leukemia).
 The common feature of the leukemias is an unregulated
proliferation of leukocytes in the bone marrow
 In acute forms (or late stages of chronic forms), the
proliferation of leukemic cells leaves little room for normal
cell production.
 There can also be a proliferation of cells in the liver and
spleen (extramedullary hematopoiesis).
 With acute forms, there can be infiltration of leukemic
cells in other organs, such as the meninges, lymph
nodes, gums, and skin.
 The cause of leukemia is not fully known, but exposure to
radiation or chemicals, certain genetic disorders, and viral
infections are known to be risk factors for certain types of
leukemia.
 Bone marrow damage from pelvic radiation or certain
types of chemotherapy drugs can cause acute leukemia,
typically occurring years after treatment for another
malignancy
CLASSIFICATIONS
 leukemias are commonly classified according to the stem
cell line involved, either lymphoid (referring to stem cells
that produce lymphocytes) or myeloid (referring to stem
cells that produce nonlymphoid blood cells)
 They are also classified as either acute or chronic,
based on the time it takes for symptoms to evolve and the
BSN3A | PBL GROUP 1
phase of cell development that is halted (i.e., with few
leukocytes differentiating beyond that phase).
 acute leukemia, the onset of symptoms is abrupt, often
occurring within a few weeks. Leukocyte development is
halted at the blast phase, and thus most leukocytes are
undifferentiated cells or blasts. Acute leukemia can
progress rapidly, with death occurring within weeks to
months without aggressive treatment.
 chronic leukemia, symptoms evolve over a period of
months to years, and the majority of leukocytes produced
are mature. Chronic leukemia progresses more slowly;
the disease trajectory can extend for years.
ACUTE MYELOID LEUKEMIA (AML)
 originates due to a series of genetic mutations in the
myeloid HSC leading to clonal development of abnormal
blast cells
 blast cells (i.e., immature leukocytes) continue to
proliferate, they crowd out normal bone marrow
production resulting in anemia, thrombocytopenia (i.e.,
low platelet count), and either low or elevated WBC
counts (rarely, the WBC may be within normal range).
 There is also impaired development of all myeloid cells:
monocytes, granulocytes (i.e., neutrophils, basophils,
eosinophils), erythrocytes, and platelets.
 AML is the most common form of leukemia, as well as
most common cause of death from all leukemias.
RISK FACTORS
 increasing age
 males have a higher incidence than females
 having been exposed to chemicals such as benzene or
pesticides or exposed to ionizing radiation
 a history of prior treatment with chemotherapeutic drugs,
such as alkylating agents or topoisomerase inhibitors,
tobacco smoking, other blood disorders (e.g.,
myeloproliferative diseases)
 several genetic disorders (e.g., Down syndrome, Trisomy
8, or Fanconi anemia)
Note: The prognosis and survival rates are highly variable.
Factors influencing a more positive outcome are younger age
at diagnosis, more favorable cytogenetic alterations (which
are strongly associated with younger age), and few concurrent
(or mild) health problems.
In contrast, patients with significant comorbidities, of older
age, with cytogenetic features deemed to be adverse, or who
are frail, are more likely to have a poor prognosis.
CLINICAL MANIFESTATIONS
AML often presents, initially, as nonspecific complaints that
can abruptly occur or gradually worsen over time. The signs
and symptoms result from inadequate production of normal
blood cells, especially as the leukemic cells increasingly
crowd out the bone marrow.
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 Symptoms due to neutropenia (low neutrophil count)
include fever and infection.
 Symptoms related to anemia include pallor, fatigue,
weakness, dyspnea on exertion, and dizziness.
 Symptoms reflective of thrombocytopenia include
ecchymoses (bruises), petechiae (pinpoint red or purple
hemorrhagic spots on the skin), epistaxis (nosebleeds),
and gingival bleeding.
 The proliferation of leukemic cells within organs leads to
a variety of additional symptoms: pain from an enlarged
liver or spleen, hyperplasia of the gums, and bone pain
from expansion of marrow
o Petechia or ecchymoses are common on
the skin
o Occasionally, leukemic infiltrates are seen
o Leukemic cells can also infiltrate the gingiva
or synovial spaces of joints.
Lymphadenopathy (enlargement of lymph
nodes) or splenomegaly. (enlargement of
the spleen) is rare. Fevers may occur and
are not always due to infection.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 complete blood count (CBC) commonly shows a
decrease in both erythrocytes and platelets
 AML can be further classified into seven different
subgroups, based on cytogenetics, histology, and
morphology of the blasts, as well as the presence of
genetic mutations.
 The actual prognosis varies somewhat between
subgroups and with the extent of cytogenetic
abnormalities and genetic mutations, yet the clinical
course and treatment differ substantially with only
one subtype.
MEDICAL MANAGEMENT
 achieve complete remission of the disease, in which
there is no residual leukemic cells in the bone
marrow or peripheral blood.
 chemotherapy treatment is administered in two parts:
induction and consolidation.
 Induction therapy typically involves high doses of
cytarabine and either daunorubicin, idarubicin, or
mitoxantrone; etoposide is occasionally added to the
regimen.
 Older patients (especially those older than 70 years)
or those unable to tolerate standard therapy (in poor
health) may receive lower-intensity therapy (using
hypomethylating agents, low doses of cytarabine, or
hydroxyurea), which may extend survival without a
significant increase in toxicity beyond that of the
underlying disease
NOTE: During induction therapy, chemotherapy not only
destroys leukemic cells, but also healthy cells, requiring
patients to be hospitalized for several weeks (typically 4 to 6
weeks) due to severe and potentially life-threatening side
effects, such as neutropenia.
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 consolidation therapy is given to eliminate any residual
leukemic cells that are not clinically detectable and to
reduce the chance for recurrence of leukemia.
 Allogeneic stem cell transplant is the most common form
of hematopoietic stem cell transplant (HSCT) used in the
treatment of AML
 HSCT is routinely done following induction and
consolidation therapy.
 The process of HSCT requires that patients begin by
receiving high-dose, aggressive chemotherapy,
sometimes in tandem with radiation therapy, to destroy
the hematopoietic functioning in the bone marrow and to
kill any residual leukemic cells. This process is called
conditioning therapy.
 patient is given human leukocyte antigen (HLA-matched)
donor stems cells via intravenous (IV) infusion to
reestablish bone marrow functioning and to create a new
immune system
 Patients with a poorer prognosis may benefit from early
HSCT; those with a good prognosis may not ever require
HSCT
 Other approaches may include treatment with
enasidenib, a cytarabine-based regimen, along with other
agents (e.g., cladribine, fludarabine, mitoxantrone,
etoposide); palliative care; or use of a hypomethylating
agent (e.g., azacitidine or decitabine).
 Supportive care may be the best treatment option to
consider if the patient has significant comorbidity, such as
extremely poor cardiac, pulmonary, renal, or hepatic
function; is older and frail; or both.
COMPLICATIONS
 bleeding and infection, which are the major causes of
death.
 The low platelet count can cause ecchymoses and
petechiae.
 Major hemorrhages also may develop when the platelet
count drops to less than 10,000/mm3.
 The most common bleeding sources include
gastrointestinal (GI), pulmonary, vaginal, and intracranial.
 Disseminated intravascular coagulation (DIC) is
common, particularly in patients with the APL subtype
 very high WBC count (greater than 100,000/mm3) can
cause stasis within the cerebral or pulmonary circulation
 Because of the lack of mature and normal granulocytes
that help fight infection, patients with leukemia are prone
to infection
 Massive leukemic cell destruction from chemotherapy
results in the release of intracellular electrolytes and fluids
into the systemic circulation.
 Increases in uric acid levels, potassium, and phosphate
are seen; this process is referred to as tumor lysis
syndrome
 The increased uric acid and phosphorus levels make the
patient vulnerable to renal stone formation and renal
colic, which can progress to acute kidney injury.
 Hyperkalemia and hypocalcemia can lead to cardiac
arrhythmias; hypotension; neuromuscular effects such as
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CELLULAR ABERATIONS
muscle cramps, weakness, and spasm/tetany; and
confusion; and seizures may also develop
 Patients require a high fluid intake, and prophylaxis with
allopurinol or rasburicase to prevent crystallization of uric
acid and subsequent stone formation.
 GI problems may result from the infiltration of abnormal
leukocytes into the abdominal organs and from the
toxicity of the chemotherapeutic agents. Anorexia,
nausea, vomiting, diarrhea, and severe mucositis are
common.
NURSING MANAGEMENT
 Emphasize comfort
 Minimize the adverse effects of chemotherapy
 Promote preservation of veins
 Manage complications
 Provide teaching and psychological support
CHRONIC MYELOID LEUKEMIA
 Chronic myeloid leukemia (CML) arises from a mutation
in the myeloid stem cell.
 CML results from a chromosomal translocation, where a
section of deoxyribonucleic acid (DNA) is shifted from
chromosome 22 to chromosome 9, forming what is known
as a “fusion gene” that is abnormal.
 CML accounts for 15% of all new cases of leukemia
RISK FACTORS
increasing age, being male, having a history of smoking,
and being exposed to high doses of radiation (e.g., atomic
bomb survivors).
CLINICAL MANIFESTATIONS
 There are three stages in CML that include chronic,
accelerated, and blast crisis
 During the chronic phase, patients have few symptoms,
leukocytosis is detected by a CBC performed for some
other reason, and complications from the disease itself
are rare
 The accelerated phase can be insidious or rapid; it marks
the process of evolution (or transformation) to the acute
form of leukemia (blast crisis).
 In the accelerated phase of disease, blood counts begin
to worsen, new chromosomal changes may be seen on
analysis, and symptoms consistent with leukemia may
start to appear, such as fatigue, anemia, splenomegaly,
or dyspnea
 The patient may complain of bone pain and may report
fevers (without any obvious sign of infection) and weight
loss
 Blast crisis or blast phase of CML is the most advanced
phase.
 Patients in this phase exhibit signs and symptoms that
are more like AML than a chronic disease.
 Patients with extremely high leukocyte counts may be
dyspneic or slightly confused because of decreased
BSN3A | PBL GROUP 1
perfusion to the lungs and brain from leukostasis (the
excessive volume of leukocytes inhibits blood flow
through the capillaries).
 The patient may have an enlarged, tender spleen, and
occasionally the liver may also be enlarged and tender.
 Some patients have insidious symptoms, such as
malaise, anorexia, and weight loss.
 Lymphadenopathy is uncommon, but if present, indicates
late disease and a poor prognosis
MEDICAL MANAGEMENT
The goal of treatment for CML is to control the disease, either
by obtaining remission or by keeping the patient in the chronic
phase for as long as possible. CML is not considered to be
curable among older adults despite advances in
understanding the pathophysiology of the disease and the
advent of new agents.
 the use of tyrosine kinase inhibitors (TKIs) has
significantly improved treatment and long-term survival
for patients with CML
 Medical management is based upon the patient’s age,
general health, calculation of risk-score (based upon
stage of disease and prognosis), and phase of disease.
 TKIs work by blocking the signals within the leukemic
cells that express the BCR-ABL protein.
 The TKI imatinib mesylate is considered to be standard
of care for patients with CML.
 Newer, alternative TKIs approved for first-line (primary)
therapy for patients in the chronic phase of CML include
dasatinib or nilotinib
NOTE: periorbital edema is common with long-term use of
imatinib; dasatinib is very myelosuppressive, and its use
carries a significant risk for pleural effusion and for causing a
prolonged QT interval; and nilotinib has cardiotoxic effects.
 Other TKIs approved for second-line therapy (when
patients do not respond satisfactorily to the first-line
agents) are bosutinib and ponatinib.
 All TKIs are metabolized by the cytochrome P450
pathway, which means that drug-to-drug interactions are
common.
 Drugs that may decrease the effects of the TKI are
corticosteroids, antiseizure medications, antacids, and
St. John’s wort.
 Drugs that may increase the effects of the TKI include
grapefruit juice, certain antibiotics (e.g., clarithromycin),
and azole antifungals (e.g., clotrimazole, ketoconazole).
 CML is a disease that can potentially be cured with
allogeneic HSCT in otherwise healthy patients who are
younger than 65 years.
 acute form of CML (blast crisis), treatment may resemble
induction therapy for acute leukemia, using the same
medications as for AML or acute lymphocytic leukemia.
 Patients whose disease evolves into a “lymphoid” blast
crisis are more likely to be able to reenter a chronic phase
after induction therapy
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NCM112 LECTURE
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CELLULAR ABERATIONS
NURSING MANAGEMENT
 Most TKIs are oral agents; therefore, their effectiveness
is dependent upon the patient’s ability and motivation to
adhere to the prescribed treatment regimen (These drugs
may cause side effects that the patient may find difficult
to manage, such as fatigue, asthenia (weakness),
pruritus (itching), headache, skin rash, and
oropharyngeal pain.
 It is extremely important for the nurse to educate the
patient about the medication regimen, how to manage
side effects, drug interactions, and safe handling
 The nurse should also monitor the patient for adverse
signs and symptoms of therapy, such as decreased
urinary output, changes in the electrocardiogram (ECG;
TKIs can cause arrhythmias and prolonged QT intervals),
and myelosuppression (e.g., fevers, chills, changes in the
CBC).
ACUTE LYMPHOCYTIC LEUKEMIA
 results from an uncontrolled proliferation of immature
cells (lymphoblasts) derived from the lymphoid stem cell.
 The cell of origin is the precursor to the B lymphocyte in
approximately 75% of ALL cases; Tlymphocyte ALL
occurs in approximately 25% of cases.
 ALL can occur at any age, but 75% to 80% of all cases
are found in children, with the median age at diagnosis
being 15 years
 Boys are affected more often than girls; the peak
incidence is 4 years of age. After 15 years of age, it is
relatively uncommon, until age 45 when the incidence
again rises
 For those over age 45, risk factors for ALL include older
age (especially over 70 years), prior exposure to
chemotherapy or radiation therapy, having certain genetic
conditions (e.g., especially Down syndrome; also
neurofibromatosis, Klinefelter syndrome, and Fanconi
anemia)
CLINICAL MANIFESTATIONS
 may be nonspecific while others have no symptoms
initially.
 Manifestations of leukemic cell infiltration into other
organs are more common with ALL than with other forms
of leukemia and include pain from an enlarged liver or
spleen as well as bone pain.
 The central nervous system (CNS) is frequently a site for
leukemic cells; thus, patients may exhibit cranial nerve
palsies or headache and vomiting because of meningeal
involvement. Other extranodal sites include the testes
and breasts.
MEDICAL MANAGEMENT
 obtain remission without excess toxicity and with a rapid
hematologic recovery so that additional therapy can be
given if needed.
BSN3A | PBL GROUP 1
 Similar to treatment for AML, treatment for ALL can be
grouped into induction, consolidation, and maintenance
phases.
 Because ALL frequently invades the CNS, preventive
intrathecal chemotherapy or, less frequently, cranial
irradiation, are also a key part of the treatment plan
 TKIs (e.g., imatinib) are effective in patients with
Philadelphia chromosome-positive ALL; these drugs can
be used alone or in combination with conventional
chemotherapy
 Lymphoid blast cells are typically very sensitive to
corticosteroids and to vinca alkaloids; therefore, these
medications are an integral part of the initial induction
therapy
 Lymphoid blast cells are typically very sensitive to
corticosteroids and to vinca alkaloids; therefore, these
medications are an integral part of the initial induction
therapy
 Typically, an anthracycline is included, sometimes with
asparaginase.
 Once a patient is in remission, special testing
(immunophenotyping, immunoglobulin gene
rearrangements, T-cell receptor genes, molecular
testing) is done to look for residual leukemic cells; these
tests can detect as few as a single ALL cell among 10,000
to 100,000 normal cells.
 For patients with relapsed or refractory B-cell precursor
ALL, agents such as blinatumomab or inotuzumab
ozogamicin have been found to be effective
 The development of chimeric antigen receptor (CAR) T
cells has significantly improved treatment outcomes and
overall survival in patients with ALL
NURSING MANAGEMENT
 Emphasize comfort
 Minimize the adverse effects of chemotherapy
 Promote preservation of veins
 Manage complications
 Provide teaching and psychological support
CHRONIC LYMPHOCYTIC LEUKEMIA
 Chronic lymphocytic leukemia (CLL) is a common
malignancy of older adults, and the most prevalent type
of adult leukemia in the Western world
 The average age at diagnosis is 71 years
 CLL is rarely seen in Native Americans and infrequently
among people of Asian descent. Unlike other forms of
leukemia, a strong familial predisposition exists with CLL;
the disease can occur in 10% of those with a first- or
second-degree relative with the same diagnosis.
 Veterans of the Vietnam War who were exposed to Agent
Orange may be at risk for developing this disease
PATHOPHYSIOLOGY
 CLL is typically derived from a malignant clone of B
lymphocytes.
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 A clone proliferates from a cell of origin so that
descendent cells are identical to the cell of origin. In
contrast to the acute forms of leukemia, most leukemic
cells in CLL are fully mature.
 One possible mechanism that explains this oncogenesis
is that these cells can escape apoptosis (programmed
cell death), resulting in an excessive accumulation of the
cells in the marrow and circulation
 CLL is characterized by the progressive accumulation of
leukemic cells in the bone marrow, blood, and lymphoid
tissues
 Because the lymphocytes are small, they can easily travel
through the small capillaries within the circulation, and the
pulmonary and cerebral complications of leukocytosis
seen with myeloid leukemias are not typically found in
CLL. However, these cells often accumulate within the
lymph nodes and spleen. When it takes less than 12
months for the absolute number of lymphocytes to double
(lymphocyte doubling time), a more aggressive disease
course may ensue. Immunophenotyping of the circulating
B cells is critical to establish the diagnosis by identifying
the presence of a malignant clone of these cells; it is also
used to gauge the prognosis
 Beta-2 microglobulin, a protein found on the surface of
lymphocytes, can be measured in the serum; an elevated
level correlates with a more advanced clinical stage and
poorer prognosis.
o Autoimmune complications can occur at
any stage, as either autoimmune hemolytic
anemia or idiopathic thrombocytopenic
purpura. In the autoimmune process, the
reticuloendothelial system destroys the
body’s own erythrocytes or platelets.
Patients with CLL also have a greater risk
for developing other cancers
 Approximately 2% to 10% of patients with CLL will
experience transformation of their disease to a very
aggressive lymphoma, known as Richter’s
transformation
CLINICAL MANIFESTATIONS
 Lymphocytosis (an increased lymphocyte count) is
always present.
 The erythrocyte and platelet counts may be normal or, in
later stages of the illness, decreased. Lymphadenopathy
is common; this can be severe and sometimes painful
 Splenomegaly may also occur
 T-cell function is impaired and may be the cause of tumor
progression and increased susceptibility to second
malignancies and infections.
 Viral infections, such as herpes zoster, can become
widely disseminated.
 Defects in the complement system are also seen, which
results in increased risk of developing infection with
encapsulated organisms (e.g., Haemophilus influenzae).
 Patients should receive an annual comprehensive skin
examination (as the incidence of skin cancer is higher in
this group), and screening guidelines for other cancers
BSN3A | PBL GROUP 1
should be followed, such as for breast, colorectal, lung,
and prostate cancer
MEDICAL MANAGEMENT
 For patients with no symptoms at the time of diagnosis,
the traditional “watchand-wait” approach is often used
until progression of disease is noted (which could be
months to years)
 Treatment for CLL is variable and can consist of a single
immunotherapy agent administered in combination with
chemotherapeutic agents, such as an immunotherapeutic
antibody against the B-lymphocyte antigen CD20 (e.g.,
rituximab, ofatumumab, obinutuzumab) with
chemotherapeutic agents (e.g., fludarabine,
cyclophosphamide, bendamustine, chlorambucil) as
initial therapy.
 The most commonly prescribed first-line
chemotherapeutic agent is fludarabine. When the disease
is accompanied by a deletion of the TP53 gene or a
mutation of this gene, TKIs such as ibrutinib or idelalisib
may be used as either monotherapy or in combination
with other agents
 Depending upon the age of the patient (less than or
greater than 65 years of age) and whether or not the
patient has comorbidities, patients with relapsed or
refractory disease may also receive newer agents such
as venetoclax, duvelisib, or acalabrutinib
 The major side effect of fludarabine is prolonged bone
marrow suppression, manifested by prolonged periods of
neutropenia, lymphopenia, and thrombocytopenia, which
puts patients at risk for such infections as Pneumocystis
jiroveci, Listeria, mycobacteria, herpes viruses, and
cytomegalovirus (CMV).
 The monoclonal antibody (MoAb) alemtuzumab is often
used in combination with other chemotherapeutic agents
 when the disease is refractory to fludarabine, the patient
has very poor prognostic markers, or it is necessary to
eradicate residual disease after initial treatment.
 Alemtuzumab targets the CD52 antigen commonly found
on CLL cells, and it is effective in clearing the marrow and
circulation of these cells without affecting the stem cells.
Because CD52 is present on both B and T lymphocytes,
patients receiving alemtuzumab are at significant risk for
infection; prophylactic use of antiviral agents and
antibiotics (e.g., trimethoprim–sulfamethoxazole) is
important and needs to continue for several months after
treatment ends.
 CMV infection is also common with alemtuzumab,
idelalisib, and duvelisib, and prophylaxis is important;
among commonly prescribed antiviral agents, vancyclovir
is more effective than acyclovir for treating CMV
 Patients receiving idelalisib or duvelisib have an
increased risk of hepatotoxicity, severe diarrhea, colitis,
and pneumonitis. TKIs have been found to increase the
risk of cardiovascular toxicities, including hypertension,
prolonged QT interval, left ventricular dysfunction, and
heart failure
 Ongoing periodic assessment of the CBC, blood
chemistries, ECG, blood pressure, and bowel habits are
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CELLULAR ABERATIONS
important parameters to monitor among patients taking
these various agents.
 Because of the older age of most patients with CLL,
allogeneic HSCT may not be an option, particularly if
significant comorbidities exist. However, allogeneic
HSCT might be considered for some patients with TP53
deletions or mutations who otherwise have a poor
prognosis. Morbidity and mortality rates remain high
(20%); thus, this treatment modality may be reserved for
those patients with high-risk disease, younger age, and
high degree of match from the donor
NURSING MANAGEMENT
 Emphasize comfort
 Minimize the adverse effects of chemotherapy
 Promote preservation of veins
 Manage complications
 Provide teaching and psychological support
LYMPHOMA
 The lymphomas are neoplasms of cells of lymphoid
origin. These tumors usually start in lymph nodes but can
involve lymphoid tissue in the spleen, GI tract (e.g., the
wall of the stomach), liver, or bone marrow
CLASSIFICATIONS
 They are often classified according to the degree of cell
differentiation and the origin of the predominant malignant
cell. Lymphomas are broadly classified into two
categories: Hodgkin lymphoma and NHL.
HODGKIN LYMPHOMA
 Hodgkin lymphoma is a relatively rare malignancy that
has a high cure rate.
 It is somewhat more common in males than in females
and has two peaks of incidence: one from ages 15 to 34
and the other after 60 years of age
RISK FACTORS
 The cause of Hodgkin lymphoma is unknown. However,
several risk factors have been identified, which include
age, a history of viral infections (particularly the Epstein–
Barr virus, human immune deficiency virus [HIV], or
human herpesvirus 8 [HHV8]), having a family history,
and being exposed to cytotoxic agents.
 Additionally, Hodgkin lymphoma is seen more commonly
in patients receiving long-term immunosuppressive
therapy (e.g., organ transplant recipients) and in veterans
who were exposed to the herbicide Agent Orange (see
Veterans Considerations section in CLL)
 The 5-year survival rate for Hodgkin lymphoma is about
92% to 94% for localized/regional disease (stage I or II)
and 78% for those with distant disease (stage IV)
BSN3A | PBL GROUP 1
PATHOPHYSIOLOGY
 Hodgkin lymphoma is unicentric in origin, meaning that it
initiates in a single node.
 The disease spreads by contiguous extension along the
lymphatic system.
 The malignant cell of Hodgkin lymphoma is the Reed–
Sternberg cell, a gigantic tumor cell that is
morphologically unique and thought to be of immature
lymphoid origin.
 These cells arise from the B lymphocyte. They may have
more than one nucleus and often have an owl-like
appearance
 The presence of Reed–Sternberg cells is the pathologic
hallmark and essential diagnostic criterion
 The World Health Organization (WHO) has classified
Hodgkin lymphoma into five subtypes based on
pathologic analyses that reflect the natural history of the
disease and suggest the prognosis
 Four of these subtypes of Hodgkin lymphoma are
recognized as being consistent with classical disease
SUBTYPES
 Nodular sclerosis: This is the most common form of
Hodgkin lymphoma, accounting for about 70% of all
cases. It is seen most often in the young; among
these patients, the lymph node contains elements of
fibrous (sclerotic) tissue; approximately 40% of
patients have B symptoms. This type of Hodgkin
lymphoma is highly curable.
 Mixed cellularity: This is the second most common
form of Hodgkin lymphoma, accounting for 20% to
25% of all cases. This subtype is more common in
older adults and in males; it is frequently seen in
patients with HIV infection, and B symptoms are
frequently reported.
 Lymphocyte-depleted: This form of Hodgkin
lymphoma is rare; it is characterized by involved
lymph node(s) with few normal lymphocytes but
numerous Reed–Sternberg cells. B symptoms are
commonly reported
 Lymphocyte-rich: This type of Hodgkin lymphoma
is also an uncommon form of the disease; the lymph
node(s) has numerous normal lymphocytes and
Reed–Sternberg cells and B symptoms are rare.
 Nodular lymphocytes predominant Hodgkin
lymphoma (NLPHL): This is the lone type of
Hodgkin lymphoma that is not considered of the
classical type. In NLPHL there are few Reed–
Sternberg cells; rather, there is a predominance of
lymphocyte cells called “popcorn” cells.
o Furthermore, there is minimal involvement of the
lymph nodes as compared to the subtypes that
fall under the four classical Hodgkin types.
o NLPHL is seen more often in males than
females and the age at diagnosis is more often
between 30 and 50 years.
o Patients tend to present with peripheral
adenopathy and with early-stage disease.
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o NLPHL is slow growing and highly curable, but
some patients can relapse while others can
transform to an aggressive NHL
CLINICAL MANIFESTATIONS
 Hodgkin lymphoma usually begins as an enlargement of
one or more lymph nodes on one side of the neck.
 The individual nodes are painless and firm but not hard.
The most common sites for lymphadenopathy are the
cervical nodes. However, other nodes that can be
affected include the supraclavicular and mediastinal
nodes; involvement of the iliac or inguinal nodes or spleen
is much less common
 A mediastinal mass may be seen on chest x-ray;
occasionally, the mass is large enough to compress the
trachea and cause dyspnea. B symptoms, if present, are
indicative of more advanced disease
 Clinical manifestations result from compression of organs
by the tumor, such as cough and pulmonary effusion
(from pulmonary infiltrates), jaundice (from hepatic
involvement or bile duct obstruction), abdominal pain
(from splenomegaly or retroperitoneal adenopathy), or
bone pain (from skeletal involvement).
 A mild anemia is the most common hematologic finding.
The leukocyte count may be elevated or decreased.
 The platelet count is typically normal, unless the tumor
has invaded the bone marrow, suppressing
hematopoiesis.
 Laboratory tests that may be assessed to detect disease
activity include the serum copper level, which may be
elevated, and the erythrocyte sedimentation rate (ESR).
 The ESR measures the rate of settling of RBCs; elevation
is indicative of inflammation; it is also called the sed rate.
 Other symptoms seen in patients with Hodgkin lymphoma
are pruritus, which is common and can be extremely
distressing, fatigue, decreased appetite, abdominal pain,
splenomegaly, and although rare, occasional pain in
affected lymph node after drinking alcohol
 Patients may also have impaired cellular immunity, as
evidenced by an absent or decreased reaction to skin
sensitivity tests (i.e., Candida, mumps) and increased
susceptibility to infections, particularly herpes zoster
ASSESSMENT AND DIAGNOSTIC FINDINGS
 The diagnosis is made by means of an excisional lymph
node biopsy and the presence of Reed–Sternberg cells.
Once the diagnosis is confirmed and the histologic type is
established, it is necessary to assess the stage of the
disease
 Physical examination requires a careful, systematic
evaluation of all palpable lymph node chains as well as
the size of the spleen and liver.
 A chest x-ray and a computed tomography (CT) scan of
the chest, abdomen, and pelvis are crucial to identify the
extent of lymphadenopathy within these regions. A
positron emission tomography (PET) scan is the most
sensitive imaging test and is recommended for initial
BSN3A | PBL GROUP 1
staging to help determine the extent of disease as well as
later for evaluation of response to treatment
 Laboratory tests include CBC with differential; serum
electrolytes, blood urea nitrogen (BUN) and creatinine;
ESR; liver and renal function studies;
immunohistochemistry and cytogenetic evaluation; HIV
testing; and hepatitis B and C testing.
 A multiple-gated acquisition (MUGA) scan and/or ECG
should be performed prior to the start of therapy if the
patient is to receive an anthracycline-based treatment
regimen, as these chemotherapeutic agents are
associated with adverse cardiovascular effects.
 Bone marrow biopsies are not routinely performed unless
cytopenias are present and the PET scan is negative
MEDICAL MANAGEMENT
 The goal in the treatment of Hodgkin lymphoma is cure,
as the overall cure rate is about 90%
 Treatment is determined primarily by stage of disease,
not histologic type, utilizing the Ann Arbor staging system
 Patients with early disease (stage I-II) may receive one of
the following combination chemotherapy regimens:
ABVD (doxorubicin [trade name Adriamycin], bleomycin,
vinblastine, and dacarbazine) or Stanford V (doxorubicin,
vinblastine, mechlorethamine, etoposide, vincristine,
bleomycin, and prednisone)
 The standard treatment for patients with advanced
disease (stages III to IV) and those with B symptoms is
also ABVD chemotherapy, although these patients
typically receive additional cycles of chemotherapy
treatment.
 Other combinations of chemotherapy may be used;
however, these options have more toxic effects.
 When a patient has a suspected relapse of disease, a
biopsy and a PET scan are performed to confirm the
diagnosis and stage of disease.
 Treatment options for patients with refractory or relapsed
disease include immunotherapeutic agents, such as a
monoclonal antibody (MoAb) (e.g., everolimus,
brentuximab), or a checkpoint inhibitor (e.g., nivolumab,
pembrolizumab)
 Treatment for patients with NLPHL in the early stage of
disease may include radiation therapy only
 Treatment for patients with NLPHL in the early stage of
disease may include radiation therapy only
 Patients with stage IB to IIB disease may receive ABVD,
CHOP (cyclophosphamide, doxorubicin [also less
commonly called hydroxydaunorubicin], vincristine [trade
name of Oncovin], and prednisone) or CVP
(cyclophosphamide, vincristine, and prednisone)
regimens in combination with rituximab.
 Those with advanced stage disease are treated with
these same regimens but with radiation therapy added.
 Patients typically feel better following therapy. Late
effects of treatment, which may occur months to years
following treatment, include development of a secondary
malignancy, or cardiovascular disease, hypothyroidism,
and infertility
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 Secondary malignancies (most common are lung and
breast) often develop more than 10 years following
completion of therapy. This is especially true in females
who received radiation therapy to the chest or axillary
areas
 Cardiovascular disease (e.g., coronary artery disease,
arrhythmias, and cardiomyopathy) is also seen 10 years
posttreatment and tends to occur in patients who received
mediastinal radiation or an anthracycline-based
chemotherapeutic agent (e.g., daunorubicin,
doxorubicin).
 Hypothyroidism may occur in about 50% of long-term
survivors of Hodgkin lymphoma, particularly in those who
received neck or upper mediastinal radiation
 The use of some chemotherapy combinations can lead to
infertility in both males and females. For instance,
females of childbearing years may experience premature
menopause following treatment with alkylating agents
(e.g., cyclophosphamide, dacarbazine,
mechlorethamine).
 Other organ dysfunction is also well documented,
including that of the endocrine system.
 Persistent fatigue is common in survivors and can be
exacerbated by depression and other treatment-related
comorbidities
NURSING MANAGEMENT
 The nurse should encourage patients to reduce
factors that increase the risk of developing second
cancers, such as use of tobacco and alcohol and
exposure to environmental carcinogens and
excessive sunlight.
 Screening for late effects of treatment, such as
chemotherapy
 the nurse should provide education about relevant
self-care strategies and disease management.
NON-HODGKIN LYMPHOMAS
 The NHLs are a heterogeneous group of cancers that
originate from the neoplastic growth of lymphoid tissue.
Similar to CLL, the neoplastic cells are thought to arise
from a single clone of lymphocytes; however, in NHL, the
cells may vary morphologically. In contrast to Hodgkin
lymphoma, the lymphoid tissues involved are largely
infiltrated with malignant cells.
 The spread of these malignant lymphoid cells occurs
unpredictably; true localized disease is uncommon.
Lymph nodes from multiple sites may be infiltrated, as
may sites outside the lymphoid system (i.e., extranodal
tissue;
RISK FACTORS
 NHL is the seventh most common type of cancer
diagnosed in the United States, accounting for about 4%
to 5% of all new cancer cases each year. It occurs more
commonly in males.
BSN3A | PBL GROUP 1
 The incidence increases with each decade of life; the
median age at diagnosis is 66 years
 The natural course of the disease is variable and
dependent upon the type of lymphoma.
 NHLs can be categorized as indolent (i.e., a slow-
growing cancer that often remains localized or causes
few symptoms) or aggressive (i.e., a fast-growing cancer
that spreads rapidly and causes significant morbidity)
CLINICAL MANIFESTATIONS
 Symptoms of NHL are highly variable, reflecting the
diverse nature of the disease. Similar to Hodgkin
lymphoma, NHL may start as a painless swelling in one
or more lymph nodes in the neck, axillary region, or groin.
 If the lymphoma is indolent in nature, symptoms may be
absent or very minor
 Other symptoms depend upon enlarged lymph node site
and size, which can compress organs, compromising
function. For example, a mass in the mediastinum can
cause cough, shortness of breath, and chest pain that
may lead to cardiovascular or respiratory distress.
 An abdominal mass may compromise the bowel or
ureters, leading to acute kidney injury or bowel
obstruction.
 Splenomegaly can cause abdominal pain, nausea, early
satiety, and weight loss.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 Similar to Hodgkin lymphoma, an incisional or excisional
lymph node biopsy is required for immunophenotyping
and cytogenetic analysis testing
 The specific histopathologic type of the disease is used
to differentiate the subtype of NHL; it also has important
prognostic implications and is used to determine
appropriate treatment
 Flow cytometry is commonly performed to determine the
specific antigen on the malignant cell.
 Another test that may be performed is fluorescence in situ
hybridization (FISH), which analyzes the DNA and RNA
of the biopsy or blood sample for chromosomal
abnormalities.
 Laboratory studies mirror those done for a patient with
Hodgkin lymphoma (see that previous discussion). In
addition, there may be testing for viruses (e.g., Epstein–
Barr, HHV8, hepatitis B); polymerase chain reaction
(PCR); CT scans of the chest, abdomen, and pelvis; PET
scan; MUGA or ECG (if patient is to receive
anthracycline-based regimen); and bone marrow biopsy
and aspirate (if marrow involvement is suspected).
 Although the stage of disease is important, often it is not
an accurate predictor of prognosis. Two prognostic
classification systems are used: the International
Prognostic Index (IPI) and, for follicular lymphomas, the
Follicular Lymphoma International Prognostic Index
(FLIPI).
35
NCM112 LECTURE
MEDICAL-SURGICAL NURSING

CELLULAR ABERATIONS
 Age, performance status, lactate dehydrogenase levels, complication. The fatality rate is 90% and tends to occur
stage of disease, and extranodal involvement are scored within 2 months after the diagnosis is confirmed
to determine risk of failure or death from disease
NURSING MANAGEMENT
MEDICAL MANAGEMENT
 Lymphoma is a highly complex constellation of diseases.
 The goal of treatment for NHL is to obtain remission of When caring for patients with lymphoma, it is extremely
disease by killing as many of the malignant cells as important for the nurse to know the specific disease type,
possible; in contrast, the goal is cure for Hodgkin stage of disease, treatment history, and current treatment
lymphoma. plan.
 Treatment for NHL is based upon the specific subtype of  Most of the care for patients with Hodgkin lymphoma or
lymphoma and the stage of disease. NHL takes place in the outpatient setting, unless
 If the disease is indolent and localized, the treatment of complications occur (e.g., infection, respiratory
choice may be radiation therapy alone. “Watchful waiting” compromise due to mediastinal mass).
may also be a choice for patients with an indolent form of  Patients need to be educated to minimize the risks of
NHL, such as stage I follicular lymphoma, who have no or infection, to recognize signs of possible infection, and to
few symptoms at time of diagnosis. contact their primary provider if such signs develop
 For aggressive subtypes of NHL, combination  regular follow-up appointments and be screened for the
chemotherapy is typically indicated. One of the most signs and symptoms of possible secondary malignancies.
common combinations is CHOP. Additionally, patients should be evaluated for
 A MoAb (e.g., rituximab, obinutuzumab) may be given cardiovascular and fertility concerns with each patient
along with the chemotherapy visit.
 Radiation therapy may or may not be added to the
treatment regimen. In some cases, a MoAb may be
conjugated with a radioactive isotope and used for
treatment (e.g., ibritumomab tiuxetan).
 CNS involvement is common with some aggressive forms
of NHL; in this situation, cranial radiation or intrathecal
chemotherapy is used in addition to systemic
chemotherapy.
 When NHL has relapsed or is refractory to standard
treatments, other single agent or combination
chemotherapy regimens may be used. For instance, the
ICE regimen (i.e., ifosfamide, carboplatin, and etoposide)
may be implemented; or agents such as bendamustine,
brentuximab vedotin, romidepsin, or axicabtagene may
be tried
 Autologous HSCT (AuHSCT) is another treatment option
for relapsed or refractory NHL, particularly in patients
younger than 60 years
 A rare but potentially life-threatening complication of
chemotherapy is tumor lysis syndrome. Tumor lysis
syndrome occurs when the intracellular content of the
malignant cell breaks down and is released into the
peripheral blood and typically occurs 12 to 72 hours after
initiation of therapy
 Reactivation of hepatitis B virus may be seen in patients
with NHL who become immunosuppressed following
chemotherapy. For example, hepatitis B reactivation can
occur in patients treated with rituximab-containing
regimens, even if the patient had tested negative for
hepatitis B prior to start of treatment
 Preemptive treatment is recommended, including
antiviral therapy (i.e., lamivudine or entecavir) and close
surveillance in patients at high risk
 Symptoms include confusion, motor weakness or poor
motor coordination, and visual and possibly speech
changes. Currently, there is no effective treatment for this

BSN3A | PBL GROUP 1 36